robertstainton

Fixing mental Chains

An important tenet of DBT is that behaviours and emotional outbursts, including unhealthy ones, have different kinds of causes. The causes aren’t just (conscious and unconscious) beliefs and desires; nor are they just electrical signals carried by chemicals in the brain.

In addition, these varying causes form a chain:

Vulnerability → Prompting event → Interpretation and other intermediate links → Problematic reaction → Consequences

In my own case, the “problematic reactions” aren’t things like abusing alcohol or drugs, angry explosions, etc. Mine are inner feelings – especially overblown fear and sadness – and the outer expression of those feelings – such as freezing up and sobbing uncontrollably.

Part of DBT therapy is analysing these chains. “Chain analysis” has a descriptive and a prescriptive part: not just identifying the links in the chain, but therapeutically breaking the maladaptive chains and replacing them.

A recent example. The vulnerability: I was alone, with too many tasks to complete, on a grey and cold afternoon. The prompting event: I saw an East Indian girl in a pink jacket with short dark hair. The problematic behavior: I started sobbing, repeatedly clenching my hands and toes, lowered my chin to my neck, closed my eyes; and I felt dreadful grief and hopelessness. The consequence: the young girl and her grandfather noticed me with shock and became frightened.

As for the interpretation, I thought:

“That girl looks like Moon and Saima when they were young”
“My little girls are gone”
“They loved me back when they were that age, but do they love me now?”
“My life is full of loss”
“Everything around me ages and dies”.

This amplification of the prompting event – via the intermediate links – is what yielded an outsized physical and emotional reaction, the sobbing, etc. Then there was a subsequent chain. (Cue a downward spiral.)

The vulnerabilities came to include my present state of desperately grieving, of being even more emotionally fragile. A new prompting event on the scene was the very fact that I reacted so strongly to the initial one, and that this hurt others. A resulting “meta-chain” went:

“I am a bad person because I’ve upset this poor family”
“That I reacted this way shows that I am sick and won’t get better”.

As you can tell from this example, I’ve become pretty astute when it comes to recognizing the varying causes and the chains. My present homework is to focus on the prescriptive bit. I’m working on four aspects right now.

1) Checking the facts. Is my interpretation complete and accurate?

(In the example, checking the facts would involve asking: “Have I really ‘lost’ my girls?” “Am I truly getting worse?” “Did I do so much harm that I’m an awful person?” The facts were: No, no and no.)

2) Identifying more effective links. Where could I have replaced a problematic link? Which links are such that, had I conceived things differently, the consequence would have been avoided?

(I might have interpreted the scene as: “It’s nice that that girl is happy”; “Her coat reminds me of wonderful Winter outings with Moon and Saima”; “Change and loss are constant and universal, they aren’t specific to me”.)

3) Recalling DBT skills during a prompting event. Which techniques would have forestalled the chain?

(I could have paused, mindfully, to focus on and describe the initial sensations in the body when I first saw the girl.)

4) Strategizing about how to prevent such a chain next time.

(But not by avoidance of, e.g., seeing happy children outdoors! Nor by quashing the feelings entirely. That’s aversion rather than prevention.)

TMS and emotional vulnerabilities

I have just been scheduled for Transcranial Magnetic Stimulation (TMS). It’s a six-week long, non-invasive neurological treatment for severe depression. I’ll begin in mid-April at London’s Parkwood Institute.

For those who know nothing about it, here is a very brief but useful primer:

https://www.health.harvard.edu/blog/transcranial-magnetic-stimulation-for-depression-2018022313335

How might TMS help in the context of my psychotherapy? DBT identifies several elements in an episode of anxiety or depression: vulnerabilities; a prompting event or “trigger”; an emotion-infused reaction in the body (e.g., increased heartbeat, clenching of muscles); and an interpretation which the reasoning mind creates in light of all this.

The most relevant element here are the vulnerabilities. They can be short-term or long-term. The former pertain especially to i) reduced sleep, ii) unhealthy diet, and iii) insufficient exercise. Sleep in particular is a very strong predictor of emotional fragility in my case. Long-term vulnerabilities lie in iv) psychological history (e.g., an abusive childhood or a catastrophic loss) and v) biomedical diagnoses, such as my own Bipolar Disorder Type II.

I can and do work constantly at reducing those short-term vulnerabilities: I’ve learned lots about sleep hygiene and a mind-wise diet (think Mediterranean), and I run all the time.

