Persistent Depressive Disorder: Not All Depressions are Alike

Some therapists don’t talk much about diagnosis, but it is essential they think about diagnosis. Proper treatment depends on the correct classification.

In the case of longstanding depression, here’s why:

  1. Effective therapy for Persistent Depressive Disorder (PDD) differs from approaches to other types.
  2. Persistent Depressive Disorder consists of a distinct set of symptoms not typical of the broad range of mood problems.

How is PDD different from other periods of unusual sorrow? Duration is emphasized.*

The syndrome lasts longer (at least two years) and often starts early. Symptom-free periods, if they happen, last no more than two months. More comorbidities are present: that is, other diagnosable conditions.

Among additional distinguishing characteristics, traumatic and abusive childhood experiences are frequently a part of the individual’s back story. In general, the younger the patient was at onset, the more limited his problem-solving skills are today.

Though the above list may be daunting, the evidence supporting the effectiveness of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is impressive. Indeed, an extensive review of the scientific literature endorsed by the European Psychiatric Association recommended it as a top-line psychotherapeutic procedure for people with PDD.**

Perhaps not surprisingly, significant improvement tends to demand an extended therapeutic regime. More than a year would not be uncommon, with an indefinite but lengthy course of less frequent follow-up sessions to maintain gains.

The prescription of psychotropic medication in combination with the “talking cure” is customary, as well.

One of the most notable features of CBASP is its focus on fragile self-esteem. The client views himself as unable to produce satisfying encounters with acquaintances, coworkers, and friends. Nor does he realize the degree to which his words and deeds (or their absence) cause some of his unhappiness.

While his pain is acknowledged as genuine, CBASP views the new client as someone with chronic and pessimistic expectations of the world: self-fulfilling prophecies.

History informs him of how his life has worked out and, he believes, will work out. The evaluation of the patient, therefore, seeks to uncover the ways he contributes (without intention) to the repetition of disappointments characteristic of his past.

Moreover, the practitioner expects such counterproductive social interactions not to be restricted to life outside the consulting room. Comparable events are predicted in-session. The provider of treatment discusses this prospect with the sufferer.

Together they analyze what the depressed individual forecasts will happen between them, along with the actual effects of his behavioral choices. The atmosphere of the conversation must ensure a feeling of safety, not judgement.

An enlargement of the patient’s self-awareness develops as his anticipation of the psychotherapist’s behavior is explored. The Socratic dialogue with the healer should lead him to conclusions he comes to on his own.

This enlightenment is also fostered when the therapist tells him of his own internal reactions to what the client is doing: the feelings or thoughts emerging inside himself (the analyst) in-the-moment. In this way, the patient begins to become aware of his impact on others.

When the process works as designed, the outpatient starts to try out what are novel efforts to accomplish the kind of responses he desires. This begins in the office and extends to people he encounters elsewhere.

Thus, the transference relationship with the counselor is key. The system builds toward recognition of the healer as somebody who responds differently from those in his pretreatment life who caused harm or neglect.

Just as he comes to grasp he was mistaken in many of his beliefs about the adviser, so he begins to recognize routine errors in expecting the worst from much of the rest of the human world.

Progress relies, in part, on the subject’s growing ability to sense his own power to affect how people react to him. Another marker of improvement is his expanding understanding of how failed actions and inactions have added to his fixed sense of helplessness and hopelessness. Increased flexibility in both cognitive and emotional domains is a goal.

The therapeutic conversation includes a step-wise analysis of how troublesome situations in the client’s life developed – what happened at the start, in the middle, and at the end of them. Questions include, for example, “How did you interpret what occurred?” “What did you do?” “What did you want” and “Did you get what you wanted?”

A successful course of CBASP empowers the patient to gain insight through the emotions and thoughts evoked by inquiries like this. The ease of performing similar analyses on his own expands. He reaches the point of engaging the interpersonal world with an enhanced belief in what is possible.

Hopefulness comes to occupy an enlarged place in the client’s vision of what lies ahead. As a result, he risks letting go of passive-aggressive, hostile, submissive, and avoidant strategies. Friendly and assertive advances toward society increase.

Put simply, while there are no guarantees, the news is encouraging for those long-depressed souls who have yet to find a satisfying route to the alleviation of their unhappiness.

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*The complete diagnostic criteria for Persistent Depressive Disorder can be found here: https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_PersistentDepressiveDisorder.pdf

**Jobst, A., Brakemeier, E. L.., Buchheim, A., Caspar, F., Cuijpers, P., Ebmeier, K. P., … Padberg, F. (2016). European Psychiatric Association guidance on psychotherapy in chronic depression across Europe. European Psychiatry, 33, 18-36. http://doi.org/10.1016/j.eurpsy.2015.12.003

The bottom photo is Central Utah in Late Summer at Sunset by Laura Hedien, with her kind permission: https://laura-hedien.pixels.com/

For the Curious and the Brave

Are you an optimist, a pessimist, or a realist? Are you curious? Are you brave?

Think of your life as a challenging but unique voyage. Just as we find ourselves in the churn of a pandemic, so others we call heroes endured and survived their own dangers.

Take the ever-resourceful Odysseus (Ulysses) in Homer’s Odyssey.

