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Wednesday, June 28, 2006

The Hidden People

Who are the hidden people? They are all around us. But in one way or another we do not see them.

They are the elderly and impaired people in nursing homes that no one visits.

They are the mentally retarded who are boarded in schools.

They are the people in prison.

There are visible people and invisible people in our society. Visible people are the ones with their pictures in the paper and on the TV. In a more mundane sense, they are the people you see in the malls and at the restaurants. They have the money, the mobility, the psychological and financial resources to take charge of their own lives and to be involved in life.

But there are all kinds of hidden people.

There are the people who hide themselves. They are depressed or have other emotional problems. They are not able to stand the glare of being around other people. They fear rejection or harm.

There are people who are hidden in plain sight. They are the people we would rather not look at, and generally we turn out heads because we do not wish to see them--the homeless, the addicted, the streetwalkers.

How is this a psychological issue? Many of the hidden people are there because of psychological reasons--dementia, retardation, schizophrenia, and so on. This is a psychological issue, but it is also a social issue and a spiritual issue. For those of us in plain sight, we need to be become aware of the hidden people of the world.

Tuesday, June 06, 2006

The Importance of Regular Body Rhythms

Recent research has shown that in Bipolar patients, but also perhaps with Unipolar depressed patients, the 24-hour sleep/awake cycle is very important in establishing a normal mood condition. People with Bipolar Disorder are very susceptible to disruption of their moods when their 24-hour sleep/awake cycles are disrupted. Bipolar Disorder, for example, is the only psychiatric disorder which can be triggered by something positive happening in the person’s life. When a person has positive events occur it may lead to changes in their routine and in their sleep/awake cycle. When people stay up later and later, it can trigger the onset of a bipolar episode. In working with bipolar patients, we emphasize the importance of getting regular sleep, and regular waking periods. That is easier said than done, but it is important.

Research has also shown that in addition to having regular sleep/awake periods that it is important to have regular social interaction. The body sets its 24-hour cycle not just on the basis of sunlight, sleeping and waking, but also on the basis of regular social interaction. This could include something such as going to work, going to church, going at a regular time for doughnuts with a social circle, and so on. For that reason, the therapy based on this principle is called "Social Rhythm Therapy” because it involves both biological rhythms and using social events to set those biological rhythms.

For many individuals, the seasons of the year are important, and getting enough sunlight is important in stabilizing their moods. For that reason, one option is for people to stabilize their moods by walking every day at noontime for an hour. This ensures that they will get enough sunlight, and it also establishes a particular time by which the body can set its internal clock.

Persons living with Bipolar Disorder often seek out excitement and stimulation. They like change. However, too much change and too much stimulation will often trigger episodes of mania or depression.

Friday, April 28, 2006

The Dead End of Perfectionism

Many of the people consulting with psychologists have a problem with perfectionism. Some of them understand the problem and burden imposed by their own perfectionism. They are tired to having to do everything just right; they are worn out. Or they are depressed and they realize where the depression is coming from.

For others, doing things perfectly is a lifelong value, even a cherished value. They do not realize the full downside to the perfectionistic way of doing things. They may be depressed or anxious, and they may want to feel better, but they may want to feel better without giving up their quest for perfection.

There are multiple problems with perfectionism. These are discussed more fully in the chapter available on my website under "handouts."

