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.

—–

*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/

Is There a Downside to Beauty?

The legend tells us that King Midas, given a choice of any reward in the world, requested “the golden touch.The fulfillment of his wish left him overjoyed. Everything at hand could be turned to gold!

When dinner arrived, however, the greedy regent discovered a downside. The food, once meeting his flesh, became the inedible precious metal.

He starved to death.

With Midas as an example, we might ask ourselves what becomes of those who receive another much wished-for gift: beauty.

The upside is well-known: attention, popularity, crowds of suitors, and more. Data suggest this group gets higher ratings on a wide range of characteristics. More social and career doors are thought to open, too.

The challenges of being adorable receive less comment. Here are a few of the problems attached to living inside a lovely face or form. Not every such individual suffers them all, but please imagine I’m talking about you.

  • Start with stereotyping. Think of golden curls atop your head. Some will suppose you are foolish, scatterbrained, and insubstantial. Thoughtless discounting of your loftier attributes must be overcome, at least in the USA.
  • What happens when you speak? Will your voice and words alter your appeal? Might dullness downsize the appraisal?
  • Acquaintances sometimes think physical charm places the lucky one at the front of every line. Such onlookers suppose your innate power to enchant obliterates all obstacles. They misunderstand your life.
  • Jealousy follows from the idea of “unearned rewards.” Some conclude your professional achievement came because of a “special relationship” with a supervisor or boss. Sexual harassment and gossip remain a hazard for all women.
  • If you are introverted, the buzz of attraction you create might overwhelm and fatigue you. The world expects you to be delighted to mingle among multiple eyes and swiveling heads. Refusal to attend group events can label you as rude or “stuck-up.
  • The potency of physical allure lays a trap for the gorgeous. Shall you depend on your attractiveness alone to generate a satisfying life? Perhaps you can prosper without much education, wit, or humanity – for a while. You would do better to recognize your season comes – and goes.
  • Aging for the comely one, when her self-image depends too much on the mirror’s reflection, carries dreaded anticipations of future invisibility. The male gaze includes no lifetime guarantee. Cosmetic surgery can slow but not stop the clock. The battle with a younger self is unwinnable.
  • A life graced by a perfect “package” does not eliminate all the hurdles and heartbreaks suffered by homo sapiens. Work, dating, friendship, athletics, and raising children offer satisfaction, but also potential woe. This fact remains unknown to those who think your angelic wings lift you beyond everyday travail.

  • Comparisons abound. You will be compared to your friends and offspring by the friends and offspring themselves. Observers note the pecking order in any lineup and coworkers join in the chorus of the judges and the judged. Many will name you a blessing, some a complication to their place in the world.
  • Your life as an object of desire means categorization as a competitor. The insecure will be troubled by your presence. If you divorce, do not expect your position within your community of friends to go unaffected. You are now a threat.
  • The exquisiteness of a woman both enhances and complicates the search for a mate, scares some men off, and causes commodification by the players. The role of a trophy – shiny, polished, and metallic – won’t keep you warm inside.
  • All of us understand society through the lens of personal experience. With enough time and interaction with people, we begin to fathom those who are different from us.
  • The magnetic life of a radiant creature presents her with the task of grasping the psychological state of peers who sit below the radar she never escapes herself. Since ravishing visions are always in short supply, those who are “easy on the eyes” tend to lack a confidant who identifies with being “the fairest of them all.

Even if you are a member of the club I’ve described here, you needn’t fit my description. On balance, it is thought far better to be attractive than not, just as it is preferable to be the tallest candidate for President of the USA. He wins the popular vote in most elections.

Few of us would turn down a pleasing combination of body and brain. I’m not suggesting you should. But when we think of the best-looking mermaids in our pool, perhaps we might recall they occasionally envy our safety from fishermen and their hooks.

—–

The three images above are publicity photos sourced from Wikimedia Commons. The Ingrid Bergman picture was used to promote her 1944 MGM movie Gaslight, for which she won the Academy Award for Best Actress.

Next comes Joan Crawford in a 1936 shot taken by George Hurrell. Finally, Dorothy Malone as captured in 1956 by Universal International Pictures.

Thinking About the Erotic Leap in a World Without Touch

The human world is aching. Hands and shoulders and skin are beyond reach. We have awakened to a sensual world in flight, moving at least six feet away.

