Category: Therapy


Laugh and Be Married!

Review:  Laugh Your Way to a Better Marriage by Mark Gungor

After one of my dear friends proclaimed that this book, “Laugh Your Way  Better Marriage” had saved her marriage, I decided to check it out for myself.  After reading the first section, I actually found myself laughing out loud.  Mr. Gungor presents a very solid look at marriages: the myths, realities, and land mines that can occur.  Gungor begins with the supposition that there is no such thing as a “soul mate” and that relationships succeed by learning to live well with the person chosen to be one’s mate.  He presents the “Laws of Marriage Physics”, most of which have been well established in various books on male-female relationships (men and women are different and have different wants, needs, and communication styles), in such a way that is both insightful and entertaining.  I found myself in agreement with most of Mr. Gungor’s assessments and advice: “Marriage takes courage…discipline…endurance…forgiveness.”  I recommend this book for any couple in any stage of marriage.  While most of the information is not novel, it is refreshing to find a book that doesn’t encourage people to “follow their bliss” but rather teaches them how to work together and cultivate their relationship skills.

I love mnemonics and acronyms; they make it easy to remember useful information.  We tend to use them frequently in medicine (ie, RICE: rest, ice, compression, elevation) and in mental health (ie, screening for alcohol dependence, CAGE: cut down, annoyed, guilty, eye opener).  I was reminded of a particularly useful one this week: HALT.  While HALT is primarily used for individuals in recovery for substance abuse issues, I find it useful to apply to any automatic, problematic behaviors in which people engage (including emotional eating).

HALT refers to the possible responses to the question “Why am I doing this? How am I really feeling? Am I really…?”

  • H- Hungry
  • A- Angry
  • L- Lonely
  • T- Tired

By asking oneself these questions, it enables the individual to be more mindful of the situation and more accurately meet his or her needs at that moment instead of engaging in emotion-led, automatic behaviors.  So the next time you find yourself grabbing for a cookie or glass of wine, try asking yourself if you need to HALT and be certain of your motivations at that moment.

Mindfulness meditation is a term that is used to describe the cultivation of “non-judgemental, moment-to-moment awareness” of events in our daily life.  Through the purposeful exercise of bringing our awareness to the present moment, we can learn to be “more present” in our day to day lives and less distracted by ruminations of the past or anxieties about the future.  Such a practice can lead to a greater richness and fullness in relationships with spouses & children, help with problems with over-eating, as well as help coping with chronic stress, pain, or illness.  While it is based in Buddhist mediative discipline, Mindfulness Mediation is not a religious meditation; although, being “mindful” and “present” is emphasized by most religious and spiritual traditions.  Mindfulness meditation is not for the purpose of relaxation, although you may feel more relaxed, but rather an exercise in bringing our awareness to the present moment, “the only moment in which we are really alive”.  Most any activity can be done “mindfully” by experiencing the activity with all of our senses.

Mindful breathing is foundational to many mindfulness exercises and is a great place from which to begin a mindful meditation practice.  Mindful breathing does not require a large commitment of time, any special equipment, or location.  Our “breath” intersects both the voluntary and involuntary nervous systems.  Because of this, mindful breathing offers a wonderful opportunity to experience mind-body connectedness.  You may have noticed that when you are very upset or agitated, your breath becomes shallow and rapid.  This shallow breathing further exacerbates feelings of anxiety and creates a negative feedback loop.  Conversely, when we focus our attention on the breath and allow it to “be” without forcing it to be any particular way, our breathing calms down and with it, our mind calms down as well.  Our mind receives the message, “Everything is okay, no need to worry”, which helps us to feel at ease.

Here is a brief, introductory mindful breathing exercise:

Assume a comfortable position, either seated or lying down.  Allow your awareness to center on one area of the breath: such as the flow of air at the nostrils or rise and fall of the abdomen, but away from the mind and “thinking”.  Allow your body to breathe in and out exactly as it wants to.  You may notice the flow of the air in and out, the onset of the breath, the inflection point just before you begin to exhale, and the length of the pause before your next breath begins. Be aware that with every breath you are nourishing every cell in your body. Continue to follow the breath in and out of our body.  When your thinking pulls you away, as it will certainly do, notice the thoughts without judgement and gently bring your focus back to your breath.  Continue your practice for a comfortable period of time; perhaps starting with five to ten minutes.

Guided mindful mediations are a great way to experience Mindfulness Meditation and are readily available from various sources.  I have enjoyed the CD “Mindfulness for Beginners” by Jon Kabat-Zinn (available on iTunes or through Amazon.com).  I also highly recommend “A Mindfulness-Based Stress Reduction Workbook” by Bob Stahl, PhD and Elisha Goldstein, PhD. for more complete instruction in the art of mindfulness meditation.

5 Misconceptions About Therapy

I was inspired by Therese Borchard’s post today, “9 Rules for Survivng Therapy” to include some common misconceptions that I have encountered regarding therapy.

