O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Teletherapy–One Year Later

Psychologists help people cope with change in ways that enlarge and nourish them. Perhaps the most important thing we do is witness our clients’ stories by the deceptively simple act of listening and observing. But that simple act became complicated when the COVID-19 pandemic thrust us overnight into the new territory of telemedicine.

The pandemic and quarantine were accompanied last year by unimaginable tectonic shifts in almost every aspect of life. Police violence, civil protests, and political unrest made us rethink our relationships with some of the most fundamental aspects of being human. We went through it all alongside our clients, yet our code of ethics demands keeping such fears to ourselves and keeping self-disclosure to a minimum.

For therapists and clients alike, teletherapy presented an unexpected and steep learning curve. Many patients felt awkward having painful or intimate discussions while being physically separated, sometimes while dealing with technological issues. Behind the scenes, therapists had to master new technology and change our billing and documentation procedures while ensuring the new system was secure and  HIPAA-compliant.

It could be awkward for us too. and I worried about staying attuned to my clients and whether I could still practice deep listening as described by Theodor Reik in his book Listening with the Third Ear.

We are… encouraged to rely on a series of most delicate communications… collecting all our impressions; to extend our feelers, to seize the secret messages that go from one unconscious to another. . . . The student often analyzes the material without considering that it is so much richer, subtler, finer than what can be caught in the net of conscious observation. The small fish that escapes through the mesh is often the most precious.

Nevertheless, we figured it out. Therapists and clients found that we could make deep contact even through a screen once the technology got sorted out. We learned new ways of observing and gaining information, and I was impressed to see my clients’ resilience in using telehealth apps from their cars, in a dark garage, or from a closet. We found ways to see the whole person without needing to see their whole body by listening with the fullness of all our senses.

In my practice, I’ve also observed how the pandemic has allowed more time for hobbies, family life, and other pursuits. Seeing opportunities for growth in the midst of difficulty is an insight with wide application beyond the pandemic. It’s helped me grow in my job as a psychologist; in the words of the Shaker hymn, I’ve found that to “turn, turn will be our delight, / Till by turning, turning we come ’round right.”

That said, it’s important to acknowledge that the terrifying awareness of our tremendous vulnerability and life’s fragility has severely tested our defenses. In our communities and the world, the grief we’ve experienced and witnessed differs from anything we’ve seen before. It’s what Pauline Boss calls “ambiguous loss”—unresolved loss without closure and no end in sight.

We must carry this ambiguous loss for our clients and ourselves, knowing that the way ahead is still dark. Fortunately, our training as psychologists provides us with the clinical foundation to continue to practice in empathic and ethical ways even as we traversed the chthonic underworld along with our clients. Our ability to stay with the depths of despair alongside the knowledge that we can still hope and dream is the stuff of our work and our personal lives. As the poet Theodore Roethke wrote, “In a dark time, the eye begins to see.”

 

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Bittersweet and Everything In Between

Being able to hold opposing emotions is one of the hallmarks of good mental health. Something can be both bitter and sweet, and we tend to feel that we must pick sides. To our confusion, we often can’t stick with one or the other feelings — either getting pulled back and forth, or stuck in one or the other. Getting mired in the bitter side can lead to depression, but the sweet side has its own pitfall, such as denial about problems.

What does it take to hold the tension of the opposites? A willingness to acknowledge that we can be both happy and sad, weak and strong, and that we are in a continual state of change. If we can’t accept that  impermanence underlies life, we can be badly rattled when fortune’s wheel turns for the worse, or overly elated (and sure that things won’t change) when it turns for the better.  We must learn to live in between, alongside the difficult and the pleasant. When we taste only sweetness, then bitterness will not long follow — because nothing lasts forever.

We are living through a historic pandemic that’s made more acute by the daily (or hourly!)  news we get on the ever-present phone in our pockets. Adding to the constant angst is social media, frequently showing a rosy view of other people’s lives— the victory garden that is blooming like crazy, the family game night, Instagram-ready special recipes . All of these are examples of how we have made sweetness of a difficult situation, but they don’t tell the whole story. They can  also serve as stark reminders of all we had intended to do in the weeks of our confinement leading to feelings of loss that, that when combined with daily news of deaths, disease, and economic hardship, are very real reminders of the bitter side of life.