I can’t do much about (iv): history is what it is. My pre-adolescence was a traumatic domestic nightmare. And, after a devastating five years of surgeries, radiation, and chemo, I lost my first wife to cancer. She was 29, I was 28.

TMS comes in with respect to that fifth vulnerability. It helps approximately 50-60% of people suffering treatment resistant clinical depression.

It’s very, very important that I focus on this fact, viz., that TMS might very well help with number (v), but cannot “fix me”. For, anticipating that 30 days of brain stimulation will itself excise all my sadness and fear sets me up for disillusion and despair. It is self-defeating.

So, wish me luck. And remind me to manage my expectations.

mental health downward spirals

I experience a variety of mental health downward spirals.

I tend to get unduly sad; this fact about myself makes me sad. I get unduly anxious, which makes me feel anxious. And when I start to feel slightly anxious, I immediately get “meta-anxious”: Am I about to get really anxious? Then I do, of course. Hypervigilance of whether I’m safe and in control makes me feel unsafe and not in control. That encourages still greater vigilance. I get depressed by the fact that I am depressive.

Most dangerous of all the spirals, it seems like a life worth living is, by definition, a life such that I want to be alive. So, on those days when I don’t care whether I’m alive, or full-on want to die, those dark feelings confirm that my life isn’t worth living. That makes me want to die.

There’s no click-bait “The one simple secret to getting out of mental health spirals!” But there are two steps forward which I’m working on.

No surprise: part of what causes the spiral is a focus on the negative. I look over the precipice, I feel more afraid of falling. One partial remedy is to not set up as my goal a negative, viz., simply wanting to not be… unduly sad, unduly anxious, etc. Having such goals is itself a barrier to overcoming the negatives. Nor is “achieving mental health” a helpful thing to aim for. For, what is that anyway? In fact, it is implicitly a negative goal, since it really means: free of undue sadness, undue anxiety, undue need for control, etc. Besides, what exactly is it to work towards “mental health”?

The other step forward is the flip side: having, as a positive goal, promoting my values and experiencing the things which give me joy. (A sub-step here, which I’m also working on, is explicitly identifying what those values are in my own case; more on that in another post.) I can’t manage the the joy/values things all the time, but I should be capable of taking advantage when the opportunities come around for delight.

Aiming for that can (maybe) rejig the spiral from downwards to upwards.

Decisions and Anxiety

Something which gets me very anxious nowadays is facing a decision – especially a really trivial decision. Recent examples: “Which kind of ice cream should I buy as a treat for Anita?” Tightness in my chest. “Which task should I do first, write that lecture or do some grading?” Quickening heartbeat. “Should I go for walk or a run?” Clenched fists and toes.

DBT homework has given me some answers to “Why?” Partly, decisions are anxiety inducing because I convince myself that every option but one must be sub-optimal. And that means I am very likely to make a mistake, for how likely is it that I’ll land on that single best choice? Why is that so anxiety inducing? Because making a mistake, even a tiny mistake, means that I am valueless. Unworthy of love. As if that’s not bad enough, I convince myself that any fool could make this decision: the whole point is that it’s unimportant. That I can’t means that I’m meta-worthless. And then it’s the meta-anxiety. I get anxious that I’ll get more anxious, which makes me more anxious, which…

With the help of both Dr. D and my occupational therapist Ms. W, I’ve developed some strategies for combatting this train of thought.

1) In the short term, I try to avoid having to choose in the moment. For instance, when grocery shopping, in doubt, I always pick the President’s Choice brand. (This one was Anita’s tip.) Or again, I draw up a detailed schedule the day before, even if it’s arbitrary: do email at 11:00 a.m.; write lectures at 2:45 p.m.; go for a run at 5:00 p.m.; call my Dad at 7:30 p.m. I put all of this in my calendar and try to stick to it. That way “what now?” just gets sidestepped. (Ms. W taught me that one. Anita, my rock, often helps me execute it.)

This isn’t really an answer to the problem, though. Ultimately, I need to overcome my anxiety about decisions (which anxiety itself causes anxiety…)

2) A step in the direction of overcoming the pattern has been practicing making little decisions. This is like “exposure therapy”. I try to decide what song to hum. I try to decide which finger to bend. Etc.

3) Working towards a more long-term solution, I’ve been saying to myself: “Even if you make the wrong choice, you’re still a valuable person. Mistakes are constant in everyone’s life, including in the lives of those you value most. Be compassionate towards yourself in the way you would to them”.

life before dbt: the psychiatric machine

As background to why DBT has been such a positive change, I thought I’d share my truly awful experiences with the “psychiatric machine” here in London, Ontario.

