psychotherapy

January 24, 2017 By Susan O'Grady 10 Comments

How to Be Sad

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:

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.

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.

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.

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

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.

February 23, 2016 By Susan O'Grady 4 Comments

Waking up on the Grumpy Side of the Bed: Coping with difficult moods

“Yesterday all day a small gardenia was a great consolation.”

Thomas Merton

A Year with Thomas Merton: Daily Meditations from His Journals

Some days are harder than others. It’s tempting to find something or someone to blame, even if it’s just the wrong side of the bed. Yesterday, I woke up grumpy, but instead of fault-finding, I announced to my family that I was grumpy and not to take anything that happens between us too personally.

My bad mood persisted through breakfast. In fact, I kind of enjoyed feeling grumpy. Especially because there was no apparent reason and I didn’t care to find one. I felt defiant.

I took my hike as I usually do, on this sunny morning. I begrudgingly admitted it was a stunning day. Yet my mood persisted—and became worse as a large group of hikers, some meet-up group or club, began to pass me on the narrow trail. As I walked in the opposite direction up the hill while they clomped down, one by one, they each said good morning, smiling as if the day was something really special. In my sour mood I thought, ”How many more are there? Don’t they realize that, as one person going against the tide of walkers, I would already have been greeted numerous times? And how many more good mornings and fake smiles do I have to return?”

Many, many more, it turned out, because the group numbered more than 80. And every single person smiled at me and said “Good morning,” or a variant of it. By about the 40^th person, something happened without any volition on my part: I began to smile back with genuine happiness. At first, it was in amusement at my grumpy predicament of sharing a trail with 80 very happy hikers, but as the group moved past me, I felt a stirring of good will toward these cheerful strangers, who had unknowingly softened my mood.

Sometimes moods are like that: inexplicable and unpredictable. As a psychotherapist, I help people articulate their feelings. More expansive and more integrated awareness of emotions, achieved through therapy and mindfulness practice, helps people respond more healthily and flexibly in the moment and day by day. By doing so, we can change the quality of our lives.

It can feel as though we’re overpowered by emotions. We can become so absorbed in them that we become identified with what we feel and lose the ability to witness them. A simple misunderstanding with a friend can become an all-consuming and unbearable wound. In such cases, we risk getting stuck in a contracted state that can lead to depression or avoidance behaviors such as overeating, drinking, shopping, or sleeping, which provide a temporary illusion of feeling good. But as we know, those actions backfire, leading to more guilt and less overall effectiveness.

Noting and naming emotions, in contrast, gives us a path past denial or avoidance into acceptance, letting go, and even gratitude.

Sometimes our moods are not just difficult, but serious mood disorders, such as major depression. If feelings of sadness last longer than two weeks, and interfere with daily activities, it is important to get help from a psychotherapist to determine if psychotherapy and medication would benefit. Mindfulness-based cognitive therapy is often a good treatment for depression.

The solution is not to ignore our difficult moods, but to acknowledge them as they arise. In some situations we will be able to trace what we feel to a particular event that we can bring insight to. For other moods, like my waking up grumpy for no apparent reason, we accept them and watch what happens next, much as we do with the weather. Eighty happy hikers eventually made me smile and my bad mood passed as they passed by. That was essentially effortless, but it is often quite effortful to cope with hard emotions.

When we cultivate a disposition that witnesses and accepts passing experiences, we become more stable. In mindfulness meditation or contemplative prayer, we accept thoughts and feelings without judgment and with open and spacious awareness. Emotions arise and pass without interference. I acknowledged my grumpiness and warned my family not to mind me. In doing so, I took responsibility rather than looking for someone or something to blame. This allowed me not only to be open to my bad mood, but also to become open to the good mood that emerged later on.

Sometimes, of course, bad moods can arise for good reasons, not just something that inexplicably overtakes us. In his journal, Thomas Merton describes waking up with heart palpitations and shortness of breath, surely cause for concern. But instead of dwelling on his fear, he starts his page by recognizing the small gardenia as a consolation. He describes walking out into the woods and gazing at the tall straight oaks, closing his journal entry for that day with the lines:

“Sweet afternoon! Cool breezes and a clear sky! This day will not come again. The bulls lie under the tree in the corner of their field. Quiet afternoon! The blue hills, the daylilies in the wind. This day will not come again.”

That is more than acceptance; it’s real gratitude. It starts with accepting all our moods, the grumpy and the grateful. Without that, we can only approximate gratitude in a kind of pretending. With my softened mood, I continued on my way, grateful to the hikers, and happy to be spending my morning in the hills.