What would you give for a handshake or a hug, a kiss independent of memory, arousal satisfied by a hand not yours. Perhaps you recall your head resting over another’s heart, hearing the life pulse, moved by the rise and fall of breath.

There are fleshly palms I’d like to surround, soft cheeks to brush past, downcast heads to lift in my hands. I’d spread high-fives all around, eyes close up, too.

Our on-guard stance against illness doesn’t permit either the comfort or intensity we seek in embracing. Our passions are chilled, bottled-up, beaten down. The perspiration of the skin almost asks permission to release itself.

We are amid a famine, even we lucky ones who remain nourished by food and don’t live alone. We want the bodies, the faces, the nearby smiles we lack. Artificial substitutes are earth-bound and distant, no matter that man was not meant to be alone.

We make do. The voices speak on phones across the world. Masks hide faces speeding through stores. Proximity is shunned. The Zoom-altered space-time continuum offers lips that move … followed by broken, inhuman sounds. If space aliens appeared, immune from our looming affliction, we would surrender and rush into their strange arms … all five of them.

I once treated a woman so starved for affection, she coupled with a canine. I believed her at the time but now understand her more.

We want sex, no mistake. But I heard many female patients talk about their need to be held – just held, including those with a regular bed partner. It is worth remembering what one hears on the battlefield among the wounded. They call not to lovers but to mothers.

Humans survived because love and care and emotional intimacy signified more than lovemaking. The buttons to such responses overlap the erotic zone, but one can also be mistaken for the other.

The sex of things is not solely dependent upon what catches the eye. It can be kindness or words or a voice or a gentle touch as much as security or a reminder of someone else. No wonder we experience the presence of erotic transference in the therapist’s office.

We are befuddled creatures, we humans: confusing and confused, less rational than we’d like to believe, unable to predict our feelings far ahead of the present. Kirkegaard acknowledged this truth:Life can only be understood backward, but must be lived forward.Backward, indeed, but not always grasped even then.

In 1900 the average life expectancy for men in the USA was 46.3 years. People laughed at home and made love at home. They gave birth, got sick, and died at home.

The cycle of life had many witnesses. Death made his place in the next room, overheard in an unfair wrestling match, an unbeatable competitor you recognized. Those people knew what we have been reminded of.

Perhaps hellos and goodbyes meant more in those days. No planes eased the route to reunion. Travel required time and patience. Letters were sent by snail mail while the writer lived, many arriving when he or the reader or both were dead.

Now we recognize (or should admit) “next time” is a wish without guarantee, a blessing when fulfilled. We’ve sobered up from a mass delusion of early death as an oddity, a fantasy never bothering to say goodbye. It left too many the parting gift of the grim reaper’s embrace.

The lessons of our ancestors need relearning. Catastrophe has a way of forcing its muscular arms around us. Remember that when all the unhugged-hugs – the ones pressing out from the prison of your skin – finally emerge from captivity.

Like Times Square at the end of WWII, when strangers swept each other into their arms, the reborn world will discover our reconstituted virginal state.

Our mundane existence will be reenchanted.

There are simple things worth waiting for.

—–

The three images are sourced from Wikimedia Commons. First comes The Embrace by Auguste Rodin, then William Adolph Bouguereau’s Admiration (Cupid). The final artwork is Mary Cassatt’s Maternal Caress.

Who Was That Masked Man? Psychological Self-protection in an Age of Masking

Stepping out of my home early Tuesday morning, I stepped into a strange world. Nature wore a mask of fog. Not me, mask free. Well, unless you believe I am a man of false faces.

We outfit ourselves with disguises. One mask fits atop another. Some use different camouflage depending on the set of friends nearby.

For the dress conscious, clothing plays its part in the costume, hiding that which we don’t want revealed. Rather like an actor’s stage makeup or Halloween for the kiddies.

The coverups take many forms. First, there are the ideas we don’t share. Next come the beliefs we don’t believe, but repeat to get-along.

Feelings and weaknesses are on display without trickery, the ones of which we are aware and those too crushing to accept.

Sometimes the concealing tarp drapes over our opinions, while secrecy extends to our plans. For example, the-intention to rob a bank.

