October 31, 2013

Stress Savvy

When I teach mindfulness-based stress reduction (MBSR) class, we spend a lot of time discussing ways that mindfulness can help us behave more adaptively when we're facing a challenge or stressor. I emphasize the idea of developing adaptive responses to stressors, rather than engaging in automatic and habitual stress reactions that invariably make things worse.

Everyone loves the idea of coping better with stressors, and most people have personal strategies that they apply during periods of particular stress; examples include exercising more, taking extra care to eat well and get enough sleep, going for a massage, spending more time with family, and spending less time with family. Such stress reduction/management strategies help us avoid slipping into the kind of automatic reactions that stress can produce (e.g., smoking, drinking, eating poorly, avoidance, withdrawal, picking fights). But the other night, one MBSR participant raised a key point: What if you don't know you're stressed out?

Good question! After all, we can't implement our stress reduction/management strategies if we aren't aware that we're stressed out. We've all had the experience of making a poor decision, hurting someone's feelings, or otherwise saying or doing something mindless or maladaptive only to later realize that we were completely stressed out at the time. This is where mindfulness enters the picture to help us know ourselves better and recognize our patterns.

Here are two questions we can ask ourselves--right now--that can help us recognize earlier that we're stressed out.

1) What are the first signs that I'm stressed out? For some people, the first sign is physical: shoulder tension, belly agitation, headache, or a feeling of pressure in the chest. For others, the first symptom of stress is mental, e.g., ruminating over an issue long after it's been resolved, getting really indignant over a minor issue. For others, the first sign is behavioural, e.g., they know they're stressed out when they find themselves eating out of the container standing up. One MBSR participant reported that his first sign is that he starts being rude to cashiers, taxi drivers, and other strangers--people he usually greets with "Hi, how are you?"

2) Under which conditions am I the most likely to get stressed out? Examples include "When I'm hungry," "When I'm tired," "Toward the end of the work week," "When I've been fighting with my partner," "When I'm in a rush," "When I feel like my authority is in question."

Knowing the answers to these two questions is mindfulness gold. If you can identify that eating out of the container is a sign that you're stressed, the next time you find yourself standing in front of the open fridge with a tub of yogurt in one hand and a spoon in the other, you'll know it's time to implement your stress reduction/management strategies. If you can identify that you're prone to mindless stress reactions when you're tired, the next time your children or loud neighbours keep you up all night, you'll know to consider how to best care for yourself the following day so you don't fall prey to mindless stress reactions.

Knowing the signs and conditions that indicate stress for us doesn't eliminate our initial stressors, but can help us avoid the added stress generated by mindless reactive behaviour.

What are your signs and conditions?

September 29, 2013

Pattern Projection

Mental health tip: Experiences can make you feel the same way without being related.

When we go through a string of negative experiences (e.g., socially, professionally, romantically), our tendency is to review them as a group and search for patterns. This can be a worthwhile exercise: identifying patterns helps us establish what went wrong and determine whether or not there's something we could be doing differently. On the flipside, though, identifying a pattern where none exists can be quite unhelpful:

One of my clients has been looking for work for months and becoming progressively discouraged. Last week, after another promising interview failed to result in a job, he concluded that since "this keeps happening," he must be doing something wrong. At first glance, this seemed like a reasonable hypothesis; but when we took the time to explore the evidence for the idea that "this keeps happening," we failed to find a pattern. The most recent position my client interviewed for was filled by an internal candidate. The job before that fell through after the organization didn't received the grant needed to fund the position. Prior to that, my client was offered a part-time contract position that he declined because his daughter has a chronic medical condition and he needs health benefits to cover her medical costs. For the position prior to that, my client was short-listed but the first-choice candidate simply had more years of experience. In short, although none of the leads resulted in a job, there was no pattern.

One of my friends had two painful romantic experiences in the past six months. In the first case, a close friend for whom he harboured romantic feelings admitted that she'd always had a thing for him, too--and then promptly met and fell for another guy. In the second case, my friend ended a promising new relationship after a frank discussion revealed that the woman he was dating doesn't want to have children. These back-to-back experiences left my friend feeling pretty discouraged; he concluded that "this keeps happening" and that therefore there must be something wrong with him. Thinking of my client and his job search, I encouraged my friend to consider the possibility that he was projecting a pattern onto a patternless pair of experiences. He thought it over and acknowledged that the first situation was attributable to bad timing and the second to long-term incompatibility. That is, even though both relationships ended, there was no pattern.

How does realizing there's no pattern help? Finding patterns where none exist generally involves distorted thinking, including overgeneralization ("this always happens"), personalizing ("it's happening because of my own personal flaws and has nothing to do with external factors"), disqualifying the positive (e.g., my client ignoring the fact that he was offered a contract position; my friend dismissing the heartening facts that both women returned his feelings). Distorted thoughts make us feel bad, whereas identifying and reappraising our distortions alleviates the pain. 

Why do we project patterns onto patternless experiences? My theory is that we assume that experiences that make us feel the same way are related. My client felt discouraged and rejected each time a position didn't work out. My friend felt lonely and hopeless both times the relationship ended. But the respective HR departments made completely independent decisions not to hire my client--based, it turned out, on entirely different rationales. They weren't related. The two women my friend dated didn't know each other and didn't know of each other, and the relationships ended for entirely different reasons. They weren't related.

Both my client and my friend felt less discouraged once they stopped projecting a nonexistent pattern onto their experiences. The next time you're looking for a pattern in a string of negative outcomes, consider the possibility that there is no pattern in the experiences, only in the way you feel about them.

Does it help?

September 03, 2013


Lovingkindness is a Buddhist practice that involves wishing well to ourselves and others. It encompasses generosity, good will, friendliness, compassion, and benevolence, and is often cultivated through meditation. When I teach mindfulness-based stress reduction (MBSR), we do a lovingkindness meditation in the session devoted to relationships and relationship conflict. The rationale is that practicing lovingkindness helps cultivate patience, kindness, and acceptance--which can have only positive consequences for our relationships.

The lovingkindness meditation involves sitting quietly and "sending" well wishes, starting by sending them to ourselves. When I guide the meditation, I say the following phrases out loud, one by one, and participants repeat them silently.

May I be safe and protected
May I be happy and peaceful
May I be healthy and strong
May I live with ease and the joy of wellbeing

We then send lovingkindness, in turn, to someone we love, someone toward whom we feel neutral, and someone with whom we're experiencing conflict.

May he/she be safe and protected
May he/she happy and peaceful
May he/she healthy and strong
May he/she live with ease and the joy of wellbeing

I warn MBSR participants beforehand that they might not necessarily feel loving or kind during the meditation--in fact, that they may feel resistant or unwilling--but it doesn't matter. Compassion is being cultivated even if we don't feel it in the moment, and it's always interesting to observe what happens when we practice lovingkindness, even if what happens is struggle.

What's the impact of lovingkindness meditation?

Many people cry when they first send lovingkindness to themselves. Self-compassion isn't always easy and, for some, it's the first time they've ever expressly wished themselves peace, ease, and joy. MBSR participants variably describe the experience as a warm sensation in the chest; a feeling of the heart opening up; a softening; and a movement towards seeing themselves as fallible but worthy and okay.

What's more, the lovingkindness mediation seems to provoke a similar softening toward others, including people with whom we're experiencing conflict. Following the lovingkindness meditation, MBSR participants report that they feel more open and compassionate. Even if they experienced resistance to sending lovingkindness to the person causing them distress, they still feel less angry and confrontational, and more prepared to interact with that person.

How does lovingkindness work?

