self medication

August 20, 2016

Treating Insecurity and Anxiety: Eight Roads to a Solution

512px-Anxiety_cloudImagine you are considering therapy for the first time. Or perhaps your treatment isn’t working. You stand at a crossroads, like the hub of a wheel where eight spokes beckon for attention. How should you choose among them?

Not all are good and you may even realize that as you decide. Here is a guide to thinking about what to do (and what not to do) with the weighty package of insecurities velcroed to your life. Click the link for a comprehensive list of the signs of insecurity.

ALCOHOL AND DRUGS. The issue of substance dependency should not be ignored. Recall the old Chinese proverb, “First the man takes the drink, then the drink takes the man.” Alcohol’s comforting relief and buoyancy is commonly replaced by longer term emotional darkness. Marijuana (cannabis) might mellow the smoker out but leaves underlying insecurity and anxiety untouched when sober. If you are attempting psychotherapy, best to tell the counselor the extent of your substance use straight away. The deepest wounds are slippery things. Grasping them is harder (if not impossible) when alcohol or drugs add to the excess lubrication.

WILLPOWER AND SELF-ANALYSIS. The old saying tells us, “When the going gets tough, the tough get going.” Yes, some few people manage their own psychotherapeutic project. Indeed, Freud analyzed himself. What is required? Although I know of no research on this, I suspect one needs a strong capacity for self-reflection, high intelligence, some degree of emotional openness, the courage to look in the mirror, tenacity, and knowledge gained through reading about treatment. Willpower is necessary because the self-analyst must inevitably get out of his head and leap the wall of fear to master behaviors blocked by insecurity: good eye contact, self-assertion, saying no, asking for things, making uncomfortable phone calls, inviting someone on a date, public speaking, etc.

THE SEARCH FOR A STRONGMAN. Some rely on a mate to perform avoided tasks. The significant other becomes a caretaker or body-guard, an individual who is sought to do the jobs the hesitant one believes he cannot: return a product to a store, accompany him to events otherwise avoided, and so forth. This is no solution to anxiety or insecurity, but a human crutch to sidestep the need to change. Another danger: too often the protector becomes an overlord, pushing you around or worse; the mister turned monster you hoped he would protect you against.

PSYCHOTROPIC MEDICATION. Medications, like other drugs, carry possible side-effects. Antidepressants can impair sexual performance, anti-anxiety tablets often have addictive properties. While a good psychiatrist will carefully watch for these, pharmaceuticals do not create a sense of security and confidence beyond the time you use them. Moreover, to the extent that the psychotropics help you feel better, your motivation to tackle underlying reasons for your symptoms may be reduced. That said, sometimes susceptibility to anxiety and depression is inherited and biologically-based, making the booster of drugs a necessary and permanent mode of treatment.

Girl_suffering_from_anxiety

AVOIDANCE AND THE INTERNET. Anticipation of discomfort, humiliation, or failure translates to turning down invitations — limiting chances for growth, accomplishment, and joy. The troubled soul is assaulted by hatchet-bearing ideas that have become permanent, non-rent-paying residents in the head. The data set of the insecure is based on an unfortunate history. The job of recovery translates to writing over your old history by gradually taking on social challenges and accumulating successes reinforcing your effort.

Beware the false god of the internet! The more time you worship at its alter and “let your fingers do the walking” on the keyboard, the less you have for direct human contact (involving actual walking out of the apartment). For all its marvels, this deux ex machina can become a screen behind which to hide the human face, trading yours for a virtual one. Yes, social media can be a stepping stone to a life beyond the keypad. For many, however, it’s another form of concealment and self-distraction. You can identify too fervent online social network disciples by the pain they will suffer for their god: a malady called text neck, the product of bending over their smartphone.

PSYCHODYNAMIC PSYCHOTHERAPY. Psychodynamic treatment, the traditional talking cure, can be a foundational part of counseling. It helps one clear the life-history undergrowth undermining a healthy self-image, planting  seeds of sturdiness to deflect the inevitable defeats we all encounter. Such counseling also lifts the weight of self-blame by recognizing the fingerprints of others on one’s problematic background story. It cannot stop there, of course. Grief and grieving demand attention.

Beyond relieving submerged pain, one must eventually take psychoanalytic insight for a test-drive: try new behaviors just as one would a new car before purchase. However much a “depth psychology” approach is needed, empirically based (research supported) interventions provide the practical impetus for emotional availability, symptom reduction, and behavioral change.