I’ve been taken to hospital twice. Both visits were soul crushing. I’ll describe the second episode in a later post. Here’s the chronology of the first.

It was September of 2018, and I was alone at home. I suffered an extremely severe depressive episode. After calls with Anita and visits from caring and concerned friends, ultimately, I was taken to Victoria hospital in a police cruiser. The time was about 4 p.m.

After two hours in the emergency waiting room, the kindly officer still standing by, I was finally seen by a triage physician. There being no cubicles available, I had to explain my diagnoses, my suicidal thoughts, the historical causes of my depression – childhood trauma, the death of my first wife, and other intimate details – in sobs, in the hospital hallway. Dozens of strangers stared and eavesdropped. He decided the case was serious enough to have me examined by someone more senior. The police officer was dismissed, and I was told to wait.

Two hours later, his superior came to interview me. He had no notes from the prior doctor. So, once again, sitting on a gurney in full view, breaking down, I retold the whole thing. It was an agony of shame and grief. Redux. This doctor concluded I was a danger to myself, “committed me” in effect, and put in a call for a psychiatrist. By now it was about 8:30 in the evening.

Eventually, a bed was found. I can’t recall how, but I had a bottle of zopiclone with me. I took the half dozen or so remaining pills, indifferent to overdose. I finally feel asleep.

At 4 a.m. I was awakened by the resident psychiatrist. You can imagine what happened: he had been given no notes on my case. So, for a third time, I described the reasons behind my breakdown. Sobbing again. Shame again. Agonizing memories again.

Here was his response. He explained that there was no way to admit me, there being no beds on the ward. I could, he said, remain in Emerg for three days, under the order signed by the prior doctor. However, he told me frankly that the nurses wanted me out. His own suggestion was that I go home, have a warm bath, and be sure to take vitamin D regularly. However, the decision was mine. What did I want to do?

At 4:30 a.m. he signed a discharge. He promised that I would receive a follow up call the next day from a mental health crisis nurse. I walked out of Emergency entirely alone. I called an Uber on my own cell and went home to an empty house.

I’m lucky. My niece came that same day to look after me. Anita and Saima flew home. Friends checked in. Many other patients get sent home with no support at all. All too frequently, they take their own lives.

Such is “biomedical” psychiatry in London.

[P.S. The nurse didn’t call.]

Effective Rethinking of… Control and Anxiety

One of the tools of Dialectical Behavioral Therapy is i) recognizing thoughts which go along with mood episodes and ii) trying to retrain the mind onto other avenues.

This is my effort specifically with respect to control and anxiety. In the left column are some of the thoughts which arise when I am having a bit of an anxiety attack. On the right are thoughts I am trying to respond with, though I all too frequently forget to do so.

Ineffective	Effective Rethinking
“If I could recognize the triggers, I would be able to make all anxiety go away.”	Not every emotion has a recognizable trigger. No one can be expected to recognize every trigger, even when there is one; so, exercise self-compassion. It’s not in your power to “make it all go away”. Accept that you can’t entirely understand the anxiety.
“I should be able to control the anxiety.”	Lack of control is universal. Anxiety is universal too, especially nowadays; it doesn’t mean that you are weak (And weakness is okay). So, accept that you can’t entirely control the anxiety.
“Getting anxious without a recognizable trigger means that I am not getting better.”	Progress isn’t linear: a step back doesn’t mean you’ve failed. To the contrary, you have come very, very far. This bout of “floating anxiety” is like a minor injury when training for a long race. It’s an obstacle that you are dealing with, overcoming which will make you mentally stronger.
“If I can’t control things, I am at the mercy of the world, other people, and my biology/neurochemistry.”	You don’t need to have complete control. No one has that: no one is strong enough to “defeat” everything and everyone (including themselves!) But you have enough control. And you always have control over when you “radically accept”.
“Strength is admirable, weakness is shameful.”	Strength per se is neither good nor bad. It can be used for good, but it can be abused. Experiencing victimhood, “weakness”, made you empathetic, it’s the root of your kindness. No one is “completely strong”; no one is “completely weak”. So, it’s not shameful to not be omnipotent.
“The world is dangerous.”	The world is both dangerous and beneficent. No one can protect themselves from everything: strike the balance with respect to risk, and then accept the risks. Aversion to the dangers means you can’t enjoy the bounties

Depression as like a perceptual illusion

Kind and well-meaning people will tell people with depression that life is good. In my case, friends and family will remind me of genuinely positive things: my good job, the love that surrounds me, my fine home, my physical health, etc.

