Reaching Out

Not the Panacea

Almost 19 million Americans have periods where they feel a lack of pleasure or interest in what was once pleasurable and interesting. They feel tired and heavy, potentially overly emotional or numb, and experience an onslaught of negative and self defeating thoughts that can keep  invading the mind over and over again. The more periods of this depressed mood we have in life, the more likely we are to fall back into them again. Why does this relapse occur and how can mindfulness offer hope?

Falling into a depression feels traumatic and just like getting bit by a dog causes us to be fearful of and oversensitive to dogs, our minds and bodies become oversensitive to associations with the depression causing our brains to flinch at any sign of a relapse.

Feeling low mood is normal for everyone, but if we’ve experienced depression in the past, this may be a trigger for a relapse. If we feel tired or if we notice sadness, the mind pops up with the worry “uh oh, that is how I felt when I was depressed, maybe I’m getting depressed”. Our minds begin to go in overdrive with negative self judgments, “I am a failure” or “I am weak” or “I am worthless”. It then tries to solve the mystery as to why we are becoming depressed again and the more it tries to solve this puzzle, the deeper it sinks into depression. Think of a worried, judging person coming at you trying to solve your problems when you’re already not feeling well. Probably not what you’re looking for. You see, it’s not the low mood that’s the problem here, it’s the way we get stuck in habitually relating to it that pours kerosene on the fire, with our minds continuing to fan the flame rolling us into a full blown depression.

The practice of mindfulness teaches us a different way to relate to our thoughts, feelings, and emotions as they arise. It is about learning to approach and acknowledge whatever is happening in the present moment, setting aside our lenses of judgment and just being with whatever is there, rather than avoiding it or needing to fix it. It’s the mind’s attempt to avoid and fix things in this moment that fuels the negative mood.

With Uncomfortable Emotions

If sadness is there, instead of trying to fix it or figure it out, we might just acknowledge the sadness, let it be and get a better understanding of what we need in the moment.

With Self-Judgments

If self-judgments arise (e.g., I am weak, I am a loser) out of past sensitivities to having been depressed before, we can acknowledge that they are associations from the past, let them be, and then gently bring ourselves back to whatever we were doing. In doing this, we’re stopping the ruminative cycle that might occur between our thoughts, feelings, physical sensations and behaviors that can play off one another leading into another relapse (I call this “The Depression Loop” in the upcoming book Uncovering Happiness).

Now, this is easier said than done and it takes practice.

Confidence with Rumination Practice:

Let’s get our hands (or minds) into it. One way to practice mindfulness is to use the breath as an object of awareness. You can place attention at the tip of the nose or the belly and as you breathe in, just acknowledge the breath coming in and as you breathe out just acknowledge the breath going out. As if you were greeting and saying goodbye to an old friend. When the mind wanders, as it will always do, just say to yourself “wandering” and then gently bring your attention back to the breath just noticing it coming in and going out. Most of us catch the mind wandering and gently bring it back billions of times, so know that it is normal for the mind to wander often. You can do this for as little as 1 minute or as much as 30 minutes or more.

Practice this when you’re feeling well and you’ll be better able to recognize when your mind wanders off to ruminations and self judgments when you’re not feeling well.

What does this have to do with gaining confidence over rumination?

Like learning an instrument, you can develop more skill as you practice. When you’re not feeling well and the mind begins to ruminate, as you practiced with the breath, just label it as “ruminating” and then gently bring your attention back to whatever you were doing. Being more present may also give you the ability see the space between stimulus and response and see the “choice point” to  be more flexible and call a friend or do something that then gives you pleasure or connection with others.  This is what I’ve referred to as The Now Effect. 

Know that practicing is an act of self care and helps stop the cycle of rumination and cultivates more patience, compassion, and peace.  

Mindfulness is not a panacea for depression, but it’s a good foundation for preventing relapse.

As always, please write below with any comments, questions, thoughts, or additions that arise after reading this. Your comments below help provide a living wisdom for us all to share and benefit from.

Cognitive Therapy

Cognitive therapy is based on the theory that much of how we feel is determined by what we think. Disorders, such as depression, are believed to be the result of faulty thoughts and beliefs. By correcting these inaccurate beliefs, the person’s perception of events and emotional state improve.

