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A Mindful Journey 21/10/2011

One of the therapeutic approaches that I use to help manage my Depression that regular readers will have come across previously when reading my blog is Mindfulness.  Among other things it is helpful for dealing with thoughts, coping with stressors and managing physiological symptoms.  It has been used to help people manage symptoms of a range of mental health issues including Depression, Anxiety, Bipolar Disorder, psychotic illnesses, Personality Disorders and Eating Disorders.

My first experiences were vague explanations by people who I worked with about being present in the moment and awareness.  These are true and make a lot of sense now – but Mindfulness made the most sense to me after my first experiments with it with my Clinical Psychologist when I was, myself, in therapy.  The experience itself made an enormous difference to my understanding and appreciation of the discipline.  For this reason, I thought that I’d share with you some of my experiences with the use of Mindfulness.

The first exercise

My introduction to mindfulness included eating a mandarin.  The exercise involved taking the time to notice all of the sensations that were involved.  The scent of the fruit, the feel of the skin, the firmness of the mandarin before it was peeled, the colour, the weight, the sensation of peeling the mandarin.  I was to notice the texture of the inside outside of the skin and then the feel of the fruit without the skin on, the look of the fruit with its segments and the white stringy bits, the juice.  While eating it I noticed not just the flavour, but the texture in my mouth and the sensation of swallowing.  I paid attention to the sticky juice on my fingers and the sweet smell that it left on my skin before I washed my hands.  The idea was to be fully in the moment and to engage and experience all of the senses.  To be mindfully – deliberately into eating that mandarin.

The breathing exercises

After learning about the need to experience the full extent of whatever I was doing, I did some breathing exercises with my Psychologist.  The idea was not to control the breath, but to observe it – pay attention to the movement of my muscles, the sensation of the air in my body, the sounds of the breath and to concentrate my focus on that.  If I was distracted, I would just think to myself “oh, I’m distracted” – or whatever – and return my attention to the breathing.  It was hard not to start controlling the breathing – but relaxing.  It took focus, but was refreshing and left me alert.

My homework was to practice this and I also had an exercise where I was to start out with the breathing exercises and then imagine the breath that I was inhaling circulating all the way to my toes and paying attention to my toes and then following my breath as I exhaled.  From here attention moved, with my breathing, progressively from the toes to the feet, up the legs, along the other leg and then through my body and my hands, my head and back to just focusing on my lungs.  If you have ever done progressive muscle relaxation, the process is similar – however this was more to do with gradually moving awareness through the body.  Again, the instructions were to allow yourself to just dismiss distraction and go back to the exercise at hand.  I also felt more self-aware and awake after the exercise.  That one lasted about 15 mins.

The Wii game

There is a game on Wii Fit where you have to sit really still.  The graphic on the screen is of a candle and from time to time you get annoying things like a fly or mozzie and footsteps and so forth that come to distract you.  But you need to sit upright and still on the balance board for 2 mins to win the game.

I have found that this is a great exercise for my Mindfulness skills.  I sit in an alert and comfortable posture.  I focus on my breathing and I use my skills that dismiss distractions by acknowledging that they are there and accepting it to deal with the insects and so forth.  I can sit for the whole 2 minutes using my Mindfulness skills!

The fly

A while ago I was staining a piece of furniture.  I needed one hand to hold the tin of wood stain.  I was using an elbow and shoulder to stabilise myself in the most awkward position ever (!!).  The other hand was occupied with cloth working the stain into the grain of the wood.  And there was a fly buzzing in my face throughout.

Now, the same way that you consciously turn all of your senses, you may choose not to do so with some – so I am not focusing upon the fumes.  But again, with the discipline to focus on the here and now and what I want and is important, I can also notice and dismiss what I don’t want.  The fumes.  More particularly in this instance, the fly that just wouldn’t go away.  Rather than let it get me irritated and waste all that energy, the practice allowed me to focus on my work and when the fly was distracting just acknowledge “There’s that fly again.  That buzzing is loud.  I wish it would go away.”  Yes I would blow at it to try to discourage it – but no, I managed to deal with the fly without it driving me mad.  I considered this to be an achievement!

The job interview

I had a job interview at the other end of town.  I had a horrible time getting there.  There was more traffic than I anticipated, I think the tail end of a blockage after there had been a prang.  Plus I had been pushing the clock harder than I had wanted to be to start with.  The end result was that I was late to my job interview.

Bad news.

I was so flustered by the time that I got there that I couldn’t think.  My mind was pumping in circles.  They handed me the interview question for my preparation and all I could do was think,

“How am I going to pull together to do this?”

So I stopped myself.  And before I even looked at the questions I took 2 minutes out of my prep time to do my breathing exercises.  I then gradually brought myself back into awareness of the room around me and focused on the task at hand.  I was alert.  I was focused on the task and I was calm.  I had also put myself into a position that I could acknowledge that the situation was less than ideal and just accept it to focus on what I could do something about.  I could have compassion on myself for finding myself in an embarrassing situation, yet function within it and set myself to do my best in the here and now.  I prepped my questions briefly in what time I had left although I didn’t have time for much depth and then did the interview – again thinking clearly, because I was able to focus on the here and now.

In the end I think the fact that I pulled myself together worked in my favour.  I was offered the job, but turned it down.  Mindfulness got me through the job interview but it would not get me over the travelling time in peak hour traffic any quicker.

The terrible, no good, very bad day

Then there was the day that nothing went right.  Well it seemed like it.  I slept through my alarm.  Right through.  Things went wrong at home after I got up.  The trip in was slow.  I was very, very, very late for work.  Lunch time late.  I missed several appointments and was flustered about what was left of the day.  I had no idea how I was going to finish the day or face anyone.  After freaking out when I finally got to work, I finally stopped and thought, “I know better than this.”

So I paused.  I took a deep breath in and let it out, focused my attention and started observing my breathing.  I then started to pay attention to the feel of the pressure of the chair that I was sitting in and the sounds around me – not listening, just noticing – the clock, various voices, footsteps; I paid attention to the feel of the clothes on my skin and then turned my attention to my muscles and which ones were tense.  I relaxed my shoulders and my jaw and went back to my breathing and did a short version of the breathing exercise where I imagined my breath reaching every part of my body and then just focused on how it felt to breathe for a couple of moments.