The 10-year Trojan War is over. Ulysses and the men of his isle-domain proceed home to Ithaca. The warrior soon angers the sea god Poseidon. The fleet is taken off course, all but his own ship destroyed.

The journey home will match the length of the siege of Troy.

Can our protagonist “bend history” as it is happening?

Observe his encounter with a set of lovely-voiced, lute-playing enchantresses. Odysseus has been warned of them by the sorceress Circe.

First you will raise the island of the Sirens; those creatures who spellbind any man alive, whoever comes their way. Whoever draws too close, off guard, and catches the Sirens‘ voices in the air – no sailing home for him, no happy children beaming up at their father’s face. The high, thrilling song of the Sirens will transfix him, lolling there in their meadow, round them heaps of corpses rotting away, rags of skin shriveling on their bones. ...

The greathearted leader discerned more than caution in Circe’s advice. He recognized a chance to listen to songs so lovely they would make him oblivious to the danger of mindless drowning.

In effect, he wondered whether he might find a way to have his cake and eat it!

Ulysses directed his crew to plug their ears with beeswax, as his advisor suggested. All but his own.

He ordered the men to lash him to the ship’s mast and ignore whatever ravings and directions he shouted until they were past the singers’ reach.

The crisis revealed an opportunity for Odysseus. Our own challenges are less fantastic, but perhaps not less mindless. The times require the best of ourselves for ourselves and the fraternity of our fellow humans.

We can weep the fate of flash-frozen, aborted plans. Many are deserving of tears. But, our wits have not been lost. If we can keep them, and benefit from luck, sound judgment, and those who take risks on our behalf, calmer waters may yet appear.

Ulysses had no guarantee of achieving his goal of reaching his loved ones, but a god bent on frustrating him. He survived to attain Ithaca, embrace his wife Penelope, reunite with his aged father, and clutch his grown son Telemachus for the first time. Moreover, he regained his kingdom.

Though the resourceful one was no longer a young man, Alfred Lord Tennyson imagined him speaking of leaving home once more with vessel and company of sailors:

Tho’ much is taken, much abides; and tho’
We are not now that strength which in old days
Moved earth and heaven, that which we are, we are;
One equal temper of heroic hearts,
Made weak by time and fate, but strong in will
To strive, to seek, to find, and not to yield.

Ulysses’s desire to leave home once again is the English poet’s invention. It is not present Homer’s original tale. Indeed, the Ithacan had wept for Penelope more than once during their separation.

Why might the poet’s version of Odysseus wish to depart for further adventures?

Did he regret giving up the offer of immortality, love, and comfort proposed by the beautiful Calypso? Might his nature simply have been restless? Did this “master of exploits” hunger for attaching more glory to his name and legend?

Perhaps the camaraderie of his Greek companions in wartime made him most alive. Or he felt empty except when the Sirens shared their melody.

Decide for yourself. But whatever you believe, your immediate task remains this:

Find the music in your confined life.

Even now.

The first image is Ulysses and the Sirens by Léon Belly. Next comes The Sirens (1872) by Gustave Moreau followed by Odysseus and the Sirens by Otto Greiner. The same title describes the Attic Red-figured Stamnos, ca. 480-470 BC (a type of Greek pottery used to store liquids). All were sourced from Wikiart.org/

Best Man: Remembering Joe Pribyl

In a world rife with helplessness, an old friend comes to mind. His memory provides one answer to the question of life’s meaning in a moment suggestive of a heartless and strange cosmic order.

You would not think Joe Pribyl a remarkable man upon first acquaintance.

Some people possess an arresting presence. Joe did not. A stocky man, a bit under average height, he had graying hair and lacked whatever grace or style makes some people appear to be wearing a custom-made suit instead of a borrowed wardrobe.

My friend’s facial features didn’t betray high distinction either, except perhaps for deep vertical creases and old acne scars, of which Joe possessed more than a few. Yet it did convey warmth and approachability, more appreciable than any sculptural handsomeness.

At the start, I thought his everyman quality diminished him. Before the end of his life, however, I realized the inseparability of his nature and goodness from the human community.

He placed himself with and for every one of us.

Joe was a man of faith, admired by a faithless soul like me. Roman Catholic from start to finish, living his Sunday-service-beliefs every day. His grace came not from appearance, but kindness toward others, from waitresses to total strangers. The essence of his being was on display, fully himself, the rare unselfconscious human with nothing hidden.

He volunteered. He served. He raised his hand.

For years this therapist and his wife, Mary, also a psychologist in the practice they shared, organized a mission to Central America. The well-matched couple brought books to educate the sea of dispossessed, illiterate, and impoverished brown youngsters most of us don’t consider.

Doctor Pribyl did not consign a remedy for the world’s ills to someone else.

Brave enough to display tears, my friend never wept for himself, but others. Yet Joe was one of the few people I ever met who was content.

The healer displayed remarkable equanimity and courage in dealing with the near-death experience of a heart attack in a foreign and ill-equipped land. Later cancer stalked him, hanging around, as it sometimes does, never quite vanishing. Joe integrated the latter disease into the fabric of his existence as a natural event, not a matter of personal unfairness or rage.

On display was all the towering distinction my friend’s physicality lacked, but only if you focused hard, long, and understood him well.

