I had my Mardi Gras last night for the 365-day Lenten sleep hygiene. Reading therapist listserves, stoking my anxiety about the possible Affordable Care Act (ACA) repeal and playing my favorite word game in the glow of my smart phone, I watched minutes of sleep expire. I. Didn’t. Care. Ask me now about that decision. It was very fucking stupid.
I just spent 45 minutes walking the dogs and reflecting on this morning. I recalled my reading The Power of Habit by Charles Duhigg years ago and the idea of “one small change” leading to multiple changes. Earlier today – I cannot believe that I am saying this at 08:17 [sigh] – I thought, “Should I eat breakfast? When do I eat breakfast?” This small thought struck a chord deeply inside of me: I have no structure. I wake up whenever approximately eight or nine hours of sleep has been achieved or if some external factor requires it sooner (e.g., a fitness class or appointment with the orthopaedic surgeon). I eat breakfast – normally an RxBar – if I have time or on the way out the door. Sometimes I grab food – fruit, nuts or an RxBar – for time in between sessions, sometimes not. If one were to ask me basic questions about my day, such as “When do you walk the dogs in the morning?” or “When do you eat [insert meal here]?”, I honestly could not answer that question succinctly. I would say, “Well, it depends on my day! I work a lot.” Note the second sentence in that statement: it’s an excuse. Yesterday I was in therapy, and my therapist said: “So, it Netflix’s fault that you don’t go to bed on time.” I kept trying to explain my behavior to her. “So, it’s [partner’s] fault that you don’t go to bed on time.” I really was getting annoyed with her. Where was the damn empathy now?! However, less than 24 hours later, I realize that she was right. I always have a really, really good excuse. My super agile, smart brain will rationalize anything. Seriously – anything.
I am standing in the lobby of our apartment building with bags of groceries full of healthy, life-promoting food. [slight eye-roll]. No Justin’s Peanut Butter Cups are in the bags. “But it’s the organic, healthy kind of peanut butter cups”, whined my brain earlier at the market. My brain can be such an asshole. Watching the elevator alert count down, I hear the beeping of a delivery person scanning boxes in the mailroom.
He rounds the corner and states, “Hey!” It’s our neighborhood FedEx guy. Always friendly.
“Hey, how are you?”
“Doing good. Was that you sighing? You sounded so tired.”
“Yep, that was me. I got up at 5:30 today, but I didn’t go to bed on time.” [internal eye-roll]
“I got to get up at three a.m. I try to get to bed by 9 p.m., but it’s so hard.”
“Tell me about it.”
A formerly stable patient is at risk of hospitalization. My chest tightens due to anxiety. I make the best clinical judgment, but ultimately I have to trust in the patient that they will follow the plan. I am exhausted from a lack of sleep and want ice cream. Being tired always makes me crave sugar. [sigh] I take a walk and get some cool tea. There’s more work to do, but a member of my patient’s treatment gets back to me and contributes to the plan. I feel better that we’re all on the same page. “Everything will be okay,” I tell myself.
I am exhausted and paying for last night’s opposition toward “bed time”. I make a choice: take a ding on my treatment plan or be better present for my remaining patients. I take a 20-minute nap while also setting a boundary with myself: I have to go to bed at 22:30 without my phone in my hand.
I want to go home. I want protein. I am tired. The day’s earlier crisis, sleep deprivation and shame over not hitting my sleep hygiene goal on day one (!) have left me depleted. I want to see my family. I want to be surrounded by love and told that I’m a good person, I do good work and that everything will be okay. However, I have to chart on two patients who are high-risk. If something awful were to happen, I have to prove to a real family and an imagined judge, jury and state licensing board that I did my job, that I did everything I possibly could do to assess their safety and, if necessary, keep them safe. I reflect on my nap, and my shame decreases: I did what was in the best interest of my patients; I made the right choice. It’s then that I realize that “being tired” at work really is not acceptable. Historically, it has not impaired my judgment, but it could. I have to be on my “A game”. The shame washes on the shore of my brain like a never-ending tide. For how long have I been coming to work tired? Then I have to remind myself that I am not a therapist superhero; I am human. As I sit here tired and charting, there are sleep-deprived emergency room medical staff, nurses, pharmacists, truck drivers, and on and on. I complete the notes, leaving the remaining, no-risk documentation for tomorrow. And there it is: the slow clench between my ribs forming. Fuck.
After texting my partner with my bicycle route, I climb on my bike to ride home. Much of my treatment plan in this blog came up with my patients in the same day. I feel good about myself, knowing that I too am trying to do what they are doing. In other words, as a patient complained about their knowing that going to bed “on time” every night would help their anxiety and productivity, I not only felt the true, annoying struggle of this choice, but I also knew that I was making a real attempt to follow my recommendations. I was going to bed at the same time every night. Granted, I was on day one, but it felt good not to have that nagging, shameful feeling that I was going to spend the rest of my week going to bed based upon some whim or Netflix queue.
The streets are empty and red lights turn green as I approach, as if they too know what I need: my partner, dogs and home. I feel grateful. My legs pedal smoothly in a higher gear, translating a few months of classical Pilates. I cannot run a mile again yet, but I will. I don’t know when I will run a mile again yet, but I will. And then my chest reminds me: all is not well. If I were not a mental health professional, I would turn my handlebars and head to the nearest emergency room, thinking that my heart muscle were failing me. But it’s not. This, my friend, is anxiety. Beneath my sternum, I feel the clench, the reminder that I am not normal. My brain is not normal.
Yes, my brain is not normal. However, what could be triggering my brain now? Were it the high-risk patients? Is it a subconscious reaction to some choice that I might be facing when I arrive home? No, and no. And then, the deep knowing strikes me. The knowing that comes from a unique combination of years of psychotherapy, studying trauma and its effects on the brain, and the wisdom of experience:
I suck at transitions. I hate transitions, because I fear transitions. To some who survived a trauma, transitions are the moment in the air between two trapezes – there is nothing but the strength of the previous moment to propel one through.
The immediate survival of a trauma can increase one’s need for control. Children who survive chronic trauma, such as frequent changes in caregiver, neglect, emotional, physical or sexual abuse – particularly before the age of five years – have brains who have been changed forever to respond to stressors. These children (who now can be adults) tend to have higher blood cortisol levels, leaving them in a persistent, possibly low-grade state of “flight or fight”. Earlier in my career, I worked with these children and watched over-stressed mothers trying to put little arms in coat sleeves as the child screamed in a fit of confusion and anger, not knowing what came next. “Does putting on this coat mean I leave mommy? Does putting on this coat mean I go to another, different home?” It was awful to see this wee brain reacting to history and trying to process present. (Thank g’d for the very excellent supervision and psychotherapy that got me through these years. You know who are are.)
There I am on a bicycle that I love in the air between two trapezes – work and home – and there’s not enough time to adjust. I also have to be in bed in less than an hour. Everything is going too fast, and my brain tells my body to remind me. [Chest tightens] But this I know: I’m not dying. My brain just perceives danger when there is none. I just hate, hate, hate transitions – especially ones that go too fast or that I cannot control.
I pedal faster to see my beloved partner and dogs and be in my safe home. All the while, my brain is saying, “I need more time for this.” When I walk in the door, my chest is still clenched. It will take 10 to 15 minutes for it to release.
“I’m not dying. I’m feeling better.”