After this I allowed myself to think about what I should do next.  I had to accept that I was late and that I’d missed morning appointments and that because of that my afternoon wasn’t going to work as well as I had planned.  But I could now, thinking in the moment accept that just as it was and act in a manner that was compassionate toward myself, rather than sit there blaming myself for things that I might or might not have done.  It was okay that I was a bit frazzled, that was understandable – so I just needed to plan for that too.  From there I was able to return to the moment and begin the rest of my day, planning things out and actually achieved a reasonable amount – something I wouldn’t have done in the state of mind I had been in when I arrived.

The road so far …

It has taken a while to learn some of the basics of Mindfulness and get used to putting them into practice, but the journey has been infinitely worthwhile.  I still have a long way to go.  I’m not good at meditation –  I tend to be more utilitarian in my use of it.  I still need to remind myself to start and could prevent some situations by starting earlier.  However, it helps me to focus and to be able to be where I am, doing what I need to or want to be doing at the moment of time that I’m at.  My next step in the journey is to become better at noticing things about myself in the moment.  I think that this would prevent a lot of difficult situations and to help me to monitor my early warning signs.

 

Watching Wellth 16/10/2011

The journey’s oft’ rough as one travels the road

with one’s mood apt to upset the cart;

And if climbing back on aft’ one spill weren’t enough –

Alas – staying on top is an art!

For most of us who have passed though one episode of depression – or other forms of mental illness and come out the other side, a common concern draws us.  We don’t want to go back there.

Some have a harder battle ahead of them than others.  Some have different forms of depression; different forms of anxiety; different forms of mental illness that are more or less responsive to the things that we do to treat them.  Some are more vigilant than others – often this makes a big difference … and sometimes life’s not fair.  Some do all the ‘wrong’ things and yet never have another episode – but that’s unusual.

What’s usual is hard work with a need to use a range of strategies to stay well.  Things like good sleep, exercise, a nutritious diet, keeping up social support networks and getting out of the house, exposure to sunlight and fresh air, use of medications and talking therapies are just some examples of these.

But how do we know that we’re winning?  What can we do at the times when we’re worried about how our mood is going to try to prevent it from tipping over the edge into something we can’t manage?  How do we know if that new medication is doing anything to change anything at all?

One of the things that is helpful to do at times is to track your mood.  How do you do this?  You use a mood diary.  Ever done it?

The purpose of a mood diary is essentially to get a profile of what pattern your mood is following on a day-to-day basis.  At their most basic level, a mood diary will ask you to rate your mood on a numerical or incremental scale every day while you keep it.  Some will additionally ask you to record other information such as your anxiety levels, your irritability levels, how much sleep you had the night before, significant events and triggers throughout the day and/or the medication that you took.  The good thing about doing some of these other things is that they provide a much fuller picture of what is going on.

If you don’t already know what they are – this process can help you to work out what your early warning signs are as well as your triggers.  If you know your triggers and early warning signs, this can help you to monitor them. For that reason, I recommend choosing a mood diary that records significant events in the day.  I would also recommend one that includes the amount of sleep that you had the night before as this tends to be pretty universal and fairly influential.

Talk to someone close and ask for their help if you have trouble working out if you were irritable or if they noticed anything in particular that seemed to set you off if you are having trouble identifying these kinds of things – but the object of the exercise is to make observations about yourself – so do what you can on your own as well.

However, asking someone close to you whom you trust to help monitor your mood and to help you get to know your warning signs and triggers is a good strategy.  They sometimes see things that you are not in the right place to see or notice when you’re not well because your self-awareness can get a bit skewed.  They also see the ways that you differ from the way that you would normally be – so they can measure you against you and not somebody else.  Yes, it might be their perception – but it will still be your behaviour and actions and the things that you say and the responses and facial expressions that they are used to that are part of you.  Choose someone who you trust and talk with them and let them tell you about what they noticed changing last time and as you have been working through your recovery.

Do I use a mood diary and self monitoring systems all of the time?

Not on a daily basis.  When I am well I keep regular tabs on how I am going by talking about it with a good friend and checking over my early warning signs and triggers list regularly to ensure that my awareness of them is good and that I am alert to high risk periods.  I use what is called a WRAP – a Wellness Recovery Action Plan where I have identified what I am like when well, what my triggers are, what things are hints that I’m not as good as I could be, my early warning signs and so on …. I go through this regularly.  Some people do monitor their mood daily and find that it works well for them.  People with things like rapid cycling Bipolar disorder often find that they need to until it slows down and is brought under control.  At first I needed to chart my mood a lot more than I do now.

When I am in a high risk period I watch things more closely and have recently resolved to keep a mood diary through high risk periods because I still find myself at sea sometimes and feeling like I’m losing my grip.  I am particularly vigilant about my warning signs and triggers as well as their corresponding action plans during periods of high risk.  I have to be.  Recently I let things go at home and let the dishes and the housework pile up around me – a sign that things are getting away from me and didn’t act and it triggered me (it becomes a cycle).  I couldn’t face getting up to look at the house.  I didn’t want to go into the kitchen to prepare a decent meal because it was a mess and I didn’t feel up to cleaning it up – so of course my nutrition level went down, my budget blew out and thus the cycle continued.  In the end it took a cleaning weekend to put me back on track, followed by a week of very early nights and a lot  of discipline.  It’s too easy.  So I have decided that I need to do something to catch myself more quickly before it gets away from me.  Not simply cleaning, just lots of little things.  This time of year I need to be very careful about relapse prevention.  It sounds minor when I talk about dishes – but when it snowballs, I just keep sleeping and if I sleep through work or go in late consistently and am still going around in circles while I’m at work and don’t have energy or concentration to work – I could lose my job.

I’ve attached today some links to some self monitoring resources and different mood diary sites.  I know there’s a lot, but different things suit different people and I think these are important tools.  Most mood diaries have room for the full spectrum of mood disorders – both mania and depression.

Warning signs and triggers are important.  Monitoring your mood is tedious sometimes – but there are times when it is necessary.