These painful feelings can include missing  our friends, seeing our child deprived of a real graduation ceremony, and worrying about front-line health care providers and essential workers who make other people’s lives easier.  They’re certainly not getting time in their garden or finding creative ways to make a meal.

Holding opposites in tension is  based on an awareness of both good and bad, which are both always present as forces in the world and within us. It takes a great sense of balance to live with this paradox, and it’s rare to remain  in the place of balance for very long. The reason is that our thoughts and emotions will tug at us continually pulling us all along the spectrum from bitter to sweet and back.

When I first started writing this blog, I called it “Creating Well-Being.” That title no longer fits my thinking about suffering and growth. It does not represent the complexity of how we live in a world full of trauma, inequality, and paradox.

In my thirty years as a psychologist I have been seeing clients grapple with the paradoxes in their lives and within themselves. One wants to be good and moral, yet has affairs that he knows would hurt his wife; he’s unable to stop himself, unable even to see that he’s hurting himself too by being pulled apart. Another stays silent about years of sexually abusing a younger friend when they were kids, meanwhile marrying and starting a family with the burden of shame and guilt weighing him down. And often we  externalize these negative and difficult feelings, because it feels safer to blame another person, a job, or our lot in life for all that we don’t want to look at in ourselves. Instead of growing, we’re stuck.

Psychotherapy is about finding the syntheses of opposites. A helpful technique is looking  for what’s left out of a clients’ narrative. Carrying secrets creates turmoil; the omitted truth wants to be heard, on levels that range from the faintest whisper in the back of the mind to a gnawing pain that keeps us tied up in knots.. ; When we ignore our full reality and drive awareness into the unconscious, we perpetuate default patterns that prevent us from becoming whole. It takes courage to open ourselves and allow a fuller view of consciousness to dawn. Expanding of one’s being means an enlargement, and enrichment of the personality and is no easy task —  arduous, but enlightening.  

The archetype of the shadow can be seen in many stories, such as Dr. Jekyll and Mr. Hyde, or in f Frankenstein, written by Mary Shelley in 1812. It struck a huge chord with the public as a profound example of the risks of disowning our dark side. In the story, Dr. Frankenstein is consumed by the needs of his ego to create life out of death. He works tirelessly, manically stitching together the parts of dead bodies to create his masterpiece. Avoiding all human contact for years, he is eventually successful in his ambitions. But on seeing  the creature he made, he recoils, calling it The Monster and abandoning it without a thought. He betrays his own creature, and it catches up to him, finding revenge in destroying the people Dr. Frankenstein loves most.

There is a bit of Dr. Frankenstein in all of us. We pursue our dreams and then when they do not satisfy us in the way we had expected, we abandon our creation — which has its revenge  in keeping us from full aliveness and wholeness. Or, because we’ve all been hurt, betrayed, or abandoned in some way, these unprocessed wounds can create a monster that’s embittered, enraged, and revenge-seeking, even taking the shape of self-harm. 

The poem “As I Walked Out One Evening” by W.H. Auden speaks of a healthy tension of opposites, which acknowledges the contradiction and beauty of human experience: 

‘O look, look in the mirror,

  O look in your distress:

Life remains a blessing

  Although you cannot bless.

‘O stand, stand at the window

  As the tears scald and start;

You shall love your crooked neighbour

  With your crooked heart.’

Personal growth through whole-hearted openness can  heal the split within ourselves, unifying opposites and defeating divisiveness. It is then that we can love our crooked neighbor with our own crooked heart.

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Third Ear Listening: Ethics and Teletherapy in Quarantine

Social distancing due to COVID-19 has caused a radical shift in our work as psychologists. In talking with other therapists, I’ve found that many of us are feeling the strain of doing therapy by teleconferencing. Talking with our clients via a one-dimensional digital representation lacks the subtle interpersonal interaction and relationship that characterize psychotherapy. By now, we’ve created a facsimile of our psychotherapy office that accommodates teletherapy where we try to listen with free hovering attention sitting in front of a screen with a camera, microphone, and perhaps earphones.

Video can be taxing due to the way digital images are encoded, which cause artifacts such as blurring, freezing, and audio that doesn’t always sync. We miss the powerful nonverbal communications that shed so much light on the intangibles of what might be contributing to a person’s issues. A blush, an eye-roll, a tear welling up, the fidgeting of someone with a secret, the nervous giggle, or shy smile—these nuanced communications can give us insight and aid our understanding of unconscious dynamics.

