Mindfulness and Medications

 

Mindfulness and Medications:

Meditation is Medication                                                                               Jerry H. Gelbart, M.D.

Most people expect psychiatrists to be pill-pushers. That is what we are experts at. However, not all of us emphasize medications.

Before medical school and psychiatric residency, I earned a B.S. in Psychology at the University of Michigan, where I was actively involved with Behavior Modification and Transactional Analysis. After medical school, my residency training program taught a rich variety of techniques, including CBT and Intensive Psychodynamic psychotherapies. Since then, I worked for several years as Adjunct Professor of Psychiatry at Stanford, learning, then teaching Dialectical Behavior Therapy (DBT) to psychology residents. My approach has evolved more and more into behavior change, and utilizing medications to facilitate behavior and lifestyle changes.

Medications are not good or bad— each one has pros and cons. Most people worry about becoming addicted, or complacent, if they take psychiatric medications. Fears include:

  • The stigma of what it “means” to take such medication
  • Meds will not deal with what they are stressed/depressed about
  • They are just a crutch
  • Might feel better and not want to work on self-improvement
  • General fear of side effects, most often weight gain
  • Being overmedicated, drowsy, emotionally numb, not caring
  • Being unable to get off medications

These are all real concerns, and should be discussed with clients. However, they are often overblown and distorted, becoming false facts. These fears can all be addressed as part of a comprehensive treatment strategy. Usually we can find medications that don’t cause weight gain or other serious side effects. Many clients who benefit from medications can eventually come off them if the psychotherapy and medications are managed corroboratively. We can also learn to look at psychiatric medications, and people who take them, non-judgmentally.

A major part of learning mindfulness is to rid ourselves of judging; ourselves, others, and getting away from seeing things as “good or bad.” We must apply the same perspective to medications, and understand that they are not good or bad. Instead, we can see medications as having pros and cons. I often add that not taking medications has pros and cons. Remember we are in 2017. The psychiatric medications we use nowadays have far, far less side effects than the older ones.

We are not faced with a black or white choice, talk therapy or pills. The best option is often both. Medication can be used to facilitate psychotherapy. The right psychotherapy can help many people get off psychotropic medications. I feel so strongly about this I will usually only prescribe medication for patients doing psychotherapy.

A synergistic approach aims to incorporate and coordinate psychotherapy, behavior/lifestyle change, and medications when appropriate. We are not trying to “fix” the client, or the diagnosis. Instead, our goal is to move the client from Illness, to Health, and all the way on to Wellness.

ILLNESS

HEALTH

WELLNESS

        Self-doubt

        Insecurity

        Lack of confidence

        Frustration

        Pessimism

Getting by

        Confident

        Assertive

        Decisive

        Expressing needs

        Optimistic

               Low energy

Car is sputtering!

     Medium energy

Car runs but not all cylinders are firing!

Energetic, motivated

All cylinders firing!

 

 

 

 

 

 

 

 

 

 

ILLNESS

HEALTH

WELLNESS

Symptoms such as:

        Feeling hopeless, helpless, worthless, shame

        Isolation

        Sleeping too much or too little

        Trouble concentrating

No symptoms

Biological, Psychological, Social, and Spiritual 

Routines and behaviors designed to:

        Prevent slides into illness

        Maximize functioning and effectiveness

        Achieve your full potential

 

 

 

 

 

 

 

 

 

 

 

 

  

We help the client understand what Wellness looks like, what the role of therapy would be, and their own role and work. Think about medications as reducing symptoms that interfere with goals of therapy and lifestyle changes. These symptoms can include:

  • Anxiety
  • Insomnia
  • Emotion dysregulation
  • Concentration impairment
  • Lack of energy/drive
  • Persistent negative beliefs
  • Critical/shaming self-talk

 As a psychopharmacologist and psychotherapist I see how these symptoms can become hurdles to psychotherapy and behavior change, and how addressing them chemically can reduce the hurdles as we move down the field toward Health and Wellness. When we all do our jobs right, the client becomes Well and learns to maintain Wellness. Then, and only then would we start reducing medications. It is important that that time is chosen corroboratively, and that therapy continue (with modifications) while medications are titrating down. Some clients will be found to do best long term with medications.

Where does mindfulness fit in? Mindfulness practices have been translated from eastern beliefs and traditions for our “American” minds, by psychologists Jon Kabat-Zinn, Marsha Linehan, and others. In DBT, people learn a variety of coping tools for behavior change, grounding, emotion regulation, and self-care. The prime tool is Mindfulness Practice, which teaches:

  •  Being in the present, observing/aware of what’s happening, externally and internally, and
  • Non-judging, because if we get distracted with judging, blaming or criticizing we lose our focus, cause suffering, and block learning.

Most of what throws us into the past, into the future, or into self-criticism, is that voice in our head. That voice, sometimes called “the critic” or “monkey mind” (and many other names) is basically the voice of our childhood programming: our black or white beliefs, judgments, assumptions that get programmed by parents, teachers, clergy, bullies, etc. when we are young. This stream of consciousness becomes our “Default Neural Network” (DNN) which most of us confuse for our self. When we practice Mindfulness, we begin to separate our self from this stream of thinking, beliefs, interpretations and judgments, thereby seeing ourselves and events more objectively.

Our DNN is constantly judging, that’s its job. With anxiety, depression, and trauma, this system is hyper-active. The more we listen to it, the more it is fueled. Conversely, the less we listen to it (by re-directing focus elsewhere) the weaker it gets. Brain imaging studies have shown that over 6 months Mindfulness practice reduces the activity of the DNN. It changes the brain! Mindfulness training helps to separate our self from this system. By practicing mindfulness exercises regularly, we train part of our brain to track what is happening inside and outside, moment to moment. We develop a “higher part” of our mind, which in DBT is referred to as “Wise Mind.” This is an alternative brain network that is often underdeveloped, and like a muscle it can be exercised and strengthened.