One way that the lovingkindness meditation seems to work is by snapping us out of the endless cycle of you jerk you idiot how could you I can't stand you. When we're angry or otherwise upset with someone, it's easy to get stuck in a cycle of rumination, telling ourselves stories about how wronged we were, how hurt we are, and how awful that person was to do what he or she did. Whether we're upset with ourselves or with someone else, sending lovingkindness forcibly snaps us out of the rumination cycle. 

A second way that lovingkindness seems to work is by interrupting our tendency to demonize others. When someone upsets us, our minds can turn him or her into a monster who is purposely trying to hurt us or make our life difficult. My experience has been that when I force myself to wish for safety and protection, happiness and health for someone who's hurt me, two things happen: First, my mind retorts I DON'T WISH THAT, I HATE HER; second, I realize that I actually do wish those basic experiences for all people--even someone who's hurt me. This realization shrinks that person from a monster back to a human who is hurt or struggling, dealing with her own issues, and probably doing the best she can--not expressly trying to hurt me or ruin my life.

Developing compassion for ourselves and others via lovingkindness makes us more accepting and forgiving, whether we're dealing with a longstanding conflict or with someone who cuts in line at the grocery store. Lovingkindness doesn't have to involve formal meditation, but can be practiced any time you're self-flaggelating or ruminating about a conflict with someone else. Simply take a quiet minute or two to repeat the phrases above to yourself, and see what happens.

NB: An extra trick that helps me develop compassion is to picture the person with whom I'm in conflict in bed at night. Imagining him curled up under the covers in his pyjamas helps me remember that he--like me, like everyone!--crawls into bed at night wearing comfortable clothes and seeks rest. He is as vulnerable and human as any other person (and is not staying up all night plotting ways to make me miserable!).

July 24, 2013

For Better or for Worse

Warning: Mindfulness isn't always fun.

Often when I recommend mindfulness practice to a friend or client, we end up talking about the joys of being more present and less distracted, the wonderful feeling of really connecting during a conversation, or the gratifying experience of actually paying attention to what you're seeing, reading, or eating. Mindfulness is associated with pleasure, and rightfully so.

Mindfulness isn't always that pleasurable, though. Being mindful involves willingness to be present and aware of all of our experience--even when it isn't fun or exciting, and isn't what we hoped for. This includes awareness of what's going with the people around us and what's happening in our environment, but it also means being aware of what's going on inside us, i.e, our thoughts, feelings, and body sensations.

But what if what's going on inside is unpleasant? Do we really want to be aware of hateful or embarrassing thoughts, unpleasant body sensations, and painful feelings? My answer is yes and here's why:

It's a beautiful sunny day and I'm working from home and actually being quite productive--yet I don't feel good. I woke up with belly and chest pain, and the physical sensations and accompanying anxious mood persisted through meditation, breakfast, errands, and several espressos. Because I've been practicing mindfulness for a few years and because I meditated this morning, I know what's wrong: I'm upset about a conflict with a friend that happened last week, an issue I thought was resolved. Because I checked in with my thoughts, feelings, and body sensations, I know that I feel sad and uncertain, that there's a paring knife slicing through my chest and something heavy and round sitting behind my belly button, and that my mind is repeating "It's your fault" over and and over.

You might be thinking that all of this sounds quite unpleasant and you're right. The physical sensations hurt, it was uncomfortable to realize that I'm still upset about the conflict, and it's irritating that the discomfort is present on an otherwise nice day. In this case, mindful awareness is only making me aware of physical and emotional pain. So why am I glad to have tuned in to it?

Despite the discomfort, awareness of my distress is worth it because the awareness
a) helps me avoid making it worse, and b) helps me decide what to do. A few years ago, if I woke up with this feeling I might have eaten an entire jar of peanut butter for breakfast, gone to work in a zoned-out state of anxiety/peanut-butter stomach discomfort, been short with my colleagues, called my sister at work to complain about my undiagnosable free-floating anxiety, come home and automatically gone for a run whether or not I felt like it, and then gone to bed and woke up feeling even worse the next day. I might even have spent time with the friend I'm in conflict with and acted passive-aggressive or self-effacing without realizing it.

In contrast, today I noticed that something was weird as soon as I woke up. I purposely selected a guided meditation designed to help me look closely at my feelings and physical sensations, which made it clearer what was wrong. I made a good breakfast, decided to work from home, and strategically chose to work in the living room rather than the kitchen to avoid my habit of mindless overeating when I'm stressed. I resisted the temptation to call my friend and frantically make amends. I'm making decisions based on the fact that I know I'm upset; in so doing, I'm exercising self-compassion and avoiding making things worse.

Mindful awareness that I don't feel well doesn't take away the not feeling well. None of this is pleasant and I would much prefer to enjoy this gorgeous day without symptoms of anxiety and without a stressful conflict. But given that this seems to be what's happening today, I'd rather know about it.

Mindfulness can be unpleasant, but not as unpleasant as mindlessness and its repercussions.

July 21, 2013

Strike When the Iron is Cold

In a conflict, is it best to strike while the iron is hot and try to identify and resolve the problem as it's happening? Or is it better to address it later, after you've cooled off a bit?
A couple weeks ago, I attended a mindfulness retreat. During a discussion of mindful stress management, the teacher informed us that in the moment of a stress reaction (e.g., mind racing, heart pounding, blood pressure skyrocketing), access to the rational and reasonable part of our brain is essentially cut off. While this initially seemed counterintuitive, it makes sense in evolutionary terms: When we face a threat, all of our body's resources are allocated to the fight-or-flight response, helping us either fight with all of our might or escape. Survival is the only objective and our attention narrows to focus exclusively on the threat; the part of our minds that can consider and deliberate isn't needed.

This resource allocation system is adaptive when it helps us escape from a sabre-tooth tiger or lift a car off a trapped child; however, our minds and bodies do the exact same thing when we're facing everyday hassles, delays, slights, and other stressors. Not recognizing the stress reaction, we often push forward with conflict resolution and problem-solving, making things worse. 

Earlier this week, I received what I perceived to be an unprofessional, insulting, and just plain mean email from a colleague. My body immediately launched a stress reaction--hot face, pounding heart, tensed muscles. My mind racing with righteous indignation, I dialed my colleague's number and then, remembering what I learned at the retreat, hung up and decided to step away from my desk. Sitting in the lunchroom a few minutes later, I observed what was happening in my mind ("Who does she think she is! That's so mean! After all I've done for her!") and in my body (see above), and dug around to see which emotions were present (hurt, anger, frustration). This information led me to believe that I was having a stress reaction and helped me decide to put off respond to the email for 24 hours. This decision definitely led to a more satisfying resolution of the conflict!

The concept of addressing conflicts and problems once you're temporally and emotionally removed from them isn't new. But learning that half of our brain is missing when we're in the throes of a stress reaction really hits home: It explains why it's so hard to think when we're upset and why, when we're mad or scared or sad, we can't consider alternative perspectives, and often miss information that's easy to see once the stress reaction passes. But how can you tell when you're having a stress reaction? This is where mindfulness comes in: Sit or stand still for a minute and become aware of your thoughts, emotions, and body sensations. Tune into how you're feeling and then use the data to decide what to do.

NB: Strike when the iron is cold applies equally to the other parties involved in your conflict. That is, you may be calm or have moved beyond your stress reaction but you need to be sure that the other party has too. You don't want to problem-solve or conflict-resolve with someone who's missing half their brain!

June 17, 2013


Two weeks ago, I attended a psychiatry conference on mindfulness in cultural context. Many of the talks were about contemplative practices from cultures outside North America, and one in particular caught my attention:

The Japanese practice of Naikan (tr: inner-looking or introspection) is a structured method of reflection designed to help people broaden perspective, gain insight about themselves and their relationships, and increase appreciation of the kindnesses of others. Practicing Naikan involves sitting for long periods and reflecting on the following three questions as they relate to various significant others (e.g., parents, children, partners, friends, teachers):

What have I received from this person?
What have I given this person?
What troubles and difficulties have I caused this person?

