Day 2 – 26 July 2017

07:10
Despite a rough start on day one, I did it! I went to bed at 10:30. My alarm went off at 05:30, and I didn’t want to cut someone. #smallfavors

However, I have work to do this morning. I need to create some type of schedule to accomplish all that I want in a day. Not a list of work appointments or plans – an actual effing schedule with things like – oh, I don’t know – when do I eat? I am excited about this, because I do believe that: 1) it will make following my “Treatment Plan” easier (and I’m all about easier); and 2) it will bring more intention to my days. I’m all about intention these days; more to come …

Oh, and hey, good morning! đŸ™‚

09:22

I was in therapy and mentioned my “Treatment Plan”. Instead of the “Go you!” that I expected, my therapist gave me the internal eye-roll. (I learned from pros.)

“Whatever happened to the ‘good-enough mother’?”, she asked, referring to the work of Douglas Winnicott. I rolled my eyes back at her – not internally.

What she essentially was saying was that I don’t need to be a perfect therapist to help others heal. In practice, failing a patient can produce anger and be as therapeutic as being “perfect”. Is this Plan another ill-fated pursuit of perfectionism for me? I don’t think so … I’m going to have to think about this.

p.s. If she figured this out before me, I am seriously going to be pissed.

12:08
A noon fitness class that I am choosing to leave five minutes early to see a patient in crisis hasn’t started. I immediately feel annoyed and deprived. I HATE RUSHING.  Thank g’d for meditation classes and Headspace. I am able to loosen my grip on my annoyance and anxiety and use the extra time to stretch my hip flexors that are always tight from biking. At least the work of the class burns off most of the emotions. This afternoon feels like one in which I am eking every minute out of it. Ugh.

17:51
I’m going to hang out with a dear friend. We normally split a bottle of Pinot Noir when dining out. O could care less if I drink ETOH or not. However, I am feeling pulled. ETOH – or as I call it, “liquid Xanax” – puts the brakes on my anxiety and work stress. The minute I take a sip, I feel the liquid Xanax muzzle the anxiety, tape its wrists and stow it in the closet. For now. Not tomorrow, when my neurotransmitters ask, “Hey, where’s that ETOH?” as they busy about. FYI: your body AND your brain are both assholes. They love, love homeostasis and work very hard to undo all that we do. Nothing, nothing is without consequence. G’d, I hate being an adult some days.

I recall BrenĂ© Brown’s Ted Talk: when one chooses to use a substance, one does not get to choose what to numb. If I numb my anxiety, I numb my joy, empathy and other emotions. In addition, anxiety might be a really good thing at the end of the night when choosing to hop on the subway, walk home or take a cab. Anxiety can be life-preserving. So, do I really want to wipe all of that away? I love O. They are one of those people who make me feel so good about myself, because they truly love me. Really, really love me. And they show it. That’s friendship gold. Do I really want to numb that?!

Kind of. I know, right?! That’s the pull of ETOH for me. I am fortunate to be very smart (i.e., common sense) and bright (i.e., intelligent), but I also have great difficulties shutting off my brain. I also spend the great majority of time around equally or greater bright people, asking tough questions, pondering important matters and challenging me to be better. When do I stop? The first sip.

I prepared O and told them that I wasn’t drinking ETOH for 365 days. Of course, they responded in their typically non-plussed way. Damn, I love them.

21:00
I almost fall asleep on O’s sofa. W.T.F. Who is this person? I make a strangely adult decision, state that I need to go home and get to bed. I have a bedtime now.

21:07
I am on my way home in a cab when a message comes through from my partner. It’s a picture of one of our dogs in his lap. My heart and face smile. I love my family. I love O. I am very fortunate.

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.

Irony

I sit in a chair much of my day, deeply listening, developing hypotheses for my patients’ behaviors, staying mentally “in the room” and managing my anxiety. I am fortunate in so many ways, but one of my great fortunes is that I love my job. You know those crazy people who don’t quit their jobs after winning the Powerball? That’s me. (For the record, I did not win the Powerball.)

So, here’s the dialectical: I love my job, and it’s really hard. I’m not asking for a medal or empathy. It’s just a fact: my job is hard. Not only am I responsible for actual lives, I have a role in my patients’ lives that I take very seriously: contributing to their health, relationships and meaning. When one does this type of work, it’s really, really important to know one’s self. (This is why therapists seek therapy and consultation from more experienced therapists.) My blind spots could contribute to a death. I wake up and fall asleep knowing this truth. I love this job, and it makes me anxious. 

When I began my career as a therapist seven years after entering twice weekly therapy, my own, beloved therapist said to me, “If you can manage your anxiety in the room … it’s so important as a therapist.” I think of this insight day in and day out in my work. I cannot worry about what chores I neglected, the jury duty notice that I cannot find (!), my partner’s frustration with me, whether or not I paid the dog walker or if a healthier diet is vegan or paleo. 

However, my greatest source of anxiety in the room is this: my patient’s discovering that I’m a “fraud”. Okay, let’s slow the truck down a bit. I’m not a fraud: I have the degree, licensure and ongoing trained required to do my work. This is anxiety: I fear that one day – and I don’t know when – the people whom I love the most and my patients for whom I care will discover just how much I suck. (For the record, I don’t suck, but it’s a fear.)

This fear of fraudulence is not pervasive. Rather, it’s one of those irksome fears that decides to pop up at the most inopportune times. A diabetic patient might discuss managing their blood sugars, and the fear of fraudulence finds its voice: “Do they notice the extra weight that I’m now carrying?” A patient might share their abuse of ETOH to cope with a family visit, and I empathize; I then recall how I reached for a beer at the end of a rough day. Another patient might discuss her eating to cope with stress as I feel my own shame over using sugar to reward myself after a tough session. Add up enough of these occurrences, and I have given my fear of fraudulence a megaphone. I fucking hate it. It’s awful.

I want to be a better human, partner and therapist. I want to be a healthcare provider who “walks the talk”. I want to muzzle my fear of fraudulence by following every recommendation that I make to my patients. I’m not going to lie: these changes are going to suck hard. AND (note my use of DBT there?) the changes will pay off. I truly believe it. I believe in me. I’m ready. Or not.