However, most people we are trying to help have obstacles to learning. They may have negative beliefs (coming from their DNN) that nothing will change. Lack of energy and motivation are common. They may have trouble concentrating, and/or too much anxiety to do the exercises. They may be too disorganized to prioritize. Medications may help reduce these obstacles.

Since we can now “see” the DNN in imaging studies, we can see what reduces its activity. Meditation reduces the activity of DNN, and so can antidepressants. I frequently see that negative, critical voice quieting with meds. Psychotherapeutic response is accelerated.

————————————————

When I grew up, we used terms like “upset” to describe, in a very vague way, that we were emotionally off-kilter. Nowadays DBT has a better term, “dysregulated.” This also implies that we can feel “regulated.”

Consider different levels of dysregulation, beginning with zero, no dysregulation. Grounded. On a scale from 0 to 5, 5 would be off-the-wall, for me, at 5 I’m yelling at people and out-of-control.

dysreg 1

 Paying attention to our emotional state is important if we want to be fully effective. The earlier we realize that we’re dysregulated, the easier to re-regulate. Often, we don’t realize how dysregulated we are before it slaps us in the face. Often, we start the day dysregulated, only to get more and more dysregulated as the day goes on.

The solution is to begin the day with meditation, yoga, T’ai chi, or something similar so that you start off grounded, ideally close to “0”. Mindfulness practice develops the part of the brain that can actively monitor your level of regulation/dysregulation, as well as many other factors through the day. Coping tools such as breathing exercises, thought stopping, redirection and many others are useful each time you find yourself getting a little dysregulated.

In the graph above, the lower levels of dysregulation, 1,2, maybe level 3 can usually be managed with active use of coping tools. If we miss the opportunity and don’t realize we’re dysregulated until we reach higher levels of dysregulation, then it may be too late for coping tools alone. You may need to take a chill pill.

But that’s ok! Use the incident as a learning opportunity! At this point people will often get down on themselves, that they failed because they had to take the pill. Anticipate the judging, and practice non-judgmentalness toward self and medications. Taking medication isn’t good or bad.

I tell my patients they can do both, the pill and the tools. The medication makes the tools work better; the tools help the medication. Once re-regulated, look back and try to identify earlier opportunities you may have missed to apply the coping tools for next time.

 It can go this way:

 You’re at level “0”. Calm and regulated. Someone gives you a weird look. You think:

 “Why did she look at me like that?”  (level 1 dysregulation)

“Maybe I’ve got something on my face, or my hair is messed up”   (level 2 dysregulation)

“What if she thinks I’m a slob?”   (level 3 dysregulation)

“Why didn’t I check the mirror?   (level 4)

 “What’s wrong with me?”  (level 5)

Another way to describe this is at level 1 you are asking the question. If you start to answer the question it escalates you to level 2. If you get caught up in this stream of thought, you get more and more dysregulated.

Learning Mindfulness and developing Wise Mind requires active intention, prioritization and practice sessions. Over time, Wise Mind is running in the background, like a spell-checker, ready to pop out when necessary. In this case, “You just asked why that lady looked at you like that. Do you really wanna go there?”  More and more automatically you will catch the initial thought, which could lead to dysregulation. It’s like the train starting up at the station. If you automatically begin to answer the thought, you’re getting on the dysregulation train. However, if you tell yourself you just had a dysregulating thought (the train is about to take off, do I really want to get on it?) you now have a choice. Answer the thought, jump on the train, or redirect your mind in another direction. The dysregulating thought goes away in a puff.

Each time we recognize the DNN trying to hijack our brain, and we ground, re-center or re-direct our focus, we are weakening that DNN over time.

dysregtable2white

Clients need to get this! By intentionally giving less and less attention to our DNN, those judging networks become weaker and weaker. Most of the hard work is up front, learning to separate our consciousness from our DNN. In the beginning it can be like trying to train a wild horse. Many clients give up trying meditation and say “I tried it, it didn’t work for me.” Many or our medications can reduce the agitation of that wild horse, making it easier to train.

Some psychiatric medications can be used on an as-needed (“PRN”) basis, as in the earlier examples, while others are best used on a routine basis, usually once/day. Many, but not all medications which are only used PRN can be habit-forming, while most used routinely are not. Consider a daily medication for clients who are more depressed, having more trouble with activities of daily function such as concentration or self-regulation, as well as those struggling with psychotherapy (which includes ability to do homework).

Psychotherapy is treatment of choice for most emotional problems. Some people, with more biological disorders such as Schizophrenia or Bipolar, may need meds for life. The answers we receive depend on the questions we ask.  Most people ask, “Do I need medications?” usually the answer is no, you don’t “need” them. For example, you can choose to continue to struggle or suffer. The better question is “Could I benefit from medications?” which can hopefully lead to a non-judgmental, objective discussion about potential benefits versus side effects, and how medication may fit in with the overall treatment strategy.

Procrastination

By Jerry H. Gelbart, M.D.

“Tomorrow Never Comes” – My 8th grade math teacher

I won’t say his name. He put the fear of G-d in me. If homework wasn’t done on time, and especially if you made up an excuse, he would physically put you up against the wall, or worse, tease and shame you in front of the class. My homework was on time.

Although his tactics were drastic by today’s standards, he put an end to my pattern of procrastinating. Millions of other people are not so “fortunate,” and they continue to be handicapped with this solvable problem. 

To determine whether procrastination is a problem for you, answer the following questions:

– Do you put off until later what you can do now?

– Are you intentionally managing your time?

– Does “putting off” cause you anxiety that the task may not get completed adequately?

– Has “putting off” resulted in negative consequences for you or others?

– Do you feel like you need the anxiety produced by “putting off” to successfully complete the task?

If you intentionally put off something important, knowing it will get done, you later do it, there’s no anxiety about it, that’s not a problem. If you intentionally manage your time you probably don’t have procrastination issues. 

