Health Psychology

May 11, 2017 By Susan O'Grady 5 Comments

Anxiety Knows No Age Limits: Each moment is all we really ever have

We all get anxious from time to time. Even mild panic that’s morphed from mere anxiety is normal. Most often, though, anxiety will peak right before an event that makes us worry, such as an exam or dinner party—a kind of anticipatory anxiety—and then fade 10 minutes into the event. The ebb and flow of anxiety can be unpleasant but usually isn’t a major concern.

But the usual ebb and flow can worsen. According to the American Psychiatric Association’s most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), normal anxiety becomes diagnosable as generalized anxiety disorder when:

Excessive anxiety and worry occurs more days than not, for at least six months, about several events or activities (for example, performance at school or work)
Controlling the worry is difficult
The anxiety/worry includes at least three out of six symptoms (in diagnosing children, just one of these symptoms is required): restlessness or feeling on edge; being easily fatigued; difficulty concentrating, or the mind going blank; irritability; muscle tension; sleep disturbance
These symptoms cause significant distress in functioning
The disturbance isn’t related to medication, drugs, or a medical condition
The disturbance isn’t explainable by another mental disorder

I recently saw an 88-year old woman who was referred by her internist for anxiety. Her primary symptoms were her mind going blank, trouble letting go of thoughts, and agoraphobia (the desire to avoid leaving her home). The usual culprits were ruled out: hyperthyroidism, a medication side effect, or, given the client’s advanced age, dementia.

Composedly, my client said her anxiety came from feeling pressured to do more, and a sense of failure for not being good enough. This surprised me; I had expected her to talk about a fear of approaching mortality.

It’s a psychologist’s job to ask the hard questions, the ones that seem most obvious—the ones most friends and family wouldn’t touch for fear of making the person feel worse. So, I gently inquired if some of her anxiety could be related to thoughts about aging and death. But my client was quite definite that that was not the case! Her physician had assured her she would live to be 94 years old. I did a quick calculation—math was never my strength as I still count in my head with little dots—and determined that would give her five more years. Wouldn’t such a short countdown to death be enough to bring about anxiety, I still wondered?

Another job of a psychologist is not to jump to conclusions or make assumptions. Using inquiry, we ask for further thoughts, feelings, and associations. Some of her anxiety, she acknowledged, was longstanding, but a new worry was that she was no longer as interested in venturing from home. What was this about? Was she worried about taking a fall, breaking a bone, and ending up in the hospital? Again, no, it wasn’t fear that losing her balance and falling would lead to death because she knew that it most likely would. Anyone who reaches the age of 88 has seen in their own peer group how a broken hip can spiral downwards to a skilled nursing facility, with all the loss of dignity that brings.

Perhaps the most important part of our job as a psychologist is to trust that our clients know what they’re talking about. That trust is huge because it eventually leads us to an understanding of what is going on inside, in the deeper places we can touch if given time and attention. It turned out that my client’s anxiety was about just what she’d said it was. She was feeling like she should be doing more, going out more, and accomplishing more. Until she retired 23 years ago, she had been very productive in her job as an accountant. She loved her work, and she loved her retirement. She hadn’t slowed down in retirement until recently. She couldn’t understand the desire to just stay home. It was unlike her, and she felt she should be keeping up the pace she was accustomed to.

We discussed her symptoms; a mind going blank can be due to anxiety, and also to what my neuropsychologist husband refers to as benign senescent forgetfulness. (He tells me I have a mild case of it—our brains shrink as we get older, it’s entirely normal.) I also recommended that she turn off CNN. I wasn’t being flippant: Non-stop watching the news these days is making a lot of us anxious. Being bombarded with daily images of worldwide pain and suffering pervades our senses and creates disturbances that go deep into our unconscious minds, harming emotional health.

What about not wanting to leave the house? She wasn’t worried about going outside, but rather, as we figured out together, she desired to retreat from the world, to reflect and take time to appreciate her many gifts: a life well lived, a 65-year marriage to a good man, and her overall sense was that she had had a good, if not perfect, life. It was time to turn inward a bit more and let herself off the hook. Over the next several weeks, we explored how she could do just that.