The objective of Naikan is to generate a realistic view of our behaviour and of the give and take in our relationships. The obvious fourth question (What troubles and difficulties has this person caused me?) is purposely excluded, with the rationale that most of us are already quite adept at pinpointing and obsessing about the inconveniences caused us by others--and that our focus on this aspect of our relationships is responsible for much day-to-day stress and unhappiness. 

What happens when we practice Naikan? Research demonstrates that the practice increases our sense of connectedness with others and improves quality of life. If we once believed ourselves to be alone or to be "self-made," recognition of the kindness and contributions of others increases feelings of security, connection, and gratitude. Insight into the troubles and suffering we've caused others can create change in our behaviour and in our relationships.

In traditional Naikan retreats, practitioners sit in silent isolation for fourteen hours per day for two weeks reflecting on the three questions. This is described as a profound and life-changing experience, but when a week-long retreat isn't accessible or desirable, we can try daily Naikan. Daily Naikan practice means taking time at the end of the day to reflect on the three questions as they relate to the day’s events. What did I receive today? What did I give today? What troubles and difficulties did I cause today? Even trivial-seeming instances of give and take such as "My colleague brought me a coffee" and "I cut off a guy in traffic" are included.

Daily Naikan may not be as profound an experience as a week-long retreat, but I noticed that just keeping these questions in mind as I went about my daily life in the past two weeks changed my perspective. I was more mindful of the kindnesses I received and more aware of the hassles and difficulties I caused--with the end result that my behaviour was more flexible and more giving. I drove a friend to the airport, agreed to give a presentation as a favour to a supervisor, and offered my apartment to visiting friends so they won't have to book a hotel. I softened my stance against a colleague who gets under my skin, changed my schedule to accommodate a client, and called up friends just to see how they're doing. The first two Naikan questions helped me appreciate the love and guidance I receive and less apt to focus on the support or attention I don't receive. The third Naikan question helped me recognize times that I was needy, irritating, or rude--which will help me change my behaviour.


NB: Naikan has clear parallels to the What Went Well exercise and other positive psychology exercises such as keeping a gratitude journal--and the same reported outcome: improved quality of life. Naikan can also be considered to be a form of mindfulness practice in that it involves attention and awareness, and making an effort to see ourselves and our circumstances clearly.

June 03, 2013

DSM-5: Pathologizing versus Dismissing

After years of working groups, expert task forces, and public opinion, the American Psychiatric Association has finally published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is the bible of mental illness, listing every diagnosable problem from autism to post-traumatic stress disorder to attention deficit/hyperactivity disorder to cocaine addiction. It's widely used by psychologists, psychiatrists, and general practitioners to categorize symptoms, differentiate between disorders, and communicate with other professionals.

Despite its widespread applications, use of the DSM is controversial because detractors fear that the manual pathologizes normal behaviour. This is a reasonable concern: for example, homosexuality was listed in the DSM up until 1986, an inclusion that effectively labelled homosexuals as mentally ill. Today, DSM-5 is criticized for new additions such as binge eating disorder, skin-picking disorder, and premenstrual dysphoric disorder (PMDD).

While concerns about pathologizing are legitimate, it's easy to go too far in the opposite direction and dismiss psychological problems that cause real and significant distress. For example, binge eating disorder (BED) is a controversial new diagnosis in DSM-5. It's the first time that binge eating has been recognized as a problem independently of more familiar eating disorders such as anorexia and bulimia. In his article about the 'worst changes in DSM-5,' psychiatrist Allen Frances dismissed the diagnosis of BED, attributing binge eating to gluttony and the wide availability of good-tasting food.

This is irritating. Not only is Frances' attitude flippant and dismissive, his statement ignores several of the diagnostic criteria for binge eating disorder. To be diagnosed with BED, you have to overeat at least once per week for a period of three months, but you also have to experience a lack of control over eating, marked feelings of distress, and three of the following: eating much more rapidly than normal; eating until uncomfortably full; eating large quantities when not physically hungry; eating alone out of embarrassment for overeating; and feeling disgusted, depressed, or guilty after binge eating.

The characterization of binge eating as gluttony or overindulgence doesn't account for the distress, isolation, and shame involved in BED. There's a difference between overeating with friends or family on a special occasion, and regularly standing in front of your fridge one hour after dinner, furtively shoving cold leftovers into your mouth and feeling helpless to stop. The criterion of 'distress or impairment in functioning' applies to most DSM diagnoses: scratching mosquito bites the week after camping is not the same thing as regularly picking at skin blemishes until they're bloody and infected (skin-picking disorder), and occasional tearfulness following ovulation is not the same thing as the monthly mood swings and deep sadness and despair that characterize PMDD.

While so-called fad diagnoses can divert attention and resources away from serious illnesses, and hastily slapping a diagnosis on anyone who reports a symptom now and then is obviously harmful, let's not go too far in the opposite direction, dismissing symptoms and denying treatment to people who are suffering. The changes introduced in DSM-5 mean that individuals who binge eat, pick their skin, or experience monthly episodes of distressing unstable mood post-ovulation may now have better luck convincing doctors that the problem is real, explaining themselves to loved ones, and getting their insurer to pay for treatment.

What's wrong with that?

May 11, 2013

Positively Stressed

Mental health tip: Just cause it's positive doesn't mean it isn't stressful.

One of my friends is planning her wedding. She just sold her condo and she and her fiance are moving into their new house next month. Meanwhile, she was offered a promotion at work and her first short story was accepted--pending revisions--for publication in a national magazine, pending revisions. We recently met for dinner after not seeing each other for a couple months and when she told me all her news, I said something like "Wow, you must feel on top of the world!" Instead, she tearfully confessed "I'm so stressed out I can barely breathe. I've been taking sleeping pills almost every night to try and get some rest, and worst of all--I know I should be happy and enjoying all this!"

One of my mindfulness students is about to finish medical school. After four arduous years, he's going to graduate next month and is nailing down his plans to move to another city for his dream residency. In the meantime, he's training for his first triathlon and he and his girlfriend are expecting a baby in the fall. When he told me all his news, I remembered my friend and said, "Wow, that's a lot of stuff. You must be kind of stressed out." My student tearfully admitted that he hasn't been eating or sleeping well and is constantly picking fights with his girlfriend. "The worst part," he said, "is that I know I'm so lucky and that I should be happy instead of stressed out!"

What's going on here?

Both my friend and my student were compounding their stress with the erroneous belief that positive events should create only positive feelings. This idea meant that they were adding guilt on top of stress, making it worse.

Two things that helped:

a) Sharing the definition of 'stressor' that I use in teaching mindfulness-based stress reduction: "Any threat, demand, pressure, or change in the environment that requires the organism to adapt." Notice that this definition does not assume that stress is caused by negative events, but rather by pressure and change.

b) Introducing the Holmes and Rahe stress scale. Developed by two psychiatrists, this scale yields a total stress score based on life changes and experiences in the past year, including things like marriage, retirement, Christmas, change in personal habits, and change in number of family reunions.

Getting married, moving, changing jobs, morphing from student to professional, and preparing for a baby certainly all qualify as demands, pressures, or changes requiring adaptation, and almost all of them are listed in the Holmes and Rahe scale. My friend and my student were relieved to know that just cause it's positive doesn't mean it isn't stressful; acknowledging that positive stress is still stress allowed them to cut themselves some slack, decreasing the unnecessary additional stressor of guilt.

The next time you're feeling stressed out in the midst of an avalanche of good news or positive events, remember that just cause it's positive doesn't mean it isn't stressful.