Death came, a bigger than life opponent with an undefeated record, but not before Joe tricked the grim reaper into allowing additional time for attention to his patients, the woman he loved, the family dearest to him, and his lucky friends. I’ve never witnessed a better magic act.

In the overtime, extra-time of Joe’s life, I talked with him about my new grandson, almost two-years-old when the therapist passed. Grandparents wonder what the future holds for the little ones, who they will become.

I’m sorry Joe isn’t around to represent what one man can be, can do. If my grandsons were older and Joe still alive, I might point to him and say, “Look, look at this fine person. Look beyond appearances. This is a man. My friend is what a man should try to be.

This gentile soul, dead almost two years and a confidant for half my life, was a quiet fellow with an easy laugh. He didn’t come to impress you. While some people converse to be heard, he came to know you. There was little judgment in him.

His self-effacing way, at first, made me think nothing of his offer of friendship. Before the end, I recognized him as one of the great gifts of my life.

Thinking about Joe this morning, I reflected on the question with which I began this essay.

How do we persuade ourselves of a just deity in the face of all the world’s casualties? I imagined myself, a non-believer, asked to defend God in a criminal proceeding.

The reel of my imagination unspooled as a trial would.

First, the prosecutor made his case, piling up the innumerable instances of tragedy, natural and human. Of disease and murder, duplicity, betrayal, racism, slavery, and wartime. Of geological catastrophes sweeping the multitudes away, Jehovah’s Old Testament, self-created flood included.

The lawyer went on for hours and even cut short the presentation, convinced his case irrefutable. I doubted my argument in God’s defense: Joe’s life as an example of God’s best work, best man.

My turn came, the Lord’s defender. I told stories about my friend, including much of what you now know. I didn’t go on for long.

The verdict came from the bench, not a jury. The female presiding wore a blindfold, as Justice is supposed to. She gripped the scales in her right hand, on one side piled high with the prosecutor’s evidence.

On the other sat Joe, since no graven images or likenesses of the Almighty are allowed us. My friend’s figure lay in the shadow of the towering count of accusations against the God of his belief. The adjudicator would soon release the balance she maintained, allowing the evidence to determine the outcome.

A courtroom full of eyes were on the apparatus, waiting for its pivot, though I couldn’t watch. I’m told for a moment nothing happened, then the scales of justice shuddered and a grinding, terrifying sound came out of nowhere.

I looked up. One side plunged.

I cannot tell you how I knew, but beneath her blindfold, I’m certain Lady Justice was winking at me.

A Therapy for Today: Telepsychology in the Coronavirus Age

When the world is stressed, people think of therapy. But what do you do if a therapist’s waiting room makes it impossible to maintain social distance or the office has closed?

Anxiety is understandable. The nation and the world are in self-isolation. We are lonely, apprehensive about our health, and worried about the well-being of our families. Don’t be ashamed of being scared amid this new but temporary situation.

The idea of psychotherapy intimidates many people even when coughs and sneezes aren’t more dangerous than usual. The only safe therapeutic option is now online. Not only is this a change for the vast majority of current patients, but daunting to contemplate for many coming to counseling for the first time.

Welcome to membership in the largest club ever, the unusual human condition of the day. To the good, the therapist wants you to tell him of any hesitations or worries about this unfamiliar, remote method of care. He will try to calm you and work within your limits. 

Even before you seek counseling, the following often helps:

Ask yourself what other challenges you’ve had in your life. Make a list. Remember the qualities inside of you that enabled you to endure and triumph. They are still present.

Here is information to consider if you are seeking live video treatment:

  • While telepsychology or teletherapy can include phone calls, this introduction is limited to simultaneous videoconferencing in real-time.
  • Imagine yourself sitting in front of your computer in a well-lit space. The therapist sees you above the waist, and you can see only as much of him. He hears you and vice versa.
  • Although there is a bit of a time-delay in the discussion, this is an as-it-happens experience, just as in a doctor’s office. Thus, appropriate dress is required. No pajamas! 
  • Some therapists are adept at providing counseling this way. Others are new to it due to our Coronavirus emergency moment. Ask the counselor about his experience with this medium when you reach out for an appointment.
  • The provider will talk about several more things before booking your first session. Among those topics are the following:
    1. You will need a computer that includes a webcam and audio for both talking and listening. He may ask for a few more details of your setup. A phone nearby is essential; headphones are helpful. This person will try to use words you understand if you aren’t computer savvy.
    2. He needs to be acquainted with your reason for calling him. A clinical psychologist considers whether he possesses the skills to treat you for the condition you describe.
    3. Questions related to your physical and emotional history should be anticipated, as well.

Further steps follow once an appointment is made:

    1. The therapist will send you a Telehealth Informed Consent Form and go over it with you. This will include potential benefits and risks of treatment.
    2. Payment arrangements will be made. Be assured that Medicare has agreed to pay for telehealth sessions during this emergency.
    3. If you are not covered by Medicare, check with your own insurance company to determine reimbursement for such services and what portion of the fee is your responsibility.
    4. The counselor will ask you to sign a release/permission allowing him to speak with an individual designated by you in an emergency.

The professional who treats you needs the competence to provide teletherapy. Technical expertise is necessary to address an unexpected failure of the audio or video connection. Ask about this.