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 5, 2015 By Susan O'Grady 6 Comments

Psychotherapy: A Safe and Sheltered Space

One size does not fit all when it comes to finding a good therapist. Many variables influence the extent to which people get better, solve problems, and grow. While empirical support is important in choosing what treatment to provide, psychotherapists shouldn’t stick rigidly to what studies suggest; instead, they should work from the position of evidence-informed practice. This allows for treatments that respond to what clients bring to therapy—their unique histories, temperaments, and narratives. Sometimes what may be most helpful in the therapy is intangible and unmeasurable by any study. In research, these are referred to as non-specific effects. These are uncontrollable factors: the usually small, barely noticed interactions that create an unexpected effect in the subject. In other words, they are not a part of the research experiment.

In Irvin Yalom’s book Existential Psychotherapy, he describes how, during a cooking class, he wondered why the instructor’s meal always tasted better than any of the his attempts at the same recipe. He learned why after catching the teacher’s assistant throwing fistfuls of various spices in the dish before putting it in the oven. This story has stayed with me since reading it in the early years of graduate school. The crucial ingredients—the “throw-ins”— of good therapy may be unquantifiable, and untaught; even the therapist may be unaware of them.

In a previous post I wrote about love as part of the therapy. Love is a challenging factor to study because it is difficult to quantify and because love overlaps significantly with other emotional reactions such as respect, compassion and empathy, and curiosity.

What is the art of therapy? Sometimes it is as simple as being really present with clients during their pain. Being present means not interrupting, giving advice, or falling asleep, but instead staying tuned to a client’s process. As in meditation, a therapist who notices his or her mind wandering should first notice where it has gone (and if there is anything in that mental tangent that could provide meaning about the client’s situation) and second, return that attention to the client.

A safe and sheltered space

In ancient times a holy person who would descend into what was called an incubation chamber—a dark underground space—with someone in turmoil or grieving. They would remain together in the darkened underground space for three days. This practice illustrates how healing comes through being present with feelings. When someone is suffering, the willingness to go into the dark with them as they express and move through their feelings is a large part of what we do as therapists. When suffering people can take what’s vague and private, locked inside their heads, and speak out loud the unspeakable, they can gain a depth of understanding and new self-compassion.

The popular 2015 Pixar film Inside Out shows how this works. Riley, the young protagonist must endure her family’s cross-country move, which takes her away from her friends, her home, and her beloved hockey team. Believing she must be perfectly mature, she suppresses her sadness. Five personified emotions–Joy, Sadness, Anger, Disgust, and Fear –live in her head and influence her actions and memories. The dominant voice is Joy, because being happy and not expressing our negative feelings is socially rewarded. But all emotions have a role to play in living well. When Riley tries to silence Sadness, she becomes numb to all feeling, including Joy, and pandemonium ensues. It’s only when Riley can fully acknowledge the sadness in her life that she can also remember the tender, loving moments. Therapy patients must similarly accept and not disown their most difficult feelings.

Good treatment isn’t always easily available. Many therapies lend themselves to apps and downloadable protocols, making these treatments more accessible for people who are unable to find (or afford) a good-fit therapist. Videoconferencing, mobile applications, g-chats, and web- or text-based therapy have a place, and can be powerful ways to change behavior and improve symptoms, especially for those who feel shy or stigmatized about talking to a therapist. But with something gained, sometimes something is also lost with techniques that avoid human interaction and relationship.

What’s missing are 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 speak in ways where texting is mute. Staying safely in front of a screen provides shelter, to be sure, but possibly also a place to hide.

To illustrate the importance of face-to-face therapy, there’s the example of my former client who returned to therapy after a seven-year break. He told me his physician kept increasing his antidepressant dosage, but he was getting worse, not better. After sitting with him for close to an hour, listening to the many stresses he described, I gently inquired about his subtle, yet noticeable twitching. His movements were suggestive of a genetic disorder and not merely anxious fidgeting. He immediately told me “My biological father [he was adopted at birth] was really strange before he died. He moved and twitched all the time—I haven’t thought about it in years but I know he had something wrong.”

At the conclusion of our session, he promised me that he would contact his cousin and find out the name of his father’s condition. I suspected it was Huntington’s disease, a rare genetic disorder. When he emailed me the confirmation, I was able to suggest genetic counseling and testing.

So what appeared to be depression and anxiety—and was being treated as such—was in fact a neurobiological condition. While the news was not good, he could be treated by the right physician for his condition and not keep taking medication that only made him feel worse.

The opportunity to look at your darkness with someone who respects you and your process can allow you to speak the unspeakable, giving room to the ineffable—those moments of awe that come only when we let the full range of who we are be seen and known.

Rumi stated it well in his mystical poem “A Garden Beyond Paradise”:

Everything you see has its roots in the unseen world.

The forms may change, yet the essence remains the same.

Every wonderful sight will vanish; every sweet word will fade,

But do not be disheartened,

The source they come from is eternal, growing,

Branching out, giving new life and new joy.