NB: This first step will probably in itself make you feel better. However, an important second move is to take concrete steps toward stress reduction. My friend booked a massage, cancelled her bachelorette, and negotiated a week's vacation prior to beginning the new position at work. My student registered for a 10k race rather than a triathlon, and decided to stop collecting new baby gear until after the move. 

May 03, 2013

Sunday Neurosis

You know that creeping anxiety that develops on Sunday as the weekend draws to a close?

It's not just you! So many friends, patients, and mindfulness students have mentioned the "Sunday night feeling" recently that it merited a Google search. It turns out that Sunday-specific anxiety is a ubiquitous phenomenon: sources as diverse as Psychology Today and Victor Frankl--an Austrian psychiatrist famous for finding meaning in his concentration camp experience--have written about the Sunday feeling, with Frankl coining the term "Sunday Neurosis."

Sundays can be difficult for multiple reasons, including the following:

1) They're unstructured. Although we complain about workday constraints, many of us prefer routine and schedules. Saturdays are often filled with errands and chores, but Sunday is often a looser, lazier day--which is not comfortable for everyone.

2) We have to return to work the next day. Even if we're relatively happy with our job, the looming return to the office can be enough to stimulate apprehension. If we aren't happy at work, or left tasks undone on Friday, the Sunday feeling can intensify to dread.

3) We're still carrying childhood school anxiety. For many, the sad Sunday feeling has its roots in childhood, when we faced homework, the end of two days of play, and an early bedtime. If we were bullied or otherwise unhappy at school, Sunday night angst could intensify to outright fear.

4) We didn't accomplish all of our weekend goals--including relaxation. As Thursday and Friday roll around, we often build up our expectations of our precious two days off and generate unrealistic to-do lists. For example, we plan to--over the course of two days--catch up on reading, go to the market, visit our parents, sleep in, take the kids to the park, finally fix the leaky shower head, do a bit of freelance work, clean out the closets, and cook a couple dishes to freeze for dinner later in the week. Above all, we plan to relax and unwind--while accomplishing everything on the list above! Failure to meet our improbable goals contributes significantly to Sunday angst.

How can we decrease or manage Sunday Neurosis? Here are some solutions:

1) If your Sunday Neurosis is generated by unrealistic expectations for your two days off, try treating your weekend to-do list as a loose game plan, not a strict program. Better yet, identify two or three priorities and let go of the rest. For example: this weekend I will grocery shop, have dinner with a friend, and call my mom. Or: this weekend I will clean the bathroom (not the whole house), register the kids for summer camp, and take one hour to sit and read for pleasure.

2) If your angst is generated by the unstructured nature of Sundays, make a loose schedule for your day. For example, plan to go to the gym in the morning, catch up on personal email in the afternoon, and do laundry after supper before relaxing with an hour of TV. You don't have to schedule every minute of your day, but a general plan can alleviate anxiety created by lack of structure.

3) If your Sunday Neurosis is related to the upcoming return to the rush of the week, consider ways you can use your day to alleviate weekday stress. You might feel better about Monday if you took some time on Sunday to do laundry, make lunches, run errands, and otherwise prepare for the upcoming week. Getting the household to bed on time can also help.

4) If your Sunday stress is the result of a focus on Monday, try practicing mindfulness. Monday may feel looming, but today--now--is actually still the weekend. If your Sunday feeling is an echo of grade-school angst, remember that today--now--is 2013 and you're not in grade six anymore. Don't miss what could actually be a lovely day off by launching your mind back to elementary school or forward to tomorrow.

5) If your Sunday Neurosis stems from the upcoming return to work, consider some of the things you like about your job or are looking forward to. Are you going for lunch with colleagues this week? Finally submitting a big project?

6) If work-related Sunday apprehension persists, take the time to identify what is making you unhappy about your job and whether or not you can do something about it. For example, if having to be at work at 8am on Monday triggers your Sunday angst, can you negotiate to arrive at 9am and stay an hour later? If you feel isolated at work, is there a way to introduce more social contact into your workday?

Any combination of these strategies may be helpful in treating the uncomfortable Sunday night feeling. Since we tend to believe that our neuroses constitute a personal and idiosyncratic problem, just knowing that Sunday Neurosis is a common and known phenomenon may be helpful for some.

What's your strategy?

April 20, 2013

It's Your Call

Mental health tip: Just call.

When you miss a deadline or make a mistake at work, it is better to call or email? If you can't make your friend's dinner party after all, or remembered your sister's birthday only the following day, is it better to call or text?

Often when we're handling a stressful or delicate situation, we opt to email or text instead of calling. We tell ourselves that we're saving time, but usually the decision is motivated by avoidance. That is, we're anxious about the annoyance, anger, or disappointment that our communication may generate, and try to decrease our anxiety by avoiding the recipient's real-time reaction.

Is this a good strategy? Consider this story that a friend told me recently

Last Friday, a colleague missed an important commitment at work--an obligatory weekly meeting that staff in her small office cannot miss without an exceptional reason. She had a good excuse to miss the meeting, but it was personal and she didn't want to discuss the details with our boss. Anxious about his reaction to her absence, she decided to email the day before to say that she would miss the meeting for personal reasons. 

This was the first point where a phone call would have been preferable. My colleague sent the email and waited to feel relief, but none came. Instead, she became more and more nervous as she imagined our boss's angry response. Three hours later, she received a brief reply saying of course she could miss the meeting--if she really felt she needed to. The tone of the email was ambiguous and she felt flustered and panicked. This was the second point when my colleague could have picked up the phone, but the desire to avoid facing our boss was too strong. She didn't call and instead treated herself to a weekend of lingering stress.

How would calling have helped in this situation? First, my colleague would have been able to explain herself clearly, assuaging her concerns about being perceived as a slacker or malingerer. Second, she would have been able to gauge our boss's reaction, which is difficult over email. Third, the issue would have been resolved in minutes. Instead, she fretted all weekend--only to learn on Monday that our boss had been entirely unconcerned!

The question of calling versus texting or emailing is not limited to work situations, but is equally relevant in the social realm. When we're running late or have to miss a social occasion altogether, or don't want to tell our partner that we forgot to pick up milk--again--we use text messages to avoid directly witnessing negative reactions.

Example: Earlier this week, I had to cancel plans with a friend for the second time in a row. I didn't want to face his hurt or irritation so rather than calling, I texted to say I couldn't get together that evening after all, but how about Friday instead? He responded quickly: "ok." I waited for a further text, but none came, leaving me feeling uneasy and uncertain. Was "ok" equivalent to "No prob, see you Friday! :)" or did it mean something closer to "WTF?! :(" Remembering my patient's story, I called my friend instead of texting back. It turned out that he was at work--which explained the brevity of his response--and had to work late and was happy to postpone our plans.

How did calling help in this situation? First, I had the chance to fully explain why I had to cancel plans again, preventing my friend from perceiving me as inconsiderate. Second, I was able to assess his reaction, which was impossible from his ambiguous text. Third, rather than fretting about it until Friday, the situation was resolved in minutes.

Text messaging and email are great tools when used appropriately, but problematic when used in the spirit of avoidance. The next time you notice yourself texting or emailing when you know you should call, remember that avoidance maintains anxiety, and ask yourself if you'd feel better if you made the call. Even if your feared outcome comes true--e.g., your sister is hurt about her birthday, or your partner is cranky about the milk--at least you know where you stand and can start making amends. 

April 05, 2013

Friday Post-Mortem

This week I saw an exceptional number of psychotherapy patients in five days, and I noticed a few things:

a) It took a lot of energy and, even though I enjoyed many of the sessions, I was noticeably drained by the end of the week.

b) I joked around in therapy more than usual and told more quasi-personal anecdotes.

c) My patients didn't necessarily like it.

