Many of those I work with have been reeling with anguish. A sudden loss is hard enough, but with a traumatic one, it’s all the harder to wrap your brain around it.

I’ve been taken up with intensive on-the-spot crisis counseling. It has left me feeling moved and privileged to be of immediate help to many, while also a bit rocked personally.

Coincidentally, I was interviewed by a TV news crew about somewhat similar local tragedy:

Answer:  Chronic pain is experienced by at least 10% of the population and by many estimates, higher. We have developed many ways to manage it and to make life better for those who suffer it.  But modern medicine has not made much progress on how to cure it.

Here are some points on chronic pain, which I’ll simply list:

Chronic pain is not simply acute pain which has lasted a long time. Acute pain is well-understood and it responds quite well to medication. Once it becomes chronic, it takes on a very different nature.  It affects the whole person, the whole life, and treatments have to be adjusted accordingly.

One specific change is that pain often becomes neurogenic or neuropathic, or what is sometimes referred to as central sensitization. That means that it generates on its own, with no injury or disease to provoke it. The origin is in the nerves which have transmitted the same sensation for so long that they are generating the pain on their own.

Very often, physicians cannot find a physical cause for chronic pain. This does NOT mean the pain is “all in your head”. It is very real, as anyone feeling it will readily tell you. But, while not originating in the brain, it is originating in the nerves, at least partially. To put it another way, neurogenic is not psychogenic.

This is one reason why surgery often has unsuccessful outcomes – the source of the pain often cannot be eliminated, and the surgical trauma compounds the problem.

Pain medicine called opioids (that is, narcotic opiates like morphine and codeine, as well as synthetic opiates like methadone and oxycodone), are good for acute (short-term) pain. They are not so good for chronic pain. A few people are able to stay on a constant, modest dose for many, many years, and others take it occasionally for breakthrough episodes of higher pain. But with regular chronic use, you will develop tolerance, meaning more medicine is needed to achieve the same result.

Tolerance and addiction also mean that more of the negative effects come into play.  Withdrawal, for example.  Also they cause respiratory depression, which causes people die in their sleep.  The effect of respiratory depression lasts longer than the analgesic effect.  And so, patients will often take more medication when it seems to have worn off, and they essentially double down on the risk of fatality.  Add obesity, benzodiazepines, alcohol or other sedatives and and the danger is compounded.

Opioids also reduce mental and physical functioning, so that while pain levels may be marginally lower, so too is quality of life. It is simply not possible to engage as well. But, being anesthetized, the patient may not be as bothered by this as much as everyone else around.

Opioids are sneaky drugs which, as another side-effect, will create a tremendous craving for more.

Finally, they also cause hyperesthesia: lower pain tolerance. Where once a simple knock on the shin may now cause you to curse, later it is so agonizing you can barely catch your breath to cry.

What does this mean for you? In working with your health practitioner, one very important goal is to reduce the pain. But pain-reduction is only one goal, not to be over-emphasized at the expense of others. Note that the word here is reduction, not elimination. Many studies tell us that a 30% reduction is that medication can give. To aim higher is to invite trouble.

It is hard to get used to the idea that a largely pain-free life is out of reach. You will mourn the loss.  But coming to accept the new reality will bring you a new peace.

That was the bad news. Your chronic pain might not be curable, and seeking a cure can make it worse. The good news is that it is treatable, and can always be managed more effectively. Reformulate your goals, your routines and your boundaries, focusing on where you have direct control, and you can reclaim your life.

For example, expand your resources for managing pain. The first on the list of resources is relaxation and stress management. Relaxation is a skill, and it will help to practice and develop your skills in more than one method. Stress and tension mean more pain and lower pain tolerance. Relaxation is the solution.

More on relaxation: I am not talking about run-of-the-mill relaxation, which you undoubtedly practice. I’m talking about powerful relaxation. It’s a discipline which requires a bit of study and daily practice.  The goal is not to become drowsy, but actually to become more alert.

Other resources may include massage, herbs, acupuncture, aromatherapy…in fact, many others – anything and everything to expand on what you have.  Just keep in mind that the goal is not to take away the pain but to improve your management of it.

