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 How can we help when he is so withdrawn?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.

My husband is never satisfied. He complains about his work, our house and our kids, even though he’ll occasionally admit it’s all fundamentally OK.
I keep trying to tell him he’s depressed and occasionally he’ll kind of acknowledge it, but real soon he’ll go right back to blaming everyone and everything else for his woes.
I’m blue in the face from telling him he’s stuck in a bad pattern. How can I get him to address this?

Answer:

A man named Salvador Minuchin tells this story: A farmer had a donkey that would do anything he was asked. When told to stop, the donkey would stop. When told to eat, he would eat. One day the farmer sold the donkey. That same day, the new owner complained to the farmer. “donkey won’t obey me. When you ask, he will sit, stop, eat – anything. When I ask, he does nothing.” The farmer picked up a two-by-four and walloped the donkey. “He obeys,” the farmer explained. “But first you have to get his attention” *
The parable is a little crude and of course it’s not to be taken too seriously. But the point is that no communication is effective unless the receptivity is there. My guess is your husband is not in a receptive state when you talk with him, and maybe this can be addressed first.
The “two by four” can be as direct as actually saying something along the line, “I want to talk about something critically important to me. Could you promise to hear me out?” This is followed up later with something like, “It’s so important to me that I get this message across in the right way. Would you indulge me please by summing up what you heard me to say, so that I can check out your understanding?”
Another way to increase his receptivity would be to recruit others in this man’s life who have the clearest channel. Does he tend to listen to a favorite uncle, or a minister? You can also recruit the whole “village”, including his M.D., his barber, neighbors, people at work, his religious community, great aunt Gertrude and so on.
There are many other ways improve the receptivity of the listener. But you might also check to make sure you’re not inadvertently using something which is backfiring. We all fall into this – repetitious nagging, shouting, sarcasm or shutting down in the hopes that he’ll pry in just the right place…these are 2×4’s which will not budge anyone’s ass.

*Families and Family Therapy, 1974

I’m so stressed and irritated. I live with my husband, our kids and his mother. The problem is she is too hard to get along with. She pesters and criticizes me constantly. I try to be polite sometimes I just blow up. I don’t want to upset my husband but I’m afraid some day I’m just going to pack up and move out. How can I keep myself calmer?

Answer:

You’re feeling pushed out of your own house, you might lose your marriage, split your children’s’ parents… and you don’t want to upset your husband? Is he that fragile?

I always have mixed feelings about helping someone to have an acceptable mood in an unacceptable situation. Stress and irritability could be looked at as a useful signal, like fear, or pain. If it is indicating there is a problem that needs to be rectified, you don’t necessarily want to just relieve it while the problem persists or grows.

Having your husband’s mother move out could be one solution, but every problem should have more than one. Here are some things I’ll suggest. You might sit down with a friend and draw up a brainstorm list of all conceivable solutions, from the most obvious (including no action), to the overly-exotic (build a bigger house), and so on. Hopefully, by going at some length, resisting the temptation to begin evaluating ideas, you could come up with creative directions. For instance, there could be multiple ways your boyfriend’s mother could give you more space besides moving out, perhaps. There could be changes to scheduling, communication, physical arrangements, ground rules and so on.

Second, it could be that your quarrel is not so much with your mother-in-law as with your husband. If she is asked to move out, wouldn’t he have to be the one to convey the news? And, if he is giving her signals that contradict yours, you may never feel she is hearing you. So, you could be so blunt as to tell him you will not accept the current arrangement, and that it is up to him to fix it. Hopefully, you won’t have to be quite that stark, and there would be a productive process between the two of you. But, if he is not hearing you, not picking up on just how important this is, it would be natural that you would amp up in order to get the message across.

Irritability can be pretty useful in putting some intensity into a message, so that it is not ignored. However, it can backfire. When there is a little too much, the receiver begins to block it out and to shut down. This will give rise to a vicious cycle: more anger bringing on more resistance, bringing on more anger. We have all these cultural images of the communicative one, who needs to agitate for change (maybe more often the female), getting nasty labels like shrew, nag, and worse, while Mr. Brick Wall, protecting the status quo, hides behind the newspaper (and two of the classic insults for him actually apply to his mother!). It is not anyone’s fault, just a pattern we can naturally fall into. So, you might pay attention to what kind of approach is going to be the most effective with him. Consider a careful choice of timing, a soft and gentle voice, and as powerful a statement about your misery as you can compose.

Other than this, I just don’t know how you can find some kind of solution without your boyfriend having to make some tough choices, which doesn’t come without disturbance. You can help him without being upset but I’m not sure you want to protect him from it.

I take care of my ailing mother, and I’m very willing to do it. One problem though, is that she expects more than I can provide. I know that if I give her all the time she wants from me, her life would be better. On the other hand, mine would be worse, and by a larger proportion -a net loss between the two of us. She cannot recognize this, and her expressions of sadness at the neglect she experiences makes my want to cry. I am plagued by guilt. What can I do?

Answer:

Guilt is an interesting word. It’s a feeling, and it’s also a status based on fact. A feeling is never right or wrong. We cannot “correct” an emotion. But a fact is either true on untrue. We are either guilty of doing something wrong, or we are not guilty. If we do something wrong, then we should feel guilty. It’s an important emotion, a signal that you are not aligned with your values and your community. To feel better, we have to make things right, and stop the improper behavior. If you have earned guilt and don’t feel guilty, it could be a problem.

On the other hand, it’s easy to feel guilty when we aren’t actually guilty of anything. If you take some time to attend to other matters and to rejuvenate yourself, and your dependent mother complains, you are getting a signal from her that you’ve done something wrong, that you’re unfairly causing her pain. You could assume guilt, and of course you’ll feel guilty. But then you could ask:

• Is this signal from my mother an accurate one?

• If she say’s I am unfair could she be wrong?

• If she does not take responsibility for her own contentment, then must I assume the duty?

• Are there other signals telling me I am not unfair? There is my doctor’s advice, my friends, my wife, an article, etc..

• Is it not possible to be compassionate and “selfish” at the same time?

There is another aspect to this. Without guilt, you would probably still feel badly. It is hard, and sad, to see your mother suffer. And it is harder to experience a degree of helplessness in the face of this. It is difficult to accept this limitation in the ability to help someone you love. But there is an escape. If you assume guilt, the implication is that you are making a choice. Even the implication that you are making a bad choice still implies that you have some control. Oddly, this sense of having power is easier to fathom than to fully acknowledge the lack of power. So, you could make the harder – but perhaps more wholesome and congruent – stark sadness about your mother’s suffering. Or there is the possibly easier – but less authentic – sense of guilt. I’m not which is more appealing.