Whereas some therapists may tell you that procrastination, as well as the associated anxiety, are part of a work style, I disagree. Procrastination and anxiety are not necessary in order to be productive, and these patterns cause suffering for the bearer in several respects. First and foremost are the anxiety and stress, which have negative effects mentally and physically. Our immune, cardiovascular, musculo-skeletal, gastrointestinal, and other body systems react negatively to anxiety and stress, both in the short-term and long. Mentally, it can cause trouble sleeping, thinking clearly, panic attacks, and fatigue. Please see my short video called “Body States” for more information on the effects of stress on the body.

Procrastination also causes the bearer poor self-esteem, low self-confidence, and the belief that he/she is defective. This leads to shame, contributes to the avoidance of tasks, and prevents functioning at full capacity. Let’s listen in to the “voice in the head” of a procrastinator:

“I should do _________.  I can do it later. I have time.” (Finds something else to do, i.e. surf the net, talk on the phone, some other project).

Two weeks later:
“I should start on ________, but I still have plenty of time.”

One week later:
“I should __________. But it’s so overwhelming, where do I start?”

Next day:
“What if I don’t get __________ done on time? What if I do a lousy job?”

Next day:
“Geez, I’m gonna have to pull an all-nighter to get this done on time. Why do I always let this happen?  What’s wrong with me?”

Sound familiar? I know this causes anguish. You do have a choice. I have helped many people break these patterns. The result is feeling empowered, confident, and rewarded. Admitting you have a procrastination problem is the classic “First Step.” From there it gets easier. Research shows that there are phases we go through in order to change behavior:

Phase 1. Pre-contemplation: Procrastination is my work style and it works for me because I still get done what I need to.

Phase 2. Contemplation: Procrastination might be a problem for me because it causes me to feel anxiety and shame, which is bad for my physical and psychological health – but I don’t know how to NOT procrastinate!

Phase 3. Preparation: I have decided that I should both stop procrastinating and that I have the capacity to stop procrastinating. I am putting together a plan of action that works with my personality, finances, and lifestyle that will be conducive to not procrastinating. I will seek out and accept help from others.

Phase 4. Action: Putting into action the plan for not procrastinating.

Phase 5. Maintenance: I have learned to not procrastinate, and I feel less anxiety and shame as a result!

Relapse: Sometimes I slip back into procrastination, but when this happens I know how to bring myself out of it with specific skills and tools. I don’t let the shame of relapse prevent me from getting back into action and then maintenance.

If you are ready to cross into new territory now, read on!

What causes procrastination? There are 3 key forces involved: anxiety, reward, and time management. You can address each one.

Procrastination is a symptom; anxiety is the problem. The anxiety comes from how you are judging yourself, and your fears about how others will judge you. Anxiety, like fear, causes avoidance. Avoidance is putting off, i.e. procrastinating. The procrastinating reinforces the negative judgments, which fuel the procrastinating – resulting in a very frustrating and painful cycle.

There are networks in the brain that are constantly judging: good/bad, friend/foe, carrot/stick. These networks function to keep you safe, from people who might harm you, and also from being rejected by your tribe. With anxiety, these networks are hyperactive. They are overly focused on judging yourself, worrying about how others would judge you, and how to avoid being shamed. You can’t shut it off.

Most of this judging is distorted ‘black or white’ thinking. I call it “Toxic Judging.” Toxic Judging gets programmed from our childhood environment, and is also influenced by our genetics. As a priority for survival, avoiding sticks is more powerful than working toward carrots. Avoiding embarrassment becomes more powerful than the potential rewards of completion. To stop procrastinating you have to consciously shift that balance. This means decreasing fear (anxiety) in your mind and increasing reward. Lets start with the way you talk to yourself.

Step back from the voice in your head. Is it supportive and encouraging? Or does it put you down? If you procrastinate, that voice is probably very negative and cynical. It is very black or white, all or nothing. It speaks in terms of being strong or weak, success or failure, normal or defective. The real world is not so black or white. This is the Toxic Judging. Even after you get something done does it focus on what you didn’t do? This language creates fear and discouragement. It is not the language of growth and change. You can free yourself from this by paying attention to what you say to yourself in your mind, stepping back from it, and reframing it the way you would talk to a friend.  

With some work you can change that voice in your head. Practicing Mindfulness trains you to be aware of your distorted thoughts in the moment, and to not beat yourself for having them. Mindfulness puts you in a frame of mind that is Curious, Open, Accepting, and Loving (“COAL”). Cognitive Behavioral Therapy (CBT) teaches you how to challenge and neutralize the distortions (See practice worksheet). There are also medications that can be used to reduce the strength of the networks that fuel the toxic judging. 

To settle down your mind, in addition to challenging your distortions, you have to tell yourself that you are safe. There are no fires that have to be put out immediately. There is no lion in the room about to eat you. Take some time to notice your worries and fears, your “what if’s” and catastrophizing about the future. Applying your mindfulness will take you out of the future into the present.

As you practice these techniques you will catastrophize and beat yourself up less and less. Add some coping skills to lower anxiety levels, such as breathing exercises or guided imagery, which are easy to learn. You have to practice these techniques when you are calm; they can’t be learned when you are anxious, frustrated, or emotionally dysregulated.

We are coming from a past of huge anxiety and minimal reward. We begin to shift the balance, to low anxiety and huge reward. Most procrastinators try to push forward through the intense anxiety. This is unnecessary torture. This is working from fear. Instead, when you want to tackle your work, plan 10 – 30 minutes to first bring down the anxiety levels and get grounded, then start the task.

No one likes this next part: lower your expectations about how much work will get done at first. Plan 15 minutes to 1 hour, with a big reward for after. In the beginning, the work expectations have to be super low, and the reward super high. You have been steaming along with these patterns for years. Just like a large ship moving in the ocean, if you want to turn it around, extraordinary forces are required. 