Here are a few of the problems with perfection as a goal

  • It leads to depression in some people
  • It can alienate other people from us
  • It leads to procrastination in some people
  • It is ambiguous, that is it has unclear and confusing goals
  • It can lead to focusing on minor details rather than the larger issues of life
  • It is impossible to be perfect
Perfection may be a halfway possible goal for the child or teenager. Consider the sixth grader. What do they need to do to be perfect? Make straight A's, keep their room straight, and obey their parents. (Having "perfect" thoughts is more difficult, since sixth graders can have a lot of aggressive thoughts.) But with the coming of high school, it is much harder to make straight A's. And in the college years, almost impossible. Then, the person enters adulthood. They are a worker. What does it mean to be a perfect worker? If the job is straightforward enough, again it might be possible. But then they become a homeowner, and they have a house to keep up. And then they become a spouse. And then they become a parent. Now they have to be a perfect person, perfect worker, perfect homeowner, perfect spouse and perfect parent. Are there really enough hours in the day? No, there aren't. And something will suffer if they try to achieve perfection in one of these areas at the expense of another area.
Being perfect is ambiguous. As we have seen, it is relatively straightforward for a person to know what being perfect is in the sixth grade. But what does it mean at age 65 when we are retired? Does it mean keeping our lawn trimmed everyday and keeping the weeds out? Does it mean that we are volunteering? Does it mean that we are obeying all the rules? Or does it mean that we are learning which rules to break (as for example during the civil rights disobedience of the sixties). Does it mean that our house looks perfect to visitors or that we are being creative with our time? Does it mean that we keep outward appearances just right so that others will approve of us, or that we will use our time wisely so that we will approve of ourselves?
There are large issues in life, and these can rarely if ever be accomplished perfectly. Perfection is something we can accomplish when we vacuum the house. It is not likely to be accomplished in poetry, painting, volunteering, or even just helping out a friend. It is unlikely that we can write the perfect poem or be the perfect volunteer. The temptation for the perfectionist can be to do the smaller things which can be done more or less perfectly.
Perfectionism can alienate the people around us. When they do not live up to our perfectionistic standards, we may be magnanimous and forgiving--or we may be critical. And even when we attempt to be forgiving and "overlook" any mistake, our impatience with their lack of perfection may show through. This can put people off.
Perfectionism can lead to procrastination. We know that once we take on a project, we will have to do it pefectly. This can make it a daunting task, and we may find it easier to keep putting it off rather than doing it "just right."
Finally, studies have shown that perfectionism tends to lead to depression in many people. When the perfectionist falls short of their perfect goal, they may berate themselves, causing low self esteem and this may in turn lead to depression.
As an alternative to perfection, we can aim at doing things well. We can realize that it is better to be fully engaged in life and trying a lot of things rather than just doing a narrow range of activities where we can be assured of the outcome. There are times to be perfectionistic. Pilots are taught to be extremely thorough in checking over their airplane before taking off, for example. And if I ever have brain surgery, I would prefer my surgeon to be a perfectionist. However, in everyday life, perfectionism tends to detract from our productivity and feelings of well being.

Wednesday, April 26, 2006

Can People Keep Up Psychologically in a Flat World?

The recent book, The World is Flat, offers many stimulating ideas about how the world has evolved in recent years to the poker game it now is--the U.S., China, India, and the other players at the table. It gives a synopsis of the recent past but also a glimpse of the future. For people who have not yet read it, it summarizes the how the computer age has led us into a new economic age in human history.

For the first time, a person in India without an education in a first world country, can compete on almost a level playing field with people in first world countries. In the past, it might be necessary for a person from China who wanted to be successful in business, to train at Harvard or UCLA, and then to remain in the United States or Europe to establish a business. As new businesses become more computerized and more dependent on the internet, the actual geographic location of the business and entrepreneur becomes less and less important. It is becoming less important to do business physically in a first world country. Moreover, there can be a benefit to establishing the location of a business in a third world country if that is where the cheap labor is and if that's where the resources are. Sales and marketing can to a great degree be done over the internet while the physical plant is almost anywhere in the world.

The pace of change is staggering. China is turning out 65,000 engineers a year. In the United States, we are no longer just competing with others in the U.S. We are competing with China, and India, and soon others as well. We have been setting the pace for them to keep up with; soon they may be setting the pace. We have been content (many of us) to work 8 hour days. They are willing to work 12 hour days to be in the game. Can we keep up with them? Do we even want to keep up with them? Can we afford not to keep up with them? And if we do, can we deal psychologically with the continuing changes which will be at our doorstep. For persons in the computer industry, skills start to become obsolete after a year or so of not keeping up. But in the future, it could be six months, and then even less time.

In the past, individuals in the U.S. could decide whether they wanted to be ambitious or not. Whether to work hard or not. Whether to strive for more money, possessions, etc.--or not. And we can still make that choice. However, individual choices now have national implications and repurcussions, perhaps in the same way that they did during World War II. During that war, individual productivity was tied to the survival of the nation. The United States could not thrive and perhaps not even survive if people were to choose the easy life.

But whereas that war was limited to a particular period of time, there is no end in sight to the international competition which is only now gearing up to a full degree. Countries who fall behind, may stay behind for a long time. Countries who choose a life of leisure may end up being the servants of the trendsetters, that is, economically doing the bidding of those with the patents, the copyrights, and the industries.