  1. Therapy is good for everyone:  Although Socrates said, “The unexamined life is not worth living”, it doesn’t follow that every person is ready to go through therapy at any given time.  Issues with psychological or internal resistance can be uncomfortable at best, and requires that the individual be stable and secure enough in one’s ego to tolerate such conflict.
  2. All therapy is the same:  There are many different types and styles of therapy (psychoanalysis, psychodynamic, Gestalt, Interpersonal, Cognitive Behavioral, Supportive). Most therapist practice a few different types of therapy, but generally have one therapeutic approach that is their primary focus. Not all therapists and therapies may be the right fit for all patients.
  3. My therapist is my friend:  This is a difficult one for many people. The therapeutic relationship is by nature supportive, non-judgement, and personal.  While the therapeutic relationship may feel “friendly” it is a one-sided relationship (whereas friendships are inherently two-sided).  Excepting certain revelations for specific therapeutic intent, the therapist doesn’t reveal much to the patient. This allows for therapeutic process of “transference” to occur (where the patient projects their own ideas and feelings about other people onto the therapist).
  4. Therapy should feel good:  Another common misconception is that therapy should leave the patient “feeling good” after each session, much the way a visit to a “spa” would feel.  The reality is that, while most individuals eventually feel better, therapy is hard work.  Most people will feel worse, perhaps disheartened, as issues are brought up and discussed; but eventually may feel relief as issues are resolved.
  5. Therapy should be easy:  While therapy may seem simple, it is very hard work and can emotionally draining.  It takes a great deal of courage for any person to face their “demons” and come to terms with the things in their life that may be keeping them “stuck”.

The SAD time of year

2129252744_14946f56beIt’s that time of year, when the days get shorter and the amount of sunlight we are exposed to decreases dramatically. In some individuals who are predisposed to Seasonal Affective Disorder (SAD) this corresponds to an increase in depressive symptoms. While the cause of this disorder is not fully understood, many believe that changes in our neurochemicals may be responsible: specifically changes in Melatonin levels. Melatonin is a chemical that is produced during the hours of darkness; it is involved with regulation of sleep, temperature, and release of other hormones. It is thought that individuals with SAD produce an excess of Melatonin that leads to depressive symptoms.

Symptoms of SAD can sometimes mimic hibernation: tendency to sleep more, eat more (especially cravings for high carbohydrate items), weight gain, irritability, fatigue, social withdrawal and isolation (in addition to other signs of depression: sadness, hopelessness, anxiety, loss of interest and pleasure, and difficulty concentrating and focusing. SAD is more than the “winter blues” and requires a full diagnosis of Major Depression with the seasonal specifier for timing.

If you suspect that you might have SAD or Seasonal Depression, please see your doctor for full evaluation and discussion of treatment options. Many treatments are available and may include Light Therapy, medications, and psychotherapy. Light Therapy (with a specialized lamps using 10,000 Lux bulbs) should be initiated in early November and continued on a daily basis, for 30 minutes daily, until March or otherwise instructed by your healthcare professional. It’s not too late to address the cycle of moodiness and loss of motivation that may occur this time each year.

antidepressantsThe decision to seek treatment for any condition can be a difficult one.  The decision to seek treatment for depression and anxiety can be made significantly more difficult by current social stigmas and also by one’s interpretation of religious beliefs.  This question represents so many other questions that can become barriers to treatment: If I seek treatment, does it mean I don’t have enough faith in God’s healing power?  If I seek treatment, does it mean that there is something really wrong with me?  If I seek treatment and someone finds out, will they judge me in a negative manor?  I have lost count of how many believers have delayed or avoided treatment for these very reasons; not to mention how many stop treatment prematurely so they can “get back to thinking that there’s nothing wrong” with themselves.  These same people generally would not hesitate to seek treatment for high blood pressure or diabetes.

 

My response is this: Our bodies are temples that we are entrusted with caring for.  We are an incredible collection of cells, nerves, chemicals, and more that are continually changing in response to biologic, psychological, and social factors.  Sometimes our chemistry can become unbalanced necessitating the use of antidepressant medication to correct states of depression and anxiety when they cause dysfunction in our lives.  Depression and anxiety are not punishment; they are real medical conditions that can respond to specific treatments.  To not take the steps needed to maintain our bodies would be far more wrong and damaging; sometimes this might mean taking medications in addition to doing therapy and other activities.  Have faith that the God of the Universe is not limited in His capacity to heal: that healing may very well be accomplished through any variety of treatment modalities including medications. Find a physician, who understands your beliefs and listens to you, but don’t avoid or delay getting the help you need.

