Recovery from Disability

disabilitySometimes we are privileged to help someone who is disabled due to bipolar or depression to recover and resume a full and happy life.

In the beginning we face many questions about the process.

Family members may have become very skeptical about the value of treatment. Or they may wonder if the disabled person is exaggerating his or her symptoms or impairment.

Many people who find themselves in this dead end become very discouraged themselves. They go from having a sense of confidence and optimism about the future – working towards a career and a happy life – to a sense of deep doubt and despair.

Life is lived day by day. The goal is to avoid the next catastrophe, which is always lurking right around the corner.

The trouble is that the pervasive pessimism and mistrust (of the disabled person, of treatment, of the disorder) and the focus on making through the next few days without disaster are antithetical to recovery.

Our experience of this process teaches us a few things –

  1. Someone has to have a sense that there may be hope – other than the therapist or psychiatrist. It may be unrealistic to expect the disabled person to have that hope, since they have suffered the most from depression. Although getting so sick and tired of suffering that the disabled person decides to act as if they hope for recovery may be enough to get things going.
  2. The process of recovery involves several stages and often (or usually) takes between 18 months and 2 years. First is “crisis stabilization” – getting safe housing, stabilizing mood enough that thoughts of suicide no longer dominate the person’s mental life, curbing dangerous substance use, etcetera. This often takes 2 or 3 months. Then there is a process of building longer and longer periods of reasonable security, and beginning to hope for real that recovery might be possible. This might take a year or so, since there is almost inevitably one or two setbacks that make the person doubt that he or she is really getting better. Finally there is a shorter (six months or so) process of putting in place the kind of supports and structure (friends, family, school, work, etcetera) that will ensure a long term mood stability.
  3. Recovery is hard work. There is never one quick answer (or “miracle drug”). The way out involves putting together a treatment program that includes several medication trials (often combining two or three medications that worked partially), cognitive retraining to counteract the negative self-talk and sense of helplessness that can otherwise derail recovery, coaching about appropriate life choices (starting with a volunteer job and then working up to a part-time job, being realistic about one’s abilities, and making appropriate relationship choices), and support for getting physically stronger (getting necessary healthcare, exercising, eating a healthier diet, having a healthy sleep / wake cycle).
  4. Recovery is often expensive. There are (sadly) very, very few publicly funded programs that support this process. Most community mental health treatment is focused on minimizing hospitalizations rather than maximizing recovery.
  5. In medicine there is hardly anything that comes close to the improvement in health and functioning that completing this process can create.

Here are a couple of books that may be worth reading that talk about this process –


Please also consider attending a local National Alliance for the Mentally Ill (NAMI) meeting.

A Spoonful of Courage


In a previous post, I shared Linda Graham’s views on resilience from an excerpt from her article Bouncing Back :Rewiring the Brian for Maximum Resilience and Well-Being. After further reading, Graham also discusses the importance of having courage when creating a more positive outlook on life.

We have the ability to experience great personal growth when engaging in new things.  Often people are scared to dive into new, uncharted territory and have difficulty expanding their horizons in life. In order to overcome our fear of the unfamiliar, we rely on the neurotransmitter dopamine.

In every day situations, dopamine levels rarely fluctuate. It is when something unexpected occurs that dopamine levels change and create inner feelings of tension. This explains why people feel uneasy and scared when they are about to do something new or unexpected.

By doing something that scares us, we are actively putting ourselves in an uncomfortable situation in order to have a new experience. By facing the new situation, the previous feelings of fear associated with the experience are paired or replaced by the courageous response.

Linda Graham recommends an exercise to the public that will help individuals rewire their brains to face new situations with courage. In this exercise, the public is encouraged to do one scary thing every day. First, individuals must pick one fear to focus on. After making a decision, that individual must face that fear. After repeating this exercise for several years, Graham says people will start to notice a change in the way they feel about approaching scary situations.

Instead of feeling timid, afraid, and uneasy, your body will become so used to doing new things that you will instead start facing your fears with a much more positive attitude. You will gain confidence in your abilities to be successful and start believing in yourself. This is an example of how you can rewire your brain from being afraid to courageous and resilient.

Dare to challenge yourself, and test your limits. I think Graham’s advice is a great way to gain confidence in our abilities and increase our self love and appreciation. By consistently encountering new situations, we will learn to better cope with struggles and become more resilient. When we are faced with something scary in the future, we will have the tools to recover much more quickly.

Chronic Depression: What You See Depends on Where You Look

chronic depressionIt can be hard to sit with someone with depression, especially chronic depression. For me it is the fact that I am trained to try to enter a person’s world, and understand that world… but the visit to the world of someone who is depressed can be depressing. One of the reasons for this is that they describe lives where they have very little control over anything that happens to them.

Even when not depressed, this same trait can persist.

Asked to talk about why things are going better with her husband, a woman who has wrestled with depression for many years says that he is suddenly doing things that make her happy. She really enjoys it when he does work around the house. She remembers how she was attracted to him because he was so handy.