Ask your prescriber about other medicines. Old-fashioned antidepressants called tricyclics (nortriptyline, desipramine, imipramine, and others), have a good track record with pain management. And you may not need the levels which are needed for depression. They have side-effects but one of them, sedation, is great for sleep, inducing a better quality of sleep (that is, with late-onset REM stage), than other sleep medications (which tend to induce early-onset REM and a less restorative sleep).

Whether with tricyclic medications or not, take care of insomnia. You cannot cope well or heal well without adequate sleep. See relaxation, above.

Expand your activity and areas of involvement. You may not feel like this is helping at first, but it will. The less engagement in life, the more your attention will go to your pain. Meanwhile, life should be meaningful, no matter what our challenges.

Exercise. Yes, I know you get this all the time. It is the overlooked panacea. It helps with energy, with depression and of course with health. And the best way to allow pain to grow and take root is to allow your strength and flexibility to deteriorate. So one more time: Exercise. As long as it is not aggravating an injury, do it every day, no matter how much you hurt. Start with something absurdly modest, but do it daily. When you lapse, as you inevitably will at first, don’t get discouraged. Eventually it will become as automatic a part of your day as brushing your teeth. For more on this, click here.

So to sum up: The way to live with chronic pain is to live with it. Take back the driver’s seat.  Work on all the ways to diminish the pain, and no matter how much it remains, diminish its power by striving to make your life healthy, rich and meaningful.

Answer: First, let’s recognize just how important it is. Exercise is a panacea, the miracle medicine. Almost everything gets better! Low mood, high anxiety, anger, sleep, immunity, energy, concentration and productivity. Self-image, weight, appearance and confidence. Sex, strength, longevity and range of activities…

That’s sixteen things I can list right off the bat. If this stuff was sold in a bottle, we’d pay a skinny arm and a leg for it!

Second, what if you revive your relationship, resolve your depression and cure your phobia…while meanwhile inviting an early and uncomfortable demise? How successful is that?

No health practitioner anywhere will discourage exercise, as long as it’s the right form and intensity for you.

So why aren’t we all doing it?

Mainly because we’re creatures of reinforcement: we do what is rewarding and avoid what is unpleasant. The problem here is that the rewards for exercise are all delayed, while the payoff for passivity happens right here, right now. The consequences for being sedate and inert are grave, but they come later.

We can tell ourselves over and over that the delayed gratification is better, and often this works. It works for those fit and active people you see around you, and it works for anyone who goes through school, raises children and so on. But by and large, immediate reward trumps delayed reward. This is a powerful effect and it is hard to overcome.

Then there is television and the Internet. They employ genius minds designing ways to keep us hooked in and it’s not hard. The allure of the screen, is powerful.

Television creates the illusion of being highly rewarding. We may think we’re relaxing, getting positive stimulation or whatever, but how often do you turn it off and feel better for what you’ve just watched? Can you imagine nearing the end of your life and contentedly thinking on how grateful you are for the programs you saw? Or wishing you’d watched more? Don’t get me wrong – it is plenty of fun. But so is candy.

But while the reward for TV may be insubstantial, it’s quick, vivid and effortless. Again, immediate reinforcement generally beats the pants off delayed gratification – unless we are strategic and conscientiously purposeful.

Another reason it is hard to exercise is that we’re creatures of patterns and familiarity. A body at rest stays at rest, and breaking the inertia takes much more energy than sustaining momentum. If you think about it, why would anyone want to leave a comfort zone?

You do want to exercise, or increase what you going? Contemplating it? Tired of getting it going only to have it drop off? Here are a few extra ways to help yourself:

Watch a program, not the television. Decide in advance what is really worth watching; don’t turn on the tube to see what it has to offer.

Plan before you start. Get everything set up – clothes, schedule, support from others. Anticipate any barriers and scheme around them in advance. Start drinking extra water. You can mark each session in your calendar and program your program your phone to send reminders.

Watch. Watch very intently. Watch for any and all the tiny rewards. Rewards are the key to continuity, but you aren’t conditioned to catch them. You’re conditioned to make note of what a pain in the butt it is, and of all the nice restful things you could be doing instead. You’re also conditioned to look for weight-loss, washboard abs and the “positive addiction”, all of which come much later if at all.

Any improvement in sleep, focus, pride, satisfaction, energy, enjoyment of the activity itself…these things may be very elusive and you must not let them slink away. You’re training yourself to find the payoffs that are available there for you to enjoy. They will grow bigger in time, in part because you’re gaining the strength to generate more, and in part because you’re more alert to them. With time, some elements which feel negative now, like sweating and huffing, solitude and ritual, may actually become positive later.

