Day Whatever – 2 August 2017

Early Morning
I normally have most of this day to myself. I made choices, shifted boundaries – partially out of true clinical need, partially because I was anxious. I am self-employed; if I am not working, I am not making money. Patients cancel and/or reschedule more in the summer due to weddings, vacations, concerts, baseball games, etc. I regressed in my temporal boundaries and scheduled patients beyond what is normal today: two became five. It is what it is. However, my self-care – a manicure – now is a to do, something to fit in between sessions. [sigh] I put myself here. I know it.

This is accumulative, I tell myself. The result of three weeks of patients’ acuity. I know this and that if I had not been sleeping well, abstaining from ETOH and eating better than average that I too would be facing my feeling stressed as well as depleted. I am not stressed. The clinical decisions that I am making are sound.

However, I have not been reaching all of my goals. I love to meditate, and it has become a “when I have time … ” thing. I always plan on doing it first thing in the morning, but it has not been happening. The sugar thing. Fucking sugar. One serving, and I crave it the rest of the day. Crash, crave. Crash, crave. I know this, but I don’t.

My bicycle is at my office. My goal is to walk the dogs, shower and then walk the four miles to work. I see my first patient 90 minutes earlier than typical today. As my grandmother would have said, “There is no time to dilly dally.” But isn’t life there in the dilly dally?

Morning
As I walked the dogs, I deeply considered that last question, letting our middle-age dog sniff and decide whether or not to leave her scent as well. My grandmother was wrong: there is time to dilly dally. I just have to make better intentions.

Switching the focus from the rings on my Apple Watch, I surrender the notion of walking to work and give myself enough time to meditate. I am on day two (for the third day) of the Anxiety pack in Headspace. The young dog plays at my feet, giving me enough distraction to practice reorienting my attention.

I feel better, more present. Today I will go at half speed and put on flip flops instead of trainers or oxfords. I will be present for my life.

Evening
Fuuuccckkk. One of my patients is severely depressed. What is happening is fucking awful – there are no ifs, ands or buts about it. They are facing awful, awful choices. People sometimes believe that psychotherapy is just being coddled. Hells to the “no”. My patients today truly are examining their lives and, in doing so, are facing gut-wrenching losses. Recently, many of my patients mentioned the book, The Subtle Art of Not Giving a Fuck, so I read it. Manson basically rebrands the Buddhist concept of detachment in more secular, “bro-like” terms. While vast parts of the book were not eye-opening to me, one part did stick with me. Manson states that when we think about what we want (e.g., “a perfect body”), we think about the benefits but not what we would have to sacrifice (e.g., “hours in the gym”). Perhaps it is the way that I work, but my patients are facing deep losses in attempts to create better, more meaningful lives for themselves.

I leave work exhausted and sad with zero fucks to give. Again, I don’t bicycle home, knowing that I will have to close the last Apple Watch ring some other way. I arrive home, plant myself on the sofa and turn on something I never intended on watching. I know, but I don’t care.

Night
There is a ring to close on my Apple Watch. I really want to earn a “medal” that I never have: closing all three rings for one solid month, and it is 2 August. I would have to sit with my “loss” for 29 fucking days. After 21:00, I begrudgingly hunt down the missing athletic sock that my young dog stole. Everything feels harder.

Outside, the rain is light, normally the type of weather in which I cherished a run – like running through a gentle sprinkler on a hot summer day. I feel nothing. I just want this over with. So, I set a goal of one mile on my watch. I have not run a mile in 21 months; it has been 18 months since my first orthopedic surgery, seven months since my last. Here goes nothing.

I run, and my body feels more balanced. It’s more of a jog, but my right gastrocnemius feels stronger – less atrophied – and I am not having to push off so hard with my left knee. I am grateful for K and F, my Pilates instructors who have had me on the jump board. Progress is slow, but I never, ever thought that I would run again. I think of the tendon in my right ankle and wonder about the donor, how they died, what their family’s pain is like from the loss. I am grateful for them.

The mile is slow-going, but I finish. I feel no pain. No tightness or the historical “fuck you” from my right ankle. I have healed. My left knee and hip remind me that all is not balanced, but everything is okay. Everything is good. I run another one-third of a mile, and my left IT band says, “Easy there, ranchero.” I stop running and walk the remainder of the way home.

I feel nothing. This is anhedonia.

 

 

Day 8 – 1 August 2017

Afternoon
The day started out easy and fruitful: walked the dogs for 1.85 miles at 06:00; picked up the car from the body shop at 07:30; grabbed fancy tea before my fitness class; and showed up to said fitness class at 08:30. I even managed to bicycle to work. Check, check, check.