Research on depression has shown that people with depression often have inaccurate beliefs about themselves, their situation and the world. A list of common cognitive errors and real life examples is listed below:

• Personalization — relating negative events to oneself when there is no basis.
  Example — When walking down the hallway at work, John says hello to the company CEO. The CEO does not respond and keeps walking. John interprets this as the CEO’s lack of respect for him. He gets demoralized and feels rejected. However, the CEO’s behavior may have nothing to do with John. He may have been preoccupied about an upcoming meeting, or had a fight with his wife that morning. If John considered that the CEO’s behavior may not be related to him personally, he is likely to avoid this negative mood.
• Dichotomous Thinking — seeing things as black and white, all or none. This is usually detected when a person can generate only two choices in a situation.Example — Mary is having a problem at work with one of her supervisors who she believes is treating her badly. She convinces herself that she has only two options: tell her boss off or quit. She is unable to consider a host of other possibilities such as talking to her boss in a constructive way, seeking guidance from a higher supervisor, contacting employee relations, etc.
• Selective Abstraction — focusing only on certain aspects of a situation, usually the most negative.Example — During a staff meeting at work, Susan presents a proposal for solving a problem. Her solution is listened to with great interest and many of her ideas are applauded. However, at one point her supervisor points out that her budget for the project appears to be grossly inadequate. Susan ignores the positive feedback she has received and focuses on this one comment. She interprets it as a lack of support from her boss and a humiliation in front of the group.
• Magnification-Minimization — distorting the importance of particular events.Example — Robert is a college student who wants to go to medical school. He knows that his college grade point average will be used by schools during the admission process. He receives a D in a class on American History. He becomes demoralized thinking now that his lifelong dream to be a physician is no longer possible.

Dr. Losito a Cognitive therapist work with the person to challenge thinking errors like those listed above. By pointing out alternative ways of viewing a situation, the person’s view of life, and ultimately their mood will improve. Research has shown that cognitive therapy can be as effective as medication in the long-term treatment of depression.

Psychotherapy

Psychotherapy -- also called talk therapy, therapy, or counseling -- is a process focused on helping you heal and learn more constructive ways to deal with the problems or issues within your life. It can also be a supportive process when going through a difficult period or under increased stress, such as starting a new career or going through a divorce.

Generally psychotherapy is recommended whenever a person is grappling with a life, relationship or work issue or a specific mental health concern, and these issues are causing the individual a great deal of pain or upset for longer than a few days. There are exceptions to this general rule, but for the most part, there is no harm in going into therapy even if you're not entirely certain you would benefit from it.

Millions of people visit a psychotherapist every year, and most research shows that people who do so benefit from the interaction. Most therapists will also be honest with you if they believe you won't benefit or, in their opinion, don't need psychotherapy.

Modern psychotherapy differs significantly from the Hollywood version. Typically, most people see their therapist once a week for 50 minutes. For medication-only appointments, sessions will be with a psychiatric nurse or psychiatrist and tend to last only 15 to 20 minutes. These medication appointments tend to be scheduled once per month or once every six weeks.

Most psychotherapy today is short-term and lasts less than a year. Most common mental disorders can often be successfully treated in this time frame, often with a combination of psychotherapy and medications.Most psychotherapy tends to focus on problem solving and is goal-oriented. That means at the onset of treatment, you and your therapist decide upon which specific changes you would like to make in your life. These goals will often be broken down into smaller attainable objectives and put into a formal treatment plan. Most psychotherapists today work on and focus on helping you to achieve those goals. This is done simply through talking and discussing techniques that the therapist can suggest that may help you better navigate those difficult areas within your life. Often psychotherapy will help teach people about their disorder, too, and suggest additional coping mechanisms that the person may find more effective.

Psychotherapy is most successful when the individual enters therapy on their own and has a strong desire to change. If you don’t want to change, change will be slow in coming. Change means altering those aspects of your life that aren’t working for you any longer, or are contributing to your problems or ongoing issues. It is also best to keep an open mind while in psychotherapy, and be willing to try out new things that ordinarily you may not do. 

Psychotherapy is often about challenging one’s existing set of beliefs and often, one’s very self. It is most successful when a person is able and willing to try to do this in a safe and supportive environment.

What is “Palliative Care”?

The World Health Organization defines palliative care (PC) as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention of and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.” To meet these multidimensional needs, PC is usually provided by a team including physicians, nurses, social workers, and chaplains. Patients can receive PC at any time along the trajectory of a serious or life-threatening illness. (This is distinguished from hospice care, a subset of PC that is reserved for end of life treatment.) PC can also be provided in conjunction with treatments aimed at life prolongation. For example, a patient with metastatic breast cancer may be treated by an oncologist who focuses on cancer treatment while a PC team focuses on management of symptoms (pain, nausea, shortness of breath, depression, anorexia, fatigue, spiritual distress, etc) and assists with advance care planning.

In the United States, PC is generally provided as an inpatient or outpatient consultation. Providers may request a PC consultation to assist with clarification of the patient’s goals of medical care, symptom management, communication between the medical team(s) and the patient and family, prognostication in advanced illness, advance care planning, and end of life (EOL) care. For instance, a common consultation is to help a patient with advanced liver disease to understand the severity of the illness and treatment options, and to manage pain, shortness of breath, and nausea.