Accomplished athletes do not have it any easier than you do. They have simply aligned the reinforcers.

Finally exercise every darn day. I did not advise this in the past. I used to advise starting with however many days are realistic, and that approach may be what would work for you. But it doesn’t allow you to develop a hard-and-fast routine. Remember learning to brush your teeth? Did you learn by brushing when it felt right? And how disciplined are you with this dull chore now? Where there is no decision-making, there is no waffling and where there is no waffling you won’t…pancake. So do start small – but only in terms of the duration and the intensity of the exercise, which you’ll expand upon later. The success with frequency starts on day 2.

For more, see Self-Motivating When Stuck.

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.

Our adult son is getting more and more disabled with his depression. Whether he has bipolar, schizophrenia or something else, we’re not sure, but he is so isolated he’ll hardly talk to anyone. His basement room is in shambles and he smells bad. He used to talk about killing himself but now he doesn’t even talk enough to let us know if he’s suicidal. We worry too about our granddaughter who is brave, but should be a little frightened to visit him on weekends. How can we help when he is so withdrawn? This has been a recurrent or cyclic problem by the way, but more intense each time.

Answer:

Your situation sounds excruciating. At the bottom line, while not ‘hovering’, it’s good that you can remain watchful, given that he’s been on such a downward slide. In some ways, he could be safer while he’s nearly debilitated. I would suggest that you remain vigilant when he begins to get activated again, even if he appears cheerful at first, as this is statistically a risky time.

Apart from his essential safety needs, the question is how to get him in for mental health treatment. If it comes to it, you can call the County Designated Mental Health Professionals in Seattle. These are the people who come to make an outreach visit and, if necessary, have the authority to impose a 72-hour mandatory commitment for safety, evaluation and treatment. In King County they are accessed by calling the Crisis Clinic at 206-451-322.

Your son would have to meet stringent criteria before he is forced into inpatient treatment – in his case, being either a danger to himself or what they call gravely disabled. The latter category is more likely to be met if you tell them that on your part you are not able to adequately tend to his essential daily needs. This might be the stance to take depending on how you would want to influence their decision. The CDMHP’s can at least make an on-site assessment and give some key recommendations apart from anything being involuntary, so don’t hesitate to call them if you feel you should.

I wonder if you could marshal as many others in your community and his as possible. Consider asking neighbors, his doctor (via phone), past friends of his, co-workers, his boss or former boss – anyone and everyone, to periodically make a brief visit, express their concern and reinforce your message that he needs to accept help. The idea would be not only that you get help in your role but that he gets the sturdy demonstration of support. I wouldn’t think that his daughter could be enlisted without it being a little too frightening and heavy a burden for a 15 year-old. I can only offer this as a tentative suggestion that needs to be heavily tempered with your own judgment. A key factor though would be that all those in the network come across as loving and supportive, not confrontational.

Finally, recall the speech given by flight attendants before takeoff. If the cabin loses pressure and the oxygen masks come down, you must put your own on first, your child’s next. In other words please take care to conserve your own energy and to get what you need to keep going for the long haul. You want to mean it when you tell your son you’re strong for him and are never giving up.

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?

I moved to Seattle to renew my life, yet I’ve been as depressed as ever. Shouldn’t I be less vulnerable in a beautiful place like this?

Answer:

I encounter people in this situation regularly. Seattle is a city of transplants, and the adjustment is not always quick or easy. Here are several reasons we could designate a special “Seattle depression” for newcomers in the the Emerald City.

First of all, moving sucks. You may have escaped a messy family situation and a doomed marriage, a rotten job and hell-hole physical setting, but you’ve come to a place where you don’t know many people. Isolation correlates with depression. Often, being with irritating people who you know may still better for your mood than being alone. Seattle has a reputation as a place where people are generally insular and hard to get to know. Whether or not the reputation is deserved your feeling blue and insecure will not help your efforts to integrate.

But I’m an introvert, you may say. People are a pain, and I like to be alone! Just the same, being human, you have tribalism in your genes. You don’t have to change you personal nature, but you might benefit by adjusting your patterns of affilliation.