Our face covers save us from relationship troubles, too. Remember four-months-ago when you recognized someone at a distance, a character you wished to avoid? Now you can cross to the other side of the street without hesitation or worry.

Time and circumstance have transformed the meaning of our action, changed it from a dis to distancing.

Alcohol has long been a tool like a self-protective armor plate. “Take a drink, you needn’t think,” says the bottle. “Dispense with your memories and feelings. I am your magic potion. I’ll erase your internal maelstrom – for a little while.”

Denial pursues this end, too, shrouding all our mirrors so we can’t recognize who we are, what we do. Others admit themselves to themselves but rationalize the necessity of being so.

Remember Salome? The girlish teen was Herod’s step-daughter, the child of his wife in the age of Jesus. The regent wanted the erotic young woman to dance. She did so with seven veils at the start and none at the finish.

The temptress then accepted payment for her star-turn: the head of John the Baptist on a silver platter, the better to kiss a decapitated man. The watchful Herod found the latter so disturbing he had her killed.

Removing veils can be a risky business.

Back to the present, our century encourages coverups via computer technology.

Are you uncomfortable on the phone? Want to dump someone? Turn away and send a text.

Are you bursting with unexpressed electoral anger or racism? A fake name and an itchy Twitter finger will fire the ballot bullet.

How about flirting or infidelity? The online world offers a digital dodge and a new name to hide behind.

A therapist is challenged by those patients who have never been unmasked. The sun never reaches their pale faces.

Take one mask off and you’d find another, masks on masks, layers piled up. The wearers have never seen themselves. The person underneath is a mystery.

And yet there is hope. Here is an example, a fellow I’d treated for some time.

Q: What price do you pay for the psychological protective equipment you employ?

The gentle soul lowered his head. His shoulders trembled as he wept.

A: Everything I want in life, friendship and love. I act like I’m a spy, in the shadows, on duty 24/7.

The door to recovery thus opened.

Like Tuesday’s lifting fog, a new day in my client’s life took a peek at possibility. The more we depend on masks, the less we own the joy of recognition and acceptance by another.

He discovered his disguises hid the best of him.

My advice? The next time you remove a cloth mask from your face, ask yourself this: Am I still wearing a mask?

Until then, donate what you can to a food bank.

The top image is Paul Hartland Carnival. Composition with Two Masks, 1934, by Lazlo Moholy-Nagy. Next comes Mask, 1919, by Marcel Janco. Finally, Lady Taking Off a Mask, 1906, by Konstantin Somov.

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.

What Do Therapists Dream About?

I found myself in my office. A couple of men walked past, removing the metal file cabinets full of patient records.

Names, birthdates, and notes. All the descriptions and observations, what they said, the way they said it. Outsized lives crammed into tiny words, into pages crammed into files, into hardened enclosures requiring a key for the locks.

People of emotion and disappointment and heartbreak. Joy and progress, too. Jobs, romance, decisions errant and expert. Fathers and grandparents and lovers, hellos and goodbyes.

Precious, each one.

The laborers put the compacted, enclosed cases of cases on handcarts. My efficient and conscientious office manager stared.

“What’s happening, Lynette?” No words. The men worked on.

I was close to retirement. I knew I wouldn’t be in the clinic for long, nor seeing patients and taking notes. Not looking into their eyes and hearing their laughter. Not buying more tissues to catch their tears.

I stopped the men. I told them to retrieve the paper mountains and put them in place.

They did.

Interpretations anyone? Many possibilities. Here’s one.

These records were not the lives of my clients, but the material evidence of the caravan of humanity passing my way. If lives were lines on a graph, my time with them would be like the point of intersection between their lifeline and mine.

When our contact was productive, the trajectory of their path changed.

They’d touched me and, for some, vice versa. The sheaves were the remnants of my vocation to help, enlighten, and open them to a new life: rewrite the words to their story.

No one else had the same relationship with them when I did. Now, no one else could read their tale without their permission.

Why did I have this dream as the pandemic closed in?

Did the workmen represent a virus-like invasion? Was my defensive stance a symbol for the protection of my family, friends, and all the ones I loved?

Did I fear the virus sweeping them away, as the blue-collar workers intended with pushcarts and trucks?

An old teaching cliche applies to dream divination: there are no right or wrong answers. Someone else, perhaps, will compile a book of COVID-19 sleep-befogged meanings.