If I am trying to get myself to exercise, I plan for myself a big reward (i.e. 15 minutes in sauna and Jacuzzi) for small requirement. At first it might be 5 minutes on the Elliptical machine. Then 8 minutes, then 10, etc. Over time the requirement to get my reward goes up. It comes easier and easier as I establish the routines. When I think about going to exercise I focus on the immediate rewards I’ll get, plus the long term health rewards.

You want to develop rewards that excite you- that you will want to do- and ask a (very) small work price. When you approach your work keep your focus on the reward that’s coming after, and how little you have to do to get it. This way you are doing your work via motivation networks rather than battling the fear networks. Your dopamine levels will be higher while you work and when you get the reward your dopamine levels spike even higher (You got the carrot!). This breaks the pattern.

Choosing rewards can be tricky. Reward means it has to be earned. Self-care routines, such as healthy meals, sleep, unwinding time, relationship time, and spirituality, should not be used as rewards. Rewards can be cheap or expensive. Examples of cheap rewards:

  • Watching TV/movie
  • Playing game(s)
  • Extra time with musical instrument
  • Sitting by a fire
  • Getting a massage from partner or friend

Examples of more moderately priced rewards:

  • Going out for a meal, or round of golf
  • Sauna/Jacuzzi
  • Buy music or a book
  • Pay for a massage
  • Token system to save up for something (ie. clothing, trip)

To summarize the steps:

1) Plan small task. What and when. Plan your reward.

2) Before approaching task, take time for calming/grounding (reducing sticks). Try the Cognitive Restructuring worksheet.

3) Focus on the big reward you will be giving yourself, how good it will feel, and how little you have to do to get it.

4) Do the small task. If anxiety levels increase go back to step 2.

5) Give yourself a big reward (eat the carrot)! Feel good about it.

Music can help with each step. Create different playlists. For example, one playlist would be for the relaxation step. Another would be music that motivates you and helps you get focused. Another playlist could be songs that you play for “reward” when you’ve accomplished something.

This all comes together through intentional time management.  In order to schedule and follow through with your grounding time, work time, and reward time you have to be in the present and act with intention. Often a coach or therapist can help you get organized. The judging and catastrophizing will keep throwing you off course. Don’t be discouraged!

Expect frustration and difficulties as you try to change your approach. Trust in our human ability to adapt. You don’t need to be shamed in front of the class to wake up. The human brain (including yours!) can be gradually re-wired by working with these techniques, and you can be more grounded, self-confident, and productive.


Thanks to Brittany Gelbart for her great suggestions!


 

The Xanax Equivalency: Translating Medication Into Lifestyle

The Xanax Equivalency: Translating Medication Into Lifestyle

 

Back in the 60’s, according to Mick Jagger, Valium was “Mother’s Little Helper.” Other than alcohol, it was probably the number one coping tool. An appropriate dose would relax and calm the recipient, make everything feel ok. Valium is very addicting. By the 90’s it was mostly replaced by Xanax.  Although it is even more addicting than Valium, Xanax has its benefits: it’s better at lifting the mood and less likely to accumulate in the body. Both are basically “band aids” to numb the recipient and manage symptoms simply and quickly.

 

Yesterday I was talking to a patient about the value of her yoga class, her swimming, and her social time. We got into comparing how she felt after these activities, versus how she felt after taking a Xanax. Of course these activities require prioritization, time, and effort. Way easier and faster to take a pill. But it was clear that these activities led to feelings of relaxation, inner peace, and pride in self. These and similar routines also begin to address areas that have been neglected in life.

 

Are you using chemicals, such as tranquilizers, alcohol, or caffeine, to help manage stress or anxiety? Would you rather use more natural and sustainable methods of regulating your moods? Shifting from chemicals to a healthier lifestyle takes some work but if it’s important to you, then you can modify your routines. Making these changes will not only reduce your need for chemicals, it will also elevate your quality of life to a whole new level!

 

Many activities and routines can help optimize body and mind. That means that if you prioritize and give these activities special attention you will function at your best, feel better, and live longer. Likewise, ignoring these important activities can cripple you. Here is a partial list:

 

BIOLOGICAL

 

Nutrition/Diet- Healthy meal planning, shopping, cooking and eating

 

Exercise- Every other day, stretching, aerobic, cardiovascular, musculoskeletal

 

Outdoor Recreation- Your doses of sunlight and fresh air

 

Body/Mind- Yoga, T’ai Chi, others

 

Sleep- Healthy sleep schedule and routines (look up “Sleep Hygiene”)

 

PSYCHOLOGICAL 

 

Mindfulness practice- Routine practice of being in the moment and disengaging from judging

 

Self-soothing activities- On a regular basis!

 

Creativity- Music, art, dance, writing, inventing…

 

Self-Challenge- Stimulating activities that are challenging but do-able

 

“No self”- Activities that get you so absorbed you don’t think about yourself

Life Of Values- Living and acting on your values

 

Love and Compassion- Giving and receiving

 

SOCIAL

 

Sense of community, belonging- Spending time connecting with others

 

Working on circles of relations- Improving relationships, getting closer (or more distant and setting boundaries)

 

Family- Bonding time

 

Fun with others

 

SPIRITUAL

 

Meditation- Doesn’t have to be sitting still!

 

Contemplation/inquisitive- Asking “Why?”

 

Contemplation/appreciative- Accepting, gratitude

 

Religious/Spiritual practice

 

 

Which of these areas are working well for you? Which are not?

 

Living healthier includes examining your values… What’s important and what you consider the “right” way to live. If you’re considering making changes to your life, the best place to start is to examine and solidify your values. Everything will fall into place from there. When you live your values you can be guilt and anxiety free, and feel good about yourself.

 

When you do review your values, you will find that self-care is up there. That’s what this article is about. Most people can see it would be hard to be depressed or unhappy when living a life that includes these activities on a regular basis. When engaging in these activities, and for a time after, we often forget about our pressures, give our body a chance to unwind and rejuvenate. That includes stabilizing hormones and the immune system.

 

What gets in your way of making the lifestyle changes necessary in order to be “Optimally well?”