Later on in the conversation we are talking about how different she finds it working with her boss, who is very good at recognizing her unique abilities, as opposed to her husband, who tends to get frustrated that she can’t do things that he finds easy – for example, things involving spatial ability – seeing complicated drawings in 3 dimensions. She notes that he is “very good with people…” and again it seems to me, listening to her, that she is at the mercy of whether or not the person she is spending time with values her.

Ten minutes later, as she describes how she has been really recognizing her husband’s work around the house, and I can see from her smile and excited way of talking that this enthusiasm is really infectious, it occurs to me that she is actually pretty “good with people…” and in particular is usually very generous in recognizing each person’s unique contributions and strengths.

So I point out that probably some of the good feeling that she is experiencing because of her husband’s rekindled interest in working around the house is probably due to how she has expressed her appreciation for that effort. In other words, I point out how she has some influence or control over what happens to her.

She changes the subject to another topic which is along the same lines as her original observation – another way that she is benefiting from her husband’s changed behavior.

This tendency of depressed people to not notice the influence and control that they do have on the environment has been most articulately described by Jim McCullough in his books about the Cognitive Behavioral Analysis System of Psychotherapy.

Changing this pattern is hard work… but it is worth it. Because when someone starts to notice how the “glass if half full” (they do have some control) it leads to a pattern of behavior that prevents further depression.

Check Your Wallet

checkRecently, we were writing about the bias that practitioners have that the technique that they they have mastered is the most effective treatment for any condition.

We were reminded of this issue very vividly this morning when we met up with one of our favorite people, an older man who has been seeing us for a couple of years.

He had very severe depression that he developed beginning about five years ago, which he associated with retirement and the break-up of an important romantic relationship.

When he first started treatment with him, we had a very interesting experience.

We did our assessment, and it suggested that there were definitely some treatment options for his depression that had not been tried. We didn’t know it at the time, but he was nearly at the end of his rope and was trying to decide whether to commit suicide or not. He had come in to make “one last try” to find help.

He had gotten very little benefit from more than two years of treatment with his previous psychiatrist and therapist.

After the initial consultation, he was very reassured and decided to pursue treatment with us. At that point, he gave us consent to contacting his therapist and psychiatrist for records and information.

Often, it’s very hard to get information out of mental health professionals; it’s one of the things that we think is the most frustrating about the preoccupation with confidentiality, and at its worst, secrecy, in our profession.

In this case, however, we got a very prompt reply from his therapist.

She insisted that she wanted to talk to us right away, and we set up a phone appointment.

She told us that he was “in analysis” with her and asked if we knew that. It sounded like something that was almost religious, and the implication was that somehow we were breaking an important bond.

I said that I hadn’t known, and he had decided that he wanted to come and see us and I thought we might well be able to help him.

At that point, she insisted that intensive psychoanalysis with her was the only thing that could save his life and we were gambling with his life by offering him another option for treatment. I was stunned.

I must say, it gave me considerable pause, and I went back and reviewed the assessment carefully, and after much reflection I decided that we had been accurate in our estimation that there were some types of medications and psychotherapies that hadn’t been tried and that had a good chance of helping him.

He is now completely well, and has been for almost a year.

In fact he says he can’t ever remember feeling this good, and although one is inclined to wonder if that is hyperbole; in his case, it doesn’t seem to be.

A couple of months ago he called his former therapist to share a little bit about what had happened and what he was doing. She had absolutely no interest in hearing what he had to say. She insisted that her assessment was right (!)

All of this reminds us of one of our rules about healthcare:

If a healthcare provider tells you that what they do is the only thing that could possibly help your health problem, you should back away from that provider, check your wallet. Their interest in viewing what they do as “special” is very likely to be affecting their ability to provided you with the best. Someone who really is that knowledgeable about your illness must surely be aware that there are always other options worth considering.

Parallel Universes: The Duality of Hopelessness and Optimism

dualityIt’s hard to explain how it is possible to go from a state of complete hopelessness and a sense that the universe is profoundly hostile, to a state of optimism and and the experience of receiving support from the world and others within a single day. The fact of the matter is that it often seems as though there are parallel universes that we live in.

The universe we live in is defined to a large extent by our mood and beliefs. Right next door to the one we live in are a series of alternate universes that we could inhabit that are defined by a different mood and set of beliefs.

It’s not necessarily that one universe is more “real” than another. The person who is depressed can point to very real negative things in the world around him, but at the same time, he is attending to only parts of the world. He searches the world and finds all the things that are scary or disturbing, in another state of mind he might find only things that are exciting and encouraging. All of us have to filter the overwhelming sensory information that comes our way, and all of us have a strong tendency to notice things that fit our current mood and our current beliefs.

But how can we find those parallel universes?

Mood charting, or writing a diary, or going through photo albums, any activity that allows us to recall times when we were in a different mood, can all be helpful.