FaceTime and Skype are not secure platforms for the delivery of videotherapy, meaning your protected health information in a session might be compromised and your confidentiality breached. Nonetheless, during the Coronavirus emergency, HHS (the US Department of Health and Human Services) is permitting the use of insecure platforms to meet the demand for psychological assistance.

The doctor will discuss potential privacy concerns within your residence. Will anyone try to hear what you are talking about? Might another person enter the room? Will a pet or child show up?

White noise machines may reduce the chance someone else will overhear you. You will be encouraged to minimize distractions to the extent possible.

Your telephone is used as a backup in case of temporary loss of video or audio, not as the primary source of communication.

Visual cues such as your facial expressions, tears in your eyes, or tremulousness in your movements are indications of your emotional state. He must know that you are not engaging in harmful activities within his sight, etc. None of these indicators are knowable if he speaks with you on the phone.

Research suggests that teletherapy patients are about as satisfied as those who participate in traditional office visits. Most dissatisfactions come from technical problems in the course of the sessions.

Consider this an introduction to the treatment closest to an in-person office visit. You can expect other matters to be brought up, too.

Do not take what you have read here as a complete overview of the field. As the virus peril continues, federal and state laws may well change rules to adapt to changing circumstances. These might impact the delivery of psychological assistance.

Know that help is available to respond to the heightened stress of our situation. Talented psychologists, psychiatric social workers, psychiatrists, and other license counselors will continue to render the comfort they provide every day.

All these health professionals work with you, not on you. If you embrace the idea of partnership, both of you will work to create a bridge to a better time for everyone.

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The photos above come courtesy of Laura Hedien, a gifted and generous photographer. They are Crossing Chicago River at Michigan Avenue on March 21, 2020, and Crazy Luminescence. Much more of her work can be found at: https://laura-hedien.pixels.com/

In Search of a Rescuer: Where Erotic Transference and Politics Intersect

Most of us have hoped, early or late in life, for someone to “make it better.” Children want this when they fall. They need to believe instant magic is possible, and often it is. A smile, a hug, or a kiss can be enough. We are social creatures looking for connection, sensual and emotional.

When illness is serious, medical professionals are asked for their form of hocus pocus. Those people possess specialized knowledge. The name for it is “health care.” A proper physician communicates his expertise, but the care, as well.

Those with injuries to the soul seek a specific category of treatment: psychotherapy. You might be the perfect physical being, beautiful and whole except for the unseen pain of twisting emotion and turbulent thought. But, you ask, how much can another human do when no surgery or potion fixes what isn’t working?

Should the attempt to help succeed, admiration for the one who helped tends to follow. Sometimes before aid occurs.

The idea of a protector is potent and easily sexualized. “Someone to Watch Over Me,” the old Gershwin song goes. There are moments in life when we call out for such a knight or sorceress to summon the daylight.

The problem, though, is that life’s manufacture of dilemmas doesn’t stop. The factory assembly line can be unkind. Joys and sorrows are randomly generated. Nor does love offer a permanent cure-all.

The nourishment given by passionate and abiding affection helps with many problems, within limits. The lover (or potential partner) can offer only one hand when you find yourself in the soup of struggle. The other he needs to keep himself afloat. Lasting sorcery available 24/7 is in short supply.

If the therapy client searches for a deliverer or a romance in the counselor’s office, desire gets in the way of the best the therapist can provide: for the patient to rescue himself with expert and sensitive help.

The doctor’s assistance does not demand his becoming a brawny stretcher-bearer throughout the client’s life. Instead, the latter learns to take on present challenges and get past his past to make his way.

To do so, our wounded hero must allow (in small doses) uncomfortable emotions access to his heart. Similarly, he begins to permit uneasy topics and memories admittance to his thoughts. Taking responsibility for recovery requires behavioral changes, too; actions he hesitates to try. New and more workable ideas will disentangle the ones binding him if he recognizes their mirage of false security and unties them.

Some argue there is a benign supernatural healer in an afterlife, but I don’t know anyone who claims he now walks the earth. Some of us do, however, mistake mortal beings for more than they are. Thus, no matter the gifts of the therapist, he is not, by himself, the answer.

Current politics reflects this problem. Close to half of the United States thinks they’ve found their savior, a sheep in wolf’s clothing. Nothing short of a no-holds-barred holy terror will save them, they believe.

The other 50% hopes a nobler protector is yet to come. The latter group has been disappointed in people with names like Mueller and fears there is no other metaphorical wolf-slayer at hand.

Here, as well, many who wait and dream make the same error as some counseling clients. The hoped-for wizard in the office is like the fictional Wizard of Oz, just another man. The heavy lifting of well-being will require the muscle of those who lift themselves. The psychologist might suggest a path and a pace, display encouragement and understanding, but no more.

Neither a passive role in counseling nor remaining inactive until election day will accomplish a rescue, whether it be from personal despair or a case of national turmoil.

In 1867 John Stuart Mill put the governmental situation this way:

Bad men need nothing more to compass their ends, than that good men should look on and do nothing.

It is often quoted in these words:

The only thing necessary for evil to triumph is for good men to do nothing.

Whether the worthy man or woman is a therapy patient or a nervous citizen in a shaky republic, he is tasked with principled action to effect the change he wants.

Postcard and letter writing, marching and registering voters, phone calls and donations wait for us only for a while. Energy enacted creates its own source of energy, confidence, hope, and a sense of control: steps in the defeat of passivity, dependency, and worry.