Dream interpretation is like listening to a recitation of religious scripture. No two people hear the same message, as if the words, their order, and the language change while floating in the air.

The viral moment persuades me that if we lived a life of infinite length, we would also live every possible life, dream all dreams, meet every person, and write all the books that shall ever be written and read.

The full moon woke me, seemingly summoned to dispel the nightmare and enchant the night. Better to conjure sweet silent dreams than my professional dystopia. No witches and warlocks and werewolves. No cabinets spirited away by strangers.

Let me craft what is possible on our now slumbering globe: dreams of action and improvement, agency and creation.

Join me.

Daniel Burnham said, “Make no small plans.”

—–

The top image is described as Logistics of Watsons Distilled Water, 12 Bottles in Yau Ma Tei Nathan Road, Kowloon, Hong Kong. It is the work of Leideomangeos.

The second image is the Lorry of a Paper Shredding Company, 2006. It was taken on March 24, 2006 in Central London by Edward.

Both are sourced from Wikimedia Commons.

What the Coronavirus Taught Me About Love

When I practiced therapy, I reminded myself to bring intensity to my work. Every day, every hour.

Each patient was a kind of wayfarer. His journey had reached a sticking point. He was faltering with sadness, loss, or anxiety, guilt or helplessness.

A bit like a pilgrim, the searcher hoped to find a balm for the soul.

Life brings routine. We create routines to make it easier, more efficient, to avert the wasteful reinvention of our daily tasks.

But routine deadens, too. A therapist must make the work fresh.

The healer must be present, concentrate, note the body language, and not offer words far from the point, missing the point. I tried to give each meeting “life.I didn’t always succeed. No one can, but the next time my patient visited offered another chance to join him in searching out an oasis: a green, peaceful, and certain place, where refreshment might bring renewal.

The aging of my parents brought home the recognition it always does. One never knows when the last time will be. The twilight handshake, the final moment of laughter, the embrace of someone we love.

I made sure to part from my folks with an “I love you.Now my children and grandchildren do this with their parents and grandparents.

These parting words are never enough by themselves. The pandemic tells me so. Its voice calls out, “There is more to do.

Why do I hear this now? Because I can’t do more, I am separated from so many, as you are. What, then, does “more” mean when the opportunity comes?

The voice did not say.

Here’s my answer.

The heartbreak of a goodbye must be balanced by delight in a hello. We must treat each new contact as a gift, greet the friend or lover, the father or a brother as though it were the first time: the moment we discovered something unique in him. Graceful, beautiful, kind — it does not matter. Strong, faithful, wise — whatever are the qualities embedded within him.

We need to try to sum up the other’s every sacrifice for us, all the touching words they said to us, their thoughts and prayers for us and approach him anew. With gratitude.

In another dreadful historical moment, Abraham Lincoln said, “we must rise — with the occasion. As our case is new, so must we think anew, and act anew.

The virus teaches us the day is short, no matter how long the sunshine lasts. The message is the same, regardless of the time or place. Since we do not have eternity, the moment and the people must be grasped, held close.

If we safeguard ourselves and others, and if we are lucky, a reunion yet will come.

When you see loved ones again, remember: speed to them as if it were the first time and the last time, every time.

—–

The photos above come courtesy of Laura Hedien, a gifted and generous photographer. They are The Look and Splashes. Much more of her work can be found at: https://laura-hedien.pixels.com/

 

 

Coping with “Skin Hunger” in the Coronavirus Age: Entry from an Unwritten Journal

I’ve never written in a journal, despite offering the idea to many patients. Today I write because writing permits expression in the absence of nearness. At this moment, we mustn’t be close to others no matter what we want.

Yet we are the same creatures evolved to be social, to touch and more than touch: to shake hands, hug, embrace, caress, kiss, fondle, and lose ourselves in love and friendship.

We suffer from a pandemic side-effect called Skin Hunger by some, a too familiar, but unspoken condition among us, soon to be known by almost everyone. We have become experimental subjects in an unplanned scientific inquiry.

Still, today offered some small compensation. Here is a morning snapshot without mourning.

I wanted fresh orange juice. I’m lucky in many ways, including a meer 10-minute drive to a store that almost gives it away and a car to get there.

