Category: Effective Rethinking

Today’s homework assignment is motivated by some pretty bad news. Dr. D. is taking early retirement next month, for personal reasons. Given the severe shortage of psychiatrists in London, I may find myself without anyone to even oversee my meds. It’s very unlikely that I’ll be able to locate a replacement any time soon who will complement the biomedical bit with psychotherapy. Pretty much impossible that there will be someone to continue with DBT.

My assigned task is to consider a “limiting belief” provoked by the situation. More on that shortly.

The general exercise is a cornerstone of Dialectical Behavioral Therapy. It works like this. A limiting belief holds you back. It has bad emotional and behavioral consequences. Such a belief is like a tabletop in that it arises out of misleading stories we tell ourselves, analogous to “table legs”. The legs, the “evidence”, has filtered through age-old biases and assumptions. The point of this particular DBT skill is to chip away at those misbegotten supports by simultaneously reconsidering the story, and pondering the pros and cons of holding onto the belief.

So, the limiting belief in this particular case is: that I need a psychiatrist who “treats the whole patient”. The conviction, that is, that a combination of practitioners won’t suffice; and that I certainly can’t continue to improve on my own.

The story is that by Summer 2019 my prior psychiatrist had prescribed a slew of drugs, to no avail. I was in terrible shape. Emergency-room terrible. Aphasic terrible. It was only when I started to learn DBT techniques with Dr. D that I made real progress. It is true that my occupational therapist, who first introduced me to Cognitive Behavioral Therapy (the umbrella under which DBT falls), really helped me. True, then, that someone without an MD can and did help. But it’s also true that it was Dr. D’s dual mode of treatment that brought me back to functioning.

What consequences are entrained by this limiting belief of mine? How does buying the story hold me back? In the first place, it makes me feel anxious about not making further progress. It leaves me worried that I have hit a permanent plateau, and one which, though liveable, is frequently unpleasant and sometimes horrible. Worse, maybe I’ll even backslide. That fear, in turn, makes it more likely that I truly will plateau/backslide. Obsessing about needing a new psychiatrist also leaves me blinded to the many positive things in my life.

What are the pros of sticking to the limiting belief? Practically, it may motivate me to find some sort of replacement, if only pro tem. In fact, I’m already working on that. I’ve written to the depression clinic at University of Toronto, contacted some local psychologists, and am reaching out to Hannah. Epistemically, the belief just seems to be justified by my past decline and my failure to improve until I began CBT-style therapy. And, says my philosopher’s head, it’s a pro to believe what’s true and well justified. The cons? Practically, the belief that I need a multidisciplinary psychiatrist if I’m not to fail stands to put me into a panic on my final day with Dr. D and in the weeks thereafter. The belief also makes me feel that I’m once again losing someone really important, and that it isn’t fair. Epistemically speaking, it’s a con to ignore salient facts. And the fact is, I made all that progress – yes, with Hannah and Dr. D as my coaches; but the achievements were mine. Are mine.

Obviously, the pros have it. I should try to ditch the belief. In addition to reciting the cons to myself, stressing my successes, I think another thing that may help is to recite the first three parts of my CLUM-C mantra, namely:

Change is constant

Loss is constant

Unfairness is constant

Everyone gets stuck sometimes. Folks with depression and anxiety are especially prone to do so. DBT includes in its tool kit three things to ponder when it happens: the emotional source, the worst-case scenario, and the actual objective facts.

For today’s homework, I worked through an example. I’ve been stuck on writing two papers. More than that, I’ve become phobic about even trying.

With respect to emotional sources, I identified two. On the one hand, I’ve become afraid of finding out that I’m no longer able to perform well in a task that has been central to who I am. So much of my worth has been tied up in impressing, academically, those who matter to me. What if I can’t do it anymore? On the other hand, I no longer know why it’s important to publish papers. Too many are being churned out already. No one will read these latest ones. And, more deeply, my career goals have changed in recent years. I’ve set aside old ones, yet haven’t identified replacements. (Ah yes, that old problem of my values.) My aim, from High School onwards, was climbing the ladder and achieving “glory”. Scoring a medal in the Academic Olympics. (A bronze would do. But I needed to be on the podium.) By now, however, I’m perched at the highest level professionally that it’s reasonable to aim for. (Getting still “higher” – e.g., becoming a named Chair at Princeton, on everyone’s tongue, receiving ever bigger awards – doesn’t matter to me.) In sum, I’m stuck because writing these papers feels like a huge challenge given where I am mental health wise, and I don’t know why I should undertake the challenge anyway.