Walt Kelly’s old Pogo comic strip told us “We have met the enemy and he is us.”

If the cartoonist were working today he might prefer this, a remedy of which each of us should remind ourselves:

I have met my rescuer and I am he.

What Your Therapist Didn’t Tell You

Many therapists spend most of a session without uttering a sound. The more they talk, the less they are heard. The more they speak, the less the patient does his own emotional processing.

The more they offer answers, the less the client claims ownership of his happiness, responsibility, and control.

When treatment works, the seeker isn’t passive but active. The new thought is taken, not given. He grasps the reins, a voluntary effort.

Clinicians should rarely propel the train, though they may clear some of the tracks. Persuasion and insistence have limits. A parental, authoritative position creates a struggle for power or dependency.

Repetition is tiresome. Some people won’t change. They sought a remedy with the wish for someone else to do something.

We are not surgeons who administer an anesthetic so you can be redesigned while unconscious. If we possessed a storeroom full of magical potions, we’d be drinking them ourselves.

The counselor asks questions, points in a direction, and monitors the strength of the resistant wind. He manages the temperature and allows hope to enter the room.

Who will reach for it? Not all do.

Like marriages and friendships, there are signs of trouble. The sessions drag, the medic becomes a debater, misunderstandings occur. The analyst drains his life force; perhaps he dreads the next appointment. The psychologist tries too hard, his counterpart too little.

Though the lesson is unwanted, the other’s life is not ours to reshape. The patient has the right to stay where he is, no matter the suffering.

The only adult we can alter is the one in the mirror. The man reflected in the silvered glass must reflect, claim his own agency, and act.

Mallets won’t hammer others to the shape desired. We are not sculptors or portrait painters. Sometimes the best we can do for another person is to give up on our capacity to do him good.

At least this permits him to take back his life.

Some people, including a few “helping professionals,” listen to be heard, to make pronouncements. They do better to listen to understand.

We all have limits. We all have goals and choices. Regarding the latter pair, here are mine for 2020:

To better understand myself and others. To discover an enlightening idea, an unexpected sight or sound.

I choose to search for these; and perhaps to change the world.

Disarming Your Negative Thoughts: How Meditation Helps

We expect too much of language. People use it to console, laugh, and express love. Phrases manage our relationships and help us make a living. We grab them to persuade and to injure.

Regrettably, our words also damage us. I refer to the private internal self-torture we alone can hear.

One remedy for this problem does not involve the pitiless expressions themselves. Instead, the method helps get us away from the typed black and white creatures inhabiting dictionaries, the ones we utter within our inner sanctum.

Allow me to explain the background first.

In cases of depression and anxiety, the voice inside our head is leaden, crushing. The word contraption called the brain pumps out endless discouragement, self-doubt, potential catastrophe, regret, and self-blame. All in letters of the alphabet, all caps in a giant font.

Some of this is caused by our genetic wiring, some learned. Homo sapiens survived because ancestors could anticipate problems and plan for defense. Communication helped. Thinking ahead and in our head was vital, allowing reflection on the past and learning from personal history, too. We take in criticism as they did, especially when young, to better adapt to conditions, meet inescapable demands, and achieve acceptance by the community.

For the troubled among us in particular, when nothing else occupies our attention, invading armies of words sometimes describe an unfortunate back story, accuse one of inadequacy, and generate fear of the future. The space between the ears is filled with emotionally charged, unsettling sentences. We try to avoid or escape them by occupying our time in productive and joyous activities, embracing love, and engaging in hobbies.

Some use the radio or TV to drown out their self-loathing. Books might distract, video games entertain. Others imbibe alcohol or take drugs. The lucky sleep self-recrimination away, fortunate unless slumber is all they can do.

When work and play are done — often late at night or when we are by ourselves — the loquacious intercranial attack picks up. Try as we do to kick the phrases away, they rebound in our direction. The more our ideas are repeated internally, the more they boomerang, as if connected to a rubber band we can only stretch so far before a snapping return to the original shape, shooting the trouble back at us.

The harsh routine at its worst implies, “Sorry, your lifetime allotment of happiness is used up.”The task for winning the battle for our distressed brain’s attention is to drain the words of their power. Cognitive Behavior Therapy (CBT) can do some of that, increasing our ability to talk back to irrational cognitions.

Traditional dynamic psychotherapy, in addition, aims to relieve us of our sense of unworthiness based on mistreatment by parents and other misfortunes. Grief-work is necessary.

As for the rest, all of us benefit from being calmed and relieved of the tendency to give too much desperate meaning to the reflexive thoughts that seem to think themselves into us and against us.

Mindfulness meditation can address this. The usual instruction is to concentrate on your breathing. If you are like me, a few seconds into early meditation sessions a distraction will pull you away from a focus on the breath. Many of the intrusions are benign and random. This is typical and not a bad thing.

Once you recognize what happened you are informed how your mind works. Even more so, if the topic taking your attention off breathing is challenging and you notice this. Maybe it’s anxiety or worry about what is before you, perhaps downing yourself over a comment you made or sadness and anger about what a neighbor said about you.