However, four hours later the heaviness of the day weighs on me. My patients are not well – of course they are not well, or they would not be here. However, the last three weeks have been very difficult. It is not spring, when weather fluctuations stir the contradicting moods of my bipolar patients. It is summer – “bright, easy summer”. In this City, patients at intake talk about their mood and how it worsens in the dark, cold winter. I am curious, curious as to why patients are sicker now. The rain and air now rumbling outside match the air in my office: wet and heavy from tears and pain. I cannot shake what I have experienced during the past few hours. It weighs on my heart and mind. I worry that things will not get better quickly enough for some of my patients or – if and when they do – they will have to suffer great losses to affect the necessary changes. It is awful either way.

I think of The Hub, staring at black screens of code and solving problems. I could telephone him, say that it’s been a rough afternoon. He would reply and say the same. It’s true, is it not? His work is difficult, managing the expectations of developers, project managers and his own manager. I could say, “I am worried about my patients’ lives”, trying to convey the weight of the day, but that is not news to him. He knows this about me – that I care, that I worry.

I have progress notes to write, but the motivation that spurred me forward in the morning has been transmuted by my patients. I am lethargic, fatigued and ready to quit. This is the challenge of empathy – understanding what is mine and what is theirs. At moments like these, I think of my friend W and her history of just getting in her car and driving, driving. Silence, freedom, space.

My morning plans with O tomorrow for a walk and tea have been dashed. I need to fit in a patient. It’s the right thing to do – we don’t get to decide when symptoms worsen – AND I am disappointed. I just want to crawl into a ball on the sofa in my office and hate the universe for so much suffering.

“Good time for a change
See, the luck I’ve had
Can make a good man
Turn bad

“So please please, please
Let me, let me, let me
Let me get what I want
This time

“Haven’t had a dream in a long time
See, the life I’ve had
Can make a good man bad

“So for once in my life
Let me get what I want
Lord knows, it would be the first time
Lord knows, it would be the first time”

– The Smiths

Evening
Again, a difficult session. My patient’s anxiety filled me, and I could barely sit still. I felt their discomfort, the constant agitation of their body. I feel so relieved at the end of the session when I can stand up and move, and I wonder how they too literally sit with it. My last session has canceled, and I can go home. All three rings on my Apple Watch are closed, and I decide not to bicycle home. I have nothing left. I am depleted.

Night
The pulled pork from the Sous Vide preparation tastes amazing. I know this, but I cannot taste. It is one of those nights when nothing will satisfy. I know this, but I don’t. I have some cookies, chocolate-covered almonds. Nothing satisfies. Nothing will. I know this, but I don’t. I stare at the television, not caring what is on. I just want hours to pass until my body matches my consciousness.

I lie in bed and open the book. I cannot recall what I last read, where I am in the story. I read, and sleep comes fast – well before my bedtime.

An Old Friend

About six weeks ago, I was leaving therapy and had a “doorknob moment”. I looked at my therapist and stated, “It’s like I’m an adolescent and have to figure out how to live.” She enthusiastically replied, “Yes! Exactly.”

Half-way through my life I am figuring out how to live: how to not eat more than needed, how to pause before I act or speak outside work, how to directly ask for what I need, how to say “no” without explanation, how to eat vegetables beyond my small repertoire, how to set boundaries in relationships, how to manage my expectations of others, how to laugh when things go wrong and then wronger, and how to forgive.

You see, I did not plan to be here. Fifteen years ago, when I gained courage from my husband to see a psychotherapist, the script was this:

“[The Hub] will discover how awful I am just like my family has. He will leave, and I will have nothing left. Then I will jump off a bridge into water.”

I actually can tell you which bridge in this City because I walked over it many times, “rehearsing” as it were: gauging the depth of the water (I then could not swim) and noting the lack of witnesses. Now that I think about it, I don’t cross that bridge any more – in car or on bicycle or foot. I haven’t in years …

The first time I remember thinking about suicide, I was 11 or 12. My mother was on some bloody warpath over some small infraction that I could not have imagined then. Trying to drown out the sound of her still yelling at me after sending me to my room, I put the needle on my Mickey Mouse record player. Turning up the music as loud as the little machine could muster, I remember thinking, “I wish I were dead.” Everything got quieter and calmer in my head.

An A student who showed up at mass with her Catholic family every week throughout grade and high schools, I flew under the radar. I never acted out. I never did drugs. I spent my weekends in high school babysitting and saving money for my eyeglasses and clothes. When I didn’t babysit, I went to the video store and rented a movie to watch at home. I ironed church linens. I never went on dates. I didn’t consume ETOH until college. I read voraciously. While the thought of dying crossed my mind during these times, another plan was more pressing: get the fuck out of Dodge.