This can help. But mostly it won’t – because the person with depression already knows these things.

It’s like one is split in two: a rational observer who recognizes the objective positives; and an emotional “feeler” who responds sadly, nonetheless.

I like to explain this “split” in perceptions by analogy with a visual illusion. An example. In the Muller-Lyer illusion, below, one knows that the two lines are the same length:

If you have any doubt, draw two lines yourself on a piece of paper, and triple check that they match. Then add the arrow heads. One line, the one with the arrows pointed inwards, will look longer.

Depression is like that. Often (not always), I know rationally, intellectually, about all the positives. Emphasizing them isn’t necessary. Indeed, too much emphasizing makes me feel worse – guilty and shameful that I can’t appreciate the good things as I ought to. Yet, despite what Rational Rob knows, things “look” dark and dangerous to Emotional Rob.

What can a friend or family member do, when accentuating the positive fails? Try saying “I can see that this is awful for you. But you’ve faced it before, and it passes. We’re here for you, while you’re depressed and while you’re not”.

Functions of Grief

A massive part of my depression is grief. Horrible, deep, abiding grief.

A recent homework assignment from Dr. D, then, was to think about the function of grief. If one can see that it has a purpose — at a time and for a time — maybe one can reckon with it. Or reckon with it just a little better.

Here, based on some google searches, a few academic articles, and a bunch of introspective pondering, are five functions I came up with.

1) Bonding

Grief plays a role in bonding prior to a loss. It encourages us to protect existing bonds by making us sad when we are apart. That means that we learn to protect things we love, so as to not feel the grief (cf. pain as negative feedback). In this sense, grief is the flip side of close emotional attachment. Grief, in other words, is a specialized sort of sadness: it’s the reaction to “extreme parting”.

Grief is also important after a loss, to encourage bonding with supportive others. To share the grief. To seek help.

2) Pausing/resting

The period of grieving allows one to take a moment for oneself. A moment for saying goodbye. A moment for recovering energy for the difficult task ahead.

3) Boundary marking

Grief, in its great force, delineates the past from the “new terrain” going forward. It is so obvious to the sufferer and those around them that it cleaves time, marking the past as genuinely and definitively on the other side of the boundary. That too is an important function.

4) Recognition

The grieving period is the time for accepting that the loss is permanent, final. That one’s world has irrevocably changed. Being on that far side of the before/after boundary, no more protecting of the loved one is possible.

5) Prompt for relearning

After the pause, and with the boundary firmly in place, grief starts the process of adjusting to the world as changed by the loss. With the support of those one has become bound to, the sufferer can learn to live with the loss, the new reality, in a healthy way: psychologically and socially.

In light of this, ideally…

grief can serve its purpose and then subside;
there’s no need to cling to it;
but no need to fear it either.

Leaving all this abstract homework behind and coming back to myself, I have never been able fully to do the recognition and relearning steps.

A crucial lesson will be to convince myself that the deceased are not owed my grief. That is, my grief isn’t a sign of how much I loved those who I’ve lost.

introducing annals of recovery

About me and the motivation for blogging.

I have been battling chronic depression pretty much my whole adult life. My diagnosis is Bipolar II. My first really serious depressive episode occurred when I was 28, shortly after my first wife Hamila died of cancer. But, in retrospect, I think I was experiencing hypomanias and depressed periods from about 17 forward.

Things got much worse half a dozen years ago, as I entered my 50s. What had been depressive periods tied reliably to dates – e.g., Hamila’s birthday and the anniversary of her passing – became more frequent and unpredictable. The hypomanias were swapped out for anxiety attacks.

I was in a mess and feeling hopeless. For the last 18 months or so, however, I have been under the care of a psychiatrist who actually treats me. I’ll call her “Dr. D”. Yes, she monitors my meds. But she also gives me homework exercises based in Dialectical Behavioral Therapy, an offshoot of Cognitive Behavioral Therapy (CBT) owing to Prof. Marsha Linehan of the University of Washington. Its emphasis is on “building a life worth living” and it draws heavily on Buddhist theory and practice.

The point of this blog is to share the results of all that homework. I hope it will speak to readers. I hope too that it will prove therapeutic for me.