In a worst case scenario there might be a frenetic pace of competition in which there was no pause. This is the most troubling aspect of the coming situation psychologically. People need balance in their lives. They need some leisure. They need time to reflect. A state of urgency (if not emergency) could be imposed theoretically, not this time by a dictator or the need to respond to a dictator as in World War II, but by the simple need not to be left behind, not to become a satellite nation to other more industrious nations which were willing to do whatever it took to be the inventors, the producers, and hence the dominators of the world economy.
This is reminiscent of the Charlie Chaplin movie, Modern Times, in which the machine conveyor belt gets the best of him . He cannot stop it. Once the machine is started, it seems unstoppable. In contrast to his movie The Great Dictator, it is now the machines (and those who run it) which are in control. Is it possible that the nations of the world could, in their competition to survive and flourish, get onto a treadmill in the world where no nation can afford to pause or get off? Is it possible that no one would dare to get off? And how might this translate down to the level of the individual? Could individuals get caught up in this same frenetic pace? What of the people who cannot deal with that new pace? It is not only cultures but also individuals which must adapt to it.

But perhaps this is looking at the situation somewhat pessimistically, from the vantage point of one living in America, where comfortable living is now rather taken for granted. It can be daunting facing the new crop of 65,000 engineers a year coming from China. But for one of those graduating students, the internet revolution flattening the Earth is indeed an opportunity to break free of poverty and isolation.

The long term consequences cannot be foreseen. But we can keep our eyes open to both the potential rewards and the dangers of the new and accelerating pace of global competition.

Wednesday, February 22, 2006

Supporting the Depressed Person

Yesterday, I said that I would write something about how to best support the depressed person. I basically said what not to do. It can be difficult to be supportive when one sees the depression going on and on. But there are some things which I believe to be helpful.

First of all, there are different levels of depression. Even within the diagnosis of major depression, there are mild, moderate, and severe levels. A person with severe major depression will need more support than a person with mild major depression. And a person with milder forms of depression (dysthymic disorder, adjustment disorder, etc.) will not need the same kind of support. Persons with more severe depressions need practical as well as emotional support (such as filling out forms to be absent from work, setting up therapy sessions, making sure that the person takes their medication accurately, or driving them to therapy). Persons with milder levels of depression need more emotional support. For them, the practical support may be helpful, but it may have more of a symbolic helpfulness (showing that you care).

So, keeping in mind that it is difficult to give guidelines that would apply to all depressed persons, here are some suggestions:

First of all, support the person being in treatment. Don't criticize them being in treatment. If they are still depressed after being in treatment, that doesn't mean that they need to stop it and "buck up." It may mean, however, that some type of change is needed in their treatment strategy.

If you don't think that their current psychiatrist or therapist is helping, you can suggest that they seek a second opinion without criticizing their current doctor. Or alternatively, you could even ask if it would be okay for you to speak to their doctor and give feedback about your concern that they are not improving.

Realize that they don't want to be depressed. They most likely want desperately to feel good. They are trapped in a maze. They don't know how to get out. Communicate to them that you understand that they want to feel better and that you are there to help.

If they talk negatively, give them gentle feedback. For example, if they said "I'm just stupid," you could reply that you don't believe that and that there is no evidence for it. They may not accept your reassurance or believe you, but it is probably better to provide a gentle confrontation than to say nothing.

Help them to get out of the house. Staying at home allows them to ruminate over their negative thoughts more. They may not want to get out, but give them encouragement to do so. Make it easy. You do the footwork. Buy the tickets to the movie or make the babysitter arrangements.

Don't take their depression personally. It can be helpful to look to see if you are doing anything that is contributing to their depression. By all means. But oftentimes, you will have nothing to do with their depression. If you don't take it personally, you can be of more help because you won't be defensive. Support the person, but don't take responsibility for them getting well.

If on the other hand, your self-examination leads you to believe that you are part of the problem, then try some marital therapy sessions to work on those issues.

If the depressed person is also abusing substances of some sort, don't assume that this is their only problem. Oftentimes, there is depression behind their alcoholism or drug abuse. AA can be helpful for alcohol abuse, but it is not likely to be an effective treatment for depression.