COGNITIVE-BEHAVIORAL THERAPY (CBT). Many of the well-researched and effective treatments just referred to fall into the category of CBT. Obsessive-Compulsive Disorder (OCD), for example, is among those problems amenable to this set of tools. Indeed, attempting a solution for OCD psychodynamically is, in contrast, a therapeutic cul-de-sac. CBT can often, however, be combined with more traditional talking therapy to join the best of both worlds.

ACT (ACCEPTANCE AND COMMITMENT THERAPY). ACT is described in the following way on its website: “Developed within a coherent theoretical and philosophical framework, Acceptance and Commitment Therapy (ACT) is a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. Psychological flexibility means contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.”

Plowing through this technical language, ACT deals with the losses most patients have sustained, traveling from a grieving process toward acceptance of those life circumstances that can’t be changed, reduced avoidance, learning to live in the moment via meditation, deciding what is most important to you, and choosing behavior consistent with your stated values.

WE ALL TAKE TURNS at life’s crossroads. Sometimes the best advice is to make no movement, patiently waiting for the traffic to clear. Do remember, however, not choosing is also a choice. The clock is always ticking, even if, in the digital age, we must strain to hear it.

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The top image by John Hain is called Anxiety Cloud sourced from Wikipedia Commons. The photo beneath it is Girl Suffering from Anxiety by Bablekahn at Kurdish Wikipedia.

March 20, 2013

Avoiding Life’s Pain: Drugs, Deadening, and the Defeat of Therapy

anesthesia

Having been raised in a secular home, I remember being shocked the first time I saw a religious carving in someone’s abode. It happened in my next-door-neighbor’s house. There he was, Jesus Christ, impaled right on the kitchen wall. Lunch was an ordeal given that Jesus was suffering just over my shoulder. For me I mean. My buddy and his mom didn’t seem bothered.

Since they were raised with crucifixion images all around, some indifference to the human sacrifice might have been expected of my hosts. The effect was similar to that produced by watching the first story on the TV news day-after-day, chosen by TV producers who use the mantra “If it bleeds, it leads.” We have all been desensitized by images of dead bodies, burnt flesh, undernourished children, and violence. Words like inured, deadened, habituated, and coarsened also come to mind; as well as accustomed, toughened, and hardened.

Drugs, alcohol, and antidepressant medication can play a part on the road to both callousness and self-protection. And, as I shall try to show, the question of how much of life to let in — how much to “feel” — is a big one for those in therapy and for all of those outside of it, as well.

Take one example. How are we expected to react to the TV news story of a murder? Should it be a matter of curiosity, the same kind that causes us to slow down on the highway to check-out an accident? Should we empathize with the pain of the afflicted? Should it provoke our action to prevent future calamities of the same kind; or reach out to the victims featured in the news story? Should we immediately feel a sense of gratitude that it didn’t happen to someone we love?

How is one of the faithful expected to react to the image of Christ on the cross? Is it supposed to just blend into the kitchen wallpaper? Or, should one react as if seeing it for the first time, aware of the horror of it, and the measure of sacrifice proclaimed to be done for all of humanity?

A Wood Carved Baroque Crucifix in St. Oswald's Church, Kastleruth, Germany by Wolfgang Moroder

A Wood Carved Baroque Crucifix in St. Oswald’s Church, Kastleruth, Germany by Wolfgang Moroder

Therapy confronts this dilemma. Simply put, it faces the problem of how to live in a world where emotional injury is inevitable. Most people come to treatment feeling too much. Part of the counselor’s job will turn on the question of openness to both pain and pleasure. The intimacy that we all want requires some amount of that openness, otherwise the closeness cannot happen. But, by permitting vulnerability, we suffer more when we have loved and lost; or lost anything or anyone we value. Consciously or not, man comes to a crossroads where one path leads to a deadened life and the other to one alive with pain and pleasure. You choose.

People vary in their sensitivity to even the vicarious experience of life’s emotional afflictions. Those variations are at least partially determined by the individual’s nature. I recall evaluating a teenager who appeared to have had an unremarkable childhood: no abuse, good parents, only the garden-variety of growing-up challenges. Yet, she wanted to keep a distance from others, in part because she felt their pain too acutely. Indeed, she was unable even to watch the TV news because the kinds of stories I mentioned earlier brought tears.