Another source of information about parallel universes is derived from our relationships with other people. Probably all of us have had the experience of spending time with a good friend and, at the end of that time together, realizing that one’s sense of the world has changed as a result of seeing things through the other person’s eyes.

Carl Rogers, who long time readers of this blog will recall, is a favorite author on topics related to psychology, had this to say in a chapter he wrote about personal learnings.

“I have found it of enormous help when I can permit myself to understand another.”

He was referring to the value of entering into another person’s world and seeing things as the other person sees them.

I believe that one of the values of this experience is that it is an antidote to our tendency to get stuck in one particular universe, or one particular view of the world.

I wrote this piece as a way of putting together some of my thoughts about how it may be possible to come out of a state of chronic depression, for the mother of a wonderful man who we have been seeing for a while who seems really stuck in his view of the world as hopeless and hostile.

The attitude of openness to understanding others’ experiences and the willingness to consider how it might be possible to see the world in a different way, is part of how it is that some people are able avoid depression.

Often it seems that cognitive therapy is founded on the idea that one way of perceiving the world is “true” and another way is not accurate.

I am not sure that this is at all helpful or accurate.

The most helpful experience may be just the recognition that there are alternative universes that could be experienced. None of these universes is real in the sense that it contains all the truth. But exploring these other worlds can be very valuable.

The Facts are Friendly

factsWe have found ourselves wrestling with a couple of situations where patients seem to be trying to help us come to the “right” conclusion about their problems.  For example, one young woman is very adamant about the fact that she does not have bipolar disorder.  She has a family history of bipolar moods (her mother was bipolar) and the idea that she might have the some condition of course connects with her fear that she is “becoming her mother”.

At the same time, she really has not been responding to traditional antidepressant treatments, and in fact, has had a few episodes of becoming energized and irritable when starting antidepressants, this suggests at least the possibility of a bipolar mood disorder.

When we first met her, we were struck by how quickly and completely she denied even the hint of any mood variation.  Frankly, when people report that there is absolutely nothing that they have ever experienced that is at all like a bipolar mood shift, we are a bit surprised.  Most people have at least some of these experiences.

Another woman we’ve been working with for a while is very unhappy about the possibility of switching to a different medication.  For that reason, she has been telling us inaccurate information about her symptoms.  Because having symptoms would mean that we would wonder about switching medication, she decided that she wouldn’t have symptoms, at least when she talked to us.

Recently we started to notice that she was not doing very well in her relationships and at work.  And this made us wonder what was going on.  Eventually the true story emerged.

We contrast all of this with a quote that we ran across many years ago from one of our favorite psychologist authors, Carl Rogers.  Dr. Rogers wrote a chapter on personal learnings that he had made over the course of his career, one of these was that “the facts are friendly”.

By this he meant that when one engages the facts in a straightforward and direct fashion, the results are positive. Even if initially you had hoped that things might be otherwise.

This learning is really not so much about the facts themselves (I think) but about how one relates to them. If we assume that the facts are friendly, we can be curious about them, face them directly, and play with them (engage our creative mind rather than our fearful mind).

That stance works remarkably well. Even if the facts seem really challenging at first.

Phew… That’s Done: Sustaining Attention

attentionIt is such a relief, after worrying about some health problem for a long time, to suddenly realize that that problem no longer needs acute and urgent attention. This is as true for an ankle or knee injury in sports as it is of anxiety or depression, or any other mood state that impairs our ability to function.

There is a natural wish to put the thoughts that have consumed so much time and caused so much worry aside and move on with your life.

That strategy works reasonably well for an acute injury that completely heals. It works less well for something like a recurring injury like an ankle sprain or a chronic knee problem…  or a depression that has come and gone before.

The wish to close the book on a problem solved is a tendency shared by much of American medicine. It has been noted elsewhere that the American healthcare system is not very good at helping people deal with chronic health problems. The goal is usually to fix a problem and move on, and many doctors interest in helping is markedly reduced when such a “quick fix” is not possible.

And it is a tendency that crops up often in my practice. Thursday I saw a woman who has been depressed for a couple of years. Our latest treatment plan finally seemed to be working, but rather than encouraging her to continue the effort, she seemed to have decided that it was time to take a break from paying attention to her depression.

With a chronic problem like recurrent depression, turning away from thinking about the problem as soon as the symptoms are better more or less guarantees that the problem will come back sooner.

As a young man I had several sprains to my right ankle. I was a runner at the time, and irritated with having to stop my training. As soon as each sprain was healed I went back to my regular routine… But it gradually became clear that I needed to do something to stop this from happening again and a gain… and I was able to really return to full functioning only when I devoted a small amount of attention to preventing this injury from happening again on an ongoing basis.

The same thing is true of depression.

The challenge is how to find a sustainable level of ongoing attention. You can’t worry about a chronic problem all the time or it begins to dominate your life. The challenge is how to go from anxious thoughts to preventative thinking.