The proverbial “Dodge” was not of my choosing. After skipping a grade in grade school, I was very young for my class and graduated high school at the age of 17 years. The orders had come in: I had to go to a Catholic college or university, and the Federal aid had to be there. While I wanted to go to a large university far, far away from my family in a large City, there were no funds for transportation; the gas money to drive me to college was limited and that was if the car made it there. Sometimes it did not.

After spending 12 years of education with the same sixty Catholic kids who had all sorts of names for me – their favorite being the then-maligned-label, “lesbian” – I could not wait for a “do over”. I so desperately wanted to fit in, to find my “tribe”, to belong. After all, I belonged nowhere – not at school, not at home, not at church. (I fought my being confirmed and duly lost.) The fact that four other students from my high school went to the same college should have served as a warning, but I did not heed it.

Within weeks of my arrival at college, I again knew it: I was different. No hair bows hung on ribbons on the back of my closet door. I didn’t care about the football team. If the boys only dated girls with bows in their hair, I was never, ever going to get laid. Most students drove nicer cars than my parents had ever hoped to drive. My family took two vacations that crossed two state lines in my life. I didn’t have the clothes, the identity and most importantly – the self esteem. I had spent four years, pulling the grades to get into college and to get the fuck out of Dodge – for this?

With absolutely no emotional maturity to handle all that was thrust at me, I gave up being a “good girl”. I didn’t fucking care. I was going to have fun, g’d damnit. I was going to break every g’d-damn rule that I had so religiously [pun intended] followed since birth and have fun doing so. I found a department at my college that tolerated difference and found a few friends there. However, the faculty might as well placed a sign on the building, stating “Resettlement Agency”, because we all were refugees from the same dictate: go to a Catholic school, be a nice girl and find a good husband. If you can’t do the latter, be a teacher or nurse – a job that would work well for when you have children.

Listening to Tom Waits, The Smiths, Billy Bragg and P.I.L., we did our school work (sometimes) and bitched about the school, our parents and the boys from which we had to choose. I earned honors for my work until I didn’t.

At the onset of my junior year, I realized that if I did not find a job after this education, I would have to go home. I. Could. Not. Go. Home. Home = death. If I were to go home, I knew deeply that I would kill myself. I could not live another day in that house. No, nope, nyet. I cursed my ignorance – that I could choose a “trust fund” or “rich girl’s” major with no clear employment track. I loved what I was learning, but it was not practical. It was a fool’s errand. The joke was on me.

I spent my junior year trying to piece together a more marketable major. My grades fell, and I lost the support of my department. I will never forget crying in front of my peers when a professor stated, “I see nothing of value or interest here.” How the mighty fall. While my thoughts of suicide never translated into a “means” – there was no Internet or Google then – they were omnipresent.

Early in my senior year, I met my now husband at a bar. It is hard to separate my deep love and respect for him now from then; however, I do recall that I thought he was “very hot” and wanted to “hook up” with him. We did – and have been ever since. In many ways, he saved my life by helping me to see what I needed, by helping me to make choices that year – and now – that have kept me alive. I did not go home. Ever again. That choice has had awful consequences that I will discuss another time. But I can without a doubt say this: I did not go home after my senior year of university, and that choice saved my life. I am proud of that decision. It was extraordinarily difficult, and I did it.

As I write this now, I realize that my survival throughout my adolescence, early adulthood and adulthood – until I entered therapy – was always about the “next thing”:

  • “When I get to college, life will [be better in some way].”
  • “When I get married, my life [be better in some way].”
  • When I get [the next job], my life [be better in some way].”
  • When I get a [trinket], I will feel loved.”

The “next thing” would happen, and the hopelessness and anger would sink in all over again. I was different. I was ugly. I was fat. I was fucked. I was awful. My husband didn’t love me. I was “the poor kid”. I heard my father’s voice: “Life is not fair. Get used to it.” Every time one of these punches to the gut occurred, I sidled up to my old friend and felt comfort: “I could end this at any moment.” When things go wrong over and over and it feels “done to you”, you accept that sooner or later, you will take your life.

So, I had resigned myself to the fact that my husband would see what all the others who had left had seen: I was unlovable and deeply awful. He would leave, and so would I.