The new meditator’s job is observing the unpleasantness and then returning attention to his inhalation and exhalation. You don’t flee the interruption, indeed you recognize it without judgment. Meditation experts tell us our value judgments (good/bad, right wrong, pleasant/unpleasant, positive/negative, wise/foolish) make such disruptive notions and feelings more painful than would otherwise be the case.

When everything goes as planned, a practice of daily meditation allows you to accept these thoughts for what they are (just thoughts). Life gets a bit easier. One’s intelligence is pulled away from self-disparagement, concentration improves, and you become calmer. Your head is emptied of incessant involuntary terminology and its tag-along emotions. Words separate from their previous emotional resonance and residue.

In one sense you have grown more observant of your cognitive and affective private life while more distant from it: less trapped and victimized by the historically fraught words. Their grip on you is loosened. A state of liberation follows, along with an experiential realization the punisher inside is not your master any longer: not essential to who you are.

A personal example: I once went to the Emergency Room with unendurable, hours-long pain from a kidney stone. I’d encountered a few such hard but injurious objects before, but never so lasting and punishing. I was given morphine, a narcotic.

Once medicated my body reminded me the affliction was yet there, but I was distanced and detached from the hurt: more accepting of it. I no longer cared. My feelings about the discomfort dissolved. For a meditator who is far enough along, the concepts once capable of hijacking your well-being lose the authority to harm you, though you still sometimes note the same terms in your head. You stop giving them importance, thus robbing them of their “truth” and impact.

Instead, you deem the terms as arguable statements, not indictments of your worth. They rest easier, not allowed to be a part of you, not taken to heart. These perceptions and notions have detached from your identity. The experience is like reading a book or watching a movie about someone else, not you. Separation from such things permits you to see the world and yourself in a more objective fashion.

In effect, the meaningful labels you attached to many of these internal communications lose their sticking ability, as if the “glue” adhering to your self-image dried up. The stickers fall off. The readiness to judge falls away. Room for beauty and fascination take up space once occupied by darkness.

Nor is your decision-making as likely to be influenced by the hyper-emotional thought-generation machine. The enemy within the language has been disarmed. Life can be more in your control, free of the ever-growing clutter of self-inflicted emotions and concepts you’ve been living with. The reprogrammed cerebral cortex is more settled. Moments of serenity are possible.

Do not minimize the amount of work involved in the process. Most people I’ve known who try meditation give up early. They believe they are “bad at it,” bored, or report the assault of troublesome beliefs and worries entering their attempt to quiet the mind makes them worse than before. Others only begin when their suffering is already at a peak rather than when depression or anxiety is not so present. Some find the needed time and discipline of a once-a-day devotion to the endeavor more than they can do.

I can only say that persistence, dedication, and the capacity to wait for delayed gratification are useful in meditation and much else in life. Combined with CBT (including any needed grief-work), the world may open to you in a new and better way.

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The first photo is of Cadillac Mountain in Arcadia National Park. Next comes Composition VII by Kandinsky, followed by 72 Seconds Before Actual Sunrise, Southern California, USA by Jessie Eastland from Wikimedia Commons. Finally, The Rayleigh Effect, Seconds Before Sunrise in New Zealand by Moriori, also from Wikimedia Commons.

Is There a Better Path to Happiness?

Most of us wish we were happier at least some of the time. In the West, we pick from a list of goals expected to boost well-being, targets outside ourselves: a better job, a more pleasing mate, and more status; money, too. But if we extend our reach in a different direction, we might find an unexpected road to joy: one demeaned or ignored by much of the human community.

I suggest we start by looking East and backward about 2500 years. An ancient teacher thought mankind’s flourishing required relationships invested in ceremony and ritual, in deference and respect. Here was a far more formal, harmonious way of interacting with others than we observe today.

The way fathers and sons addressed and behaved toward each other, for example, was a matter of custom and civility. Love, in part, was demonstrated by investing ritual deeds with sincerity, not grudging routine. Virtue and benevolence flowered in the performance of patterned actions and words. They became embedded in how people went about their lives, made their living, and honored the family.

What might be a ritual? Utterances and gestures as simple as our handshakes or embraces and expressions when greeting or parting. Somewhat more elaborate customs include how people are seated at a meal, who is served first, and who takes precedence in getting extra food. Use of stately words of address replaces familiar pronouns.

Voices don’t talk over others, but convey honor and recognize a hierarchy of roles. How we dress for dinner matters. So too, all expect the meal to unfold in a relaxed fashion. Our behavior indicates the importance of the event, not something less significant than whatever comes next.

Delight is taken in the simple presence and happiness of loved ones and guests. Think of conversation within appropriate boundaries, not a script.

This might sound unnatural to you in a world where time is money and ceremony reeks of elitism. Before you dismiss the notion, however, consider the growing incivility in our much less formal, modern, Western civilization, where corrosive vulgarity and worse are often excused.

Think, as well, how we skate over opportunities for rich and meaningful social contact with friends and relatives, speeding through meals, checking the iPhone, and treating wait-staff in an indifferent or demeaning fashion. We do so at the risk of diminishing ourselves and triggering a reciprocal lack of kindness, patience, and interest from those we claim to care about.

Confucius, whose Way I am referring to, formalized his guidance during the chaotic and dreadful Warring States period in China. Little happiness was present. People, we are told, were reduced to animals.