There are a great many ways to deaden oneself to depression and lesser states of sadness. Therapists are well-advised to find out whether their clients are using significant amounts of alcohol or drugs while they attempt therapy. Since counseling deals with emotion, those substances can keep the soft and sensitive parts inaccessible to even an expert therapist. If past losses need to be confronted, the grieving-project can be stalled by the artificial numbness or buoyancy of chemically induced mood alteration. Even antidepressants sometimes create the same challenge to reaching the wound so that one can treat it.

Therapy is difficult. Courage is required to deal with the pain, along with a therapist who can provide the most easeful way forward. Counseling can be a tightrope walk for both the sufferer and the healer: too much pain and the treatment will be as bad as or worse than the illness, too much anesthetic and there will be no cure at all; instead, a dependency on the joint or wine or antidepressant, perhaps in perpetuity.

At this point you might ask why a chemical solution to pain would be so bad. Indeed, for those who have a biologically-based mood disorder, psychosis, or Attention Deficit Hyperactivity Disorder (ADHD), medication may be essential. But what of those for whom drugs or alcohol or medication represent an avoidance of “real life,” an escape from the job of confronting their own internal discomfort? Let me give you an example.

The woman in question had an admirable life in objective terms. Nice family, nice career, large nest egg. She was haunted, however, by her long deceased, disapproving father. Though he’d been dead for 20 years, not a day went by without thinking about him. She tried therapy because she was depressed, but her therapist never inquired about possible drug use and the patient didn’t report it. Yet, nearly every evening for those same decades she’d lived in a cannabis-induced haze and continued to do so during her treatment.

Therapy tried to focus much of its attention on her relationship with her dad, his lack of affection, and his failure to praise her considerable accomplishments. The therapist hoped that this woman could break through to a depth of feeling (both sadness and anger at the father) that would free her from the sense of inadequacy she struggled with every day. The psychologist believed that by getting her to re-experience the intensity of her injury, she would recognize its unfairness and her father’s indefensible cruelty, not just intellectually but with her whole being. Perhaps then she would no longer blame herself.

It didn’t happen. One suspects that the treatment failure — the defeat of this woman’s therapeutic project — was due to her marijuana use, a kind of self-medication that took the edge off the worst of her pain. It kept the patient just above water, but didn’t allow her (or the therapist) to go below sea level to the grip that her father had on her — a dead hand that metaphorically threatened to drown her. Had she not been smoking pot, it is possible that further exploration below the surface and into the depth of her pain would have released the dreadful downward pull of a ghost’s grip, permitting the grieving needed to free her from his verdict that she was worthless.

There is yet another reason to be concerned about an anesthetized life and reliance upon those substances that can be bottled, injected, and smoked; quite apart from the potential for addiction and bodily destruction. Yes, the blitzkrieg of life is a challenge to an undistracted, full-frontal awareness of your suffering at every moment. But if life is indeed sometimes simply “too much,” we must still choose carefully how to cope with that difficult reality so that the remedy isn’t also “too much” in a different way.

The death of pain means the death of life itself. Our defenses against feeling the bad also can prevent us from feeling the good. The question of anesthesia’s uses and misuses must be faced: whether to use it, how much to use it, and when to use it; reminding ourselves that the more anesthetic, the more we become inured to everything, the good and beautiful and poignant, as well as the painful. And the more we simply watch, sit back, and let the best of life pass us by.

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The Crucifix is sourced from Wikimedia Commons.

July 23, 2011

Too Many Balls in the Air: The Frustrated and Frustrating Life of ADHD

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He was dynamic, outgoing, and enormously entertaining.

He was creative, full of ideas, and energetic.

And he was one of the most frustrating people you would ever care to be around.

About whom do I speak? A bright, charming man with Attention Deficit Hyperactivity Disorder.

ADHD is more complicated than you might think. Although there is much written about it, I want to cover a few of the things that can be missed about the condition. But first, let me explain the name and define it.