Whether in person or over the phone, we can still be attuned to our clients in the moment. In my psychotherapy practice, I have been influenced by Theodor Reik and his book Listening with the Third Ear (1943): 

We are… encouraged to rely on a series of most delicate communications… collecting all our impressions; to extend our feelers, to seize the secret messages that go from one unconscious to another. . . . The student often analyzes the material without considering that it is so much richer, subtler, finer than what can be caught in the net of conscious observation. The small fish that escapes through the mesh is often the most precious. 

Important in adjusting to providing teletherapy that most approximates in-person sessions is solving technical problems while paying attention to ethics (see updated information on ethical practice from the American Psychological Association) and HIPAA compliance. Some of these issues include:

  • Deciding on a HIPAA- compliant secure videoconference platform such as VSee, Zoom, Doxy, or Simple Practice (which I use.) 
  • Ensuring good WIFI (I had to buy an extender because my home office’s connection was sluggish and intermittent) and closing all other browser windows 
  • Learning how to code for insurance reimbursement
  • Giving clients clear instructions on how to access our video link and what to do if we get disconnected
  • Creating  a telehealth consent form and discussing potential risks and limitations of treatment 
  • Discussing safety plans
  • Confirming with clients how to ensure privacy and security before, during, and after our video call. 
  • Clarifying how to send payment
  • Asking for ID from new clients to confirm they live in California (unless we’re licensed to provide service in another state)

Other telehealth considerations have to do with making the session work visually. We’ve learned to position screens so the camera catches us from above and doesn’t show a double chin. To see each other clearly,  we’ve learned to position the lighting behind our screen, and when necessary, have instructed clients to do the same. To lessen distraction and be better present in the session, we avoid glancing down at our own image. Though it’s impossible to make real eye contact in a video call, we can better focus on a patient’s facial expressions by minimizing their image and moving it up the top of the screen nearer to the camera. This helps with connection, even if we can’t pass a tissue when we see our client cry. I have also discovered that sitting a little way back more clearly echoes sitting somewhat apart, as we would in person. There is more of a space between us. 

But there’s no new thing under the sun, and telemental health has been used for decades. Before smartphones, video chat, FaceTime, or Zoom, therapy via landline improved access to care, offering a cost-effective alternative to in-person therapy in many situations and populations. In Mules of Love (2002), Ellen Bass — poet and co-author of The Courage to Heal — wrote about the possibilities for therapeutic connection even across a seemingly impersonal, clunky telephone line:

Phone Therapy

I was relief, once, for a doctor on vacation

and got a call from a man on a window sill.

This was New York, a dozen stories up.

He was going to kill himself, he said.

I said everything I could think of.

And when nothing worked, when the guy

was still determined to slide out that window

and smash his delicate skull

on the indifferent sidewalk, “Do you think,”

I asked, “you could just postpone it

until Monday, when Dr. Lewis gets back?”

The cord that connected us—strung

under the dirty streets, the pizza parlors, taxis,

women in sneakers carrying their high heels,

drunks lying in piss—that thick coiled wire

waited for the waves of sound.

In the silence I could feel the air slip

in and out of his lungs and the moment

when the motion reversed, like a goldfish

making the turn at the glass end of its tank.

I matched my breath to his, slid

into the water and swam with him.

“Okay,” he agreed.

During this global crisis, doing psychotherapy so differently from our usual way of working requires facile adaptability, even once the practicalities are solved. But we can rely on our ethical principles to give us, and our clients, a safe and secure way to experience the moment. By endeavoring to listen and respond with the Third Ear, we strengthen our ability to make a healing therapeutic connection. In fact, being forced into this situation may reveal the usefulness of teletherapy that will last well beyond COVID-19.

This article was originally published in The Contra Costa Psychological Association Newsletter, May 2020.

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Working with Emotions: How mindfulness and awareness help

hiding from emotions is never a good strategy
Hiding from emotions is never a good strategy

Bringing the hidden to light is an important part of psychotherapy, sometimes achieved through focus on intellectual reflections. But in recent years, mindfulness-based therapies emphasize awareness of how feelings and physical sensations are related. It is enlightening to notice what happens in the body when we feel strong emotions.

As an example of how lack of mindfulness can hurt, I would sometimes react with anger at my husband when he disagreed or corrected me. But rather than seeing my point of view, he only experienced my anger as defensiveness, while I experienced him as overbearing. The result was that I felt worse.