I've been thinking about how the first two observations are related and I think I've cracked the code: Therapy takes a lot of energy because you have to be thoughtful and mindful and helpful and insightful, but an additional element that takes considerable energy--for me, at least--is not being totally myself. It's not that I'm a blank automaton with my patients, but in therapy, I don't make express opinions or preferences, make jokes, seek support, gossip, compliment, or reassure, and I rarely give advice. If a patient is telling an anecdote and I've experienced the exact same thing I don't say "Oh my God, me too!" If a patient is recounting a dilemma, I can't tell him what I'd do if I were in his shoes.

I think the extra jokes and quasi-personal anecdotes this week represent a kind of resistance to the additional hours of personality suppression. When a patient mentioned that the hospital security guard made a weird comment to him, I said "Yeah, he's done that to me too a few times, he's kind of an 'unusual' guy," rather than "What was that like for you?" When a patient reported that she didn't work out this week, I said "Yeah, it's not always easy to get to the gym after work, I've had weeks like that," rather than "What were some of your obstacles?" These responses weren't particularly out of line, but they weren't particularly helpful either. 

Finally, I think that this kind of over-sharing is confusing for the therapy relationship, and here's why: I'm particuarly likely to joke or to reveal glimpses of my personal life in session with patients who are similar to me--patients who have the same sense of humour or the same personal conflicts as me, who live in the same neighbourhood as me and have a similar lifestyle, or who share my cultural or academic background. But although I know that we have a lot in common, patients aren't aware of our similarities. So if I suddenly mention that I too am attending a Passover seder this year or that I too experience daily frustration with the ongoing construction at the subway station nearest both our homes, it comes out of the blue. It's also worth remembering that I've had therapists who shared personal details about themselves with me, and that I disliked it and preferred to maintain our one-way relationship. My own patients may not feel this way, but it's my responsibility to err on the side of reticence.

Reining in your own opinions and preferences and experiences isn't easy and explains why therapists can feel isolated despite interacting with people all day. For the therapist, psychotherapy doesn't meet the need for communication because it's not reciprocal. All the more reason to keep up my usual strategy of calling up a friend or family member for a brief chat when I have a break in my day, and why I like the idea of mixing private psychotherapy practice with other pursuits. 

March 25, 2013

Worst-Case Scenario

What's the best strategy for coping with anxiety generated by hypothetical scenarios and "what if" questions (What if I hit 'reply all?' What if I made a mistake at work? What if I offended my friend?) Should we reassure ourselves that the scenario didn't or won't happen (we didn't hit reply all, we didn't make a mistake or offend anyone), or should we imagine the worst-case scenario?

You'd think that imagining the worst-case scenario would make us feel worse but counterintuitively, following anxiety-provoking "what if" thoughts to their conclusion can sometimes provide greater relief.

How does this work? The key principle is this: avoidance maintains anxiety. When we reassure ourselves that our stressful or scary thoughts probably won't come true, we're essentially avoiding the possibility--pushing it away and dismissing it. Avoidance is often effective in the short term, but the stressful what ifs return in full force after a few minutes, leaving us thinking "Okay I know I probably didn't hit reply all...but what if I did?" The possibility is still there so the anxiety remains.

When this happens, it can help to consider what would happen in the what ifs came true. Examples:

1) After some hemming and hawing about whether or not to make the trip, I booked an expensive airplane ticket to attend an engagement celebration in another city. As soon as I pressed 'purchase' on the airline website, my mind raced to "What if it's not that weekend after all? What if they change the date?" I tried to reassure myself that the party date was unlikely to change, but the anxiety remained. What worked was asking myself what if it were changed--then what? Answer: I'd be stuck with an expensive plane ticket I couldn't use and I'd be out $500.

2) I received an email from a supervisor concerning a decision I'd made about a project we're working on together. Before even reading the message, my mind reacted: "What if she thinks I made a bad decision?" Instead of reassuring myself that my supervisor probably doesn't care that much, I asked myself what if she did disagree--then what? Answer: My supervisor would be unhappy with one thing that I did.

3) I was running late and arrived only minutes before teaching a class, without time to review my notes as I usually do. My mind leapt to: "What if I'm unprepared and the class doesn't go well?" When it didn't work to reassure myself that not reviewing my notes wouldn't affect my teaching, I switched strategies, asking myself what if the class doesn't go well--then what? Answer: One of the classes in the eight-week course would be inferior to the rest and students might be dissatisfied with the one class.

In each of these situations, exploring the worst-case scenario was more effective than reassurance in alleviating my anxiety. Why?

a) Knowing the worst-case scenario puts an end to the what ifs. The answer is clear.

b) Knowing the worst-case scenario allowed me to figure out how to deal with it, and how to not make the same mistake in the future. I determined that if the party date changed, I'd try to sell my ticket online but that next time I'll double-confirm the date before booking. I realized that my supervisor disagreeing with one decision isn't the end of the world, but that next time I'll check with her first. I concluded that sub-par teaching wasn't something I was willing to risk, and that it was worth it to start class a few minutes late in order to review my notes.

Considering the worst-case scenario might not alleviate anxiety in every situation but next time reassurance isn't helping, try it out and see what happens!

March 15, 2013

Stress Reduction for Normal People

Last post, I wrote about the benefits of taking time out for relaxation, meditation, or other forms of non-productive downtime. But what if you want to be less stressed, and more relaxed and mindful in everyday life without setting aside time to officially relax or meditate?

Here are a few simple things that I've been trying lately:

1) Not jaywalking. A lot of us automatically cross the street as soon as it's clear, regardless of the colour of the traffic light. Last year, as part of a one-month mindfulness challenge, I resisted jaywalking for 30 days, and enjoyed it. I recently returned to this practice and have concluded that not jaywalking decreases stress and promotes relaxation and mindfulness in three ways: a) It's relaxing to realize that no matter how rushed you feel or how important your destination, you actually can afford to wait twenty seconds for the light to change; b) The twenty seconds of waiting at a red light is an opportunity to get out of your head, check out your surroundings, and ground yourself in the present (I sometimes say to myself things like "Here I am, this Tuesday morning at 9:15 in March 2013, walking to the bus stop"); c) It's relaxing to cross the street without having to suddenly sprint to avoid a car that came out of nowhere.

2) Going out without your phone. I'll admit this usually only happens by mistake, but it's undeniably relaxing. Cell phones are really good at taking us out of the present moment. When I pass an adorable kitten in an apartment window, I can notice and appreciate it and experience an awesome moment of kittenness. When I take out my phone to take a photo of the kitten and text it to my sister with a cute comment, I'm no longer present. Similarly, if you're having brunch with a friend but keep checking your phone for updates on dinner plans, you're not really experiencing brunch with your friend because your mind is already at dinner. Not having your phone on you can admittedly be inconvenient sometimes, but there are few things that actually can't wait; wouldn't it be nice to sometimes, instead of returning a call or posting on Instagram while we wait for the bus, actually just... wait for the bus?

3) Moving more slowly. If you don't jaywalk or engage in compulsive cell phone use, you probably still have the nearly universal habit of moving more quickly when you're stressed. I observed this on a recent morning when I was rushing around trying to eat breakfast, pack my lunch, brush my teeth, and get out the door. My movements were speedy and frantic and inefficient (e.g., picking things up and putting them down in the wrong room, banging my shoulder on the door frame), and I realized that moving my body on fast-forward was reinforcing the URGENT! LATE! message from my mind, amplifying my stress. In moments like this, simply returning to a normal pace lets your body send your mind a different message, instantly decreasing stress. 

Let me know how these work out!