A few months ago, I decided that I was going to start mood charting. I’ve been recommending it to others for so long that it only seemed fair that I do it myself.

What I discovered is that it was important to connect the activity of charting to a sense of reflecting on the day. That way filling out the daily entry was a way of achieving a sense of peace and clarity about how things turned out. Peace and clarity.

In other words, I needed to make mood charting an activity that was an exercise in mindfulness. If I didn’t do that then filling out the chart seemed like a moment to reflect on failures. And when I did that, I found that I enjoyed taking that moment at the end of the day to write a few notes and reflect on my mood and my sleep.

The Gift of Hope

hopeI have never been able to find the short article in the Journal of the American Medical Association that talked about a miraculous treatment for many ailments of the human mind and body…

The article was about “hope.”

When we have it there is hardly any problem we can’t tackle, and when we lack it every challenge seems insurmountable.

This afternoon I met with a man in his 40’s who has wrestled almost his entire life with substance abuse, bipolar disorder, and psychosis. His support system came along – his elderly parents, his case manager and his substance abuse counselor.

We wrestled with the question, what can we do to help him find a pathway towards wellness. Everyone had a different idea… but he had very little to say.

Finally, I said that I thought that the key issue was that he lacked “hope.”

He could not really commit to any plan to change things in his life – Alcoholics Anonymous, volunteer work, a support group, working with his psychiatrist to optimize his medications – for more than a month or two. And given that he had been struggling for decades, the odds of any plan working dramatically in a month was pretty slim.

There was a momentary silence in the room.

On our discussion forum (which you are invited to join… email me for how to do that… I talked about a project that I am interested in pursuing – collecting stories of people who have found a way out of darkness and into light. Those of you who read the interview with Descartes Li will have read about his awe at some of these stories of hope.

Over the next few weeks I want to focus on how this website can best generate hope and optimism in those who read it. Email me your thoughts.

Trojan Horse Medications

medicationsFrom time to time we are asked to review the care that people with cycling moods have received, trying to figure out, from a complicated story of medication changes and mood cycles, what to do to get someone out of a period of deep pain and dysfunction.

A few years ago I did such a review on a young man with bipolar moods and a history of severe childhood trauma which taught me a lesson about the importance of mood charting, and why it is essential to look at long term medication response (not just the immediate reaction to a change).

Fortunately, this young man had been keeping a very careful mood chart, and all I had to do was download the information from his online spreadsheet and then add in the information about medication changes. Beau Mood Chart and Zyprexa

The chart to the right shows his mood chart.

The hard to see blue line traced his mood (increasing depression) and the yellow line tracked his mental energy (speed of thought).

The medications were added in as colored bars showing when the medication was started and when it ended.

From this chart it was almost immediately obvious that the change that most clearly seemed to be associated with his depression was the addition of olanzapine (OLZ on this chart). There are several reasons why this association was missed. For one thing, studies find that olanzapine is usually associated with the opposite effect – a reduction in depression and anxiety. But the key issue was that right after starting the medication, this young man came in to see his psychiatrist and said “this medication is great, it is really helping…” And he said the same thing a week later… and so neither the psychiatrist nor the patient had any idea that, after that positive response, the medication gradually became the source of a pervasive depression. In other words, that early positive response was a Trojan Horse.

Small Rewards

rewardsA young woman who was scheduled to go on a big trek in the Himalayas was not doing the training she needed to in order to have a good experience. She had been depressed for the last few months and this was probably a manifestation of that mood.

She told me that she felt she “should be doing much more.” I wondered if she could instead ask herself the question, “How can I be doing better?”
Her reply was that she had already tried doing all of the things which had in the past been successful. She had tried putting workouts into her schedule, signing up for a competitive event to have a clear goal and trying to train with friends.
I suggested that she might want to hire a trainer (someone she might be accountable to), but she was very uncomfortable with that idea.
In the end, the idea that seemed to have the most traction was coming up with a set of rewards for the behavior. There’s a site called SparkPeople that was set up by a couple of folks who made lots of money from eBay to support positive changes in diet and exercise. It does an excellent job of using techniques to motivate behavior change, including rewards.
There is a great deal of evidence that simple reward programs can be amazingly effective. For instance, in one trial, people with severe heroin abuse problems who had not been successful maintaining sobriety using many other strategies, found that a reward program that involved accumulating points that could be traded in for very inexpensive prizes (meaning that the money was not the motivation) when the participants were able to maintain a record of drug free urine tests, was remarkably effective at motivating change. And, if this kind of program will work with heroin addicts, it probably will work for you.
Check out the SparkPeople site or just come up with your own simple reward program. Or, for a much more complicated and probably more effective approach (using variable rewards), you can read this post by Jason Shen on variable rewards.

A Protest

protestSo many of us have to deal with things that are not fair – depression, unsupporting spouses, financial reversals, weight gain, etcetera, it can be tempting to launch a protest of some kind against the unfairness.

