I decided that my string of failures comes from my lack of self-confidence. I was always fearful and timid and I can see now that this brought me just what I used to dread.

But I’m on a new pathway now. I started my own business, I have a new marriage and a I’m keeping to a solid fitness plan. I know that in the past I would have found some way to sabotage this initiative with doom-and-gloom thinking. This time it’s going to be different! My only enemy is my own fear. I’m visualizing success and refusing to consider a bad outcome. I’m not stupid enough to think failure is impossible, but I do know that we tend to create the reality we expect.

Agreed?

Answer:

Not quite.

Of course confidence is good, and we need to visualize where we want to go. But to think the positive visualization itself has much power is naive. Instead, I might coach you to study your enemy. That is, imagine and list all the ways in which this initiative could fall dead. Not enough business? Or so successful that you can’t fit in the full workout…or that you have to grab a burger just this time…and one more time the next week…

This is not a lack of self-assurance; it’s a recognition of reality. It’s not pessimistic thinking; it’s strategic foresight. And it’s not a lack of hope; it’s building the confidence to know you won’t come upon bad surprises ill-prepared.

If you made a mistake with your past “gloom-and-doom” thinking it wasn’t in predicting bad events, it was in dwelling on them passively, over-estimating their power, and thinking you couldn’t cope when they came. And a mistake now would be to think that fear has more power than it does. Or that you have the power to control an emotion. These are the surprise enemies, oddly familiar to us all.

So visualize failure. Welcome your fear. Harness it as caution, make your contingency plans and build your preparedness. Then go forward with the confidence that makes you strong. Tempered with the anxiety that makes you human.

How can I decide whether to take an antidepressant medication?

Answer:

It’s good to be ambivalent. Careful thought is better than little thought. Usually, I will support the decision a patient makes. Occasionally, I’ll lean on someone to take something or to delay taking it. Here are guidelines I’ll often bring up in a discussion about the decision:

You may want to gather information, but you may also want to limit your research. The more you cruise the information sources, the more you may find that there are few established facts that aren’t contradicted by someone. I myself hold with the dominant view that most people who take an antidepressant are helped, and that the benefit outweighs the consequences. As with all health information, consider the source. Treat carefully any testimonials, no matter how impassioned or who they are from. Take the same care with information that comes from the pharmaceutical companies as well as that which comes from the rabid zealots in any camp.

If you are inclined against taking medication, you should ask yourself how much energy you are prepared to put into the alternatives. A passive sit-and-wait strategy may or may not be a good one, whereas a reasonable plan of action should give you more confidence. You should also ask, if I’m not doing badly enough to take a medication now, how much worse would it have to get to change my mind? How will I know when I’m there, and can get past my hesitation if I get there?

If you are inclined to take it, can you make a good commitment to doing it right? This means taking it daily as prescribed, keeping in touch with the one who prescribes it, tolerating the manageable side effects, and staying on it for a long-enough period of time. As a general rule, eight months is the shortest period of time anyone should be on the medication, and longer is often better, depending on your specifics. While on it, would you enjoy the benefit with complacency, or could you use the opportunity to learn what got you down and what can keep you up, so that you’ll be equipped to stay off it once finished?

Can you explain to me why it helps with post-traumatic stress to revisit the upsetting event or scene?

Answer:

Can you imagine a cowboy getting over a fear of horses by talking about it in an office?

When we’re in the midst of the horror of a traumatic event, our bodies are thrown into a high state of overdrive. This fight-or-flight response instantly puts the body into just the right mode for survival – battle-or-bolt. We need this arousal reaction – it’s very handy for self-preservation, not to mention the survival of the species. But, it has some disadvantages.

For one, it is easy to get too trigger-sensitive. That is, the merest hint of danger may ignite you. Say, a combat vet hearing a sudden noise, or a rape victim approached by a gentle man just a little too close and quickly. Both of these otherwise calm and poised individuals are instantly pitched into the same dreaded state.

A second disadvantage is that this fight-or-flight just shrieks. It’s terribly uncomfortable and we’ll do almost anything to avoid it. It’s supposed to be uncomfortable by the way. Is there any smoke alarm which gives a comforting little melody? The discomfort puts us on high alert, and trains us to avoid dangerous situations where we might experience the punishing sensation.

Finally, just as we link the “shriek” of the full-throttle fear response to the presence of danger, we also link danger to the response. Pavlov’s dogs hear a bell, therefore, they assume, it’s chow-time. It’s as if we say “I feel like there’s a grave danger, therefore, there must be a grave danger.” The sense of impending doom causes panic, which increases the sense of doom, and through the roof we go.