 

Here are common excuses:

 

1. “I don’t have enough time”

 

2. “I feel guilty”

 

3. “Nothing will change”

 

4. “No money”

 

 

Let’s address these.

 

1. “I don’t have enough time.”

 

There are 24 X 7 = 168 hours in a week. Let’s subtract out 8 hours sleep per night (- 56) and let’s consider if you work more than 40 hours, let’s say 70 including travel or if you’re a stay at home parent. 168 – 56 – 70 leaves about 40 hours per week when you are not sleeping or working. 

 

How do you use that time?

 

Solutions:

 

-Schedule your time wisely. Little by little learn what you need in order to function optimally, and prioritize those activities.

 

-Follow through on those activities whether or not you “feel like it.”

 

-Set boundaries on what you do for others.

 

If necessary, practice in front of a mirror:

 

“I’m sorry I can’t do that because if I don’t  _________  (exercise, meditate, etc.) then:

 

a) “I won’t be able to function well.” Or,

b) “You won’t wanna be around me.”

 

-Combine activities to cross categories and save time. For example;

 

A walk = Biological and Psychological

A walk with a friend = Biological, Psychological, and Social

A nature walk with a friend = Bio-psycho-socio-spiritual!

 

 

2. “I feel guilty.”

 

This is about self worth, and setting boundaries.

 

It means that you consider needs of others, and deny your own. Often people say they feel like they don’t “deserve” to put their needs before those of others.

 

The pros and cons exercise is an eye opener. You could do this with every activity. We’ll do a general practice here:

 

What are the pros of prioritizing wellness activities? What are the cons?

What are the pros of not prioritizing wellness activities? What are the cons?

 

Pros

Prioritizing Wellness Activities

Cons

I feel better

Takes effort

My body and mind work better

Less time to give others

 

I have to say “no” more often to people

I’ll probably live longer, less likely to get ill

People will be mad at me

Better quality of life

I have to do things for myself even if I don’t feel like it

I feel more in control of my life

I have to plan my day, week and be more deliberate  and intentional about my time

 

 

 

Now we flip it:

 

Pros

NOT Prioritizing Wellness Activities

Cons

I don’t have to say “no” as much

More stress, anxiety, depression, unhappiness

No one gets mad at me

I won’t function that well

Just do whatever comes up

Probably have shorter life and get ill more often

Easier

Worse quality of life

I don’t have to take responsibility for my body

I don’t feel in control of my life

 

I feel resentful

 

 

 

3. “Nothing will change.”

 

Everything will change. See #2.

 

4. “No money.”

 

Many healthy activities can be done cheaply or at no cost. You can spend a lot of money on a health club, or walk or jog for free. Similarly, you can pay for a meditation class, or many churches, synagogues, and Buddhist centers give free classes. Activities with friends can be expensive or cheap.

 

It’s very easy to make excuses for not taking care of our basic needs. It’s very easy to take a pill and suck it in. It takes more effort to make lifestyle changes. 

 

Which pills do we need, and which can we potentially get off of?

 

Most people have a lot of judgments about psychiatric medications, and those who take them. Medications can be useful, even necessary for some. They are not good or bad. Those who take psychiatric meds are not any more “defective” than those of us who don’t, and often they are less “defective” than people who afraid to take meds because of how they’ll be judged. If you are on prescription medications you should work closely with a doctor and potentially a psychotherapist.

 

I see many people who would suffer less and be more effective if they were on the right meds. I also see many people taking medications who would not need them if they changed their lifestyle, priorities, and learned to be assertive about their needs.

 

We know what “Illness” is. You are sick, you have symptoms. “Health” is when you are not sick. That does not mean you are well. “Wellness” is when you are actively living your Bio-psycho-socio-spiritual program. Work out your Wellness Program and strive to stick with it!

The Reverse-Stress Mentality

REVERSE-STRESS MENTALITY

What is Stress Mentality? In S.M. the belief is:

“I can’t take care of myself until I get everything done.”

We have all experienced the short-term stimulation of an upcoming deadline, exam, or speaking engagement, and when necessary temporarily set aside our basic needs to accomplish a higher goal. Stress mentality here refers to a more ongoing, chronic, “self-sacrificial” way of thinking.

Many people self-medicate with sleeping pills, alcohol or other substances, or are prescribed antidepressants or addicting benzodiazepines for stress or anxiety. While medications can play an important role, all too often they are utilized instead of more powerful alternatives, such as changing the way you think, or how you take care of yourself.

What are the pros and cons, the plusses and minuses of stress mentality? Is there a better alternative?

First, what are the plusses, the benefits, of stress mentality?

I. Many people believe they need stress and fear of failure, or bad consequences to be motivated. However, there are much healthier ways to self-motivate (Hint: it is connected to your values and passions).

Now, what are the minuses, the cons, of S.M?

I. There are always things that need to get done.

II. S.M. generates chronic stress and all of its negative effects on the body. (link to Body states Video)

III. Like a car, our mind and body needs basic maintenance to run. I have to put gas in and change the oil even if I’m busy or else bad things happen.

IV. Similar to the car, stress mentality ends up with some sort of breakdown of mind or body.

What, then, is the alternative? The reverse. In Reverse-Stress Mentality the belief is:

“If I take care of myself first I will be more efficient in getting my work done.
“I have to differentiate between what needs to be done and what can wait so there’s balance.”

What are the plusses of reverse-stress mentality?

You start to take care of yourself, therefore you will have:
More energy
More clarity
More efficiency
More balance
Better mood
Minimal stress.

What are the negatives of reverse-stress mentality?

I. Not everything will get done right away.

II. You have to learn new (healthier) ways to motivate

III. You have to set limits, including saying “no” and sometimes disappointing people.

Most of us have a never-ending conveyor belt of things that need to get done. Many people really believe that they can’t take care of themselves until the belt stops.