Turning to the worst-case scenario, the question is: what would failure look like? Well, of course, a very direct consequence of giving up is that I won’t finish the papers; in turn, that means disappointing my editors and my co-authors. Suppose I finish, and that they aren’t as good as others I’ve written? My reputation suffers.

That all looks pretty bleak. No wonder I’m floundering. Time, however, to check the facts. Do the emotions evinced by the papers depict things objectively? How bad are the scenarios, and how likely are they anyway?

This is the toughest bit. The emotions are very compelling, the scenarios seem daunting. However…

Suppose I don’t finish the papers. In fact, others won’t be disappointed in me. The editors of the volume, Ernie Lepore and Una Stojnic, are kind. They care about me and know my situation. Ditto for my co-authors Arthur Sullivan and Chris Viger.

Suppose I finish them, but the papers are plain-old terrible. Well, first, that’s actually very unlikely: my co-authors and our peers would catch blunders. But even if they slipped passed everyone, and the papers were so bad that my reputation was tarnished, how bad would that be? No one would die. I wouldn’t lose my family or my home. I wouldn’t even lose my job.

Where are we? Ah yes. I’m stuck with respect to finishing two academic articles. To move forward, I’ve been considering what the consequences of failure could be, and how likely they are. Time to check the facts regarding my emotions.

My fear of incompetence is misplaced. Let’s face it, when I compare myself with the appropriate group (e.g., not my teacher Noam Chomsky), I am still succeeding. I know this – well, I should know this – because there are other academic tasks where I still flourish: preparing complex lectures, refereeing papers for journals, writing these blog posts. More than that, I have written some excellent papers recently. It’s true, there was a time when I literally couldn’t type because my hands were shaking; a time when my speech was aphasic, and I couldn’t read a novel, let alone Plato. But those times are past. So, I haven’t lost the capacity. Besides, again: I have help from talented friends who care.

More importantly, I’m not valuable merely because of how I’m seen by others; my worth doesn’t flow entirely from impressing other people academically. My reputation isn’t as central to my validation as it can seem. Indeed, my worth academic or otherwise doesn’t flow entirely from others. (A slogan I commend to all: “Do unto yourself as you would do unto others”. I do unto others taking them as inherently valuable. Ergo…)

Next emotional fact to check: that it feels kind of pointless. That too is a bit askew. First off, it’s too strong to say that my work no longer has impact. The actual fact is, my papers get downloaded about five times a day, I regularly get emails asking about them, and I frequently receive requests to referee papers on my stuff. Secondly, being Bipolar, my temptation is to push farther and farther back in seeking a reason to do anything, including publishing. “What’s the point, from the perspective of the galaxy and its eons of existence?” But interim goals are enough. And for the time being, my motivation can be learning, thinking, collaborating, creating. Relatedly, overcoming a challenge can be a good thing in itself. (Why run farther, Rob? Why master a new fly-casting technique? What does the galaxy care about those achievements? These are bad questions. Similarly for getting these papers done: coming up with excellent results is something to be proud of, even if nobody reads the articles.)

In sum, the emotions turn out to be overblown too. Emotions, including fear and desire, are important, they send me messages; in this case, though, they have been tilted unduly to the negative.

[Postscript: I ended up working on a draft of one of the papers today.]

An important part of a “life worth living”, says DBT, is identifying your values. Sure. But, the latter causes me no end of grief – as you can tell from the fact that I keep promising to post about my values, and keep failing to do so.

A big part of the problem is that, since my teens, I’ve been seeking out the deepest, grandest values. Ones which can ground everything else. I arrive, inevitably, at existential despair (which is, of course, the very opposite of “life worth living”). That’s because I think: my life gets its meaning only from what I contribute to others’ lives; whose lives get their meaning from how they help others; whose lives… A vicious regress with no bottom.

What Dr. D has me working on presently is setting aside pro tem the quest for my “mega-values”, instead approaching things in stages. Identifying do-able things to aim for here and now. The approach takes ideas from Dr. Charles Swenson of UMass Medical School. He suggests a metaphor of a ladder of DBT goals.