There are three types of ADHD (Attention Deficit Hyperactivity Disorder):

  • 1. ADHD, Predominantly Inattentive Type. This used to be called ADD, but technically speaking, sufficient inattentiveness is considered a category of ADHD, even though little hyperactivity may be present. These are the folks who seem to be listening, but are lost in space; easily taken away by a tune, a sound, or an idea; the people who miss the details and forget the assignments.
  • 2. ADHD, Predominantly Hyperactive-impulsive Type. This is what most people think of when they hear or read the four letter acronym ADHD. People with this diagnosis are characteristically talkative, active, intrusive; a bundle of unmanaged, impulsive activity.
  • 3. ADHD, Combined Type (meaning it includes the symptoms typical of the first two categories); too many balls in the air, for sure.

What about the man I mentioned at the top; a person who had the “combined type” of ADHD?

He had lots of energy and ideas, so people found him engaging. But it wasn’t a very productive sort of energy. He would begin things, but not complete them. He was disorganized — losing keys and papers, and forgetting appointments. He promised to do things, but couldn’t be relied upon to do them as quickly or as well as expected, if at all.

This man (let’s call him A.T.) went nowhere fast; very fast. A.T. looked liked the “Energizer Bunny,” but mostly traveled in circles.

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He tended to over commit himself, taking on more tasks than he could handle effectively, chronically underestimating what he could accomplish in the time available. A.T. was routinely late for appointments, and made decisions quickly, without fully considering the longer term consequences of his actions. Bored easily, distracted more easily, and prone to procrastination, he knew that he wasn’t what others hoped for and expected. Although he was full of promise, his reputation was that of someone who was a thoughtless, irresponsible underachiever — an individual who needed minding.

Employers were disappointed, co-workers were frustrated by A.T., and his spouse was driven just a little crazy, feeling that she couldn’t depend on her partner. She’d married someone who was exciting, only to find that the excitement he produced was more of the “Oh, no!” kind that made her sweat when she discovered he was late to pay a bill or pick up the kids. Not surprisingly, she started to see him as just another one of the kids, as their partnership turned into more of a “disapproving mother/resentful child” relationship than either of them wanted.

http://upload.wikimedia.org/wikipedia/commons/thumb/9/96/Europa-Park_-_getroffen_4_-_von_Mama_ausgeschimpft.jpg/240px-Europa-Park_-_getroffen_4_-_von_Mama_ausgeschimpft.jpg

Before I tell you about A.T.’s treatment, let me say a few things that might not automatically come to mind about the condition and its consequences:

1. Hyperactive/impulsive ADHD individuals can sometimes look like they are world beaters, but mostly beat themselves; indeed, they are often chronic underachievers. If you are planning on forming a working group or partnership with such a person, don’t be fooled by a positive first impression of excitement and energy. You will almost certainly be disappointed down the road.

2. ADHD, even today, is sometimes not detected in schools. There are several reasons:

  • The inattentive form of this condition may well produce school failure, but not misbehavior. Inattentive children are often quiet and relatively well-behaved, unlike their hyperactive-impulsive counterparts.
  • School personnel may incorrectly attribute ADHD-like behavior to laziness or oppositionality. Moreover, school systems, even when they do formal evaluations, are frequently reluctant to identify problems that require additional resources and personnel, which they are hard-pressed to provide given their limited funds.
  • An ADHD child who is bright can compensate (to some extent) for his attentional problems by relying on his excellent intellectual abilities, at least for a while. Eventually, however, many of these children (as they age and school begins to demand more of them) find out that advanced intelligence is no longer sufficient to permit success.
  • There is no single standard measure that reliably identifies ADHD. Evaluators commonly use some combination of paper and pencil tests, clinical judgment, and attentional measurements. Intelligence (IQ) and neuropsychological tests can easily miss some of the most clinically obvious cases of this condition.

3. The fact that ADHD children are able to become “hyperfocused” on things like computer games or other tasks that they find especially interesting, does not invalidate the diagnosis of ADHD. Indeed, this sort of selective attention is seen fairly often.

Some researchers believe that those games provide rewarding stimulation in the form of frequently changing images, sounds, and challenges; as well as the success of achieving points or increasing levels of success, thus “capturing” the attention and imagination of the ADHD youngster. By comparison, the real world school room seems boring. Recommendation? Limit your child’s screen time, even in front of regular TV shows.

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4. Although many people are hesitant to take medication, ADHD is a diagnostic category that is especially responsive to psychotropic medication. Hundreds of studies support the effectiveness of such treatment for about 85% of children with this condition according to Russell Barkley’s authoritative 2006 book Attention-Deficit Hyperactivity Disorder. In a 2007 paper by Elliot and Kelly — “ADHD medications: an overview” published in the journal Attention — the authors state that “No medicine available to psychiatrists produces a more rapid and dramatic effect more safely than the proper dose of a stimulant to a patient with ADHD.”