March 10, 2013

Dying to Relax

One of my mindfulness-based stress reduction (MBSR) students has three kids, a husband, and a demanding job. On occasion, she stops at a cafe on her way home from work to have a cup of tea and take a 30-minute breather before launching into her evening of dinner, homework, lunches, and bedtimes. When she makes the stop, she notices that she feels relaxed and grounded afterwards, and that she's more patient and present with her husband and kids. Despite the obvious benefits of the cafe pit stop, she hasn't made it a regular habit; it's too hard to justify "doing nothing" for half an hour when she could be completing one more task at work or getting a head start on dinner before her husband gets home. It feels indulgent, selfish, and like a waste of time.

This client isn't the only person who finds it hard to be unproductive for a few minutes, or who feels like they simply don't have time to relax. Friends, patients, and MBSR students struggle to find a few minutes per day to breathe, meditate, read, or simply be. So do I. How can we spend fifteen minutes sitting quietly and watching our breath when we have emails to send, texts to answer, and dishes to wash? How can we read a novel when we have a backlog of articles to read for work and the laundry isn't done? Not only is there a lot to do, but often each item on our to-do lists feels absolutely urgent--as if it needs to be checked off right this minute.

Even though we intuitively know that down time is good for us, many of us are unaccustomed to being unproductive, and find relaxing difficult to prioritize. When you're struggling between sending one more email and having a quiet cup of tea before bed, or between your morning meditation and getting to work a few minutes early, consider the following:  

a) Non-productivity is productive. The minutes you "waste" relaxing or meditating return to you several-fold in productivity. The relationships between relaxation and productivity and between meditation and productivity are well established--but research aside, most of us have experienced how much better we work when we're relaxed, when we're well rested, when we're able to focus. This is one reason that successful companies like Google, Sun Life, Ford, General Mills, and Twitter have established mindfulness training programs for employees.

b) Dying to relax. In his book Wherever You Go, There You Are (WYGTYA; see right sidebar), MBSR founder Jon Kabat-Zinn refers to meditation as "dying" to the world for a few minutes. He reminds us that if we died right this minute, our personal agenda would dissolve immediately. That is, some of our projects would be absorbed by others, but most of our oh-so-important goals and must-be-done-right-this-second tasks would simply evaporate. JKZ says "So if this is true, maybe you don't need to worry about it in any absolute way. Maybe you don't need to make one more phone call right now, even if you think you do. Maybe you don't need to read one more thing or do one more errand. Stopping for a few minutes--dying on purpose--to the rush of time, you free yourself to actually have time for the present. You become more alive now, and once you do decide to go again, it's more deliberate, more vivid, richer."

I love this! A friend recently reminded me of this passage from WYGTYA, and I used it the other night: I was getting ready for bed after an evening of baking, and as I turned out the kitchen light long past my bedtime, I noticed that there were still crumbs on the kitchen table. As I picked up the dishcloth, I stopped to ask myself what would happen if I died and the table didn't get a second wipe. Answer: nothing. Result: I put down the dishcloth and got in bed. Reminder: sometimes you just don't need to do one more thing.

Do the ideas of productivity via relaxation or meditation, and dying to our responsibilities mean we should all spend our days relaxing, meditating, and not answering emails or cleaning up after ourselves? That our personal agendas aren't important? No, of course not. But next time you're considering eating lunch at your desk, remember that taking a real lunch break isn't a waste of time. Next time you're sending work emails from your phone while you brush your teeth before bed, consider that managing your inbox at 11pm might not be as urgent as it feels.

NB: If you want to try adding ten minutes of mindfulness meditation to your day but aren't sure how, I recommend this free and easy guided program. 

February 26, 2013


Lately I've been feeling impressed by the courage of my patients and my friends.

Once a month at the clinic where I work, two members of the team conduct a psychological evaluation with a new patient, while a group of medical residents and psych interns observes. Each time, I'm struck by the courage of the patient who sits before the group and describes in detail the manifestations and origin of the presenting mental health problem, the distress or impairment it causes, current and past relationships, and goals for treatment. How brave is that!

I was similarly struck a few weeks ago when a colleague told me that her patient with panic disorder willingly ran up and down the stairs inside the clinic, trying to expose himself to the terrifying breathlessness that triggers his panic attacks. I feel the same respect when a patient with chronic health anxiety successfully writes, records, and listens to an exposure scenario describing himself dying of cancer, or when a painfully shy patient reports that she successfully completed her plan to initiate a conversation with one of the other parents in her son's class.

It's not just my patients who are impressive: my friends are, too. A few months ago, one of my friends was diagnosed with schizoaffective disorder, a difficult-to-diagnose mix of depression, mania, and psychosis that neatly explains symptoms he's been experiencing for years. Following the diagnosis, he took his mental health into his own hands--seeking out a support group and tirelessly navigating the overwhelming bureaucracy of the health care system until he found a doctor who understood the diagnosis, prescribed medication appropriately, and addressed his concerns about side effects. Another friend recently began psychotherapy to deal with a procrastination problem that has plagued her for years. A third friend called me up for a referral for a couples therapist so that he and his partner could address some issues they were unable to resolve on their own.

My friends' and patients' initiative touches and impresses me. There's still a stigma attached to mental health care and there are still people who believe that seeing a psychologist or psychiatrist or taking medication is a sign of weakness. I'm pretty sure that acknowledging a problem and seeking help demonstrates the precise opposite.

Think about it.

February 09, 2013

First World Problems

Are you distracted from the truth that everything is basically okay? I often am. 

I didn't get my favourite seat on the bus yesterday morning; it was snowing and there were no cabs when I left home to go out for dinner last night; I woke up this morning feeling anxious about work; a friend said something that hurt my feelings; the market didn't have the kind of cheese I wanted; and my hair doesn't look right as I'm getting ready to go out tonight.

I know what you're thinking: rough life, right? Yet each of these things bothered me, however briefly, and created annoyance or hurt or stress or disappointment.

When I teach mindfulness-based stress reduction (MBSR), one of the classes in the eight-week program is dedicated to coping mindfully with unpleasant emotions. In the discussion about mindful emotion regulation, we identify that negative feelings often stem from wanting--and not getting--things our way. That is, we want there to be taxis at the taxi stand, we want our favourite seat on the bus, we want our friends to be sensitive to our feelings, we want to look good all the time, and we want to be in a good mood. We want things our way.

It's easy to get so caught up in wanting what we want that the smallest deviations make us all worked up and unhappy. What's more, as soon as we get what we want, we usually want something else or something more. On the bus yesterday morning, I was initially pleased to get a seat on a very busy route that usually has standing room only. But no sooner did I sit down than I was distracted by the thought that I would prefer to sit further back. This morning I definitely was getting my way as I leisurely drank my coffee and read a magazine before heading to the gym--yet I was irritated and upset by my lingering anxiety. Although my Saturday morning was actually pretty lovely, I wanted it to be completely lovely. I wanted it my way.

What helped me snap out of it was one of the phrases we use in MBSR in the meditation related to painful emotions. Participants are asked to sit quietly and reflect on several questions, including the following: "Am I distracted from the truth that everything is basically okay?"

This question is great because in 99% of cases, the answer is YES. Yes, everything is basically okay and yes, I'm distracted from that truth. Yesterday, I was distracted from the pleasure of getting a seat on the bus by the existence of a "better" seat. Today, I was distracted from the truth that I was having a lovely morning by the prospect of the even lovelier one I wasn't having. Last night, I was distracted by the lack of cabs from the truth that I was happily headed to nice restaurant to enjoy a meal and a bottle of wine with good company. In each case, there's no question that the truth was that everything was basically okay.