Now, you can read many books about post-traumatic stress disorder. You can talk with friends and therapists at length and you can perform rituals complete with incense. Actually these things are important – the support of friends and family, a sense of belonging, comforting rituals, a consistent structure to the day, a sense of purpose and meaning in your work and so on. Elements like this in your day-to-day life may prevent a traumatic event from shaping into post-traumatic stress disorder, or may soften PTSD and hasten its resolution. But the instant, patterned reactivity of PTST is in the gut, so to speak, and might remain untouched. In this case, you have to have the bodily experience, in a perfectly safe situation, to “unlearn” the reaction.

Think of the cowboy who’s been thrown from his horse. He can stay away from horses and feel just fine. He walks up to a horse though, and panic wells up. If he’s sensible like I am (or, uh…try to be), he’ll walk away from the horse and instantly feel better. But what just happened? The lesson is “close = danger, and distance = safety”. This has just confirmed to him that the horse is indeed hell-bent on killing him. He feels good for the time being, but has strengthened his PTSD.

Let’s go to the rape victim. She might stay away from a two-mile perimeter of the crime scene, she might avoid unknown men and will avoid imagining the awful event. Then she sees a therapist, who in this case is a little like the dentist in that he or she has to create discomfort to be effective. After plenty of preparation, and when the victim – wait – she was a victim. Now we’ll call her a client. When the client can pronounce with confidence that the office is in fact perfectly safe, she might be instructed to tell the story of the rape. In the present-tense, with detail. In all likelihood it will bring on that old terror. Almost like she’s there. “I feel like there’s grave danger, therefore… hey!” This time she sees that she is alive, safe and intact. She has started to learn, experientially, that she can afford to disconnect this particular alarm.

I’ll leave out other details of the process but if she repeats something like this often enough, very soon she’ll find that the retelling sparks less and less of a reaction. Keep going, and it will become downright manageable. She’ll be instructed to go out at night to safe places with safe people, and so on, to “desensitize” outside the therapy office in the same way.

The trauma happened in the past. Revisiting is not re-experiencing; it just feels like it. But feelings cannot harm you. Saddle up.

I’m feeling so crummy these days. When I’m at my lowest, the negative thoughts start to take over and I feel like a goner. Any suggestions? I’m stuck at home with a disabled spouse.

Answer:

I’ll suggest it’s more useful to see how the negative thoughts trigger the emotions. While we can’t directly or easily control our emotions, we can get a better handle on our thoughts. Also, while emotions by their definition can never be wrong, thoughts generally either true or false. They can be put to the test.

What you can do is start to look for your own most depressing thoughts (maybe something like, “this life stinks”), and try to see how it is distorted (see below). Then you can practice taking a more rational assessment (perhaps, “this life is hard, not stinky, and it is meaningful and principled, and furthermore, I still have a good measure of control over the quality of my days”), which will begin to improve your mood. It takes some concerted practice.

You can try reading Feeling Good and The Feeling Good Workbook by David Burns for more on all this. As a preview, here are what he might consider the “Top Ten” cognitive distortions. It would be a strange individual who never engaged in a few of these:

1. All or Nothing Thinking
This refers to the tendency to evaluate personal qualities or situations in extreme, black or white categories. For example, before you developed chronic pain, you used to play baseball on the weekends. Now you find yourself thinking, “If I can’t play baseball, I can’t enjoy the sport anymore.” There is an apparent advantage to thinking in black-and-white, all-or-nothing terms. It is more predictable and creates the feeling that there is order in the world around you. This, in turn, should give you an edge to controlling your world. Unfortunately, it doesn’t work that way. Uncertainty is all that we have. Living comfortably with uncertainty is possible, but it takes time to master.

2. Overgeneralization
This refers to the tendency to see a single negative event as a never-ending pattern of defeat. Given the preceding example, you might respond, I’ll never be able to enjoy anything anymore. Misery does love company, but globalizing misfortune in this way creates an exaggerated sense of rejection and loneliness.

3. Mental Filtering
This refers to the tendency to dwell exclusively on a single negative event, and thus to perceive the whole situation as negative. For example, you are preparing brunch for some friends and discover that you do not have an essential ingredient to make a dish you were planning to include. All you can think about is how the whole brunch will be ruined. It gives you indigestion.