General

http://breeze.blackdoginstitute.org.au/keepingwell/

Mood Diaries

http://www.bipolar.com.au/common/pdf/mood-diary.pdf

http://www.blackdoginstitute.org.au/docs/MoodChartforDepressionandhowtomonitoryourprogress.pdf

http://www.blackdoginstitute.org.au/docs/DailyRatingScale.pdf
http://www.psychiatry24x7.com/bgdisplay.jhtml?itemname=mooddiary

http://www.moodscope.com/ for those who like online resources

https://www.moodtracker.com/ another online resource

http://itunes.apple.com/au/app/moody-me-mood-diary-tracker/id411567371?mt=8 for those who like apps

Mood Monitoring & Relapse Prevention Programmes

http://www.cci.health.wa.gov.au/docs/KYB-3-Self%20Monitoring.pdf

http://www.idamaecampbell.org/files/40263519.pdf (WRAP personal workbook)

Early Warning Signs

http://www.health.qld.gov.au/rbwh/docs/early_warming_signs.pdf

http://www.blackdoginstitute.org.au/docs/20.WellbeingPlanforBipolarDisorder.pdf (can be used for depression too)

Healthy Lifestyle

https://www.mindbodylife.com.au/Downloads/index.cfm

 

 

 

Medication: Weight or Baggage? 09/10/2011

Ever want to hear a room full of doctors or mental  health workers stop talking?

Introduce debates that have been raised in recent years questioning the effectiveness or the place of medications in the treatment of mental illness.  Suggest that there might be evidence of options that would be more appropriate starting points for treatment.  Ask them whether they would be ready to choose to live with the side effects that may result from some of the anti-depressants that are out there.

Have I surprised you?

I am not anti-medication by any means.  I use medication.  Unfortunately, at present, a lot of it although I hope in time to be in a position to reduce this.  There are some people who are.  They say that Depression can and should be managed by using strategies such as those that I discuss in “Beyond Medicine” with use of lifestyle strategies with regularity and discipline as well as well evidenced ‘talk therapies’ that build skills and resilience like CBT and Mindfulness.  Some even think that medication makes depression worse.

There are now groups who go over research that comes out about treatments to see what standards people are using to measure ‘success’ of treatments against and how it really measures up with other treatments if judged by the same criteria (eg http://www.power2u.org/medication-optimization.html ).

My depression falls within the ‘major depression’ and severe spheres.  That is within the spectrum of severity where it is clear from research that anti-depressants have a measurable effect.  It can be proven that they make a difference.  Research is finding not much evidence to prove that medication makes a measurable difference as opposed to placebo or other forms of therapy for mild depression and little more so for moderate depression.  Now, that’s not saying that there are no cases where it doesn’t work and all cases where it won’t be worth a shot – or that you won’t underestimate how severe your own depression is.  I certainly did at first.  What it does say is that it is worth asking some serious questions and exploring a range of other treatments either before or instead of medications.

Consider the some of the side effects of antidepressants.

Short term side effects of SSRIs can include nervousness, anxiety, muscle tics, suppression of REM sleep (and then drowsiness), nausea, dizziness, diarrhea, gastrointestinal problems, different types of sexual dysfunction, emotional blunting and apathy.  With long-term use come risks of cognitive changes.  Now most short-term effects will pass as the body gets used to the medication, but still …

Tricyclic antidepressants have potential side effects that include blurred vision, dry mouth, constipation, bladder problems, sexual dysfunction, dizziness, drowsiness and increased heart rate among others – again some settling after a short time and others continuing.  Not everyone gets any or all side effects, but most experience some.

If you take MAOI anti-depressants, then you can’t eat certain types of food.  Potential side effects here include low blood pressure, constipation, vomiting,  headache, altered sleep, dry mouth, drowsiness, fainting, sexual dysfunction, weight gain and lower alcohol tolerance.

And people wonder why people stop taking medications!!?!  Do you want to take them?  How will they help you?  Sometimes trying the non-medication based therapies first does make a lot of sense.  While it seems easier to just take a tablet, how confident can you be that the tablet will make you feel better?  Mine do.  But remember, firstly, my Depression is severe and secondly, I also need to bolster it with management strategies that aren’t medication-based.  I need both.

Here’s the thing though.  What ever you do decide to do – make sure that you are fully informed.  Do your research.  Also – ask your doctor the hard questions like:

“Why this medication?”

“What are the side effects?  How long would I expect them to last?”

“Are there any risks associated with this medication?”

“Will I be able to keep working while I start taking it (if you are working) or will it affect my performance?  Should I take a few days off?”

“How will I know if the medication is starting to work?  How long should it take?”

“Are there any precautions that I should follow over the next few days/weeks?”

“What happens if this medication doesn’t work?”

If you do agree to try a medication, stick with it as advised.  The time frame your doctor gives you for how long it should take to work will be only an estimate.  Also, some medications are dangerous to stop unsupervised.  If you are trying a medication, consider it a joint experiment by yourself and your doctor.  You bring your expertise of your experience and the effect that the medication has upon you.  Your doctor brings medical training and independent observations.  Both are needed to make an informed decision about where to go with your medications.

If you are on long-term medication, you doctor and yourself share a partnership.  Again, you are the expert on yourself, your symptoms, experience and how the medication is (or isn’t) impacting your life.  Your doctor is the expert on the medical facts, observations and assessments as well as the medication itself.  In any partnership for decisions to work to their best advantage both people should be involved in the decision-making event – even if the right of decision is mostly with one person.  This means that both people’s expertise can be used.  Sure, ultimately, it’s your life and your right to agree or disagree with your doctor’s medical opinion – but when there’s medication involved and you want to change it or come off it, at least informing them is a smart thing to do.  They can then tell you if you need to know about any risks and you can ask them what you need to know to make sure that you are safe.  You can also make a judgement call about how much you think you can manage with your own strategies with a lower dose of medication in place and work to negotiate this with your doctor.

Ultimately, I think it comes down to the type of depression that you have.  Some don’t need medication.  For some the decision could go either way.  And there will always be some that need it.  However, the question about whether we do or don’t use medication is weightier than deciding whether we can tolerate side-effects or would rather carry a load of self management strategies that may seem burdensome when we feel so amotivated.