Acceptance of who we are, imperfect and flawed, allows us to live more fully each moment, for as is said in mindfulness practices, each moment is all we really ever have.

January 9, 2017 By Susan O'Grady 7 Comments

Psychologists Need Self-Care Too

Who Helps the Helper?

Self-care and Professional Ethics

Most psychologists get into this profession because we get deep satisfaction from helping people. But who helps the helpers?

What about us, anyway? We sit for hour after hour, year after year, listening to our patients’ troubles. We help them make sense of what brings them to our office. We help them deepen their understanding of themselves, working with them to bring meaning and healing. But as psychologists, our training is not very conducive to our taking care of ourselves. The doctorate alone requires years of study, often at great expense, to say nothing of the 3,000 hours of unpaid or poorly pay internships, post-docs, and fellowships. It doesn’t end there; paying back debt and building a practice all take a toll on our self-care.

And of course, while dealing with these stresses, we must be effective and ethical therapists, even when clients may be testing our limits, perplexing us, or causing us worry.

A therapist’s most valuable tool is the therapist’s own self. We need to model a healthy self to our patients, and this is where self-care comes in. In fact, self-care is an ethical obligation to maintain our competence as psychologists. Caring for ourselves as well as others is an inherently integrated and reciprocal process. When we “more readily realize the false demarcations between ourselves and our clients, self-care becomes both an ethical imperative, and a humanistic one.”

So as a therapist, don’t forget to ask “What about me?” Issues that can challenge self-care include:

Balancing our own and clients’ needs
Countertransference reactions such as envy or erotic feelings
Confidentiality

For example, let’s take envy, a problem that can loom large in this time of widening income inequality or for any therapist working with wealthier patients. No one likes to admit to these feelings, but denial is never a good strategy.

And this can especially be a problem if we feel stalled in our own lives. We’re in the trenches; meanwhile, we’re helping others live fuller lives. They write books, get fit, flourish. Good for them—but here we sit, with unfinished books, unexercised bodies, unexplored possibilities.

Here’s an example from practice. I had a patient with a lucrative professional job who came to me for anxiety. His wife was leading one of my dream lives, an unlived life: owning, showing, and riding horses. I thought “Damn, she is lucky.” I felt impatient with his problems and had to stop myself from telling him his wife should get a job. Because we have lots of training in recognizing when our reactions are countertransference, I was able to see my envy at the moment so as not to let it interfere with my client’s process.

Or again, I authorized a patient’s disability leave. He got four months of paid time off, lost 20 pounds, got a personal trainer, went on a luxurious retreat, and returned looking 15 years younger. Good for him again, but I was seeing 30 patients a week and couldn’t help contrasting my responsibilities with his fortune. For those of us in private practice, taking time off is tricky. We lose income, and our clients may have a hard time without the continuity of their therapy.

When our patients improve and surpass us, how do we deal with that? That’s our goal, after all, to help them attain full lives and be the best selves they can. It’s not their fault we haven’t achieved the same goals. We must move forward in our own lives if we’re going to maintain ethical principles and standards.

Another challenge can be secrecy. Keeping patients’ secrets is an ethical imperative, but not always easy. A very famous person came to me for something highly scandalous, something I was dying to tell—but even married to a psychologist, I could only mention broad strokes, no name, and no juicy details. It’d be a great story to tell at parties, but I have to keep all such secrets locked in a vault. It’s a peculiar situation to know more about the inner world of a very famous person than anyone else and not be able to tell a soul, but as an ethical psychologist, I can’t.

Heal Thyself, Know Thyself

The arduous, never-ending self-scrutiny and inner work required by our profession is like no other. Gaining deep intimacy with our clients requires us to be just as deeply familiar with our own feelings. As therapists, we’re already familiar with the value of therapeutic lifestyle changes in areas like exercise, nutrition, rest and relaxation, maintaining good relationships, and service to others. We recommend these to our clients, so we should also practice them ourselves, along with helpful interventions like apps to help monitor diet, movement, and sleep. To that list, we should add personal therapy and development for ourselves, not just clients.