These protest actions don’t have to be obvious at all, but they can have powerful effects, nonetheless.

A few women recently told me, “I would be less depressed if I was not so fat.”

As a psychiatrist, I sometimes feel defensive when someone tells me  that, not because I disagree with the goal of having a healthy weight, but because it seems to put a barrier in front of the goal of reducing depression.

Even though the sentence seems to be merely reporting a subjective fact (I know this about how I feel) it may be doing more than that, it may be also serving as a protest against being fat – sort of like the protest of a child when there is something unfair going on (“I am going to hold my breath until I am treated fairly”). In other words it might not be saying, “this is how I am, and I know it is a problem to set conditions on improving my mood, but I still haven’t figured a way around how my weight affects my mood…” but rather…. “I am not going to do the things that I know would improve my mood until someone (the universe? God? my psychiatrist?) gets my weight down….”

Sometimes a protest can be effective. We all know about injustices that have been corrected due to the action of a small dedicated group of individuals. But these kind of protests are very unlikely to achieve their goal (losing weight, getting treated better, finally getting paid what I deserve) and can be remarkably effective at preventing someone from getting less depressed.

And it is not infrequently the case that a more creative solution to the basic problem (weight loss, etcetera) can be found and acted upon once the depression lifts.

Mood and Food

foodToday’s post was inspired by Disorderly Chickadee’s blog. She has been in an unstable (irritable) mood but her post is about how proud she is of the fact that she has been losing weight. For some reason, several people we have been working with have also been feeling irritable and agitated, and using some of that energy to lose weight…It sparked me to think about how often diet and mood interact.

Here are some of my observations –

  1. Successful dieting seems to require a fair amount of energy. Often a successful diet begins when someone is in an energized state (whether irritable or optimistic may not matter). After a period of thinking about diet, wanting to lose weight, perhaps even obsessing about Positive Start to Dietingit, many people discover that one day they are able to really do something about it – and what seems to make that possible is having a bit more energy. For that reason, I encourage those who are interested in getting started to do a bit more physical activity – particularly things that might be inspiring – as a way to get started (even though increasing physical activity by itself is not likely to lead to much weight loss). This approach, which is an example of “tacking” (getting your energy up before making a change, even if it means you don’t right away tackle the problem), is illustrated by the drawing at right. It is in contrast to the often unsuccessful strategy of – “damn I have to lose weight… I guess I will just have to stop eating all the stuff that I enjoy in life…”
  2. Once you are up and running with a diet it can return energy to you. Especially if your diet gets you into a state of ketosis. There are some diets that do that particularly well (phase one of the South Beach Diet or the Atkins Diet). But most diets do it to some extent. In fact, we have had a few folks who shifted briefly into hypomania due to ketosis from a diet.
  3. Eating has an anti-anxiety effect, especially eating high carbohydrate food. I think of carbs as having somewhat similar effects to a benzodiazepine like Valium. They reduce anxiety, make you feel briefly better, but they tend to take away energy. And, like Valium, they become a bit addictive. If you don’t make the transition to positive energy and a focus on a bright new future, starting a diet feels a lot like going “cold turkey” from Valium. It is easy to feel deprived and for your mood to go south… and then a diet becomes impossible.

I would love to hear about your experiences. Email me at

Be Helpful

helpfulWe love today’s post from Just One Thing! (And yes, we have had several references to this site in the last few days… but he is starting the year by reviewing the best ideas on his site).

And we felt compelled to put this post up today when we checked our email and found that today’s blog post from the Moodscope folks was on the topic of “Cool to be kind” – the value of helping others as a way of improving your own mood…

The Practice: Be helpful.




I’m doing a series on my personal top five practices (all tied for first place),  and have so far named three: meditate (including mindfulness, self-awareness, and, if you like, prayer), take in the good, and bless (including compassion, generosity, and love).

I saw one way to bless on a recent trip to Haiti, in the efforts of many dedicated people: be helpful. As you probably know, Haiti is the poorest country in the Western Hemisphere, with roughly 80% unemployment. The national government seemed like a tattered sheet in the wind. A public middle and high school I visited was missing half its schoolbooks as well as the funds for the last two grades. Imagine your own child in such a school . . . and that the $30 it takes to buy the books she needs is a month’s wages, as out of reach as the moon.

Yet in the face of these enormous challenges, I met so many people – both in NGOs and in everyday life – who kept doing whatever they could to help things get better each day. I was humbled by their heart and their efforts. And especially by the joy they could still find even in hard, hard conditions. It reminded me of this story:

Two women are walking along a beach after a storm swept countless starfish up onto the sand, now dying in the sun. As they talk, one reaches down every few paces to pick up a starfish and flick it back into the sea. After a while, her friend points at the miles of beach and bursts out, “Why do you bother?! You’re not making any  difference!” Her friend replies, “It makes a big difference to the ones I touch.” 