We all need the self-management strategies.  These have been proven to be effective in reduction of depression regardless of the level of severity.  Our decisions about medications need to be weighed carefully.  How much of the work are we expecting them to do?  They are a tool, not a workshop and not a finished project.  They are designed to equip us to work at life.  If they’re working, you’ll be able to take up the management strategies that are more lifestyle driven and see your mental health improve to wellness.  Sometimes with meds still in the background.  Yet for others, in time a mutual farewell to the partnerships with doctors and health workers gives way to a continuing lifestyle-driven means of managing wellness.

 

The Wall with a Hole in it … 30/09/2011

And I’m not talking ATM.
Have you ever felt yourself to be up against that dragon that you were never destined to slay?  That worm you’ll never be early enough to get? The one that leaves you feeling like the Emperor in all his glory when he set out in grand style to show off his ‘new clothes’ just when you think you’ve gotten a hold on it.

My nemesis is time.  Not just any time – although we have a slippery time keeping pace with each other continually.  No, the ultimate battle is drawn around the time of sleep and waking.  Here I am repeatedly mauled by my dragon, eaten by the worm and left with nothing but the Emperor’s new clothes to show for all the effort that I have made to conquer the struggle.  I feel as though I am beating my head against a brick wall.

What happens you ask?

I set an alarm clock.  Actually I set two alarm clocks ten minutes apart.  I do not trust myself with one.  I have been known to turn one off in my sleep!  I set one to raise my level of consciousness and the other to wake me.  For most of the year this is adequate.  But then comes the changing of the guard – it starts to get light earlier or later in the spring or autumn and for several weeks my dog hides the alarm clocks.  He must.  Some nights anyway – because they sure as hell don’t wake me.  But then I also have trouble in getting to sleep – so maybe it’s not all the dog’s fault.  At times I sleep no more than an hour or two a night.  Others I may get to sleep and then wake up at two in the afternoon – ON A WORK DAY!  This year I thought that I was winning at work until the seasonal sleep monster set in.

Right now I feel like I am beating my head against a brick clock.  In getting to sleep.  In waking up.  In getting to work.  My psychiatrist has given me something to try for the short-term (ie 4-6 weeks) as it’s a regular pattern and struggle and part of a bigger picture of short-term seasonal change in my mood.  It’s not a relapse – just a dip.  But oh so disappointing because its been so stable for so long.  In lots of ways I think I could handle it if the sleep didn’t go out the window.  It’s started to affect my work though, so I’m taking the medical option this time.  Maybe next time I’ll be able to have the personal strategies down strongly enough to manage it without boosting my meds for a few weeks – but I need to prioritise keeping my job over my pride for this time.  I may have to wake up and phone in to work in the Emperor’s new clothes.  I do not have to parade through the streets in them.

Bloody Dog.

Damn Clock.

So for now I get my sleep under control.  I keep my mood stable with a little extra help than usual until the season settles.  At least I will be able to keep the dog in his place.  At least I will stop messing things up so badly in getting to work.  It will only be for a few weeks and then its back to the normal cocktail that I’ve accepted will be a part of everyday.  Back to using my ‘personal medicine’ or lifestyle strategies to manage life and its stressors.  Then I get summer to strengthen my other skills and to be ready for autumn when it comes.  Perhaps I will plan a short increase in meds again.  Perhaps I will plan time off work.  Perhaps I will be enough on top of my sleep to manage it with flying colours.

My Dog loves the twilight of the seasons.  He thinks its play time.  He loves the dawn.  He dances while I wake.

Oh to be able to open one eye and say in my firmest voice.

“Sit. Dog.  Sit!”

And have confidence that he’d obey.

One day.  One day he will.  One day I am determined to slay that dragon.

One day.

 

The Best Bucket For Fishing In 27/08/2011

I have been cleaning out my study over the last couple of days – no small job – I have been putting it off for a long time.  I unearthed a lot of rubbish, a tonne of reading, receipts, filing, thankfully nothing that should have been included in my tax (which I have done already this year – yay me!) and my bucket list that I did for my Psychologist earlier in the year.

Why a bucket list?

I had been depressed on and off for years.  When I was well I had only just been coping with no room for anything but putting one foot in front of the other.  It had been a long time since I had really allowed myself to cast my eyes very far into the future.  It was hard to do.  My life had become so tied up in looking after the dog and keeping him out of the way so that I could manage walking that it was hard to picture anything else.  This is not a healthy way to live!

Maybe not – but everyone knows that we need to get through each day – so what’s the point of looking any further?

My first response to this would be to give you a reason to stick to the fundamentals that feel so arduous when times are tough.  The healthy lifestyle, the sleep, the medication, the self management strategies that you’ve chosen to compliment your medical treatment (see my post Beyond Medicine) can feel like such a chore at times, and there are days when you question if your daily struggles are all that important.  Things that have some value and potential to motivate you are important.

My second is that a routine is strongly recommended, but often hard to fill out.  An exercise like doing a bucket list may give some clues to your interests or things that you could start even now to use time doing something that you are more likely to consider worthwhile.

Thirdly, if you are getting well and your health is stable, but you’re a bit lost about what you want to do – this is a great way to brainstorm ideas that you can later use to figure out what direction you want to work towards and what sort of goals you want to set for yourself.  You can also look at the different sort of things you have put on your list and use it to try to make sure you keep some balance to your goals so that you can target a balanced lifestyle that reflects you.

Fourthly, if you are struggling to stay well and all that you are focussing on your health or perhaps your health and keeping your job – perhaps you can use it to choose one thing to help with relaxation and/or re-energising.  Often – and I speak from several years of experience here – this is neglected to our detriment when expanding our support network and finding opportunities elsewhere for success would improve our workplace performance and keep the dog in his place much more effectively.

Not sure what you’d put on it?  Try meeting up with a friend and do bucket lists together (I met up with a couple of different people).  This helps stretch your ideas until you start freeing up your mind.  Read past journals if you have some if you used to write about things you’d like to do one day.  Be as vague or specific as you like – it’s your list.