4. Discounting the Positive
This refers to the tendency to take neutral or even positive experiences and turn them into negative ones. For example, a friend comes over to visit and tells you that you look great. Your immediate though is this: I don’t feel great. She doesn’t understand. Maybe not, but try a simple thank you first before you check it out. Maybe you don’t look as bad as you feel!

5. Jumping to Conclusions
This refers specifically to jumping to a negative conclusion that is not justified by the facts of the situation. Two types of jumping to conclusions are mind reading and fortune telling.

5-A. Mind Reading
You assume you know why someone else does what he or she does, and you don’t bother to check it out. For example, you pass a coworker in the hallway and say Hi! He doesn’t respond. You think He must be upset with me. What did I do wrong? When you check it out, you find that the coworker was preoccupied about a sick child he had just left at home.

5-B. Fortune Telling
You know that things will turn out badly. Given your bad luck, you predict it as an already established fact. For example, you wake up with a headache. You say, Now my whole day is ruined. I had so much to do and I’ll never get it all done.

6. Magnification and Minimization
In magnification, you exaggerate the importance of a negative event or mistake. If, for example, you experience a flare-up in your pain, you find yourself saying, I can’t stand this! I can’t take this anymore. As a matter of fact, however, you can. You may not want to, and that’s okay, but you can take it. In minimization, conversely, you take positive personal qualities or events and deny them their importance. For example, a family member comments on how nice it is to see you at a family outing, and you reply, A lot of good it does if I can’t participate in the activities.

7. Emotional Reasoning
This refers to taking your emotions as evidence for the truth. If you feel that something is right, then it must be true. For example, you find yourself thinking, I feel useless. [Therefore] I am useless.

8. Labeling
This refers specifically to identifying a mistake or negative quality and then describing an entire situation or individual in terms of that quality. For example, instead of seeing yourself as an individual who has a pain problem, you find yourself saying, I’m defective, imperfect, and good for nothing.

9. Personalization
This refers to taking responsibility for a negative event even when the circumstances are beyond your control. For example, you and your spouse go out to eat at a fancy restaurant, but the service and food are poor. You find yourself feeling responsible for making a bad choice and ruining your evening together.

10. Shoulds
These are attempts to motivate (or browbeat) yourself by saying things like, I should know better, I should go there, or I must do that. Such statements set you up for feeling resentful and pressured. They also imply that you are complying with an external authority.

I have a fear of all the suffering and death I see around me. I watch the news, with all the war, starvation, crime and death around us, and my thinking reels. I feel completely powerless to protect my family and myself. What do I do?

Answer:

How can we not overreact to the catastrophes you describe? I personally worry that there are not more people without at least occasional significant sadness and fear. You might even believe that to somehow be successful with positive thinking on the tragedies and terror around us, you would be to ignoring your compassion, even to living in tacit collusion with it all. This is a double bind you cannot win.
I would not always try to find positive thinking and I’m not sure you should either. It’s comparable to the tar baby in the Brier Rabbit tale: the more you try to grapple with it the more stuck you become. Instead, maybe you could think of those lines of thought as an inherent part of living, and work instead to expand on the moments when your attention is on matters of immediate value to you. Trying to live your own life well becomes the focus of your efforts. It can start simply, with momentary full sensory awareness while eating a good fresh piece of fruit for instance. It’s hard to be fully depressed at that moment, and it should do nothing to trivialize all that is grave.
While it may seem like a contradiction, you can also practice recognizing your own distorted thinking. With a little practice, you can catch yourself before you buy into certain fictions. Examples? “I’m completely powerless”, “It’s bad everywhere, always, with everyone” or “Good times are not legitimate”. It works to replace ideas like this when you can see that it is completely rational, and your attention can go towards rich pleasures and quality work.

Answer: The single most potent tool against anxiety always seems at first to be rather lame. It is slow, controlled breathing using the belly. It is not the only measure, but it may be the simplest, most effective one. Because we’re so inclined to dispense with it or misuse it, it’s important to understand how it works.

When we’re anxious or in a panic we tend to breath in a rapid shallow way, using the chest. When relaxed, breathing slows down and we use more of the belly. Likewise, when we can force the breathing to be more slow and “diaphragmatic” (that’s belly-breathing), anxiety will reduce.

First, a biology reminder. The lungs function as a bellows: we expand the chest wall and the lungs within expand, drawing air in. But you can also breathe without moving the chest wall at all. If you push out your belly, you can draw down the horizontal membrane that separates all the lower organs from the heart and lungs above. The lungs expand downwards. Try it. You might find this method of breathing difficult, even impossible at first. It is counter-instinctive, and you may be many years out of the habit.