This is because our work depends on the personal/professional therapeutic bond. In turn, this largely reflects and depends on the therapist’s interpersonal skills and capacities, which must be developed in the therapist’s personal growth. The link between ethics and self-care is professional competence, which is necessary to protect our patients. Clients’ experiences of the therapeutic relationship—the respective interpersonal capacities of the client and therapist—are among the strongest predictors of outcome in psychotherapy. Those of us who are reluctant to practice self-care techniques should remember that we are decreasing our competence as therapists.

More information on these principles can be found in the American Psychological Association’s “Ethical Principles of Psychologists and Code of Conduct.”

Taking care of ourselves

When we say we’re not taking care of ourselves, what does that mean? Examples include overbooking or double-booking clients and working late; taking no breaks; being distracted, impatient, or bored; giving clients the same exercise as last week; talking about your problems instead of the client’s; or falling asleep. As you can see, these actions affect clients as well as ourselves. If we’re not getting our needs met, we may look to our clients to meet them, a violation of their boundaries.

Occupational hazards

In our jobs, occupational hazards include isolation, demands on body and psyche, frustration, and never-ending self-scrutiny. Burnout, compassion fatigue, secondary traumatic stress, suicidal patients or our own suicidal feelings, depression, anxiety, boredom, conflicts with co-workers, practice logistics, insurance company hassle, money problems, personal losses—these can all add to professional stress. To cope, we need inner strength, self-soothing skills, and awareness of our own strengths and vulnerabilities.

Even when we’re well aware of the damages we’ve suffered, we can fall into the mistake of projecting all such woundedness onto patients, and claiming the role of healer—and healed—for ourselves. Self-knowledge helps prevent this trap. It’s also important to seek peer support through professional groups and other networks, social support from friends, and develop coping methods like cultivating humor and a positive attitude.

Occupational Privileges

As psychologists, we live a life of service. We are always growing and our work protects us from stagnation. As Irvin Yalom states in his book The Gift of Therapy, we daily transcend our personal wishes and turn our gaze toward the needs and growth of the other. We take pleasure in the growth of our patients and also in the ripple effect–the salutary influence our patients have upon those whom they though in life. Viewed the right way, the very stresses of our job help prevent stagnation. Continual growth and self-examination help us to see the world, ourselves, and our patients for what they are, making us better able to help—which is what brought us into this field in the first place.

The result of my exploration on this topic is that I am taking a sabbatical during the month of January. I plan to write, read, and spend more time deepening my self-care.

References

In pursuit of wellness: The self-care imperative. Barnett, J. E., Baker, E. K., Elman, N. S., & Schoener, G. R. (2007). Professional Psychology: Research and Practice, 38(6), 603–612. http://doi.org/10.1037/0735-7028.38.6.603

What Therapists Don’t Talk About and Why: Understanding taboos that hurt us and our clients. Kenneth S. Pope, PhD, Janet L. Sonne, PhD, and Beverly Greene, PhD Second Edition, APA Books, second edition, 2006.

Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum. Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Professional Psychology: Research and Practice, 43(5), 487–494. http://doi.org/10.1037/a0029446

Ethical principles of psychologists and code of conduct. The American Psychologist, 57(12), 1060–1073. http://doi.org/10.1037/0003-066X.57.12.1060

September 19, 2016 By Susan O'Grady 1 Comment

How to Keep Your Marriage Healthy While Coping with Chronic Illness

Most marriages will be confronted with challenges. How we cope, make meaning from, and find benefit in challenges affects our overall satisfaction in our marriage. One of these biggest challenges marriages face is health

In Sickness and In Health Till Death do us part

We take our marriage vows in innocence and with deeply felt sincerity. That’s probably a very good thing, because the reality of coping with a chronic, debilitating illness such as a stroke, Parkinson’s disease (PD), or dementia, makes many question or regret their vows to stay together in sickness and in health.

When our love is new, we don’t vow to love honor and cherish until. And usually, we don’t intend to leave when our partner becomes ill—but we may feel like it at times.

When One Partner Becomes a Caregiver

In the United States, spouses are first in line to take on caregiving responsibilities (Pinquart and Sorensen, 2011.) We are living longer than ever before, so the likelihood that one partner will become a caregiver is high. Studies have shown that the caregiver burden when a spouse has a chronic illness negatively affects the non-ill partner both physically and mentally: more depression, more financial and physical strain, and lower levels of well-being.