Here are some of the things on my list:

Bushwalking

Make a pretty garden

Redo a house

Teach professional practice skills

Overcome Depression and Anxiety to the point where they no longer require any intervention – even meds

Stay well

To make sure I keep up friendships and make new ones

To grow wise but be humble

To be physically fit and able to run without getting puffed out

To get good at being organised and reliable

To learn lots of interesting things eg Ancient Greek, Ancient & modern History, Latin, Languages, Leadlighting, Aromatherapy, Sciences, making things, gardening, writing and publication industry, professional development and research, theology …

Write a book and publish it

Write a children’s book, get it illustrated and publish it

Go to Scotland, Ireland and Canada and see lots of other places too

Learn Piano

Write a song

Learn to play Cello and/or an alto/tenor woodwind instrument

Research and develop useful intervention strategy for use in Mental Health Recovery – meaningful to and valued by consumers – well weighted by evidence

Learn to tap dance

Build a doll house

Act in a stage performance

There’s a tonne of others that I’m not going to share and I’ve simplified a lot of these.  But they have made way for goals and routine and positive steps.

There are six major themes among the things in my bucket:

Creativity

Learning

Relationships

Social Responsibility/contributing to others

Travel/adventure

Growth (language, fitness etc)

My challenge is to have something – one thing at a time among my goals that touches on each of these areas.  I also try to include something of each – at least most – in my routine.

The steps to some dreams are appealing.  The way to others not so much.  The keys are choice, balance and timing.

Never let the dog stop you from dreaming.  Sure, be careful not to get stuck in them – but be careful not to lose sight of the things that you’d like to do or some day.  These are the things that give you a reason to put your next foot forward.  These are the things that make it matter that the dog stays out of your path.  These are the things that help you choose which direction you walk in.  These are the things that make it matter that it’s you and not the dog that does the choosing.

Look where you are going.  Move deliberately.  Walk one step at a time if you must during the hard times, catching your balance and calling the dog back to heel in between.   Don’t let him draw you down to wrestle with him while you walk.  When you stop looking where you are going, the dog has the upper paw.  Shorten the leash.  Keep him close.  Don’t give him an inch.

Heel, Dog.  Heel!

 

Planning with Purpose 21/08/2011

In my last entry I wrote about going back to work.  I also made brief reference to having a need for some kind of productive activity if I wasn’t.  One of my regular readers made a comment that spoke directly to something really important.  The need for purposeful activity.  Not necessarily work – but activity that is goal directed and meaningful to you.  Activity in which you are setting out to achieve something that you are interested in achieving.  It doesn’t need to be paid activity, but it needs to provide you with a sense of purpose and achievement.  This reader suggested that – but for the expense of living, she would not even care so much about paid work as long as she had purposeful activity.  I have to say that I agree.  Sound odd?  It’s one of the biggest problems people have when they retire.  Not having planned for their need for purposeful activity.
The thing is – people have an innate need to do something.  Preferably something they value and something that is purposeful.  All you have to listen to one of the things that we complain about.
“I’m bored”, “There’s nothing to do”
“What’s the point of this?”, “This is a waste of time!”, “I hate doing this.”, “I’d rather …”, “I’m sick of doing this”, “None of this does anyone any good”
“When am I ever going to use this?”, “No-one’s going to look at it …”, “All I did was sit and look at the …”
Examination of research into the presentation of people with long-term unemployment and people with Depression actually show a lot of similarities.  Things like loss of routine, beginning to neglect personal appearance, poor diet, lack of activity, sedentary lifestyle, poor sleep habits, loss of motivation, social isolation, loss of self-esteem …
Of course for many there are possibly crossover elements of situational depression, however it is interesting to note that the lack of purposeful activity can have such a strong effect.  A study that I heard presented followed up some people some of whom pursued work – some full-time, some part-time; some of whom pursued volunteering.  The outcome – purposeful activity made an enormous difference to quality of life.
But other studies show that it does not even need to be work related.  Simply valued and purposeful – and it will improve quality of life and wellness.  Take up gardening.  Build a doll house for a kid.  Join a gym or walk somewhere every day.  Volunteer at a local charity, Church or club.  Write a book.  Go to a local community centre and check out the programme.  Do a course on something that interests you.  Join a book club.  Start meeting a friend for coffee regularly.  Take up cooking.  Invite a friend over for dinner.  Try that sport you always wanted to try – talk a friend or family member into coming with you if you like.  See if you can find some old friends you’ve lost contact with – you might be surprised how many want to catch up.  Try that hobby you always wanted to take up.  Research your genealogy.
Purposeful activity.  This is what forms the building blocks.  This is where a healthy routine can be built.  This is where a healing routine can be built.  Research says it works.  My training says it works.  My observations of the people I have worked with as a mental health worker say that it works.  My experience of healing says it works.
 

Beyond Medicine 06/08/2011

Personal Medicine

What's missing from your treatment regime?

Taking a dog to obedience school can be a challenge.  The thing is – it’s you that get’s stuck with the homework.  You that has to reinforce the training and know that the dog understands what you are telling it to do.  You that has to maintain all that new knowledge. (Just who is being trained anyway?)  Tiresome? Yes, while the dog is learning.  Worth it?  When the dog does what it’s told and behaves?  Certainly.

There are “medicines” beyond the pills and potions that I take that serve to keep my black dog in check.  “Personal medicines” if you like.  But to me these are the things that have made the difference between ‘a life half lived’ and the journey of recovery.  Let me share some of these with you now:

Routine:  Keeping up some kind of regular pattern of activity helps to keep the dog at bay.  It’s hard to start with to fill up when there is ‘nothing’ to put in it.  I start by setting meal times and trying to put one thing in the slots of time between meals, perhaps a short walk, washing dishes, putting a load of washing on, having a shower, reading – it doesn’t have to be big.  Then I build up from there as I work on other things on the personal medicine list.

Sleep:  Work out how much sleep you need to have and make sure you get it.  I need to make sure I have at least 8 hrs consistently.  That also means I need to allow time for falling asleep when I go to bed.  Now I have a bed time and a getting up time.  This means that I shouldn’t over-sleep (although sometimes I stay up too late and still do) and that I shouldn’t lie around in bed all day either.  Bed becomes a sleeping place.  I will often allow myself 10 hrs sleep on weekends and 8 hrs through the week.  This suits my work schedule.