If chest-breathing adds to anxiety, why do we do it? Why would we tend to breathe in a way that adds to our misery? In short, we evolved this way. Chest-breathing is part of the fight-or-flight survival system. Think of our ancient ancestors, surviving all the threats they encountered over countless generations. We can suppose that in your lineage there were many thousands who heard a sound which could indicate a tiger coming over the hill. Or who saw someone from another tribe, with an ambiguous facial expression which might have warned of developing hostility. We can suppose that some remained relaxed in these situations…and we can suppose that they did not live to pass along their genes. We inherited our traits from the most jumpy, reactive survivalists.

So, when your brain senses something ambiguous, it may be inclined to interpret it as a danger signal. Having done so, it will send a signal to the rest of your body. A message, “Hey! Get ready for survival action!” Your body will immediately adopt its finely-honed set of survival-mode responses, everything you want happening when it’s time to flee that tiger or fight the attacker from the marauding tribe. Adrenaline and cortisol will surge, your heart rate will increase, your blood pressure will rise, blood flow will change, the upper digestive system will shut down (so the blood can go elsewhere), while the lower tract will activate (so you can quickly shed excess weight), you’ll have rapid, shallow breathing, and so forth. These and other physical changes are beyond our control. We cannot willfully manage any of them…except one: The breathing. I’ll come back to this in a moment.

When the body is in its activated state, you are ready to fight or flee. Battle or bolt. It is exactly what you want to have happen if you really are in a sudden struggle for survival. But in the absence of a real, immediate and identifiable threat, the whole arousal process has another effect: it is terribly uncomfortable. This too has a positive function. When your home smoke alarm goes off, it does not emit a pleasant little melody but rather an ear-splitting shriek. This gets people out of burning homes and it saves lives. Likewise, your fight-or-flight arousal system is unsettling. Just as the brain sent a signal to the body, the body sends a return message, “We’re doing our part here! You better do yours!”

Now, the brain has its own survival response as part of this whole system. All our higher-order abilities such as imagination, planning, analysis, creativity, empathy – things which can be awfully darn helpful in managing conflicts and solving problems – are out the window. We strip the thinking down to two essential questions: “Where is the danger?” And, “What am I going to do about it?” We want to zero in on the problem and take immediate, drastic action. We scan the horizon and hone in on whatever seems to be the culprit. The perceived threat might be the sense that you’re about to have a heart attack, it may be the spider on the other side of the room, it could be worries about your others judging you, or just a general sense that things are falling apart…there is a limitless variety. But when it comes to need to take fight-or-flight action, we’re stuck.

So now, not only do we sense there is an impending danger, not only are your internal alarms blaring, not only is your body amped up and your thoughts racing, now on top of it all you feel helpless to do anything about it. We’re all the more stuck with the problem that caused the anxiety, and beset by acute discomfort on top of it all.

So what is to be done?? Right now!!

Again, all those physical components of anxiety are “autonomic”, beyond our direct control. You cannot, for instance, willfully lower your heart rate. But ONE of them can be controlled – your breathing. This is the chink in the dragon’s armor.

Again anxious breathing is rapid, shallow and up in the chest. When you can force the opposite, slow, deep and using the belly or diaphragm, it is like an “all-clear” signal to the whole rest of the system. You can settle uncontrolled crying, improve your focus, find better comfort, expand creative thinking, lower your blood pressure…it’s a virtual panacea.

A word of caution. Controlled breathing does not feel like it is doing much at the moment. Remember, we instinctively search for the “big guns” solutions. Something sweeping and fast-acting. The relatively soft effects of slow breathing certainly do not fit that bill.

Try this method. Use it twice every day for several minutes, paring it with something you already do regularly such as brushing your teeth. It will then be more accessible for putting it to use as needed, whenever you are tense or panicky:

• Sit comfortably.
• Inhale fully through the nose, counting slowly to two.
• Be sure to use the diaphragm pushing outwards with your belly, pulling downwards on your lungs.
• Pause for the count of one.
• Exhale slowly, counting to four, through pursed lips.
• Focus on your breaths, and on relaxing your stomach, shoulders and face.

If you feel at all lightheaded, it is merely a sign you are going too fast, eliminating carbon dioxide too quickly. Slow down, and it will clear up immediately.

Questions? Email me.