Why do you weep?

The source is within you

And this whole world is springing up from it.

The joy of which he wrote cannot spring forth without awareness that it will also fade. Trust that the source of life is in sitting with and sharing the difficult parts of ourselves in a safe and sheltered space.

January 12, 2015 By Susan O'Grady 3 Comments

The New Year, Rebirth, and Obstacles

By the third or fourth week of January, many of us are reevaluating our lives. We’ve either made resolutions (and perhaps already broken them) or we are resisting this ancient practice with awareness of the years of collapsed intentions when previous New Year’s hopes didn’t pan out.

Yet we continue to be drawn to the symbolic cycle of each New Year because we crave growth and change. Like the snake, the symbol of healing (seen in the Rod of Asclepius), we long to shed our skin and emerge from the constraints that hold us back.

Stories of rebirth offer hope that change is possible, and that we can be made new again. The parts of ourselves that we’ve outgrown—the aspects of our personality and our life that keep us stuck, can be discarded, making room for new growth. With each new year, we imagine ourselves in new light—and set intentions to change.

Images of rebirth in faith traditions, in myths, and in nature symbolize the cycle of death, liberation, and ultimately rebirth. The Phoenix, for example, is a mythical bird that was said to live 500 years, burst into flame, and then arise from its own ashes after three days. This image represents the recurring cycle of resurrection, immortality, and the indestructible nature of the spirit, as well as the pain and destruction necessary to this cycle.

In the Gospel of John, Lazarus is raised from the dead after being buried four days in a dark tomb. Jesus tells Lazarus—still wrapped in the cloth that bound him—to get up and come to the entrance of his tomb. He commands Martha and Mary, Lazarus’s sisters, to unbind their poor brother so that he can be free to live life with fullness. Imagine that you can unbind yourself from whatever darkness holds you.

The lotus flower is another symbol of rebirth. The Sanskrit word for lotus, pankaja, means “mud-born.” Although rooted in mire and nourished by decomposed matter, the lotus rises each day and opens radiantly into the light. Throughout the day the flowers turn to face the sun as it moves across the southern sky. After sunset the petals close into a tight bud before the lotus descends into the murky soil of the pond or river. We are not separate from the earth. We grow from it and each day is a new beginning. All arises and passes away.

We must be willing to let go of parts of ourselves that do not serve us well. That might mean something as seemingly small as forgoing coffee in the afternoon so we sleep better at night, or as large as leaving a job or relationship that no longer fits who we are becoming. Growing into our fullness requires that we accept the mud from which we come.

The butterfly is a ubiquitous symbol of transition, growth, and rebirth because of how the crawling caterpillar enters its cocoon and is transformed into the delicate and graceful winged butterfly. But this process needs effort to work, as Paulo Coelho describes in his Dec. 2007 blog entry “Lesson of the Butterfly.” A man watches “a butterfly struggling to emerge” and decides to help it by cutting open the cocoon, but the butterfly never flies, never even opens its wings, remaining shrunken and shriveled:

What the man – out of kindness and his eagerness to help – had failed to understand was that the tight cocoon and the efforts that the butterfly had to make in order to squeeze out of that tiny hole were Nature’s way of training the butterfly and of strengthening its wings.

Psychotherapy is not painless. People wanting to change must face fundamental aspects of themselves that no longer (or never did) serve them. The obstacles we confront help us to be whole; avoiding them never does.

It’s popular in social media to present lists of “5 ways to cure” this or that. Such lists simplify and distort what is often difficult inner work. Some psychotherapy sessions are smooth and feel-good, but if every session is like that, the work may not be deep enough—for surely change involves difficulty.

We can be born anew each day, and in every moment. Many traditions teach lessons about renewal. Mindfulness meditation, when done regularly, can provide the foundation to live each moment and then let go of it as the next moment comes.

What are the important images in your life, and what do they say about you? Find the images that form inside you, as you listen to stories, poetry, or in the silence of the meditations. Your image could be a butterfly, a lotus flower, even a humble loaf of bread (which can’t be made without punching and kneading). Allow images to form in your awareness, and then bring insight and understanding to what they might symbolize.

Think of a story that was central to you and your development. For me, the tortoise and the hare was important, and one I have returned to many times in my dreams and as I face challenges.

You cannot live without dying. You cannot live if you do not die psychologically every minute. This is not an intellectual paradox. To live completely, wholly, every day as if it were a new loveliness, there must be dying to everything of yesterday, otherwise you live mechanically, and a mechanical mind can never know what love is or what freedom is.

~ J. Krishnamurti

We need stories to grow.

Habits are hard to change. There are ways to help you keep realistic resolutions. This NY Times article summaries several studies that show ways to make good habits stick.

How to Be Sad