This pattern continued until I learned to slow down my automatic reaction of anger, by becoming aware of the physical sensations that accompanied my feelings. This allowed me to become aware of the small, fleeting, and easily overlooked span of time between my internal commentary about his comment and my emotional reaction.

What was surprisingly helpful in doing this was to become aware of physical sensations; in mindfulness practices, we call this “mindfulness of the body.” Sleuthing out my emotions when corrected by my husband, I could actually feel my hackles go up. It was subtle but unmistakable.

Sensing our Hackles Before a Fight

When a dog’s hackles go up, the hair between their shoulder blades becomes erect as an automatic reaction to feeling threatened. As Adrienne Janet Farricell, a certified dog trainer explains, special muscles attached to hair follicles “are innervated by the sympathetic branch of the autonomic nervous system and are therefore not under conscious control. The function allows the dog to appear larger, taller and therefore more intimidating than it is. This is a ‘fight or flight’ response triggered by adrenaline.”

Paying attention to my physical response after my husband criticized me, I began to sense that distinct feeling of my hackles going up. But what surprised me even more was what followed:  I felt myself contract, my shoulders dropping and my chest becoming slightly concave. I submitted instead of fighting, just as a dog lies submissively on the ground. In the animal world, cowering is a useful and self-protective signaling “I am not a threat to you, so you don’t need to attack me.“ But when we humans do that, we lose some of our power.

Paying attention to this small and subtle sequence of physical sensation help us notice the physical reactions that often precede the ultimate expression of strong emotion. Without being aware of how we succumb to our initial reactions we are unable to address the problem that’s making us react.

Making the automatic conscious is liberating on many levels. First, we gain some control over our automatic responses—something dogs cannot easily do. Second, greater physical and emotional awareness lets us link direct relationship to felt experiences. Being able to name an experience or find an image for it, as I did with the hackles example, opens our understanding, bringing meaning to what on the surface looks like plain old anger.

It is important to know that an angry outburst is not always a bad thing. Anger is a reaction that often stands in for other feelings that are less available to us. Let’s imagine a typical couple’s situation of the sort I see in my practice.  When Jill got angry at Sam, she didn’t always stop to feel what that anger signified. Their arguments escalated as they each get more flooded with emotions. But when Jill reflected on her anger, her felt-sense was of being small, childlike, and without a voice of her own. Childlike? Sure enough, just as she’d felt in her family growing up with three older brothers, she experienced Sam as being dismissive of her opinions and dominating her in a situation where she was powerless.

Sam, meanwhile, had no idea she was feeling this way, because all he saw was her childish, to him, outburst. He tagged Jill as being easily out of control, making him feel all the more self-righteous toward her, which further reinforced Jill—and Sam–feeling like Jill was the problem in the relationship. Sam was off the hook, and did not have to look at his role.

Pausing Before Reacting

As this example shows, our reactions and feelings may mean more than we consciously know. In some traditions such as Tibetan Buddhism, mindfulness translates as “to remember.” This process of witnessing our emotions and our physical sensations requires remembering to push the pause button before our automatic reactions take hold. In a disagreement between couples, this may mean agreeing to a time-out, or the pause may be as subtle as one breath—a period between two sentences. Pausing gives us the space to be aware without becoming stuck in automatic reactions, attacking back, or inwardly growing smaller and losing the essence of our feelings, which are usually quite valid.

This pause also gives us time to consolidate our understanding of our self. Jill recognized an old memory: that of being discounted, unheard, or dismissed. She also understood that when anger dominates, the more important issues get lost.

Being Alert to Underlying Emotions

Of course, staying calm while having hard conversations can be challenging. It helps to recognize the early and subtle signs that you are becoming flooded. Once flooded, meaningful conversations come to a grinding halt or turn into a yelling match. Be alert for automatic reactions. Remembering to pause before automatically reacting allows us to tune into the deeper, less conscious feeling: what emotions and what physical sensations are triggered?

At this point, we have a choice. We can either use our awareness to ask directly for a bit of time to get back in emotional balance before continuing. Or, we can use the pause to go deeper into what may be coming up from within. This doesn’t have to be a lengthy process; with practice, that pause can take mere seconds for insight to come.