Besides the isolation that comes with moving, you have disrupted your usual routines. Routine is good for your mood, plain and simple. Humdrum activity is still activity. It gives a sense of purpose it keeps you in motion and it lends structure to your day, whereas now that structure may be hard to come by.

The reduced light that comes with our long winters is undeniably a factor in depression, but an overblown one in my opinion. The problem with winter is not just the reduced sunlight but the fact that we don’t move around as much. Physical activity is good medicine for depression and it just doesn’t come as easily in the Seattle winter.  If you get a boost from taking walks in the summer, get a good parka and don’t let the went winter stop you.

All the disruption, lack of routine, reduced activity, seperation and isolation contributes to a sense of anomie – a breakdown in the usual social norms and standards that give us a sense of regulation, stability and belonging. Even a slight sense of dysregulation and weakened structure adds to anxiety.

As I have mentioned several times before, depressed people ruminate to try to find answers. Ruminating is a vortex. It gives the allusion that we are seeking answers when in fact we’re moving farther from solutions.

You can place all blame the nature of the city if you wish.  But if depression is the fault of this locale, we would have a measurably higher rate of depression.  We don’t.  Incidentally, the only city with a measurably higher rate of suicide is Los Vegas.

So what is to be done? As Mark Twain stated, “It takes a heap of livin’ to make a house a home”. You may need a plan to direct your activity more productively, to find more connection, gratification and pleasure, and tune your thinking to be less depressive. Then, you can begin feeling like you belong, perhaps even like it would be depressing to leave. CBT or cognitive-behavioral therapy is a practical way to do this.

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 want a therapist who likes me. Therapists I’ve had in the past seem to just seem to want to to want to get me in and get me out. Or, they’d treat me like a child, using pity and patronizing. Another one was young and inexperienced and seemed awed by me which wasn’t helpful, and I imagine others are remote and analytical, too removed.

Answer:
As a therapist it’s something of a duty to find a way to like everyone I’m working with. But of course, it’s a complicated task. No one is likeable or dislikable at all times, and I myself have moments when I seem to hate everyone (not in the therapy office, luckily; it’s when I stub my toe badly). Also, “like” has different components, all of which vary in degree with different relationships. There is admiration, compassion, curiosity, attraction, shared values and so on.

To a large degree, it’s harder to like someone who I cannot get to know, and easier to like someone the more I can get to know them – and by this I mean not just their story and worldview, but their feelings as we interact.

But it’s a two-way street. If I may be so blunt, you have a role to play in how a therapist responds to you. I would not want to promise to like someone who doesn’t earn my fondess, and I would do you no favors by giving unearned appreciation. What I can do, over time as we build a relationship, is give direct feedback on those things you do which are likeable, and those that may elicit negative reactions. Our feelings toward each other can be a window we both utilize.

I want you to be someone who can be liked by your therapist – and the others in your life.  We’ll work on it.

Why wouldn’t I want some intensive, ongoing therapy, which will instill change on a “deeper” level?

Answer:

First, it is worth mentioning that time-effective is not necessarily the same as short-term.  There are many instances where we decide to spread out the frequency over time, meeting every other week or monthly, for instance.  Also there are a few people I see every one or two weeks over the course of a long time.

Overall, my analogy with goal-directed, time-effective therapy vs. the more ponderous approaches is that you can take a drive to a destination in two ways. One would be to take the long, winding scenic road and the other, a strait superhighway. Both will get you there. The long road will allow you more fascinating views, maybe some exciting twists and turns and possibly some long tedious stretches. The problem is, you pay as you go and the cost will add up. Also, you may find in the future that you have strayed away from where you want to be, and you will not be able to retrace the route. 

The superhighway gets you there more efficiently. It is cheaper. Quicker. Uncomplicated. If in the future you need to make movement again, you will remember the route and can take it on your own, or with a little more brushing up with the therapist.

If I allow myself to get cynical I would say too that there is too much potential for a conflict of interest. In other words if you get well, your therapist loses a golden goose. I fear that analytic therapy can often foster an unhealthy dependence. It has also fostered systems of analytic theory that are far too complicated, inherently unverifiable and rarely effective. The poster boy for this view would be Woody Allen (as he is often portrayed), a lifetime psychoanalysis devotee and just as neurotic as ever.

So, I try not to be too cynical. I know that there are many wise and effective analytic therapists with many satisfied clients. It is a perfectly good direction to go in, though not with me.