Take PD, for example. PD is a chronic debilitating illness characterized by complex motor and non-motor symptoms. When PD is first diagnosed and during much of the illness, the non-PD partner provides most of the informal caregiving. Roles and division of labor often shift, with the caregiving spouse taking over such tasks as scheduling and driving to medical appointments, assuming the banking and paying bills, and so forth. Chores increasingly fall on one partner, making it difficult to find time for the non-PD partner to practice their own self-care or see friends.

Research on marital satisfaction and quality of life shows that social support is a key factor in coping with illness, yet sadly, couples often become more isolated, withdrawing due to an increase in interpersonal distress, shame, or apathy. The need to cut back on work-life or retire abruptly brings another set of challenges, such as loss of work identity, fading ties with coworkers, more dependence on family, and decreased income.

My Illness or Your Illness: Attending to the relationship

Chronic illness needs to be seen not only as an individual challenge but as a relationship challenge as well. Anger at the unfairness of life when newly diagnosed is entirely normal, for example, especially if the implications of the disease process are fully understood. Wanting to blame someone is understandable, but with an illness such as PD, it’s important to ascribe the difficulties to the disease, not the person.

Studies have looked at how dyadic coping—a process by which a couple works together to cope with the stressors that one or both face—might be one way of improving health and in turn, the quality of the marriage. Couples who see the illness as a relationship issue rather than an individual issue will be more satisfied with their relationship than couples that don’t.

Coping together: We-ness in marriage

One clue to how couples see the relationship is their pronouns. These seemingly innocuous parts of our everyday speech give us an important window into the inner workings of relationship. If one member of a couple comes into my office and is talking at his/her partner, using pronouns such as I, me, my, you, your, this shows a greater sense of independence and distance in relationship. Using words like we, us, our, implies a shared identification between spouses, more intimacy, and more emotional investment in their relationship.

Self and Partner Soothing

We-ness is also associated with more positive and fewer negative feelings, and with lower autonomic nervous system arousal—the fight or flight response. When one partner is anxious or distressed, we can calm them down by using we-ness words. This produces a soothing or emotion-regulating effect on the other spouse. I have seen this many times in my office when counseling couples. For example, when Joyce was becoming agitated about how she would cope with Al’s PD, Al reached over and gently stroked her arm, saying ”We’ll deal with this together.” This had an immediate impact on Joyce’s anxiety.

That simple act can make a big difference. We refer to these as emotion-regulating behaviors. Couples can help each other cope with anger, frustration, and fear and minimize the damage to the marriage. In couples therapy, we help partners understand the importance of self-soothing during difficult times and the value of providing that to their partner when needed.

Benefit Finding: Glorifying the struggle

When couples come to therapy, I assess their strengths and the areas that need work. Asking such questions as “Looking back over the years, what moments stand out as really hard times in your marriage? Why do you think you stayed together? How did you get through these difficult times?” Or, “How would you say your marriage is different from when you first got married?” With such questions, I am looking for growth as a couple and for a sense of how they cope. Are they a team? Or do they point fingers and accuse their partner of messing things up?

By developing a shared narrative, and finding meaning in how we strengthen our bond (or we-ness), we can improve our marriage and how we cope with problems. Couples who view their struggles as hard, but worth it, demonstrate hopefulness and togetherness. Yet when one partner feels out of control of the events that they face, they may slip into passive endurance, believing there is nothing they can do about a problem. They struggle to survive instead of growing closer through the challenges. These marriages are less likely to be happy and more likely to end in divorce.

But for couples that find meaning and growth in difficult times, they “glorify the struggle” and will have a better chance of staying together through hard times. Hope and commitment toward growth as a couple are elevated over disillusionment and negative perspective. I don’t want to be dismissive of the real, hard problems such couples face or expect them to have a Pollyanna, rose-colored-glasses approach. We can acknowledge the pain and suffering we face, but at the same time, try to find something in our experience that helps us learn something new, to grow from it.

By viewing the inevitable problems that arise in marriage as “our problems” rather than blaming our partner, we strengthen our bond. Moreover, when we work as a team rather than in parallel, we are less likely to complain criticize, or be defensive. This has a valuable outcome: we naturally reduce each other’s tension or physiological arousal. When we are relaxed when confronted with problems or conflicts, we are more likely to find ways to manage them—in sickness and in health.