The ultimate goals of consultation are to treat symptoms of advanced illness and to assist patients and families in understanding their prognosis, in expressing the goals (or most important factors) in their medical care, and in receiving medical care that is aimed at achieving their goals of care. For example, is the patient with liver disease more interested in staying in the hospital to receive intravenous therapies of marginal benefit or in returning home to spend time with family and friends?

Hospice Care
Hospice care, by contrast, is a specific type of palliative care for patients nearing the end of life. In the United States, hospice refers to a healthcare benefit provided through Medicare Part A or private insurance. A patient is eligible to receive hospice care if two physicians certify that he or she has a life expectancy of six months or less if the “disease runs its usual course.” In addition, the patient must choose to trade standard Medicare Part A (inpatient) coverage for the hospice benefit, which covers medical care that is usually provided in the home and is focused on comfort and relief of suffering rather than life prolongation. Patients with any end-stage disease (heart failure, dementia, COPD, HIV, cancer) are appropriate for hospice referral. Hospice care is the form of PC that most physicians are familiar with; however PC is a much broader discipline.

Discussing End of Life Care with Patients
In addition to focusing on the relief of suffering, palliative providers are often involved in discussions about advance care planning and EOL care. For example, we may discuss prognosis, current treatment options, and options for future care with a patient with end-stage COPD. Specifically we would talk about what is most important to the patient in the time they have left to live and how their medical care can help them to achieve these goals. We would review if the patient is interested in intubation/ICU care or care that is entirely focused on their comfort in the event of a future COPD exacerbation.

There is a robust body of literature demonstrating that the majority of patients want to have these discussions with their providers, yet fewer than 50% of patients actually do (Reilly et al, Arch Intern Med 1994:154(20):2299–2308). Providers often cite barriers to having these conversations, such as a lack of training, lack of time, and concern that such discussions may harm patients or “take away their hope.”

Multiple studies have evaluated the effects of these conversations on patients’ treatment choices, quality of life, and mental health in addition to the effects on caregivers’ quality of life, mental health, and perception of the patient’s death. The Coping With Cancer study was a multisite prospective cohort study of 332 patients with metastatic cancer who progressed through first-line chemotherapy, and their caregivers (Wright et al, JAMA 2008:300(14):1665–1673). The 37% of patient/caregiver dyads who reported having a discussion about end of life care with their providers were compared to the dyads who reported not having these conversations. The patients who had the discussions were more likely to prefer medical care focused on relief of pain and suffering over life-extending treatments. These patients also were more likely to complete a DNR order and less likely to be admitted to the ICU, receive mechanical ventilation, or undergo a resuscitation attempt. Interestingly, patients who received less aggressive care experienced a better quality of life without a decrement in survival time. EOL discussions were not associated with patients feeling depressed, sad, terrified, or worried or meeting DSM criteria for a psychiatric disorder.

Their caregivers benefitted, too. Caregivers of patients who received aggressive care in the last week of life were more likely to develop major depressive disorder, experience regret, feel unprepared for the patient’s death, and report poorer quality of life and health after the patient’s death. This study supports the concept that EOL discussions and less aggressive EOL medical care are associated with better quality of life among patients and their caregivers.

Patients report that the manner in which EOL discussions are held is as important as the content of the discussions. According to current research, cancer patients in Western countries want realistic, truthful information that is delivered with a focus on what can be done (symptom management, emotional support, practical support, and maintenance of dignity). They value discussions in which the provider explores realistic goals as a means of fostering hope. Such goals might include control of pain and shortness of breath so patients can spend more time talking with their families. Patients feel that a discussion of what the future may hold should be well-timed. They want the information to be given when loved ones can be present and when the provider can spend an adequate amount of time with them. Lastly, patients value respect for their emotional state and an acknowledgement of the emotional, spiritual, and existential impact of having a life-threatening illness.

TCPR’S VERDICT: Given the heavy emotional burden associated with advanced illness, there has always been a significant role for psychiatry in PC. An important demonstration of this role is the inclusion of psychiatry as a specialty supporting the subspecialty of Hospice and Palliative Medicine. The challenge ahead is to further develop strategies for advancing the collaboration between providers of palliative and psychiatric care.

I Miss You - I love You !

 

There are enough of us that have lost loved ones over the years where we can shed tears at a

 

moments notice of good memory reoccurring. Along with that things you needed now with that loved one help to make that assignment run smoother.

 

 

This is our way of providing a honor to our loved ones that have gone before us on this joureny towards a Life of being with God and all who have helped paved the way to our success in life.

Take All the Time You Need.