_225_350_Book.68.coverAll you need is love? Not according to Dr. Eggerich:  Love & Respect, based on Ephesians 5:33 and culminating from Dr. Eggerich’s vast experience in pastoral and marital counseling, focuses on the transformational power of unconditional love and unconditional respect in marriage. Although it is certainly not the most entertaining or captivating book, Dr. Eggerich does successfully capture one of the primary sources of conflict in a majority of marriages: unmet needs.  Dr. Eggerichs postulates that women have an innate need for love and that men have an innate need, not for love, but for respect.  He explains that the failure to have this essential need met results in a cycle of reacting and withholding the other from one’s spouse, dubbed the “Crazy Cycle”.  While this may seem an overly simplistic distillation, it does have merit.  In a highly unscientific poll, I queried my patients over the past week that were experiencing challenges in their marriage: 100% agreed, not only that “love & respect” were an issue, but also that the converse had the potential for restoration.  Dr. Eggerich presents his thesis in the first section, accompanied by many relevant and supportive Biblical quotations.  He follows in the subsequent sections with suggestions for creating an “Energizing Cycle” including specifics on how to express your love/respect in a way that the other spouse can receive; then concludes with the “Rewarded Cycle” and several appendices with practical exercises.  While Eggerich tends to be redundant in his writing style, his message is both valid and useful in application.  I recommend this book for couples that are experiencing difficulties in their relationship or those who want to take their relationship to a higher level through improved communication and greater understanding.

Self-Disclosure in Therapy

One area that is sometimes contentious in therapy is that of self-disclosure. In traditional psychoanalysis, analysts deliberately refrain from revealing anything about themselves.  However, my therapeutic approach is that of Cognitive Behavioral Therapy (CBT).  There is no such prohibition in CBT and I find that I tend to do a lot of self-disclosure with patients whom I think will benefit from it.  I do, however, think it is important to differentiate between self-disclosure for the therapeutic benefit of the patient verses the burdening of the patient by unloading the therapist’s own baggage.  As one of my mentors, Dr. Murali Krisha once shared, “Never share things with patients that would add to their sorrow or cause them to worry about us.”

 

Examples of therapeutic self-disclosure may range from addressing issues that patients may have with unrealistic, perfectionistic standards through relating the standards and expectations I have of my own life to helping those who are struggling with feeling of frustration or low self-esteem by sharing how I motivate myself by “giving credit” or other such techniques I have used in my own life with success.

 

I don’t use self-disclosure with every patient but it does happen frequently. Self-disclosure is a way to give people a different perspective—a different way of thinking about their problems.   I have also found that it goes a long way in strengthening the therapeutic relationship when patients recognize that I am a human being who is willing to share something of myself to help them.  

Why do I do what I do?

At the simplest level, it is because I love what I do.  A colleague/ mentor encouraged me a few years ago, to imagine what my practice would be like if I were free to practice medicine the way I wanted to.  So I did…then I made it happen…and it has made all the difference.

 

I was originally drawn to medicine through my love of science… and the observation that nothing “grossed me out”.  In junior high, I contemplated psychiatry…as I enjoyed helping my friends work out their problems.  In med school I was drawn to OB and ER, but quickly realized that I do not function well in the middle of the night.  After a few weeks on my psychiatry rotation, the decision was clear.  I signed a residency contract before the start of my fourth year of medical school. 

 

Psychiatry embodies several aspects that I loved from ER and OB/Gyn rotations:  an ongoing relationship with patients, the opportunity to really listen and hear people, and the fact that it is never boring.  I have always loved stories… I may not be the greatest with names, but I generally remember all of the stories.

 

I often discuss with my patients the concept of basic human needs:  obviously food and shelter… but also intimacy, joy, and a sense of “purpose”.   My medical practice fills many of those needs in myself.  I sometimes question why being a wife and mother isn’t “good enough”, although I do believe that they are most noble and important roles… it seems to come back to the thought, “…because I know I’m supposed to be doing something more.”

 

A therapist who offices with me, has a verse from Galatians 6:2 on his business cards… “Bear each other’s burdens, and in this way you will fulfill the law of Christ”.  I do consider my practice as my ministry.  I am blessed and honored by these people who trust me with their wounded souls and chaotic lives.  I do not take my responsibility lightly; I continually look for ways that I can facilitate relief from their suffering.

 

My patients sometimes remark, “How can you do this?  How can you listen to these stories all day?” I guess it comes to down to my steadfast and stubborn belief that things can get better.  I was once afraid to share this optimism with patients. Now I realize that giving someone hope and the assurance that they don’t have to go down the path alone, can be very powerful medicine.

Bipolar Voices

One of the frustrations that I hear voiced from my patients with bipolar disorder is the feeling of isolation and of being an outcast.  “How can I talk with someone who will think I’m crazy if I tell them I’m bipolar.”  Add this loneliness to an existing depressed mood and you have a downward spiral of negativity and hopelessness.  One of the few positive outcomes of direct to consumer advertising by drug companies has been the subtle move towards mainstream acceptance of mental health disorders.  Unfortunately, there are miles to go before one can admit with the same nonchalance that one has bipolar (or any other mental disorder) as one would with high cholesterol.  While a few support groups exist, they do not meet the needs of all patients and tend to be utilized by those who are not functioning well.  “Where are the bipolar patients who aren’t on disability and on five different meds?”  Most likely, they are working, spending time with their family….but probably not attending a support group; at least, not while they are doing well.  It’s a shame too:  it would be nice for those who have had success in managing their condition to share some of their strategies and tips with others.  Until then, there is a wonderful multimedia collection of stories on the New York Times website from patients living with bipolar disorder:

http://tinyurl.com/bipolarvoices