Herbert Fingerette put the Confucian view this way:

To become civilized is to establish relationships that are not merely physical, biological, or instinctive: it is to establish human relationships, relationships of an essentially symbolic kind, defined by tradition and convention and rooted in respect and obligation.*

No zero-sum game of winners and losers lives here. Every honorable person has a place.

As Confucius wrote, “Virtue does not exist in isolation; there must be neighbors.”

Many of us, trying hard to get through a challenging day, are not at our best. For those who attempt to follow the Way, however, the danger is in performance done solely out of duty, to signal our goodness, or curry favor.

Were such self-interest and riches enough to guarantee happiness, the USA would be the happiest place on Earth. Instead, it ranks 10th of 40 rated countries in life satisfaction in the 2017 OECD report.

Fingarette adds:

Society is men treating each other as men … according to the obligations and privileges … out of love and loyalty and respect called for by their human relationships.*

In so doing we prioritize the group over the individual. We invest this beautifully choreographed social dance with a gracefulness that offers us grace. Profit, ego, and selfishness are restrained. Benevolence, righteousness, propriety, and wisdom enlarge.

Our human potential grows, not to become athletes of conventional success, but like those whose humanity, not financial or political triumph, we say we admire the most.

Nor is this an extreme form of self-sacrifice. We are still permitted to make a good and honorable living. We needn’t give away decent clothing and a place to live, but are discouraged from taking license just because we can.

Reciprocity thus increases. Barbarism justified as a necessary means to a desired end meets with shame. We serve as models and thereby bring out the best in those we care about. They are drawn to us.

The elusive notion of happiness resides in the group’s ritualized performance, which, like a theatrical production, is larger and more meaningful than the individual players. In embodying our role, we share the bounty of human contact where all partake.

Can we do better for ourselves and our fellow creatures by striving to be members of an orchestra rather than itinerant soloists?

Confucius believed changing the world starts with what we control, what any single person begins to reflect upon and do.

We can do worse than find out if he was right.

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The top photo comes from the Himeji Oshiro Festival, June 26, 2010. It is the work of Corpse Reviver. The Respect Expressway, a hallway sign, was created by rrafson. Finally, the Chicago Symphony Orchestra by Dan Lutz, date unknown. The first two are courtesy of Wikimedia Commons; the last, from the Art Institute of Chicago.

*Fingarette, H. Confucius: The Secular as Sacred. Prospect Hts., IL: Waveland Press, 1972.

Why Therapists Search for Your “Useful Discomfort”

One of the therapist’s first tasks is to gauge the new patient’s discomfort. If he is drowning, the doctor’s job is like that of a lifeguard, to secure and elevate him straight away. But if he is treading water, head still well above the chance of a big gulp, the inexperienced counselor’s mistake must be bypassed: taking or allowing the sufferer into the swirling downspout of his emotional whirlpool.

Entrance there leads to a subterranean dark place on a high-speed descent. His well-being and stomach for counseling might be left behind.

The depth of psychic trouble will often — and often must — wait. Trust in the relationship and safety come first. Only when some grounding work is done can you best search for a place I’d call “a useful level of discomfort.”*

Useful how? The patient, assuming the distress is not entirely new, waited for some time to come to a professional. The woman or man lived a complicated life, tried self-help books or will power or faith or work or drugs or sex or each of these to better himself. Arrival at the clinic means nothing worked or worked enough.

He needs to move past his sticking point, the concerns he didn’t want to think about, open up about. If he becomes overwhelmed, however — by too much, too soon — a premature end to the office visits is likely. Stopping short of the mucky floor of his emotions is necessary. There is a zone of useful discomfort in a less acute, sustainable place higher up.

The in-session professional senses this, watches for it. Imagine the consulting room divided in half. On one side of an invisible partition sits the counselor. On the other, his client resides in a breathable, transparent fluid. Much movement occurs within the liquid, high and low, serene or agitated or depressed: the entire range of possibilities to which our hearts are subject.

The individual requires acute attention. Where he exists within his emotional space might change a dozen times before the clock suspends his share of the therapist’s face-to-face focus; in the same place or another, up or downriver.

Here is one of the reasons the doctor monitors the elapsing passage of the hour. He must, if he can, retrieve the drifting, disconsolate patient before session’s close; get him to shore. Leaving him with “useful discomfort” is often acceptable. A client who is worse off with regularity as he leaves the building is a guarantee of treatment failure. Health care professionals don’t want those in their care suffering the engagement too much.

The time is and is not the patient’s, though he purchased the visit. He owns that it happens, but the provider’s job is to manage the way it happens. Think of the latter as a traffic cop of sorts, the conductor of the flow of ideas and moods. The doctor reinforces the guard rails, keeping his charge from careening off the tracks, the chasms in his psyche through which he will fall if the session ends in the wrong place.

Those in psychotherapy possess many escape hatches. Full frontal immersion in a place they have avoided will force them to rely upon these old survival techniques and defenses. Only these, not their healer, then signal possible relief. The patient will have returned to the place of his former misery, but be glad because the prescribed ministrations, interpretations, and nudges made him worse.

The lesson of useful discomfort takes you forward, not retreating from life. Much of our flourishing depends on finding a way to tolerate unpleasant situations, not flee them. Resilience and courage incubate here. With experience, the formerly uncomfortable territory becomes less noxious. The circle of life enlarges.