Give the other person positive reinforcements. These can be in the form of positive verbal statements ("You did a good job cleaning house today," or "You look nice") or taking them out. Don't be surprised if they disqualify your positive statements (finding ways of saying that they are not true or don't deserve compliments).

Look for a local depression support group. Take them and or attend with them, if they wish it.

Educate yourself about depression. Very thick books have been written about depression. You don't need to know everything that is in them. But it is helpful for you to realize that depression is sometimes a severe, complex illness. It is not just a feeling. Educate yourself about some of the complexities of depression.

Help them manage their medications if necessary. Depressed people may not take their medications correctly because of a variety of reasons. They may forget to take them. They may become pessimistic about the medication helping and stop taking it. They may not believe that they can afford the medicine.

Take care of yourself. Make sure that you have a social support network, too. That way, you don't burn out, and you have something to give.

Be ready to deal with your own feelings of resentment. It can be difficult being the spouse of a depressed person. Don't feel guilty about feeling that way, but don't just stew in your resentment either. Find someone with whom you can talk through your feelings.

Don't Blame the Victim

Psychological research has documented that there is an unfortunate tendency in people to blame victims. Part of the reason for this appears to be the need to reassure ourselves that bad things are not going to happen to us. When we see someone who suffers misfortune, we may feel anxiety and want to believe that it could not happen to us. Or we may feel a twinge of guilt that our lives are so good. For example if we hear of someone being robbed or attacked at night, we might think that they shouldn't have been out at night by themselves--they should have known better.

Some of my patients experience the same type of blaming. Depressed persons often report to me that their families do not understand their depression and tell them to snap out of it. People imply that they could be well if they wanted to be, that they simply want to be sick. Or there may be the implication that the person is morally weak and bad for not choosing to be well. This is also blaming the victim.

There may be some people out there who want to use their psychiatric symptoms for some reason (disability, etc.). I rarely encounter them. In my practice, I find people want to get well. If they could get better on their own, they would. One of the ways they work on getting better is by coming to see me. It does no good to tell them to snap out of it. It does no good to blame them and imply they are weak. Even worse is when people imply that their depression or anxiety is because they are out of right relationship with God.

There are ways of encouraging a depressed person to get better, but blaming them is not one of those ways. In my next piece, I will talk about some positive ways of encouraging persons who are suffering through psychological symptoms.

Friday, February 10, 2006

The Anxiety Spasm

I have sometimes referred to anxiety as a spasm. I believe that this is an excellent metaphor. As a spasm grows, it only makes itself worse. The muscle can't pull out of it. The more it spasms, well, the more it spasms. Usually, there has to be some sort of intervention to make it stop, such as pulling the muscle.

My patients often find themselves in just the same situation. Anxiety focuses their attention on the problem, and the problem increases their anxiety, and the increased anxiety focuses their attention even more on the problem. They want the anxiety to go away. But strangely, they are often reluctant to go do something else which might distract them and make them less anxious. It is not clear why this is. Perhaps, they already feel at their limit, and they just want to rest somewhere away from any demands. However, physical rest does not bring mental rest when there is an anxiety spasm. It generally gives their brain the freedom to keep focusing on the problem, obsessing, and worrying.

The cure for many spasms is to pull the muscle so that the spasm gradually subsides. The cure for the anxiety spasm is often to pull away from the worry and get into another situation until the anxiety gradually subsides. This may involve an uncomfortable feeling at first, focusing the mind on something else when the mind seems keenly bent on dealing with the problem and only the problem. However, after pulling away and focusing on something else, many people start to feel better.

I sometimes suggest to my clients that they keep a chart of their anxiety, rating it from 1 to 100 over time. It can be useful to do this when they just stay home and don't do anything special, letting their mind think and feel what it will. And then other times, the chart can be done when they get out and do something else which pulls their attention away from the anxiety. This gives the client concrete data to work from. What is going to make me feel better? How long will it take for me to feel better? How much better will I feel?

Some clients have had antianxiety medication prescribed for them. Such medication can be useful, especially when it is combined with learning psychological ways of coping with anxiety. I do not believe in any client being tortured by anxiety, and severe anxiety is a type of torture. But I also believe that it is always important to combine anti-anxiety agents with psychological coping techniques so that in the long run, persons do not become dependent on the medication.