To minimize risk, I arrived early. Really early for those of you who aren’t seniors: at the high-risk age of our world’s coronavirus stage.

I entered at nine-minutes before dawn, a trip on night’s black edge: 6:20 AM.

Few people beat me in. The magic of automatic doors saved me from contact. Then a young woman employee walked by.

“Excuse me. Where are hamburger buns?

If we have them, they’re in aisle four.

I guess “if we have them” has turned into a reflexive response. Shortages because of the terror. I went to get the juice, whose location I knew, then to aisle four. Tons of buns.

One of the automated checkouts was in use, three empty. I completed the errand while maintaining social distance. Mission accomplished! We take our triumphs where we can find them within the constraints of our present moment.

Breakfast. I had a drink of water, then prepared my typical fiber-filled repast: shredded wheat manufactured without sugar, salt, and taste. With bananas today, though I often add blueberries if the price is reasonable.

Then coffee to feel alive. Most seniors require gallons, plus medications. I don’t take many of the latter, but the standard is relative. Friends report back problems and hernias from lifting all the pharmaceuticals they use!

Now for the major event of the day. Ta-da! Walking outside. Almost three miles.

People are friendlier but maintain distance. Almost everyone now waves or says hello, even from across the street.

An outlier on a bike, a woman, widened the footage between us from 15 to 25 feet.

Some folks walked dogs. Physical contact with a loving mammal. Think about it.

I passed modest homes and a few places an old friend compared to the Palace of Versailles. He was exaggerating, of course.

I got to thinking about how COVID-19 might alter our values. We take much for granted: life, health, work, restaurants, etc.

Perhaps, for a while, the condition of our being will be differently admired, differently evaluated, differently appreciated.

The status of simple things is getting a boost, decency among them.

The birds were out and a concert in progress. A legendary symphony conductor, Carlo Maria Giulini, told me he thought this the most beautiful music of all. No disagreement from me. Even the woodpecker with his built-in jackhammer joined the sing-along.

Some folks I know are stunned at the avalanche of bad news. The ones in feathered flight don’t care. Birds chirp, chatter, and sing in their first show of the day. We hear mostly males at that time, hoping to win a female heart and trying to mark their territory.

The scale of their satisfaction is smaller than ours.

Perhaps they offer something worth learning.

The Upside: How to Survive Psychologically in a Challenging Moment

I cannot say I’d choose to witness the Coronavirus pandemic, but here I am, and so are you. What follows is some help in reducing your distress.

I shall not minimize the dangers, but no good comes of either dismissing them or worrying over them as one would a train wreck sure to happen. The situation is neither.

If you are keeping up with public health recommendations, you know this. If you are taking the advised hand-washing precautions, you know this. Moreover, various branches of government in the USA are beginning to reinforce the societal safety net for those who need such assistance.

More action will come, though increased disease is inevitable for a while.

Assuming you are maintaining your social distance, you’ve taken a significant step. But what do you do with a less structured day now, time that used to be organized by meeting friends, going to restaurants or bars, and working in an office rather than your residence?

When our minds are left to themselves, they often travel to dark places. Here are a few suggestions to help you stay in the light:

  • Notice the changes in your life and the lives of others, without catastrophizing. The present is a remarkable time to be observing the world’s reaction to the virus. Be curious, watching and listening instead of evaluating and judging. Meditation may help with this.
  • Many of us have said, “Gee, I wish I had more time.” Now some of us do. What did you mean when you spoke those words? What dreams do you hold you now can begin to fulfill?
  • Reach out to people by phone, email, and social media.
  • Remind yourself of the things for which you are grateful. Daily.
  • Plan your activities for the next day before bedtime. Give yourself a sense of control and accomplishment. Focus on the doable without excess ambition.
  • Do not watch the news or political commentary at every moment.
  • Exercise, if possible in the morning light, to reduce anxiety and improve sleep.
  • Learn something new. The internet is full of educational possibilities, many without any cost. Perhaps something as simple as learning how to tie a Windsor knot:

 