One of the most remarkable things about human beings is that we do bother. Our altruism is unique among vertebrates. An early MRI study on compassion showed that it warmed up the motor circuits of the brain, readying them for action: we don’t just feel  the suffering of others, we want to help.



In the words of Nkosi Johnson, a South African boy born with HIV who became an advocate for children with that illness before he died at about age 12: Do all you can, with what you have, in the time you have, in the place where you are. 

Do not underestimate the impact of a small deed. Think of a turning point in your own life in which another person did something objectively small – helped you fill out a form, offered an encouraging word, invited you to a meeting, mentioned an opportunity – that had big benefits for you.

In everyday life, look for small concrete physical things that would contribute to others. Empty the dishwasher, give someone a ride, scratch a back.

Also look for places where restraint would help, such as not interrupting or not  trying to win the argument.

Include inner actions, such as giving full attention instead of letting your mind wander, or mobilizing authentic interest in conversation or romance even if that wasn’t your initial impulse.

Pick a relationship or situation and ask yourself, what could I do to help? Maybe an elderly relative is bored and lonely, or a friend needs a jumpstart in clearing out a garage, or a co-parent is carrying too many tasks and too much stress.

And look for leveraged effects, where something small for you is big for someone else. For example, I’ve seen families in which one parent averages 60-70 hours/week on the job (including commute and travel), and dialing back the workweek by 10% increases the parent’s time with the kids by 100%.

Take a Chance

chanceIf you are feeling depressed or anxious, today’s post from Rick Hanson (part of his Just One Thing blog) may be helpful. If you are already feeling energized, you might not need more encouragement to do something risky/taking a chance…

Rick’s post is about how, as children, we learn to avoid certain types of conversations that seem too risky, and then as adults we come to realize that by avoiding emotionally risky conversations we live lives that are limited and unsatisfying. He talks about how to change this pattern.

His post is (as usual) well written and thoughtful.

One word of general warning about self help instructions, reading the post may seem simple, and you might find yourself thinking, “I already know that.” In a sense you are right. Nothing he has to say is likely to seem like completely new information. However, the key to changing behavior is not “book knowledge” but rather practice. If you practice his exercise you will find that it can be remarkably effective, even if it seems a bit simplistic.

To find out more, click this link. 

Running a Marathon

Mmarathonany of us are strongly motivated by the desire to achieve results, complete tasks and succeed. Often we want to get where we are going quickly. Life is too short. Seize the day.

Dealing with moods can be very frustrating. Change may take place slowly. Sometimes you have to put in a fair amount of energy just to hold on to the gains in quality of life and functioning that you have made.

MoodSurfing is not a sprint, it is a marathon.

There is no “quick cure” nor a “miracle diet” that will solve your problems and let you move on to tackle the next project.

Two young people I saw this week reminded me of this phrase from our own youth,”The trouble is you are trying to run a marathon at a sprint pace.”

One of them ( a young man) had a great deal of success using mindfulness meditation practice to deal with anxiety and depression, and decided that since some meditation was good, more would be better.

The other one ( a young woman) has been actively wrestling with the notion that she has a bipolar disorder of some kind.

The young man discovered that doing mindfulness really can’t be hurried (“rapid meditation” is something of an oxymoron – like the notion of “competitive yoga”). When he doubled the dose (going from 30 minutes a day to an hour a day) he actually got less benefit.

The young woman has been constantly alternating between trying to get everything done right now, and disappearing entirely from view (sprinting, and then dropping out of the race…. which is what you will do if you start a marathon at a sprint pace).

Find a pace for your own self care that you can sustain. One that allows you to enjoy the scenery as you go, and doesn’t leave you breathless, or tired, or discouraged.

Of Two Minds

This morning I was thinkingminds about the relationship between your pre-frontal cortex and your limbic system.

I know, it’s a little strange to be having these thoughts while out riding a bicycle in the morning… a hazard of the profession I guess.

The reason I was thinking about this subject is that people’s moods appear to be affected by both of these areas of the brain.

The limbic system is the source of emotion and, perhaps, a part of the unconscious.  You might think of it as Freud’s “id”, the animal part of the brain, the part that acts quickly, figures out very rapidly if things are safe or not safe, sees the big picture but is likely to misinterpret.

The pre-frontal cortex is the evolutionarily newer part of the brain that is where most conscious thought takes place.  It is where we think through problems and try to figure out meanings and reasons for things.  Both of these structures are very much affected by mood, and in turn, affect mood.  The limbic system is where all of the monoamine neurotransmitters like dopamine and norepinehrine  and serotonin are stored.  These are the brain chemicals that are affected by most antidepressants.  They set the emotional “tone”.  If you wake up one day and for no reason at all your mood suddenly becomes much more cheerful, you can probably thank your limbic system.