And in that pause, when we bring awareness to physical sensations like raised hackles or a churning gut, we can use these as signals to look more deeply into our role in what is getting triggered. Too often our automatic response is to assume fault lies outside us, not within. As Cassius says, “The fault, dear Brutus, is not in our stars, but in ourselves.”

While taking responsibility for what is arising in us, we also need to be aware of its impact on others. When we do this, hackles go down and the back and shoulders lengthen, bringing real power, liberating the Self to be more fully alive and present. Our defense mechanism was only masquerading as power, and that briefly.

What is Your Role?

Taking responsibility does not result in guilty self-recrimination but liberation and power. Once we take ownership of our contribution to conflict, we can more readily bring insight and thus control over our automatic reactions. It may reveal qualities within us that are active and useful in opening us up to be freer, more whole in ways we‘ve barely glimpsed.

Being aware of our default defense mechanisms can help us deal more effectively with difficulty. While many defenses help us cope—psychologists call this defense in service of the ego—they can backfire and hurt us. Because defenses are unconscious, it’s difficult to be aware when they emerge. The best clue that our defenses are lurking is when we react with strong emotions or behaviors, such as rage or sharp criticism.

Some of the most common defenses are projection and denial. They are related in that both mechanisms protect a person’s sense of self by attributing to another (projection) or rejecting (denial) their own unacceptable impulses or feelings, which are made unconscious. Let’s see how that worked with Amie and Jon, who were locked in a cycle of blame when they came to counseling. Amie saw Jon as extremely self-centered, and Jon felt Amie was too emotional, always criticizing him and trying to control him; meanwhile, each felt innocent of playing a role in this cycle.

With therapy, both Jon and Amie could see how they projected unacknowledged parts of themselves onto the other. Amie never gave herself permission to ask for time to be with her friends or to play. She then criticized Jon for taking time for himself instead of spending time with the family. Further examination revealed that Amie’s mother was a martyr and never let anyone in the family forget it. Amie grew up feeling that taking time for herself was selfish. She denied feelings of wanting to take time for herself and projected her anxiety about selfishness onto Jon. Meanwhile, Jon disowned his own anger by projecting it all onto Amie.

This dynamic created misunderstanding and distance. Once both Amie and Jon saw their role, they not only reduced conflict but had more access to dormant passions. Replacing anger with understanding brought new ways of relating. Sex reentered the marriage, along with play and a deeper acceptance of each other.

When your hackles go up–whenever you have a strong emotional reaction–you have an opportunity to learn something new. By pausing and paying close attention to your bodily sensations and your thoughts, you can discover something unexpected, something that ultimately empowers you.

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How to Be Sad

Psychotherapy for depression helps people accept that we can't force happiness.There’s a plethora of information about happiness.

My literature search on this subject yielded over 13,000 scholarly research articles and over one thousand books. Advice about how to be happy floods the internet daily with simplistic listicles and click-bait articles that make it all seem so easy.

But their advice, like telling a sad person to think about all the reasons they shouldn’t be sad, or a depressed person to just get up and exercise, doesn’t work. Thinking about the good things in life can sometimes ameliorate sad feelings, but usually, trying to grasp at happiness when in the grip of a depressed mood leads to failure. And while the research on exercise’s positive effect on depression is robust and persuasive, depressed people lack the drive to work out: that’s what depression means.

These suggestions, though well-meant, amount to telling depressed persons to snap out of it—or it’s their fault. This shames the sufferer, making things worse. And the resulting family strife doesn’t help. Well-intentioned spouses and parents who believe that snapping out of it actually is within a depressed person’s power will eventually succumb to exasperation and resignation.

A recent New York Times article gives suggestions for eliminating negative thinking, and paraphrases  Rick Hanson, author of Hardwiring Happiness: The New Brain Science of Contentment, Calm, and Confidence: ” it might be helpful to ask yourself if you are accomplishing anything by dwelling on your negative thoughts.”

Depressed people have negative thoughts. Understandable. When we’re depressed, we’re likely to feel hopeless, inadequate, and a failure. While practicing controlled breathing and mindfulness even with your eyes open, as the article suggests, will help, how do we get to the point of making these actions regular parts of daily life? When sadness overwhelms, it is often impossible to follow well-meaning suggestions with regularity. Like New Years’ resolutions, these techniques fade quickly.