  • Remember that if you are socially isolated, the prescription of interpersonal separation gives you much company, even if you don’t see those comrades on the street. We’ve been offered an opportunity to make ourselves interesting for ourselves and to ourselves.
  • If you lament the lack of a robust dating life, you needn’t apologize. Many more people are alone because of the dangers of visiting their usual haunts and loved ones.
  • If you are going through hell, keep going. Don’t stop until you find the path out.
  • Religious faith is sustaining at such times. Prayer and reliance on a higher power can be helpful.
  • People are fighting for you in the healthcare system, many also in government. Efforts are being made to ramp up diagnostic testing. Laws are being passed to make the tests free. Legislation providing paid sick leave from work is also in process, though not everyone is yet included in the plan. Watch the brief video below. The outcome is positive.
  • Much political activism is occurring online. I do not mean arguing with people. Engage in making the world better from your home to support your desire to improve the country.
  • The challenge of living in the time of COVID-19 is a chance to develop a new depth of psychological resilience. The Stoic philosophers believed we discover who we are only when we are taxed.
  • Make a list of the difficult situations you’ve survived. What strengths within you enabled you to do so? Tap such qualities once again.
  • Clean out your abode. Donate or dump all those belongings you no longer need.
  • Far more distractions are available than ever before in world history. Use them.

This crisis, too, will pass.

 

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The top image is called Sunset Dancer by Hurriagusto07. It was sourced from Wikimedia Commons.

The Danger of Secrets in Marital and Family Therapy

The watchword of therapy is confidentiality. Treatment success relies on the client’s trust. But, is it wise for mental health professionals to put themselves in a situation where keeping one person’s confidence can be used against others in the room?

Imagine the following. A couple comes to marriage counseling. They have a young daughter.*

Among the concerns expressed by the pair is the woman’s father, the child’s grandfather. He has accused his son-in-law of sexually abusing the little girl.

The woman tells the therapist her dad is unreliable, prone to irrational and outrageous statements. Moreover, he holds a long-standing grudge against the person she married.

The woman dismisses the idea of abuse by her mate, supporting his denial.

Several challenging weeks into the process, the man notifies the doctor he can’t attend the next meeting. He adds that it will be fine if his spouse comes for a solo session. She wants to.

On this occasion, she utters something never said to anyone: her father molested her when she was young. Indeed, her daughter is never permitted to be alone with the grandad for this reason.

Nonetheless, she doesn’t want the husband to know. The specialist affirms his intention to keep the confession secret.

The marital sessions remain on a downward trajectory, leading to separation and a divorce filing. The estranged woman now thinks her partner did touch the daughter inappropriately, consistent with her dad’s contention. Her earlier dismissal of this possibility, she claims, was part of an attempt to save the relationship.

Adding to the dilemma, the mother now aims for sole custody of the six-year-old. She also reminds the psychologist of his promise not to discuss or report the historical violation by her father. Legal action will follow if he breaches her trust, she threatens.

In hindsight, should the counselor have agreed to the individual appointment with the wife?

The doctor is in a box. If he reveals the mother’s history of molestation by the little girl’s gramps, she will bring suit. If he does not uncover this fact, his lack of reporting what he knows permits the woman’s demonization of her spouse to appear more convincing than it otherwise would.

The law, depending on the state in question, might yet offer a remedy.

In the event the therapist’s records of the unaccompanied session are subpoenaed by the husband’s attorney, a judge might overrule the wife’s desire to maintain the information as privileged and, therefore, outside of consideration by the court in a trial.

Nonetheless, this is a cautionary tale for all marriage and family counselors. A somewhat similar problem can occur in the absence of the child custody issue.

Within couples therapy, one party might tell the therapist of an ongoing extramarital affair in an unaccompanied interview. A different conundrum would be created thereby.

If the psychotherapist informs the naive partner of the infidelity, he has breached the confidence of the adulterer. If he continues the therapy, he is violating his responsibility only to provide care if he believes it can be potentially useful.

More examples might be offered.

An unseasoned health professional can find himself in a predicament with both ethical and clinical implications

Precise guidance to prevent such difficulties is not commonly found in the ethical guidelines of the various helping professions.

Therapists, one hopes, obtain enough supervision in the practicalities of their work to avoid horror stories of the kind described above.

Most of us achieve a measure of wisdom with hard experience and training. Of course, the truth of such a statement applies to much more than what happens in the clinic.

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*This essay is based in part on “Legal and Ethical Issues for Mental Health Professionals: Revised 2020″ by Psychotherapy.net Academy.”

The second image is Der wilde Mann (the wild man) by Paul Klee.