On the other hand, the pre-frontal cortex, particularly the part of the pre-frontal cortex that is in the midline of your brain, is very much involved in assessing risks and looking for potential catastrophes.  The extent to which you are inclined to look for risk or negative outcomes is probably largely determined by your genes and your early childhood experiences, but you can affect that tendency through conscious choice.

In other words, you might have a natural tendency to look for potential negative reactions from others, but you can consciously shift your attention towards other aspects of the situation by paying attention, for instance, to how people are interacting with each other rather than what their reactions are to you.

This ability to shift attention is the basis for psychotherapy.  By getting us to switch from risk thoughts to more positive or less negative thoughts, our mood can gradually change. In other words, the pre-frontal cortex, our conscious mind, can affect our limbic or emotional brain.

While I was riding my bicycle I was thinking about a couple of pretty depressed folks that I was going to be seeing in the morning. My eyes were downcast, I was mentally anticipating possible disasters. Then it occurred to me that I hadn’t actually looked at the scenery.  I was so immersed in those worry thoughts that I was missing the beauty of the lake, trees, and flowers I was cycling through.

The ability to focus attention is a lot of what makes us able to change our mood… look around and see if you have been missing something interesting, or positive, or beautiful.

No More New Year’s Resolutions

resolutionsWe’re going to make a strong pitch for you to not have to make any more New Year’s Resolutions.

Honestly, why this idea of deciding to make big changes in your life on January 1st has persisted, is one of the mysteries of human mythology. Perhaps it’s because we are such incurable optimists at heart. Or maybe it’s because we often have difficulty understanding how our minds work.

Whatever the reason, it has been our experience over the years that almost nobody is ever really successful with fulfilling New Year’s Resolutions. I cannot recall more than two people in a couple of decades of counseling many, many people, who were able to make this really work. And those two were folks who had an exceptional ability to commit to difficult actions and then follow through on them.

For most of us, New Year’s Resolutions are about getting to do fun stuff now that ordinarily would make us feel guilty, because we’re going to make a big change at some point in the future (a change we more often than not do not end-up making). In other words, masquerading under the guise of a decision to do something hard is permission to relax ordinary controls on behavior. Another tendency with New Year’s Resolutions is to make them about some big, dramatic change, which sets us up for failure because people typically are not able make huge changes all at once. Any significant and enduring change for the better in one’s life almost always involves many smaller and progressive steps.

The fact of the matter is, the literature on how it is that we make big changes is 100% in opposition to the notion of deciding now to do something really big in the future. How you can actually make change is to:
  • decide now that you’re going to make a small change and make that small change right now with an eye towards future additions and expansions to the process.
  • make that first step as easy as possible and one that you can and are willing to do right now
  • wait a couple of weeks and once you’ve really incorporated that change into your life, think about making another, further step on the road towards more change.
So right now we want all of you to forget the notion of New Year’s Resolutions and choose instead this simpler, more supportive, realistic and successful way of making positive change in your life.

Inspiration and Skepticism

skepticismA very dear and cherished friend is visiting us. She has inspired this post.

Every time we are fortunate enough to visit with her I have an opportunity to wrestle with the dichotomy of faith and inspiration, as opposed to science and skeptical inquiry, that is at the heart of Western medicine.

Carey has vigorously embraced healing and faith. And her enthusiasm for mysticism always calls out my skeptical side. Which leads to many enjoyable debates.

One of the key principles of the clinic where I work is something called evidence based medicine. I summarize that idea this way –

“We try to do the things that we know work before we do things where we don’t know whether they work or not.”

This is a nice summary that sounds reasonable… But one of the things that we know works is faith and inspiration.

Believing in your doctor, or healer, and being offered treatments that fit your view of what is wrong with you have very powerful beneficial effects.

Recently there has been a lot of controversy about whether or not antidepressants work. A series of articles, often written by psychologists, suggest that the effects of these medications are relatively insignificant.

There are two problem with this conclusion. The first is that it seems to fly in the face off robust clinical experience that these medications can be incredibly effective. The second is that it leaves us with relatively few options to help people with serious depression.

The literature on the effectiveness of psychotherapy for patients with more severe depression is even weaker than the literature on medications.

Here’s my quick summary of what all of this means. There are 3 types of medication effects –

  1. beneficial pharmacological effects
  2. harmful pharmacological effects
  3. and faith and hope (also called the placebo effect).

For many treatments, including antidepressants, the benefits of faith and hope are about equal to the pharmacological effects. However, because some people get worse (negative pharmacological effects) the net pharmacological effect is a lot smaller than the placebo effect.

In short term trials, where you combine negative and positive effects into a net pharmacological effect, it is often hard to show that the overall benefit is statistically significant (couldn’t have just happened by chance) when compared with placebo.

In long term use in clinical practice those people who get worse don’t keep taking the medications and so the net effect shifts more strongly to positive.

The point I wanted to make was not so much about antidepressants as about the magnitude of the effect of faith and hope. It is large.