When Sadness is Normal

Sometimes sadness is normal. Experiencing a range of feelings in reaction to painful life events is understandable; these life stressors would make most of us depressed. When psychologists see a client for a first appointment, we assess mood, its duration, and the severity of distress. Is the client’s symptoms within normal limits given the precipitant for entering therapy, e.g., a marital crisis, job loss, or death of a family member? We would say a client’s feelings are “within normal limits” when they come to therapy with sadness after losing a loved one.

In my own practice, a former client returned to treatment recently because his wife had just died. He spoke of his inability to shake the feelings of loss and sadness. It had only been four weeks, and he asked me if it is normal to feel depressed, and the question that inevitably follows: how long it will last? It’s okay to feel sad—but to someone grieving, the feelings can be so intense that time stands still. Four weeks can feel like four years.

It’s hard to feel deep emotional distress, of course. Indeed, because suffering is part of the human condition, we’ve devised a vast repertoire of ways to avoid experiencing our painful emotions and worrisome thoughts, including self-medicating by substance use, distraction by Facebook and other media outlets, and much more. Americans account for two-thirds of the global market for antidepressants, which also happen to be the most commonly prescribed drugs in the United States. These drugs can play a vital role in helping many people cope with chronic depression, but all too often these medications are over prescribed or prescribed without looking at inner sources of depression.

When Positive Thinking and Life Coaching Make it Worse

Or, life coaches with little training in mood disorders are prescribing positive thinking the way many physicians prescribe mood stabilizers, but even positive thinking strategies are ways to avoid painful feelings. I have seen the disastrous results of life coaches who work remotely from home, charging enormous amounts of money to people desperate for help. Sadly, these coaches have not laid eyes on the people they propose to help. They are unable to see the dangerous weight loss or weight gain or pick up the nuanced suicidal non-verbal communications.

One client I saw judged himself to be a failure after his six-month life-coaching sessions because he was unable to feel better or do the things the coach was suggesting. When I saw him after his failed coaching experience, he was in a deep depression, his sadness palpable. I asked if he was suicidal and he admitted that he was—something his coach had never asked about. Alerting his partner and suggesting hospitalization was imperative. Alarmingly, he had already seen three different psychiatrists and obtained antidepressants from each, and not one of them had inquired about suicidality.

Another example from my practice is that of a woman who saw a life coach because she hated her job. They talked about the need to follow her bliss and sever ties with her employer. She took this advice, quit her job, and when her unemployment ended, she was unable to find another job. Despondent, she came to therapy to help sort out her feelings about her life and to find a way to understand why she was unhappy at her former job. She needed to understand her role in how she was sabotaging herself. She took the long road to what ultimately brought her fullness and acceptance of life and work.

Accepting Suffering as Unavoidable

Suffering can’t be avoided. (In Buddhism, it’s the first Noble Truth.) But allowing ourselves to express sadness and to accept deep pain will eventually allow these feelings to dissipate; blocking emotions only deepens problems. Also, giving ourselves time to settle into feeling allows us to recognize that they ebb and flow. Through this, we can accept that while old age and death are inevitable, and feeling sad is part of living, suffering is impermanent. By being able to sit with emotions and not get caught up in either rumination or anxious fretting, we develop a steadiness of mind. Meditation works by settling our turbulent thoughts and emotions so that we can titrate them into tolerable moments.

What works

When sadness becomes major depression, positive thinking (and related approaches, such as life coaching) are like putting a Band-Aid on a gushing wound. Facing our pain, learning to bear our suffering, and then doing the deep inner work of understanding our role in our troubles is a way out. It is often slow and filled with obstacles. Here are some steps in the process:

  1. Become aware of subtle emotions as you experience them. By becoming aware of emotions as you feel them, rather than pushing them away, you will be better able to use them to employ coping strategies.

 

  1. When emotions become intense, know that feelings don’t stay that way forever. All emotions are transient. Practices such as regular meditation help us not just to become aware of feeling but also not to indulge them.

 

  1. Remember that subtle change is hard to see. A broken bone mends slowly; in the early stages, healing is hardly noticeable on an X-ray.

 

  1. Look deeply at ourselves and the role we play in our mood. Doing so opens what is within, leading to understanding and insight.

 

  1. Take into account what precipitates depression. Learning to tolerate understandable sadness and some depression helps normalize what we are experiencing. All emotions have a role to play in living well; we must accept and not disown our most difficult feelings.