Through years of twice weekly therapy, I worked through a lot of shit. It wasn’t fun, but I recommend it. I healed through this relationship and still do. Through my training as a psychotherapist, I came to understand how trauma affected my brain, how my attachment pattern plays out in my relationships and how my not acting and suicidal ideation were forms of hope. Over a decade ago, I recall the session in which I looked at my therapist and stated, “I realized the other day that I’m not going to die by suicide – that it is not inevitable.” We both sat in silence for a few minutes, understanding the moment. I was deeply – and still am – grateful for her, for The Hub and all those who loved me in spite of myself during those years. it wasn’t easy to love me. I made sure of that.

My suicidal ideation now is a symptom. I am hawkish on it. If I ever catch myself uttering the phrase, “I am done [with life]” or “I fucking give up [on life]”, I know that I need to readjust. I immediately ask, “Why now?” “What stressors have exacerbated?” “What do I need to do to take care of myself?” It does not happen often – less than once per year- but when it does, I tell my therapist. She doesn’t freak out. I don’t freak out. We just treat it like abnormal blood sugar levels and get back to work.

While my depression is in remission, it is a pernicious disease requiring structure, treatment and vigilance. I never take a good day or the very fact that I am alive for granted. I have a really good life that took about half my life to build.

My Treatment Plan is both out of respect for the perniciousness of this illness as well as for my family and patients. I have spent a very long time wanting to live, now I want to stick around for as long as possible. Oh, the irony.

 

 

The Treatment Plan

If one came into my office with a mood disorder (regardless of additional diagnoses), I would assess the following as part of their assessment and, ultimately, diagnosis(es):

  • Their sleep patterns and sleep hygiene;
  • Their relationship with food;
  • Their relationship with substances;
  • How much they move/exercise; and
  • Their compliance with any other health professional’s recommendations.

Most people with mood disorders struggle with these areas of their lives as part of their illness or to cope with their illness. Loss or increase in appetite, hypersomnia (i.e., sleeping too much) and insomnia (e.g., inability to fall asleep or intrusive wakefulness) all are diagnostic criteria for major depressive disorder. In addition, patients who struggle with depression, anxiety or post-traumatic stress can use food or substances to cope with unwanted emotions and their resulting symptoms. As a psychotherapist, looking at how people cope can tell us much about underlying emotional disturbances. Said another way, if one is in a good space in life, they sleep well, eat for fuel and the occasional indulgence, do not abuse substances and maintain or increase their health through activity and following health provider recommendations.

So why don’t people with mood disorders do what is recommended to them to manage their health?! Because their life is one big Whack-a-Mole game of managing different, sometimes conflicting symptoms. There’s another reason: most suck at structure. (You know who you are.) If they are so depressed that they cannot get out of bed in the morning, imagine trying to go to bed “on time” that night. These patients laugh in my face when I ask about their sleep schedule. I could spend the next 500 words, providing examples on how some patients hate – even are oppositional toward – structure, but I have to stick to today’s topic: The Treatment Plan.

For the next 365 days, I am going to follow every single one of the recommendations that I make to my patients. 

My immediate response to typing that sentence: “FML”, which I imagine that I will be uttering much during the next 365 days. However, I truly want to “walk the talk” as a healthcare provider. I also want to be the best damn version of me for however many years I have left on this planet. So, here it goes.

1. Sleep hygiene
Go to bed on time (22:30) and wake up on time (05:30) six days a week. No reading backlit screens after 22:00. One 30-minute nap on one weekend day is acceptable, but not recommended.
Degree of difficulty: 10/10

2. Mindfulness
Meditate for a minimum of 15 minutes per day. Lying in bed for 15 additional minutes to “meditate” does not count. (That hurt.)
Degree of difficulty: 4/10

3. No added sugar or artificial sweeteners
To clarify, naturally occurring sugars, such as in fruit, are allowed. (More on this recommendation to my self and some of my patients to come … )
Degree of difficulty: 7/10 (A 10/10 if I am around my dear friend who is an excellent baker.)

4. No ETOH (i.e., alcohol) or other substances
Nerd alert: I have never tried or done an illegal substance or something not prescribed to me. So, I will be abstaining from the one substance that I do use: ETOH.
Degree of difficulty: 9/10

5. Close all the rings on my Apple Watch
This equates to seven 30-minute workouts per week, twelve hours of standing for at least one minute and meeting a daily caloric “move” goal (currently 800 calories). One doesn’t need an Apple Watch to measure these activity or movement goals, but it’s a consistent, workable measure for me.
Degree of difficulty: 2/10

6. Follow doctors’ orders.
If I’m prescribed a medication that I agree to, I will take it. If a physician orders a test, I will do schedule and complete it. I will not cancel my dental cleanings. (I hate going to the dentist.)

That’s it in a nutshell. It – like my stubborn head – likely is going to be very hard to crack.