The examples above are mostly minor upsets, but the lesson is equally applicable to weightier matters. Consider expecting parents, for example: All they want is for their baby to be healthy. Once a healthy child is delivered, though, it's easy to immediately switch to unhappiness with the hospital food and irritation with the grandparents, forgetting the truth that everything is basically okay. 

Asking yourself "Am I distracted from the truth that everything is basically okay?" is a genius cross between getting over yourself and counting your blessings. The next time you're fretting, moping, or seething, try asking yourself the question. If you're like me, most of the time, the answer will be yes.

Let me know what happens!

PS: You can also try "Does everything have to be perfect in order for me to be happy?"

January 31, 2013

A Recipe for Depression

It's pretty much fact that people who are clinically depressed demonstrate distorted thinking. Their reactions to negative events are skewed and they're more likely to make attribution errors--that is, to assign distorted meanings and causation to the things that happen to them.

Three specific attribution errors have been demonstrated to be typical in people who are depressed; my non-scientific guess is that they also show up in non-depressed people and contribute to feeling bad.

1) Internal versus external. People who are depressed blame themselves when things go wrong. In contrast, people who aren't depressed are more likely to attribute negative events to external factors like bad luck, chance, or others' actions. For example, a depressed person who doesn't receive a call back after a job interview assumes she made a gaffe during the interview or didn't prepare well enough. A non-depressed person is more likely to acknowledge that another candidate may have had more experience, or that the position could have been given to an internal applicant. A depressed person who gets hit by a car blames himself for not being more careful, even though the driver was running a red light; if his child gets bullied at school, he blames himself for poor parenting even though the bullies are targeting other kids too.   

2) Global versus specific: Non-depressed people typically view negative events as having only isolated or limited significance. In contrast, depressed people are more likely to conclude that a negative event has far-reaching or global implications. For example, a depressed person whose relationship didn't work out generalizes to other areas of his life and concludes that he has failed in every area; a non-depressed person is upset about the end of the relationship but can still acknowledge areas of his life where things are going well. A depressed person misses the bus in the morning and concludes that her whole day is shot; a non-depressed person acknowledges that the morning started poorly but figures that everything will be fine once she arrives at work.

3) Fixed versus changeable: Whereas non-depressed people often adopt a 'this too shall pass' attitude toward negative events or situations, people who are depressed view the same problems or situations as unlikely to change or improve. A depressed person feels lonely and believes she'll always be lonely; a non-depressed person acknowledges that she's going through a period of feeling alone but that it won't always be this way. A depressed person whose washer and dryer break in the same month that his cat gets sick and his transmission dies can't imagine a future wherein such things aren't happening to him; a non-depressed person knows that he's just having an unusually bad month. A depressed person who fails her exam because of poor study habits wonders if she should just give up on school altogether; a non-depressed person figures she can probably get help and learn new study habits.

In depressed people, attribution errors are problematic because they promote hopelessness and maintain depression. In non-depressed people, attribution errors just make us feel bad unnecessarily. In both cases, the first step is to realize that we're falling for these errors in thinking. The next time you're feeling down about some negative event, ask yourself if you're making an attribution error. If you think you might be, ask yourself: Is it really my fault? Am I overgeneralizing? What can I do about it?

NB: For other good questions to help you out of negative thought patterns, see here.

January 21, 2013

Enough is Enough

How's it going with your New Year's resolutions? If you're on track, good job! If you're less on track, read on:

Sometimes we're reluctant to take a baby step toward change or toward meeting a goal because the step seems too small. For example, say you resolved to quit smoking or to develop a regular meditation practice. And you decided to start by cutting back by two cigarettes per day or by meditating for five minutes every morning. Although these objectives are minor, you may find yourself not meeting them--because they feel almost too minor. 

Part of my job as a cognitive-behavioural therapist is to help people identify the thoughts that prevent them from moving forward. One thought that shows up repeatedly is "It's not enough." For example, a patient's goal might be to introduce regular exercise into his routine in order to counter anxiety and improve physical health. If his usual day involves no exercise at all, we'd probably plan to start with something like five minutes of walking every evening. My patient might express enthusiasm about the plan--but then end up going out walking once or twice, and then quitting. When asked what happened, he might reply that five minutes just didn't seem like enough. Similarly, severely depressed patients sometimes resist the validated strategy of planning small pleasurable activities, because it seems like calling a friend, taking a bubble bath, or going to the movies just isn't enough to counter depression.

The scourge of "enough" is not limited to the clinical setting. It comes up for me regarding writing. More than once, I've set the goal of writing for fifteen minutes every day, only to abandon it because it doesn't seem like enough. Similarly, I have a friend who has already abandoned her New Year's resolution to address her credit card debt with weekly payments of $15--because $15 is just not enough.

Here are a couple tips that might help when you're set to abandon your goals because your small steps seem inconsequential:
a) "Enough" is arbitrary. Why is cutting back by two cigarettes per day insufficient? Would three be enough? Four? Where credit card debt is concerned, would $20 per week be acceptable or would it have to be $25 to meet the enough threshold? Who decides? Recognizing that our thresholds for enough are arbitrary and idiosyncratic can help us adjust our expectations and commit to small steps

b) "Not enough" is how you get to "enough." Even if five minutes per day of walking isn't enough to immediately reduce my patient's anxiety or improve his physical health, it's a step toward enough. How will he get to twenty minutes per day if he doesn't start with five? Similarly, meditating five minutes per day may not seem like enough, but it's a step toward it. Recognizing that not enough is practically a required stop on the way to enough can help us persevere with small goals.

If the concept of enough is getting in your way, hopefully these tips will help you get back on track with your New Year's resolutions. Keep me posted!

January 16, 2013

Capacity for Empathy

How come sometimes you can listen to a colleague complain or to a friend vent for hours on end, never wavering in your sympathy, empathy, or active listening skills--but on other occasions, your patience wear thin after minutes?

Last fall, I posted about our capacity for composure, suggesting that composure is a limited and fluctuating resource dependent on physical comfort, mindfulness and the intensity of our stressors. Since then, I've been thinking about empathy--the often (but not necessarily) sympathetic identification with or experiencing of another person's thoughts, feelings and experiences. Empathy is a key component of friendships and of patient-therapist relationships, and a resource that may also be fluctuating and limited in nature.

For example, consider the time I lost my patience with my friend who kept repeating herself and unwisely retorted "I get it, already!" Not exactly empathetic! In retrospect, I can identify that it was the last week before the Christmas holidays and that we were spending the evening together after a long day of back-to-back therapy patients. That is, my capacity for empathy was low.

I was once on the receiving end of a breach in empathy on the part of my own therapist: I was complaining about something I wanted but felt was impossible to have and my therapist lost his patience and snapped something like "Can't you see that what you're looking for is right in front of you? Open your eyes!" I was pretty taken aback at the time but when I later learned that he had received some extremely distressing news about five minutes before our session, I understood a bit better. My therapist's capacity for empathy was very low during our session; otherwise impeccably appropriate, he slipped up and said something unhelpful and out of place.

For therapists and lay listeners alike, capacity for empathy seems to depend on a few things. First, similar to capacity for composure, having your basic physical needs met is key. It's hard to listen helpfully to someone else's problems when you're starving, exhausted, or have a raging headache. Second, capacity for empathy suffers when there's too much demand: if your best friend's marriage is breaking up and your sister just lost her job, you might not be a very good listener for your colleague who wants to discuss his toddler's bed-wetting. Third, it can be difficult to have empathy for others if you're having your own problems. If you were just diagnosed with a serious illness, your capacity to empathize with a friend's existential angst is probably pretty low.