When I refer to self-care that means biological, psychological, social and spiritual needs. What gets in the way of carving out time for self-care, or “pushing the pause button” on the conveyor belt? Those factors include:

– Self-worth, how you judge yourself
– Fears about how others will judge you
– Fear of failure and inadequacy
– Fear of getting people upset, angry, or disappointed in you
– Fear of asking for help.

There are many ways to get help overcoming these obstacles; psychotherapy is only one of them. Learning and practicing mindfulness helps to get rid of your judging and fears about how others will judge you. It also helps take your mind out of the past, out of the future, and into the present moment, where it is needed in order to make the best decisions.

Successful implementation of the reverse stress mentality requires skills for managing time and setting boundaries, and these skills are teachable. Coaching or therapy can be helpful. If you have trouble setting boundaries and saying “no,” maybe a 12-Step program such as CODA would be helpful. If you can’t stop obsessing, newer antidepressants help that a lot, with minimal side effects.

Mindfulness (and other types of meditation), physical exercise, and other routine practices can literally change the brain, as evidenced in recent brain imaging studies. It takes hard work but it’s worth it.

Change doesn’t happen overnight. Set an intention, and mindfulness will help keep you focused on that intention. You’ll frequently slip back to your old thinking and behaviors; but when you notice that happening don’t judge – just ground yourself and re-establish your goals.

Integrative Wellness Assessment- Call office 925-254-3652 for details

Integrative Wellness Assessment

      18 and over

      6o minutes face to face session plus separate 20 min feedback session $500.00

      Framework:

  • Integrative
    • Biological, Psychological, Social, and Spiritual
    • Moving from Illness to Health to Wellness
  • Focus is on achieving synergies between:
    • Lifestyle changes
    • Psychotherapy (primarily mindfulness-oriented CBT/DBT, skills training)
    • Medications
  • Going forward rather than looking back
    • What works
    • No judging
  • Illness Evaluation Wellness Planning (I.E.W.P. Like IEP in schools except for adults)
  • Not assuming care

      Includes:

        I. Face to face evaluation

                a. History of current symptoms/illness

                        i. Including cognitive, medical, substance use, and pain issues

                b. Current and past treatments

                c. Biological, psychological, social, and spiritual strengths and weaknesses

                d. Comprehensive mental status exam


      II. Phone consultation with current/recent providers, significant other when appropriate


      III. Additional outside lab work and testing may be recommended

                a. Standard, such as thyroid and liver functions

                b. Less standard, such as vitamin levels

                c. Genetic testing- some can help predict responses to medications

                d. Neuropsychological testing for cognitive impairment


      IV. Fresh, clear perspective on:

                a. Symptoms, illness, “DSM 5 diagnosis”

                b. Stigma

                c. Concept of moving from Illness to Health and on to Wellness

                d. Importance of lifestyle changes


      V. Perspectives on treatment options

                a. Psychotherapies- individual and group

                b. Medications

                c. Combined effects of A and B plus lifestyle changes

                d. How to choose a good therapist and/or psychiatrist

                e. Short term versus long term prognosis


      VI. Brief written feedback included. Full report extra.


      VII. Brief follow-up sessions (extra) if appropriate.

                a. In these situations a medication may be started

 

Option of on-line video consults: Same fees. Cannot prescribe medications.

Call the office 925-254-3652 for additional information

GET A-HEAD SERIES: Updates and Bug Fixes For Our Brain #2

GET A-HEAD SERIES: Updates and Bug Fixes For Our Brain

 

#2: “Social Anxiety And The Brain”  Or, “Shed The Shame”

 

The first article in the GET A-HEAD SERIES, called “The Fear Switch,” explained how the amygdala has evolved to be prone to false alarms. Once the alarm is activated, the sympathetic nervous system kicks in to “fight or flight” mode. Fight or flight mode is a healthy response to some situations, such as when we’re about to be hit by a bus. However, many other situations and thoughts can activate the fear switch inappropriately, causing unnecessary distress, anxiety, or panic.  Examples include:

 

-Thinking of something bad that may or may not happen in the future.

-Thinking that we might be rejected or abandoned.

-Fear of not being normal.

-Fear of humiliation.

-Fear of being a failure.

-In chronic stress, fear that we’ll drop a ball and everything will come crashing down.

 

Article #1 also described the irrational “toxic judging” that our brain does so automatically. Everything is judged in black or white categories. A person is either normal or not normal, good or bad, strong or weak, a success or a failure. When we feel insecure about our self we think that if we are not normal… or good… or strong… or successful, then we will be rejected and alone forever. That thought sets off our fear switch big time! While the first article focused on the alarm itself and what happens, the focus here will be on the “judgment generator,” which is the source of our insecurities. I encourage the reader to review the “Patches” at the end of Article #1 related to fear.

 

PFC

Many of the situations that set off false alarms are related to toxic judging and shame. Shame is about being rejected by our “tribe.” The Ventral Medial Prefrontal Cortex (VM-PFC) in our brain can be called the “judgment generator” or, “The Shame Center.” This part of our brain focuses on how people will judge us, and whether we “fit in” or not. Its job is to protect us from rejection. But it doesn’t know when to stop! We experience the VM-PFC as that little “voice in our head” which brings up our self-doubts and insecurities. Perhaps you can see how this might be involved in social anxiety. In fact, the VM-PFC is also hyperactive in other anxiety disorders such as obsessions, compulsions, and eating disorders, with low self-esteem and when we lose our motivation.

 

When toxic judging is in high gear, your VM-PFC might say to you “If you embarrass yourself people will think you’re a fool and not take you seriously… you’ll be shunned and alone forever.” That thought, and the images in your mind of people who are written off and forgotten, sets off the fear alarm. This can include racing thoughts, racing or pounding heart, tension, shortness of breath, and butterflies in the stomach. This whole process can be reinforced by further “emotional reasoning” if you conclude, “Wow, if my body is reacting this way there must really be something wrong with me!” We can get so caught up in the automatic negative thoughts and the corresponding physiologic reactions that we can’t get out.