Nutritious Diet:  I can’t tell you what a difference it makes to my mood when I am eating a well-balanced, appropriately spaced and portioned diet compared to when I am not.  My energy levels are consistently better.  My concentration is better.  My mood is brighter.  Check out basic dietary guidelines for a balanced, healthy diet and plan your diet around them.  It will take a while to get used to doing – but you will notice the difference in your mood, wellbeing and possibly your weight.

Exercise:  There is research that shows that exercise has an antidepressant effect on the body.  Get into a regular exercise pattern.  It can be as simple as walking most days in a week, or you may choose to do different activities on different days to save yourself from boredom.  My advice – start simple.  Again – start with the recommendation made on general health sites about exercise.  I aim for approx 30 mins about 5 days per week.  At the moment I’m being slack because it’s winter here and I’m just getting over a nasty cold – but I need to get back into it.

Early Warning Signs & Trigger Watch:  Learn to spot the early signs that your mental state is slipping so that you can catch it early!  Make sure you have a plan for what you will do when you notice them – even if it is as simple as call your doctor, counsellor or case worker for help and ask them to teach you some strategies so that you can do it yourself next time.  Also, get to know the things that trigger you, that way you can either plan for them or do something about the effects of the trigger before you become symptomatic (eg relaxation, pleasant events, talk to someone, visit a friend etc).

Pleasant activities:  Plan to include things you enjoy among the things that you do.  Enjoyment is a great way to remind that dog that he’s not wanted.  If you’re not well and not enjoying things – you may find it neutral or relaxing even if it doesn’t give you the same buzz that you usually get.  Sometimes you will also find you like things more than you think you will.  I enjoy reading, getting a massage from a friend – or if I have money I used to go to someone who made me feel comfortable for a back, shoulders and head massage; seeing a movie, going to bookshops and the local wool shop.  I love spending time with my family and playing with my niece.  Doing these things – even when depressed – often leaves me feeling better.

Looking after myself:  Making sure that I shower daily and clean my teeth when I should makes a huge difference to how I feel.  Clean and trimmed nails.  Clean and presentable hair (preferably at a length I like without an inch of grey roots showing), the hair in places that it’s not wanted removed, without wax in my ears … and its nice to use a soap that feels good on my skin and some moisturiser; perhaps a face mask here and there – after all some of those medications do yucky things to my skin.  I also like to make the effort to wear clothes that make me feel nice these days.  I used to be very happy dressing very daggily – and still am often; but it helps me feel better when I’m wearing something that I like.

Social supports:  Having people who care intimidates the dog.  Essentially, he’s a shy creature when the depression’s not at its more aggressive stages or I’m not on a self-pity kick.  Take the time when things are going well – or even just okay – to “screw your courage to the sticking place” (Shakespeare) and build a network of people who will stand by you.  It doesn’t need to be a large one, just people who are friends or family and willing to stand by you.  Even better if they will help you to see when your early warning signs come and to deal with those before you sink right into depression.  Last time I was emerging from a nasty episode of depression, with the encouragement of my psychologist I gritted my teeth and started looking up old friends who I had lost contact with.  I was very surprised to find them pleased to hear from me and have rebuilt a good network from those with some more current contacts who are now more aware of how and why I vanish and are less likely to let me do so again.  They ask questions if they don’t hear from me for a while.  This is helpful.  My family is also great.

Regular Social Contact:  Make sure that you plan regular contact with people.  Coffee with a friend on a regular basis; attend a group, a club or church – something together with others; talk to family or a person who supports you a lot often.  Sometimes you will feel like it, sometimes you won’t.  If you have trouble getting started, ask them to come to you or to pick you up on the way.  Different things work for different people.  I speak to family a couple of times a week and try to make sure I see my brother and his family at least once a fortnight.  I try to cultivate a couple of friendships with people who I have met at work.  There are people who I call once every 2-3 weeks because they are friends that I want to keep close contact with who live a fair way away from me.  I open up my Facebook every day or two to just make a conscious passing by into a handful of people’s screens for the day and join a joke or post some comment about my day.  A couple of people notice if I vanish for  a while and ring me to see where I am.  I try to invite friends around for dinner about once or twice a month and have someone by for a cuppa regularly.  Of course – sometimes I go to their place or we meet elsewhere, but when I make the effort it does help.  Who I spend time with will depends on my mood – people who accept me as they find me and who just don’t see the mess or will help me with it are all I can manage at times; but these are the kind of people I like to cultivate as friends anyway.  If I never spend time with people, I never reach that level of comfort with them.  Remember – the dog does not like competition.  As I’ve pointed out before, he’s a jealous creature when all is said and done.

Mindfulness:  This is a skill that I learned with my Clinical Psychologist.  Its big at the moment and a lot of counsellors are teaching it.  There are also a number of books around and  – I haven’t explored this – you may even be able to find online tutorials (?).  A really useful skill for noticing what is happening in the moment as well as slowing things down so that you can deal with things as they are.    A couple of sites that might be helpful include http://www.bemindful.co.uk/,

http://www.blackdoginstitute.org.au/docs/10.MindfulnessinEverydayLife.pdf,

http://www.mindfulness.org.au/MINDFULNESS%20SOUNDTRACKS.htm,

http://www.dayonepublishing.com/VMC/Exercises/Exercises.html

Reality testing:  This skill is something I picked up through doing Cognitive Behavioural Therapy (CBT) with my Clinical Psychologist.  It’s about checking the evidence for those intrusive negative thoughts.  Don’t just accept them at face value.  Getting into the habit of doing so involves discipline just like everything else – and sure there are days when I don’t do it and the thoughts win out – but over all the effort is worthwhile and gets easier with practice.  If you want to know more about CBT give it a ‘google’.  The research holds up really well.  On the occasions when the reality is tough, then I follow through with a question about whether I am affected by the thought, if it matters and if I need to do anything about it and if so – ‘what?’.  If you can’t afford a therapist, I believe that some places have tried short CBT courses online – there was one in Australia pitched at Uni students a couple of years ago.  Here’s a more recent version of it that seems to have a broader audience in mind along with another I found that seems to have a good reputation:

http://moodgym.anu.edu.au/welcomehttp://www.llttf.com/

Mental stimulation:  Keeping my mind active helps me to keep the dog in check.  When there is nothing else happening in a day to stimulate my brain (eg work, other activities, people to talk to) I do puzzles – simple ones when down and more variety most of the time.  I think it just helps to keep my mind busy so that there is less room for it to ruminate on negative thoughts.  It also gets pleasantly tired so that I sleep more soundly and don’t lie awake with my mind churning for hours.