Therapists need a pretty endless supply of empathy. To maintain capacity for empathy, in addition to attending to our basic physical needs, we need peer support (i.e., don't work all alone all week in your private office with no one to provide social interaction or peer support) and should avoid scheduling too many patients in one day, or too many patients in a row without a break. Further, awareness of how our personal lives are affecting us will allow us to monitor and minimize the impact on our work. Keeping these tips in mind can help us avoid exhausting our empathy reserves.

For non-therapists, the tips for maintaining the capacity for empathy are no different: in addition to making sure your basic physical needs are met, don't spread yourself too thin empathy-wise (e.g., if you spent the morning consoling your sister over her job loss and your friend calls to discuss his relationship woes, you might want to limit the length of the conversation or call him back later). Remember that your empathy reserves may be low if you're dealing with your own serious problems, and feel free to hoard most of your empathy for yourself during those times. Keeping these tips in mind can help you avoid breaches in empathy and maintain your reputation as an empathetic listener.

January 05, 2013

I Love Ya, Tomorrow

Last month, I went to see Annie on Broadway. Annie is the story of a plucky orphan living in New York City during the Great Depression. She escapes from the orphanage on a quest to find her birth parents and ends up adopting a dog, meeting then-president Roosevelt, and getting adopted by a billionaire.

One of the things that makes orphan Annie so beloved is her unshakable and infectious optimism; despite being destitute and having been abandoned by her parents, she always keeps her chin up. Several times during the show, Annie belts out her signature song, Tomorrow: "When I'm stuck with a day/that's gray/and lonely/I just stick out my chin/and grin/and say/tomorrow, tomorrow/I love ya, tomorrow/you're only a day away!"

Watching the 12-year-old actress playing Annie sing her heart out at centre stage, I was overwhelmed by emotion and optimism. I decided to adopt Annie's anthem as my personal theme song, convinced that the simple wisdom of Tomorrow could help me cope with everyday hassles and major life stresses. I sang the song in my head for days, confident in its optimistic message.

The following week, a friend who had been going through a tough time called me up for tips on using mindfulness to manage strong unpleasant feelings. She told me that her current strategy was to try not to think about it, to pretend the feelings weren't there, and to tell herself that tomorrow would be a better day--but that is wasn't working.

I put on my mindfulness teacher cap and suggested a new strategy: rather than ignoring or avoiding the unpleasant emotions, I proposed that my friend try to identify and acknowledge them, and even try to cultivate curiosity about her uncomfortable feelings. I reminded her that mindfulness means accepting and working with whatever's happening in the present moment--even when we don't like it.

After we hung up, though, I felt conflicted. What about Annie? What about "I love ya, tomorrow?"  Mindfulness explicitly advocates being in the present moment, and optimism is generally future-oriented. So on bad days, can you live mindfully in the present and still comfort yourself with the prospect of better days to come?

I had to think about it, but the answer is yes. While mindfulness means residing primarily in the present moment, it doesn't mean never thinking about or looking forward to brighter days. The key is to be optimistic about the future without avoiding the present.

Example: Say you wake up feeling anxious. You head to the office as usual and dive into your work, doing your best to ignore the continued roiling in your belly and tightness in your chest. If you avoid addressing the feelings and sensations and just tell yourself that tomorrow will be better, you're being optimistic, and you may be right--you probably will feel better tomorrow--but you're also avoiding experiencing your feelings. In contrast, say that rather than plowing through the day ignoring your symptoms, you decide to use half your lunch hour to sit quietly, identify what's going on, and practice experiencing your emotions. You can still be optimistic and remind yourself that tomorrow will probably be better, but you're not avoiding your emotional experience (a strategy that doesn't usually work it the long term).

Second example: Say you and your partner are going through a rough patch. And say you reassure yourself with vague optimism about the future of the relationship, rather than exploring your feelings and identifying the problems. With this blind optimism strategy, you can avoid uncomfortable or unpleasant feelings, but the relationship problem might remain. Say that instead you optimistically hypothesize that you and your partner love each other enough to make it through a rough patch, and decide to try to identify the problem, investigate your feelings about it, and discuss it with your partner. Such optimism combined with your mindful acceptance of the problem will probably lead to an open conversation, increasing the likeliness that your hypothesis will come true.

I was relieved to determine that Now this is happening and I love ya, tomorrow are not incompatible and that I can keep Tomorrow as my bad-day theme song without renouncing mindfulness. So if you're having a tough day, go ahead and remind yourself that you probably won't feel this way tomorrow. The only catch is to not use optimism about tomorrow to avoid experiencing today--unpleasantness, discomfort, and all.

January 01, 2013

At Your Service

If I had a friend who began every sentence with an apology, I might eventually point it out and ask her to knock it off. If a colleague told the same anecdote three times over the course of one lunch hour, I might tell him to quit repeating himself, or else intervene and change the subject.

But what if these things happened with my patients? What's the difference between conversations with friends and conversations with patients?

The difference is that with patients, everything I say or do should be in the service of the patient. With the friend and colleague in the examples above, I'd speak up to save myself from boredom and crankiness; with patients, my personal feelings are expressed if and only to the extent that expressing them would be helpful to the patient.

Example: Say I had a self-effacing patient who was driving me crazy by beginning every sentence with an apology. By the end of a session, I might want to snap "Quit apologizing!" but that would be a mistake. A better intervention would be to gently say something like "I've noticed that you frequently begin your sentences with an apology." Whereas the former comment expresses personal irritation, the latter is a simple and therapeutically relevant observation; the latter comment also allows for follow-up questions such as "Is apologizing something you also do with other people?" "How do you think your habit impacts your conversations?" and "How might you perceive someone who apologized all the time?" If later the patient and I were hypothesizing about how other people might perceive his constant apologizing, I could ask him for ideas (e.g. "People might think I have low confidence; they might think I'm being fake"), and then maybe add something like "Some people might find it endearing; others might find it frustrating." But my personal impatience would not be relevant.

Second example: Recently, I recently expressed frustration with a friend who kept repeating herself. She was struggling with the decision to move her elderly mother into residential care; despite my validation of the struggle and the decision, my friend continued to repeat just how much she loved and respected her mother, what a good parent her mother had been, etc. Finally I lost my patience and exclaimed "I get it, already--you love your mom!" This wasn't very helpful for my friend; a more helpful response would have been something like "Yes, you've mentioned that a few times. It must be really important for you to make that point clear."

With a patient, this kind of neutral comment is even more important, and often elicits useful information such as "I didn't know if you heard me the first time I said it because you just nodded but didn't say anything" or "I guess I feel guilty, like I'm just getting rid of my mom now that she's become a nuisance, or worried you'll think I'm a bad daughter" or "Really? I already said that?" With patients, these answers can prompt valuable conversations about validation, guilt, and social skills, respectively.

In therapy, comments like "Quit apologizing!" and "I get it!" are not appropriate because they imply a responsibility of the patient toward the therapist (e.g., to not be boring, to not waste my time), and because they express therapist feelings in a way that isn't relevant or helpful. But are there occasions when a therapist should express her true feelings? The answer is yes, but the same rule applies: only in the service of the patient.

Example: A depressed patient tells me he's bad at communicating and I respond that I've noticed that he's actually quite forthcoming and articulate in our sessions.

Example: A panic disorder patient tells me that he felt silly jogging on the spot in my office to try to induce panic symptoms for an exposure exercise, and I tell him that I was just thinking how brave he was to engage in an exercise designed to bring on symptoms that terrify him.

Example: A socially anxious patient reaches over in the middle of our session to pluck a stray hair off the arm of my sweater and then immediately asks, "Was that weird? Should I not have done that?" and I respond that her act didn't seem out of the realm of normal social behaviour, but that the timing was surprising and the gesture had taken me a bit off guard.

In each of these example, my comment is authentic and is designed to validate, bolster, and/or reflect reality to patients whose perspective may be unhelpfully distorted.