This means that doctors who are better at conveying optimism about treatment are likely to get quite a bit better results.

My dilemma, then, is that my skeptical scientific mind knows that being too skeptical is not good for the people who come to me for help.

So I am always trying to look at things from two perspectives – a skeptical one which tries to avoid exposing people to treatments that turn out to actually have negative effects, and a hopeful side that seeks to inspire in people a sense of optimism that is such an important part of the work of a healer, of whatever tradition.


travelingTraveling can be exciting, but it can also be very stressful. It is particularly important for people living with moods to do prepare for travel before they leave.

A surprisingly high percentage of serious mood catastrophes, in our experience, happen during trips. And they are almost always preventable.

First, if your traveling to some place without good medical care, it’s a good idea to think through how you would deal with a mood crisis.

You don’t want to be trying to figure out the complexities of a foreign medical system when you’re very depressed or manic. Particularly because, in a country without a great medical system, there is often poor Internet access and finding people (doctors) can be difficult and time consuming.

One format we like for this kind of preparation is from the wellness recovery action program (WRAP). It might be a bit of overkill, but certainly completing this kind of crisis plan goes a very long way towards making sure that you’ll never need to use it.

Time zone changes are another challenge. They can often be mood destabilizing. We encourage you to take a look at the jet lag calculator on the British Airways site and make a plan for a smooth transition to your new time zone. For most people, bringing along a battery operated therapy light is also an extremely good idea.

Finally, it’s worthwhile trying to think about how you can replicate your usual daily routine while you’re traveling. If exercise is an important part of that routine, do some planning before you leave to find places where you can do your exercise. Similarly, make a commitment now to continue doing your meditation practice while you are on the road, if that’s part of your daily routine.

Keeping these routines is an important part of having a good and stable mood throughout your trip, which will ensure that you have a great time.

Bon voyage!


ACTThe “hot” thing in the therapy world these days is something called ACT (Acceptance and Commitment Therapy).

The radical notion behind ACT is that therapy should not be primarily about reducing symptoms (like depression) but rather increasing our ability to have a valued life (a life that is based on our deepest values) even though we have symptoms.

And, by the way, by doing that, it turns out that symptoms tend to diminish.

Of course, this is a central tenant of mindfulness, which we have talked about a great deal on this site: the idea that awareness of our thoughts and feelings, accompanied by some detachment from them (I am not just my thoughts) leads to a change in our experience of pain, depression, anxiety, etcetera.

Here is a description of the six central principles of ACT, from the well written book by Russ Harris, ACT Made Simple (written for therapists but a good resource for anyone interested in these ideas):

  1. Contacting the Present Moment (be here now). Bringing the focus of our awareness to what is happening right now. Hearing the sounds around us, experiencing the sensations, seeing what is here in front of us, instead of being caught up in our thoughts or worries.
  2. Defusion (watch your thinking). Being aware that the thoughts we have are not the same as who we are. Knowing that thoughts can, at times, not be “true” in the sense that they may not be relevant to the current situation we are facing. “We hold them lightly rather than clutching them.”
  3. Acceptance (open up). Making room for painful feelings. No longer struggling with them (I don’t want to have this pain, or sadness) because the struggle with them can make them more powerful (I have to get rid of this or I am not going to be OK). “This doesn’t mean liking them, it just means making room for them.”
  4. Self as Context (pure awareness). Recognizing that there is a self that is always thinking and planning and creating fantasies or fears, and a self that observes all of this. Knowing that this observing self is always there and strengthening our relationship with it allows us to accept painful thoughts and feelings without being overwhelmed by them.
  5. Values (know what matters). Connecting with the deepest values that we have. What is important to us? What do we want life to be about?
  6. Committed Action (do what it takes). Taking effective action, based on our values, and without getting stuck in the traps of thought that can sabotage such action (“I’ll never be able to do that”).

Here are some resources that may be useful-

Contacting the Present Moment – The Power of Now, by Eckhart Toll.. Our own page on Mindfulness has more resources.

Defusion – The Reality Slap by Russ Harris is an engaging way of reading about and thinking about a different relationship with our thoughts and fears.

Acceptance – There are a number of pages on this site that are relevant: It’s Wrong. Appreciating Depression. Imperfect Bodies.

Self as Context – George Herbert Mead got us interested in this topic a long time ago. His book Self and Society is still a classic in social psychology. Although probably overkill for our purposes. You Can’t Fool Yourself is a page that is relevant to the topic, although takes a slightly different approach.

Values – First Things First by Steven Covey is a values based approach to time management. Values Clarification by Sidney Simon is a workbook to identify your deepest values. What Color is Your Parachute has as its focus the notion that your work should be based on your values (“finding your mission”).

Committed Action – As Russ Harris points out, this really about all the strategies that we can use to be effective in acting. So it can encompass all of the techniques of behavioral therapy. A fun book on the subject is called Switch: How to Change Things When Change is Hard.