5. If medication does work, it will likely be needed on a continuing basis, not as a temporary fix. The irony is that stimulant medication, which will cause internal agitation in those who are not suffering from ADHD, actually permits the person with the condition to focus more and become less prone to the hyperactivity/impulsivity that had been a problem.

6. ADHD is correlated with a greater risk of developing a Conduct Disorder, typically characterized by antisocial misbehavior and defiance of authority. Not surprisingly, such individuals often abuse alcohol or drugs (not only as an act of rebellion, but also as a self-medication designed to calm their hyperactive state). Adolescents and adults who have ADHD are thought to make up at least 25% of the population of prisons according to Barkley.

In all these examples, the impulsive, ill-considered behavior that is typical of ADHD takes a fearful toll. Such individuals are easily bored, requiring intense and novel reinforcement (rewards) to motivate them, and are prone to “sensation-seeking” — looking for extreme excitement that their condition seems to make them crave. Indeed, one patient of mine reported driving at speeds approaching 100 MPH on city streets simply for the feeling it produced in him. Nor did he think he was at much risk (or putting others at much risk) in doing so, thus demonstrating the poor judgment characteristic of those with the hyperactive-impulsive form of ADHD, as well as their tendency to disregard rules and authority figures.

7. While many general medical practitioners (GPs) can prescribe medication for ADHD quite well, some are hesitant to do so, sometimes due to lack of training or inexperience with this particular diagnosis. Cautious GPs will prescribe psychotropic medication, but are prone to giving doses that are too small. It is generally best to see a psychiatrist in such cases; that is, someone who specializes in the prescription of medication for psychiatric disorders.

8. The frustration that ADHD produces in school children can make them give up (and eventually drop out), believing that nothing they can do will make any difference in their performance. Some of them will become avoidant of academic or other work tasks because they believe that they will fail, thus producing a self-fulfilling prophecy. Many will get angry at the teachers, bosses, and parents who so often are reminding them of their inadequacies. Thus, ADHD fuels other behaviors that make a good life difficult.

What happened to our friend A.T?

You’d think it was simply a matter of telling him of the benefits of medication, wouldn’t you?

Not so fast.

He was one of those folks who was uncomfortable with the “idea” of having to be reliant on medicine. He told me that he didn’t “believe” in medication, as if it was a matter of religious faith.

A.T. was also quite narcissistic; in denial concerning his own responsibility for the things that went wrong in his life. Similarly, he had no trouble blaming others including bosses and wives. Not to mention that he drank too much and didn’t acknowledge that it was a problem. Indeed, he had only come into treatment at his spouse’s insistence.

One of the challenges of psychotherapy is the fact that few people fit “pure” diagnostic types. Instead, one must be aware of all the complicating factors that can make effective therapy difficult. This man’s narcissism, denial, and alcohol abuse certainly created just such complications.

Had A.T. been more motivated and self-aware, less prone to denying the misery he was creating around him, a cognitive-behavioral (CBT) approach to his ADHD could well have helped, even if he chose not to take medication.

CBT programs include formal guidance in planning and organizational skills, assistance in problem solving and decision-making, help in reducing the number of distractions in the environment, practice in new thinking skills, training in ways to reduce procrastination, and advice to help you cope with failure. Homework is required between sessions.

The program described by Steven Safren and his associates in the work book Mastering Your Adult ADHD, developed by psychologists at Massachusetts General Hospital and Harvard University, was able to produce significant improvement in about 50% of those patients who continued to have clear problems even after being treated with medication.

So, if you have ADHD, medication and CBT provide reasons for optimism that things can get better.

Just don’t drop the ball!

Thumbnail for version as of 15:40, 14 September 2005

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The top image is the Carbon Cycle created by the U.S. Government Department of the Interior. The one that follows is the Tux Crystal Linus Award by Nevit Dilmen. The next photo was created by Thomas Pusch and is called Scolded By Mama. The fourth picture is of Two Men Playing a Computer Game by Love Krittaya. Finally, a picture of a Geode  by Whitsoft Development. All are sourced from Wikimedia Commons.