A first stage, which I’ve already managed, is simply getting on the ladder. This is getting in control: i.e., minimal behavioral regulation, to even allow treatment (including doing homework like this). No treatment plan is even possible while in constant crisis, whether feeling suicidal, suffering from psychosis or severe behavioral dyscontrol (e.g., violent aggression), using heavily, or what-have-you.

DBT is suspicious of the idea that mental illness is just another disease, requiring just another kind of pill. Nonetheless, its practitioners accept that there’s an important role for meds when it comes to the goal of getting in control. (Ditto for Transcranial Magnetic Stimulation. My start date has been postponed by the way, due to a COVID outbreak at the hospital.)

Climbing up a wrung, you arrive at getting in touch, i.e., being able to describe your emotions rather than immediately pushing them away. Getting in touch is coming to understand your feelings better, partly by recognizing their function, partly by being aware of the misleading “stories” that come to mind as you feel. (See my earlier post on downward spirals. It’s the stories that drag you down.)

Meds, especially alone, won’t turn the trick here. Crucial instead, for setting and working on this level of goal, were the basic DBT skills of effective rethinking, chain analysis, radical acceptance, etc.

A quick theoretical/philosophical aside. Stages one and two look mutually inconsistent: moving onto the ladder = getting into emotional control; moving up that first step = letting go of emotional control. This is where the “dialectical” aspect of Dialectical Behavioral Therapy comes in. As DBT sees it, the perfectly balanced state – Aristotle’s “golden mean” as applied to emotions – isn’t possible. Rather, the Buddha (and Hegel?) got things right. The way forward involves continually bouncing between opposite poles, but lessening the distance. That’s what working on managing emotional experiencing looks like. Rather than equilibrium, at this point the thesis-goals (control) and antithesis-goals (letting go) are to come ever closer to each other.

Wrung three on DBT’s ladder of goal setting – only reachable once you’re no longer terrified of feeling! – is getting a life, which is to say: accepting the risks of grief and fear for the trade-off of living well; embracing challenges and even back-sliding as opportunities to learn.

Swenson’s “getting a life”, in other words, is aiming for ordinary happiness — as opposed to reaching the top of his DBT ladder, i.e., deep fulfillment and joyful living. My task for next week is to prepare a list of such “ordinary” objectives – ones that feel valuable, even if I can’t give an ultimate, rational justification of their value at this stage.

[Dr. D: Get a life, Rob. Me: I’m trying.]

My homework this week is about purposes. What are they good for? Why are they so hard for me to identify and stick to?

I learned that purposes – and the plural is important because there won’t be just one – aren’t merely about “who I want to be”. A purpose must track who you have been and who you are now. They lie at an intersection: of what you value (including what you simply enjoy, what you find fun), yes; but also what you’re good at, what comes easily.

Here’s why identifying purposes is so important. They hold otherwise scattered motivations together. They also help you through the hard spots, they get you “unstuck”.

Unfortunately, I find it very tough to identify my own purposes. First, it’s hard to face up to what I’m not capable of – I need to exercise radical acceptance, to embrace the fact that some purposes attract me but are simply undoable choices. Second, it’s hard to admit to myself that there are things I don’t value, even though I think I should. “Good people value that. I’m a good person. So, I guess I value that.” I end up saddling myself with things which “should be” my purpose, but which actually aren’t rewarding for me. Relatedly, and even more specific to me, I try to reason my way into what my capabilities and values are, rather than feeling them. Depression ensues.

So, if you ask me what my purposes are, I’m not sure I’d be able to say. Sigh.

I’m also reflecting on why it’s hard to stick to purposes – maybe prematurely, since I’m not sure what mine are. Two stumbling blocks came immediately to mind. Purposes establish boundaries. Sticking to them therefore puts me in conflict with others. The thought is ever present: “Am I being unfair in sticking to my guns?” Purposes also set me up to fail, to make a mistake. It’s safer, less hard on my presently fragile confidence, to not try.

My results, then. Purposes unify twice over: 1) they reflect what you want, but also what you’re capable of; 2) they bring the wealth of your wants into focus. But finding that unity continues to be a struggle because self-knowledge is hard work and its discoveries can be painful. Finally, holding fast to those “unities” will be hard even once my purposes are identified.

Double sigh.

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.

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”.