September 9, 2015 By Susan O'Grady 9 Comments

Implacable Grandeur: Mindfulness and Change

If there is a sin against life, it consists perhaps not so much in despairing of life as in hoping for another life and in eluding the implacable grandeur of this life. Albert Camus

Much of the human experience is determined by chance—factors completely outside our control.

My father, who died of prostate cancer at the age of fifty-six, had two copies of the BRCA2 gene, one healthy and one defective. The defective BRCA2 gene greatly increases the chances of developing hereditary breast, ovarian, or prostate cancer (HBOC). My brother and I each had a 50/50 chance of getting that mutated gene. As it turns out, my brother got the broken gene, and I got the healthy one. I was lucky; I don’t have to face that increased cancer risk, and neither do my two daughters. But my brother is now fighting HBOC prostate cancer.

Surgery and treatments will hopefully keep the cancer from spreading beyond where it has already taken up residence in his body. My brother and I talked for a long time after we got the genetic news. I felt something akin to survivor guilt—why did I escape hereditary cancer while my brother was saddled with it?

Like many siblings, we had been competitive in our younger years; I worried that he would feel envy, but in fact, he congratulated me. My brother was genuinely happy for me. For anyone in that position, being able to feel glad for another in the face of your own difficult outcome takes maturity, wisdom, and a generous spirit.

Finding out that I do not carry the genetic alteration BRCA2 was a great relief. I’d had such an outpouring of kind thoughts from so many people while waiting for the results that I almost feel guilty for not having the mutation. I had this crazy thought that those who expressed love and support would think “Why was she such a drama queen bothering us with this when she only had a 50% chance?”

Some might wonder why I chose to be so transparent, especially when psychotherapists normally aren’t self-disclosing. On further reflection, I believe that transparency facilitates integration. That means that you’re working toward a more unified sense of self, rather than compartmentalizing or walling off different facets of your personality.

I use my own personal experiences, as well as the insights from my work, as a foundation for growth and self-discovery leading to greater authenticity. As we get older, we learn that being authentic feels better. I’m glad that despite my self-doubt, I opened up about that threat. By doing so, and by being present to either outcome, I learned a lot.

What I learned is the stuff of aphorisms, platitudes, teaching stories, parables, and fairy tales from all faith traditions: How to appreciate your life before you see it vanish, how to find meaning in daily challenges, and beauty in the smallest things. My wish now is to savor my sense of gratitude and good fortune and relish my current good health.

I was lucky. But the truth is, no one gets to a certain point and then lives happily ever after. Most of life is a matter of contending with problems, hardships, and unexpected turn of events. Periods of placid security are the exception rather than the rule.

Life is change. It’s our nature to want to hold onto things, always grasping to make things safe and predictable. But the wisdom of the Buddha teaches us that we will never succeed: Because life is constant change, attachment causes suffering. The only way to achieve true peace is through accepting that life is dynamic, not static. As Epictetus wrote, “It is not events that disturb the minds of men, but the view they take of them.”

But this doesn’t require superhuman serenity. I believe that we all have an instinct for wholeness at the core of our being. One way of looking at this yearning is as an archetypal urge of the Self, an archaic memory that may have been present in the lives and generations before us.

The Next Blade of Grass

“As a caterpillar, having come to the end of one blade of grass, draws itself together and reaches out for the next, so the Self, having come to the end of one life and dispelled all ignorance, gathers in his faculties and reaches out from the old body to a new.” [IV.4.3] (Easwaran, Eknath. The Upanishads. Nilgiri Press, iBooks, 2007.)

Like the caterpillar, we draw ourselves together when one phase of life ends and stretch to reach for our next landing place—a new way of being in life, despite the inevitable changes that chance throws in our path.

We all possess that ability to draw ourselves together, collecting what we have learned from our experiences (a difficult situation, an insight during mediation, inner work in psychotherapy) and stretching out for the next blade of grass, the next place of sustenance. In this way, we grow, progressing slowly and deliberately from one place to the next.