Maintaining the space around me:  I need to keep my home in some kind of order.  I’m often known to say that you can get a good idea of my mental state by looking at the state of my house!  I find that if I stay on top of my housework and the place is orderly and clean it is easier to feel on top of my game.  When the place is looking like a bomb hit it, I need to hunt for things and everything is in the wash I’m more likely to get flustered, stressed and have a blah day.

Goals & Plans:  I hate doing it, but setting goals and making plans helps to keep me on track and walking on days when I don’t feel like making a decision.  It means that I have a sense of direction and a sense of future and that I can tick things off as I achieve them.  Always make sure you have some short-term goals people!  They can be very simple, but it helps to have a map when you have a dog that wants to take over and steer a different course.  You then have a reminder why you might not want to just let it take over and be done with it.  You’re not out to live the dog’s life.  It’s yours.

Bucket list:  I lost all sense of direction during the last few years of depression.  I had long series of bombed goals and really had no idea of what I wanted to do.  My Clinical Psychologist sent me away to write a ‘bucket list’.  Now mine wasn’t a particularly daring one and there’s a lot of room on it for change; but it was permission to start dreaming again.  What we did come up with through that was that there were six main areas that I liked to be doing something in.  The end result was that we sorted the things I would like to do into those categories and I now aim to have something going from each category at a time.  I will probably never do everything on the list and will do things that aren’t there – but it was a good way to find somewhere to start ‘doing’ again.

Projects:  These come off my Bucket list.  I have only a couple on the go at once so that it doesn’t explode on me – but they give me something other than work, eat, sleep to do and be interested in.  I’m quite proud of my projects.  Engaging your interests is an important part of recovery.  Yet another way that you stay in the front seat and the dog must sit at heel while you do your own thing.

Faith:  I am a Christian and turn to God and I pray for him to support me also.  I believe that this makes an enormous difference.  I also believe that there will come a day where heaven and earth will be restored and I will be given a new, whole mind and body with no illness in it because I am one of God’s people.  I am destined for heaven.  There is hope in this.  Although I become fearful when I am depressed about my acceptability to God, I have now learned enough scripture to know that my worth has nothing to do with what qualifies me for salvation.  This helps.

A couple that I don’t use that are also highly recommended include

Relaxation Exercises:  Excellent for managing stress or unwinding enough that you have a chance of getting to sleep.

Sport:  I’ve never been able to connect well with a ball, I’m not overly coördinated and I don’t move quickly and things that you’re not good at are not lots of fun unless they’re back-yard variety with friends – so no I don’t do much sport.  BUT for those who are into it, it’s a great option not only for exercise, but for social activity and networking and hopefully a bit of fun.

And these are not the only ones there are more … all the best as you try some out if you’ve not tried them before.

 

Black Dog, White Knight 03/08/2011

If there is one thing more frustrating than the battle with the black dog, it’s the battle with the white knight.  The overprotective protector.  Oh to be able to call the white knight to heel along with a well-controlled dog!

Take for instance the plan to return to work.  A sensible return to work plan is graded with appropriate supports according to the nature of the illness or injury.  My most recent absence from the work place involved an epic trial to accomplish reentry.  It took five months to the day from the time my psychiatrist of eight years cleared me for graded reentry to the workplace – and almost two months after he cleared me for full hours – for my employer and independent occupational physicians (not psychiatrists) to clear me for a very slow and protective graded reentry programme, more suited to someone with chronic pain or active symptoms.  I, however, have an episodic illness – certainly, with excessive stress and sudden change as triggers – however having been all but symptom free for some time now, the rate of change laid out was a looooooong way from sudden.

The starting plan was laid out as 4 weeks of 3 days of 4 hour days.  This would be followed by 4 further 3 day weeks where hours increased by an hour a day per week.  Finally, a half day would be added on the ninth week to bring me to full hours.  Such a programme would have been appropriate in at the beginning when I was cleared for graded return to work by my doctor.  But five months later?  I had been stable for some time.  Depression is an episodic illness, not a static one.  I would agree that grading is wise for maintenance purposes, but given the amount of time that I’d been stable for it would have been feasible to start with a 3 day week at 4 hrs, progress from there to 6 hrs, then 8, before returning to full hours.  And that would be conservative.

The key factor that will make or break the return to work will be the provision of personal support within the workplace throughout this and over the coming months.  A clear plan for what to do with symptoms in the workplace.  A way of taking control of the situation when things get difficult.  I speak here both as a clinician with experience in work rehabilitation and as person who has treatment resistant depression.

The white knight needs to step back and stop blocking the path.  There are no dragons.  It’s a dog.  A black dog that is currently walking patiently at heel.  Please don’t let it get so bored that I trip on it.  A worthy helper walks beside, notices when the going is hard or easy and helps me to adjust the burden so that I can continue at a pace with just the right level of challenge and focus.  They are about helping me engage with what is around me without losing track of my dog.  The white knight will ultimately drive my dog crazy with all the attention and fuss.  If I don’t trip over the dog, I’ll trip over the knight – although they’ll default all responsibility and blame the dog.  Get rid of the protective sword, the suit of armour and all the pomp and ceremony.  Rather put on your hiking boots, pick up a pack, bring me a spare map and compass for if I lose my way and throw in my dog handling manual in case I lose mine; then come and walk alongside me.

 

The Dog in The Fog 27/07/2011

There are a lot of things I hate about Depression.  Take your pick – the effect it has on your self-worth, your energy levels, your mood, how sociable you feel and act, your self-image and presentation, that non-expression on your face … or the medication – weight gain, constipation, tremors, medication for the tremors … the constant need to micromanage your life to prevent relapse routine, exercise, diet, sleep, early warning signs, triggers, medications, appointments and to cap it all off there’s the increased incidence of things like diabetes and heart disease in people with depression.  Some of these are direct results of depression.  Some are spin-off effects from symptoms played out in the lifestyle.  Some are medication related.  But by far the effect that I loathe the most is the ‘fog’.

