Day 7 – 31 July 2017

08:19
I am out walking the dogs, and I hear the copyright information on Audible for The Case Against Sugar. Thank g’d I am done with that damn book. At least I won’t hear about sugar the next time I go on a walk. As Amy Poehler stated, “Good for you, not for me.”

11:33
I spent the morning writing, and I have not done any work. Fuck, fuck. I have to focus and get some work done. Love my job, hate the paper work.

15:31
I just remembered: “American Ninja Warrior” is on the television tonight. I love that show. I totally want to be a ninja. [Insert eyeroll from The Hub here.]

Evening
I am sad and anxious. Some of the patients that I have seen today are truly struggling. I am processing two sessions in particular, analyzing my every move and asking if it were the right intervention at the right time. I know deeply that there is no “right” thing to do as a psychotherapist (except in areas mandated by ethics or the law). My possible failures as a “good enough” therapist provide an opportunity for my patients to get angry and process all the times that others have failed them; however, the questions still roll like a fog over my mind.

20:38
I am late leaving the office and tired. There likely will not be time for all that I want to do: reply to my meditation instructor’s email, meditate and watch “American Ninja Warrior”. I know that the last item is silly, but I like to dream that one day I could do some of those things. There was a man who competed in his 60s this year …

21:58
Our young dog stands by the door and looks at me. These are the moments in a marriage: give or take. The Hub has worked all night on preparing dinner for the following day, so I pop up and slowly grab the leads. We walk the streets that are surprisingly quiet, and I feel time slipping away. I want to debit my sleep account.

22:28
The Hub and I crawl into bed. My smart phone lingers in my hand, and I can feel the pull to read – The New York Times, The Washington Post, Politico, Celebitchy, the day’s horoscope. I have not even completed the day’s word game. I consider the alternative to my Treatment Plan but know that the backlit device will stimulate my retinal nerves, and sleep vanish by the hour. I need to set my phone down and do so reluctantly, feeling like I’m missing out.

 

Day 3 – 27 July 2017

05:42
Partner: “So do you want me to fix that pork tenderloin tonight?”
Me: “That would be awesome. I’m done early. We could also – ” I don’t finish my sentence: grab a beer? walk for ice cream? They hesitate at the door, waiting for me to finish my sentence.
Me: “Who the fuck gives up alcohol and sugar at the same time?”
Partner: “Only you.”

09:55
I legit woke up at 05:30 – and then promptly moved to the sofa and watched a trashy show that I had recorded the previous evening. Baby steps. My work day does not start until 12:00, and I really don’t know what to do with this time. Fitness classes in which I participate are on different days at different hours. I want to meditate first thing in the morning, but the dogs have to be walked – do I meditate before or after? When do I eat breakfast if my fitness classes are at different times day to day?

Clearly I have not made a daily schedule. I am not procrastinating though. After a birthday a few years ago, I stated, “I am half-dead – if I’m lucky.” I likely am now 52 percent dead. Some might think that it is a morbid way to view one’s life. I don’t. It reminds me to be intentional with my time. Some of the questions that I have been asking of late: “When I am struggling to move or no longer have beloved people around me, how will I view my time spent:

  • watching woman fight on television?”
  • reading mindless drivel on the Internet?”
  • under the influence of substances with (i.e., essentially absent from) people whom I love?”
  • frustrated with transitions that kept me from traveling?”
  • worrying about something about which I have no control?”
  • shopping on the Internet?”
  • yelling at a driver who intrudes upon my space in a bike lane and then feeling guilty for hours?”
  • fuming over a fitness instructor who does not start a class on time?”

I still watch women fight on television, but when I do it, I am very intentional. I.e., “I am going to put my brain into a mild coma and watch crap for one 42 minutes.” When I view it in this manner, I do not get caught in the endless cycle of looking for more to watch (or more time to waste). The Holstee Manifesto hangs in my office. One line reads, “If you don’t have enough time, stop watching TV.” I remind myself of that “mantra” every time that I complain about how little time I have or sit down to watch television.

This whole line of thinking is very new to me. Impulsively I went to a meditation class one day in April. I went back the next week, and my experience was pretty life-changing. I began to view my mind differently. While I am still herding cats in my brain, the cats have changed.

12:45
Someone dear to me says, “Things are shifting. I can tell. You are way less anxious.” I smile, they’re onto me. I’m growing.

13:35
It is hot out, and the air is juicy. Earlier today, I debated “ride share or bicycle” nine miles across the city. “It’s too hot and humid out,” my brain declares. But my brain is an asshole. I live in a City in which the weather graciously – and sometimes not too graciously – provides a reason not to move. I only need to open Accuweather 338 days of the year to say, “Yep, I should take a cab or public transportation.” Ninety minutes ago, I told my brain to bite it and hopped on my bicycle. One mile in traffic, and I am drenched in sweat. It feels awful and good at the same time.

19:02
I lay on the bed, having bicycled somewhere around 20 miles on a sticky, icky day. I wanted to succumb to the allure of sleep, but I knew that doing so would mean waking up at 20:30 and then staying up until midnight knee deep in Netflix. I read the New York Times about the Affordable Care Act, and it’s a good distraction. I tried very hard not to think about how this could impact both my patients and my own healthcare.

22:00
I reluctantly set down my smartphone and pick up a book. I have 30 minutes until bedtime.

 

 

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! 🙂

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 Brené 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.

Day 1 – 25 July 2017

05:28
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.

08:17
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.

10:13
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.”

Afternoon
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.

16:55
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.

21:06
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.

21:32
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.”

 

 

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.