Homeless


Evolutionarily, there have been benefits of an active VM-PFC, along with its adjoining networks. In pre-modern times when people lived in tribes, what happened to those who did not “fit in”? Ostracism or banishment could mean death in the wilderness. Fitting in was life or death.  Although our VM-PFC still believes this is the case, it no longer is. Our shame center still acts as if we live in a tribe surrounded by wilderness, which most of us don’t. It still carries on with all the same judging and fears. When active, this area is judging you and worrying about how others are judging you.

 

Some types of judging evolved to keep us safe. For instance, judging is useful in deciding if others are trustworthy or dangerous, and for evaluating our own actions, in order to guide us to be true to our own values. However, toxic judging amplifies and exaggerates the “classification” into absolutes. It is hyper-concerned about how others will classify us, causing us to be fearful that we will be “classified” as not-normal.

 

Bad news: The more you listen to your VM-PFC and it’s black or white judging the more you strengthen it. Even arguing with that voice in your head strengthens it.

 

Good news: You can learn to disengage from that part of your brain, and thereby reduce its energy and power. Practicing mindfulness makes it easier and easier to step back, label the toxic judging and not get hijacked by it.

 

Shame generated by “toxic judging” is irrational and not based on facts. Shame is “justified” if ones’ behavior causes ejection from the group. On the other hand, guilt is “justified” if we have violated our own values. Defining your values and connecting with people who share similar values can reduce shame, and fears of rejection. You can then live a life of values instead of a life of fears (of rejection). We can replace toxic judging with healthy judging, discerning what behaviors, and which people are healthy and wholesome for you.

 

Brain Patch #2

 

1) The “voice in our head” is a remnant from tribal living plus the black or white beliefs we formed as children. Its only concern is to protect you from shame. It can hold you hostage.

 

  • Separate what your “Shame Center” is saying to you versus what’s really happening.
    • Would people you care about really reject you for certain things?
    • Do you agree with the values of these people? 
    • Ask yourself:
      • “Is this toxic judging?”
      • “What am I really afraid of?”
      • “Have I been true to my moral code?”
    • You can learn to step back from the voice and consider it as “just one opinion….” And you can respond to it “thank you for sharing.”

 

2) Unnecessary stress comes from worrying about what people will think of you if you:

 

    • Can’t handle everything put on you.
    • Let something fall through the cracks, or make a mistake.
    • Tell them “No that’s too much for me.”
    • Ask for help.

 

If you feel stressed, step back and listen to what you’re telling yourself.  If you’re hearing words like “failure,” “weak,” or “inadequate” these are indications that your stress is shame-based. 

 

3) Challenge any “all-or-nothing” thinking, labels, categorizing, judging, or jumping to conclusions. Practice NOT buying into them. It’s even better to laugh at our tendency to do this so automatically! Over time, the goal is to learn to shrug off that critical voice in our head with minimal effort.

 

4) Spend time developing your values, your own belief system about the “right” way to live, and what is most important to you for the future. Think about what character traits you want to develop in yourself. {Character traits template}

 

    • Example: What kind of “judging” do you believe is ok?
      • Judging if someone is “normal” or not? “Defective”? “Worthy or worthless”?
      • That people shouldn’t have faults or that we have to prove something?
      • Or do you think it’s better to be non-judgmental?
    • Don’t go by how you think others judge; it has to be your code of what’s right.
    • Then connect with people who share your values. Work around those who don’t.
    • What is more important, acting according to your values or being liked?

 

5) Consciously shift from blaming, faulting, and defensiveness to humility and compassion, for our self and others.

 

    • Accepting weaknesses and mistakes in our self and others.
    • Loving unconditionally
    • Healthy boundaries
    • Compassionate assertiveness
    • Awareness of inter-dependence and inter-connectedness.

 

6) People’s judgment isn’t what gets us banished; it’s breaking the code. Usually if you act on your values and get rejected, you can find others who share your values. It’s breaking laws of the land that get you removed from society.

 

A hypersensitive fear switch and overactive shame center combine to cause a huge amount of avoidable suffering. The next article in the series will help you improve your confidence, assertiveness, and intentionality. By practicing Mindfulness and following my blog you will learn to calm your fears and shed your shame!

How To Choose A Psychotherapist

How To Choose a Psychotherapist

 

By Jerry Gelbart, M.D., F.A.P.A.

Psychiatrist

 

Most people I talk to have no idea where to start looking when they want a good therapist. Many therapists can be amiable, supportive, encouraging, but in 2013 we need to expect more than that. We now have therapies such as Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy, (CBT), Acceptance and Commitment Therapy (ACT), and others that have been shown to be effective in scientific studies, and many therapists are not up to date with these. For example, many therapists still use older models such as Jungian, Analysis, or Supportive therapies that have not proven to be cost-effective in getting the job done.

 

Here are 7 things to look for if you’re choosing a therapist:

 

1. Therapist sets tangible goals with you. Goal setting:

 

a. Gets you, therapist, and other members of treatment team (i.e. Psychiatrist, Primary Care MD) all focused in same direction

 

b. Helps you see if you’re making progress.

 

c. Goals help you move forward instead of looking back.

 

2. Therapist is open minded to various treatments, including nutritional, medications, Eastern approaches, group therapy, hospital outpatient or inpatient. “Whatever works.”

 

Not defensive, willing to consult with others or send you to someone else if not a good match.

 

3. Therapist is engaged and engaging, versus passive, remote, disinterested.

 

4. Therapist is not just supportive, listening, reflecting (I call this HHT, “Hand Holding Therapy”).

 

5. Therapist can say what kind of therapy they are doing.

 

The models mentioned above are not the only effective therapies, but are a few examples based on learning new skills, and changing behaviors and thinking. They mostly stay out of the past and intellectualizing about “why” you are the way you are. Instead they are focused on being in the present, getting rid of judgments and taking more control over your life.