Thinking in ‘The Fog’ is like those movies where a character moves across a misty set barely able to see what is in front of them, working to make out the shadowy forms in the haze before them until the mist folds away just before they meet it to reveal what is there – yet the objective never quite within sight.  When I am not well my mind is in stupor.  Gears creak.  Cogs struggle to turn.  I forget things constantly.  I lose my place in what I am trying to communicate to someone.  These are things I was once very good at.  As I get better I can do all of the things that I used to do – but many of them I do more slowly than I once did.  It now takes me longer to process things in my head – arithmetic, deciding how to express something carefully, making a decision, figuring something out.  Some of this is because of medication – but not all of it.  Some is the Depression itself.  It has slowed my once quick mind.  Recent changes to medications have freed it up a little, but it is still not what it once was.

It is not obvious to everyone.  Mostly only to people who have known me for a long time before and after the Depression left its mark.  When talking with a friend and therapist with whom I once worked once told me that the difference had made her cry.  It was such a relief to know that another person was grieving too.

I had an ongoing dilemma with medications until recently that centred around a Lithium fog.  After years on a tricyclic that kept me well in tandem with Lithium, I eventually had to stop the Lithium so that I could use anti-inflammatory meds for chronic back pain that wasn’t responding to any other form of treatment.  The result was that the back pain settled reasonably quickly, but it was difficult to keep my mood stable on the tricyclic alone.  In the end, my Doctor suggested that a medication change was the way to go and I finished up on a combination of Lexapro and Edronax.  Beautiful.  I could think.  However, like the tricyclic (which I’d been on because SSRIs on their own didn’t work), in reality my mental state was still not really robust.  Finally, after much resistance on my part, I restarted Lithium as an augmenting medication to bolster the main ones – and, for stability I did need it.  But it really stank.  The fog was back.  Lithium, I find does slow me down – preferable to relapse and job loss – but still unpleasant.  My best news has come with the release of Valdoxan.  Given how much I hate and object to the use of Lithium, my doctor has trialled me on this in place of the Lithium as my augmenting drug and it is working beautifully and without fog.  So what is now left that is attributable to medication is as low as we can get it.

What has been affected is what I will call my ‘working memory’.  The part of the brain that is operating and pulling everything together at any moment so that I can think, move, find information that I know, solve problems, come up with ideas and take action of any kind.  It is where what is needed from my short & long-term memory, senses, visual-spatial understanding, communication and organisational understanding and my level and focus of attention are is pulled together and used to observe or interact with the cues, instructions or things in the environment around me to guide my actions in a certain way.  It is where, to a large extent I can regulate the speed of my actions also.  BUT here’s the thing.  When I’m not well my level of attention is affected so I miss information from the environment and not all of the information that my mind needs makes it in.  The speed of the working memory slows down, my memory is fuzzier and less accessible, I lose the flow of operations I am doing.  It’s like if there is a little man inside my memory coordinating all the information, he ages 100 years and can’t manage all of the information when I’m depressed.  When I’m well he returns to almost his original age and moves reasonably well; but he’s been left now with some injuries – back strains and a touch of arthritis that slow him down just a little on the fine and detailed work or when handling really heavy stuff.  He can handle it, but he’s not as fast as he was before the injuries that the sudden aging episode left on him.  And nor am I.

At times I think walking with a black dog is like walking through the high mountains where there is rarely a day unaffected by mist – not necessarily always pea-soup fog; yet always just a light haze.  Not enough to hamper most of the time, but enough to dampen the spirits and frustrate – especially one who is unaccustomed to fog.  But the moments when the fog lifts and the sun shines through – Oh my! They are glorious.

 

The Jealous Dog 22/07/2011

If there’s one thing that discourages a jealous dog, it’s competition.

Sounds simple, doesn’t it?

Of course like everything that sounds simple there’s a journey involved in getting to the bit that’s simple.  And at times the times the ‘simple’ bit is anything but easy.

If you were to tell me in the depths of my depression that competition was all that was needed to discourage the dog – that having other, more enjoyable things around me would make life easier to manage I would probably knock you flat.  And I hit ‘like a girl’.  When I am unwell they probably do knock the edges off things, but enjoy … ? Perhaps.  I certainly need help to initiate the diversion and the routine.  Ah … the old ‘r’ word.  Yes, I must admit – it does help.  I just hate it.  I never feel like it and it’s damn hard to do.  Especially when I still lack the sense of enjoyment of anything.

But further on – about eight months ago I gritted my teeth and reestablished contact with a long-lost world.  The friend.  The ones I lost contact with during a couple of years of withdrawing from – well – life in general.  Initially it was very tentative.  After all – who would really want to be friends with me, right?  But no, contrary to my very localised opinion friends welcomed me back with enthusiasm … on-line, phone calls, coffees, visits and finally a trip to see someone who lived a long way away for a few days (I was very nervous about this one) which was lots of fun.  I now have friends who I talk to again regularly and see when our schedules allow it, an old school friend I catch up with regularly, friends kids who are excited when I come to visit and people who miss me if I’m not around.  I never thought I’d see the day.  I’m still not sure I believe it.  By rights I should have black and blue spots up and down my arms from where I have been pinching myself but if it’s not true, I’m not planning to end the dream any time soon.

Today is my first day at home after a couple of weeks on holidays – staying with the same friends that I visited earlier in the year.  I was originally going for a few days, but the family with whom I was staying voted unanimously that I should stay longer – so I did.  I visited with other friends and their families on the way home, including one family not far from home where I stopped in filthy weather with an hour’s notice to drop onto their couch for a night.

Amidst all of this my dog stayed at heel without challenge.  This is amidst ongoing bungles with a return to work plan that has been drawn out for months.

My dog is shy around people who value me.

I need to remember this next time he pulls me in close to home.

A black dog needs a little competition from people who care.  He just wants me to believe that there aren’t any.  I did once and it turned out to be a lie.  I must remember this for another day.

My dog lies.

 

 
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