August 18, 2015 By Susan O'Grady 6 Comments

Accepting Life’s Turbulence: Fasten Your Seatbelt

Life brings ups and downs and finding a way through the stormy turbulence takes courage and grace. — Thunder Cloud from 37,000 ft

This dramatic cumulonimbus was captured at 37,000 feet over the Rocky Mountains in Colorado. Pilots know to avoid going near these thunderclouds, charting a course around them for the comfort of passengers and safety of the aircraft. Even coming close will cause turbulence—the jet trembles and shakes, often violently.

Pilots rate turbulence as mild, medium, or severe. Thankfully, excellent communication between pilots means that patches of bumpy air can be predicted well ahead of time and avoided by changing elevation or course. But sometimes turbulence is unavoidable. In that situation, fearful flyers grip armrests, pop benzodiazepines, and turn up the volume on their headsets. Eventually the air smooths out, and everyone releases their breath…and their grips.

Staying Steady During Turbulent Times

Jet travel is a great metaphor for life. Sometimes the bumpy moments are so extreme that there’s nothing you can do but sit with it and hope you don’t have to pee. But sitting with the rocky ups and downs of life isn’t always easy.

When a pilot acquaintance asked me how to survive the turbulence of his current marriage problems, I asked him what he tells his passengers to do when the flight encounters a rough patch.

He said, “I tell them to fasten their seat belts.” We have all heard the familiar words, “The captain has turned on the seat belt sign. Please return to your seats and fasten your seatbelts.” Now, I confess I sometimes use this moment to zip down the now suddenly empty aisle to use the lavatory (but only in mild turbulence.) But basically, in bad weather you need to stay seated and wait it out.

I enjoy flying, but that wasn’t always true. I was a fearful flyer for about six years. I wasn’t phobic, I didn’t avoid flying or have panic attacks, but I was alert to every squeal of the engine, movement of the wing flaps, or ring of a cabin bell,. During euphemistically described moments of “bumpy air,” I would glance up at the flight attendants’ faces to see if they were showing signs of concern.

I wasn’t afraid of heights or of being in an enclosed space—my fear was simply of crashing. Kaput, end of life, and the imagined 60 seconds of sheer terror I expected to feel going headlong into death.

We have no control over death. Once I came to terms with accepting that I could die in a plane crash, I became less afraid. It wasn’t that I was convinced by statistics showing how rare such deaths are; fearful flyers are rarely comforted by the statistics. Acceptance, in contrast, goes a long way in dealing with the bumps we encounter in life.

I found out this week that I have a 50/50 chance of having the genetic mutation associated with hereditary breast and ovarian cancer (HBOC). My family on both sides has had lots of cancer. But through advanced genetic testing, I now know that my family members have the BRCA2 mutation going back three generations. As I await the results of my blood test, I am again reminded of our lack of control. For me, it’s the toss of a coin: I either have it or I don’t. If I do, I have an 85% chance of developing breast cancer and lower risk of other cancers (ovarian, pancreatic, melanoma, and stomach). I am not comforted by those odds.

Flying has infinitely better odds. But after a week of emotional turbulence, I will meet my fate with HBOC with as much grace as I can muster. It hasn’t been an easy week, to be sure, veering between certainty of bad results and certainty of escape. So while I wait and hope that I end up on the happier side of the 50-50 split, I will fasten my seatbelt and try to steer as safe a course through the thunderstorm as I can, with all the support I’ve gathered over the years: family, friendship, work that I love, and resources (such as FORCE). Coping skills, like seat belts, keep us safe. While we generally don’t enjoy restraints, a seatbelt helps to contain our emotions so they are less likely to overwhelm.

I am reminded, once again, of a lesson taught by Thich Nhat Hanh: “When we have a toothache, we know that not having a toothache is a wonderful thing.” (Peace Is Every Step: The Path of Mindfulness in Everyday Life, 1992, p. 38). Finding comfort in the face of difficulty is possible—by riding out the painful moments and trusting that the next moment contains a potential fullness, some simple pleasure waiting to be noticed. So when the seatbelt sign is again turned off, you are free to move about the cabin. Add take a deep breath.

Anxiety Knows No Age Limits: Each moment is all we really ever have