 

6. Therapist gives homework. Homework:

 

a. Keeps you thinking and working between sessions.

b. Helps with continuity.

c. Consider therapist sessions as mostly teaching while the lab/application is in the real world between sessions.

 

7. Therapist is willing to confront you with things you may not want to hear in ways you can hear it.

 

Plusses:

1. Coping skills training.

     Especially teaching Emotion Regulation Skills (managing anxiety, anger, rejection, shame and guilt).

2. Mindfulness-based.

     Mindfulness teaches you how to be in the present and disengage from judgments.

3. Biological, Psychological, Social, and Spiritual perspective.

     Focuses on body, mind, relationships, and existential issues. 

 

Remember that no one thing makes us healthy and well. Health and Wellness require a multi-pronged approach involving self-examination, reprioritizing values, and behavior change.

 

Jerry H. Gelbart, M.D.

 

Synergies in Treatment

A series of articles written by Dr. Gelbart for the Northern California Psychiatric Society Newsletter. These articles are a bit more “technical” than others on this blog, but they can help anyone interested in how mindfulness, positive psychology, Wellness approach, and skills training can help with self-esteem, anxiety, depression, motivation, and other difficulties. It may help you in choosing a therapist, and/or bring up questions for discussion with your therapist or friends.

  1. Introduction
  2. Judgmental Thinking
  3. Mindfulness and Psychiatric Treatment
  4. Teaching The Patient To Swim
  5. Focusting On The Positive
  6. Changing The Shoulds To Wants
  7. Mindfulness Psychotherapy And The Brain
  8. Which Tool When

Part VI: Developing Integrity

Values and Priorities

“There is only one corner of the universe you can be certain of improving and that is your own self.”

Aldous Huxley

Do you have values? What are your values? If you have a choice between sticking to your values, or pleasing someone else, which do you choose? Which is more important for you, being accepted, or doing what you believe is right? Examples of values which you might believe in would be honesty, independence, compassion, treating others with respect, living by The Golden Rule, trying not to hurt others, and contributing to society and the world. Make your own list. It has to be your own, not mine, not your mother’s or father’s. It doesn’t mean that we’ll be perfect at it, but it becomes a guideline or template for our action choices. When you think about PAEJO, “what outcome do I want?,” your values will be an important guideline. You can’t control if other people will like you. But you can control your choice of actions, through mindfulness, being present, being aware of your doubts, fears, and judgements from childhood, and choosing actions which fit your values.

Many people live life by the Reverse Golden Rule, (“RGR”). We often see the world as “dog-eat-dog,” everyone out for themselves. So the belief is “people will treat me selfishly” and the RGR goes “Treat other people the way you expect them to treat you. This is also known as the “screw-’em” rule.

You can choose for yourself, and you can choose what you value in others. I have found that the “Golden Rule” rather than the RGR has brought me better relationships, and friends who similarly respect my feelings.

One of the important ways that The Potent Mind works is by helping you create a new space inside. When you start to let go of your judgments, and your fears of other people’s judgments, it will leave you with some emptiness. When you consider your values, your needs, your strengths and weaknesses, and what gets your juices flowing, you will begin to imagine new possibilities for your life. Follow your passions. Develop your values. Build your character traits. Use your strengths. Face your weaknesses and shore them up, with help where needed.

We’re a work in progress.

Here are some character traits and values that I have put together. You may not agree with all of them– you have to work out your own. We’ll never live up to all of them all the time but they are goals we set that can guide our choices of action.

Mind Gem #6: Determine your values and priorities and use these as your guides for action. Determine the character traits you value and develop them in yourself.

Part IV: Being Present and Filtering Your Emotions

Actions and Consequences

“I think you should take your job seriously but not yourself-that is the best combination.”

Judi Dench

If your mind is in the past, thinking about your mistakes, blaming yourself or others, feeling resentful about things, then you’re NOT in the pilot’s seat. If you are worrying about tomorrow, then you’re NOT in the pilot’s seat. If you’re judging yourself, wondering if you’re good enough for the job, then you are NOT in the pilot’s seat. When you notice yourself slipping out of the pilot’s seat, simply remind yourself to get back into it. One way to do that is to remind yourself to be present, take a slow deep breath, focus on your chest, on the physical sensations of the air going in, and then as you exhale focusing your attention on the sensations of the air coming out. This brings you physically and mentally into the present from wherever you were. Each time you notice yourself leaving the pilot’s seat, and nudge yourself back in, you’re practicing mindfulness.

Now that we’re starting to work on staying in the driver’s seat we can begin to look at the control panel. Reading our emotions properly and responding in healthy ways can help us navigate around obstacles and reach beyond our dreams. Trick is, we can’t always trust the instruments. Sometimes when an alarm goes off, it’s a false alarm. Doing something drastic might get us in trouble. This is how it is with our feelings and impulses. So we have to understand what can get in the way-how beliefs we formed in childhood distort, and stick-how what we think we know, and what we don’t know we don’t know, can blur our view.

Let’s go back to our three important questions.

PAEJO

  • Are my Perceptions Accurate?
  • Emotions Justified?
  • What are the possible Outcomes?

PAEJO. Perceptions Accurate?, Emotions Justified?, Possible Outcomes? I try to remember it as the consequence guy, Jo, waiting to be paid if I don’t carefully consider the outcomes of my actions and reactions.

Let’s talk about consequences. We want to move away from blame, whether it’s blaming others or blaming our self. Instead, the healthier, more effective model is that there are consequences to our actions, and we must accept them, learn, modify our behavior. So accept that we are lifetime students. Blaming and kicking ourselves, or others, only distracts from the learning process by adding hurt, shame, anger, and other negative emotions on top of the original mistake. We can’t change other people who tend to kick themselves or people around them, but we can choose for ourselves to get out of that kind of obsessing and abuse of ourself and of others. Getting rid of blame from your life is related to living nonjudgmentally. You’ll see that this is also the key to dealing with self-esteem problems.

Mind Gem # 4: Blame is a distraction. And
4a: Make a mistake, make a correction.