The therapist should not be like a sadist slow-cooking you on a spit. His desire for your useful discomfort is to sustain your capacity for facing your issues without making the offered remedy either a feel-good waste of time or an intolerable ordeal guaranteeing a defeat of the therapeutic project. In effect, he is saying, like Dorothy in The Wizard of Oz, ‘”you are not in Kansas anymore,’ but this is the necessary place for you now. I will do my best to make it manageable.”

Like Dorothy’s “yellow brick road” Odyssey, the effort leads to discovery of the strength inside you. From there, whether home or away, new adventures are possible. You are now the master of your self.

——-

The second image is Ancient Harmony by Paul Klee. *The expression “useful discomfort” is borrowed from a recent article about climate science/

What if We Could Erase Painful Memories?

Why is memory this way? Why isn’t it content to hurt you once? Why must it remind you of all the times you’ve been hurt before?

If this doesn’t sound familiar, you have been asleep for a while.

Our hearts are given as hostage when we love. The kind of love doesn’t matter: children, friends, romance, and more. Our core is at risk when we treasure books and eyes fail, or music and hearing dims, or running and knees collapse.

Think of our loves as on loan from a magical library. This institution specifies no due date for the materials checked out.

Are we fools because the absence of a precise cutoff allows us to believe our possession is secure?

Perhaps someone already grabbed the object of our desire off the shelf. Will waiting help, hoping for the item to be returned?

You say rapture is yours? Then, suddenly, the library police snatch it away. No warning. No time to prepare. Maybe an accident robs you of your mobility or another love of a lover. No aid for this, no higher authority to whom you can appeal.

The officers provide only cruel compensation: a hole inside. The happiness of what remains begins to leak, the substance of life tunneling down the bottomless sink. Food doesn’t taste right, jokes don’t make you laugh, sleep gives no rest.

You climb in and reach for what is moving away. Or lack even the strength to lift you arm, open your hand, and try.

Oh, but shards of the remembrance cut, edges slow to depart.

Where is the repair shop when you need it, something to fill up the hole, smooth the jagged places? A replacement for “one of a kind” now gone? No second hand stores carry it, no reseller offers the missing part. A proprietor says they have something like it. You know they don’t.

What if you could simply forget you’d ever had the precious commodity, as if a surgeon removed an unwanted scar?

The top quote comes from Mem, by Bethany Morrow. The novel deals with some of the implications of memory erasure, also treated in the 2004 movie, Eternal Sunshine of the Spotless Mind. Outside of fiction, scientists envision a possible future including electro-convulsive therapy (ECT), brain implants, or other methods to treat PTSD by deleting disturbing memories.

The researchers make an assumption: the stinging, sorrowing, traumatic remembrances are distinct, limited, and not integrated with the rest of you. Not all troubling events fit into this tiny package, however.

Stop for a moment.

Would you sign up?

Many questions can be expected to arise if such a tool comes to the hospital nearest you. How would the doctor measure whether a memory is terrible enough and fenced-off enough to qualify for medical vanishing cream? Would the emotion disappear along with the recollection or might one experience the trauma without the reference to what caused it?

How would a forgotten past allow us to learn from our mistakes? Some amount of pain is both inevitable and necessary for human development.

What might such experiential carve-outs do to our humanity? How might we relate to those who remember the event, but didn’t use the medical white-out?

Could the richness of life and our capacity for empathy — our moral growth and resilience — diminish with a too ready instrumental “end (to) the heart-ache, and the thousand natural shocks that flesh is heir to?”*

If the technique were extended to matters of romantic heartbreak, would the wonder of love vanish too? Might our species turn reckless once assured that losses needn’t last past our next doctor appointment?

Remember, taking something away doesn’t add anything back. Would these scrubbed souls become like white boards without the written names and meanings of the people who were once our “everything?” Does spotlessness await or just mindless?

For now we must weather the bad luck and pack an umbrella. Perhaps go to a therapist or seek the drug dispensers, insurance approved or otherwise. We count on time to pass so we no longer count the time “since” and “after.”

I wish we were guaranteed a puddle remover for the rain and a hole closer for the drain. At least they tend to get smaller.

Gratitude for what abides offers consolation, though hard to summon with speed. New people, new tasks, new beauties beckon. Acceptance, too, is instrumental in healing, another job needy of practice and patience. Religion helps some find solace.

To me, the essential lesson is to live with urgency. Not stay up nights wondering when the librarian will demand the book back. Rather, to be exhausted by bedtime for having embraced the fullness and possibility of the sunlight. If, by evening, the tale of your life is claimed, the desk won’t be piled high with regret.

Your library card might appear battered by then. Look carefully, though, and recognize something else. Good use was made of your time and the invitation to enter a wondrous place called the globe. I mean the bounty offered there: books and relationships, work and sport, nature and laughter and fulfillment from striving to repair the world.

In a place where everything is borrowed and brief, Andrew Marvell’s centuries old advice, To His Coy Mistress, still applies:

Thus, though we cannot make our sun

Stand still, yet we will make him run.

——–

The second image is Erased de Kooning by Robert Rauschenberg.

*Excerpt from the “To be, or not to be” soliloquy in Shakespeare’s Hamlet, Act III, Scene I.