Where the %^&* have you been?

I just got off the telephone with my dear friend, O. If you have been following me, you might recall that I love O. Truly, truly love O. Yet, I had not spoken to or seen O in weeks. She lives less than a mile from me! Miles become nations in urban areas. We treat crossing one street as if we were venturing across an international border. What the fuck happened?

I was not living my life with intention. For three weeks. I checked boxes: activity (all days); meditation (50/50): ETOH and sugar (if we’re counting consuming it); and sleep hygiene (if we’re counting sleeping in a bed). [Eye roll.] This is exactly the shit that I was trying NOT to do.

I have really, really good excuses: water in our apartment twice in one week; three acute patients for as many weeks; and some community activism. I also have really lame ones: summer; “I earned it”; “It-was-a-once-in-a-lifetime-concert-so-why-deprive-myself-of-beer”.

It doesn’t matter now though. I had not spoken to O in weeks. I have had sex with my husband less than I would have liked. Everyone who matters to me the fucking most received tasteless dregs while people who do matter got coffee – piping hot, steaming, designs-in-the-foam latté. “I’m that asshole,” I think. However, it is not that simple.

Here’s THE TRUTH:

I started this blog deeply ambivalent.
I was not ambivalent about the goals, but about professional, ethical challenges too numerous to list here. My first goal as a health professional is “first do no harm”.
In a recent NY Times article, the author and numerous commenters debated the ethical conundrums and inherent narcissism of psychotherapists writing about their work. I will not delve into that detail here; however, I would never, ever want a patient to happen upon this blog, recognize my voice, correlate a date and then be harmed in some way. My heart would break. That is not why I do the work that I do.

How honest do I be?
If this were a diary per se, I would write honestly and opening about my emotions. Yet, my husband reads this. Some of my struggles are change and developing within the context of a committed, long-term relationship. Are there parts of a day that should not be made public? If a patient asked me this question, my anxiety would rise due to the answer that I would want to scream: YES.

How the fuck am I going to do this?
Change is a bitch, and I am saying that as a woman who takes no offense to being called a “bitch”. So, let me trip over my feminism and say it again: Change is a motherfucking bitch. I really had no plan other than intentions. I see you eyerolleing, Q [the hub]. Yes, I am the girl who signs up for a marathon in Limerick, Ireland, and am having consistent pain in my leg. That be me!

I have spent the last few weeks, pondering these matters and finding solutions. Honestly, I had none as I sat down to type this. I truly don’t want to abandon this project. Two paragraphs ago, I came to the conclusion that this blog as I constructed it was impossible. And, then, BOOM! I had an idea.

This blog is going to happen. I intend it. I am called to it. However, the current format has to change. For everyone – me, the hub, O, W and my patients. So, here are the new boundaries:

  1. In the next 60 days, this blog will relaunch with “Day 1”.
  2. Posts will occur on a daily basis; however, they will be a delay only known to me of how many days. No actual dates will appear in the titles of posts; one should not associate the actual day of the post with the day on which it was written. Well, you can, but that would be erroneous.

Between now and the “Day 1” post, I will provide additional context on my goals as I previously did.

Finally, I am sorry that I ghosted. Truly not my intention. I do really give a shit. I hope that you know that too, O.

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.

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.

 

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.

 

 

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.”

 

 

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.