Thursday, November 25, 2010

Cognitive Behavioral Therapy -- Gingerbread Style

First Cognitive Therapy Technique -- Distraction

My therapist said Think of something you might find enjoyable.  You don't have to do it.  You don't even have to enjoy it.  The goal is not to move your mood from 1 to 10.  Any mood change is a bonus.  The goal is simply to give you something else to think about [-- besides what I had been thinking about.]

Distraction is one of those really irritating CBT techniques.  I am traumatized and can't stop thinking about this.  Okay, so think about something else.  I pay money for this?

But my other therapist, totally different method, said pretty much the same thing.  And I was six weeks from a major project I had promised for the holiday season.  And I am not sure it would have worked except that the wheel was ready to turn from early autumn danger to late autumn hypomania.  But he did and it was.  So...

She said think about it.

I guess I overshot the mark.


Ya think?

To Diagnose Hypomania -- Pay Attention

I used to churn out 10-12 gingerbread houses each season, back in my undiagnosed days.  I used the Joy of Cooking recipe and floor plan.  But each and every one was one of a kind: a log cabin made of pretzel sticks and peanuts for the chimney, another with candy canes on the roof for a chalet effect... No, I wasn't manic.  I was excited...

It could be said I don't know when to quit.  So a simple suggestion, think about something you might enjoy instead of what you are thinking about right now, became a fourteen inch high, furnished gingerbread house.


See what I mean?  Once I decided to tile the kitchen floor with candy corn, I was gone.  Note the faucets for the aluminum kitchen sink.  And the handles on the refrigerator.  There is a fireplace hearth down there, made of a Milano cookie.  Even as I was installing these things, I knew I was out of control.  But I could not stop.

Here is a nine patch quilt, made from fruit rollups.  Plus a teddy bear on the pillows.  Should you decide to start quilting with fruit rollups, here are my methods.  Unroll them a few days in advance to dry a bit.  Don't overreach.  Let the materials tell you what they are willing to do.  Use liberal amounts of vegetable oil on your fingers and cutting utensils.  Keep the knife clean.  I recommend an exacto knife, under supervision if you have a problem with sharp objects.  Place your product between oiled sheets of cling wrap, then between sheets of paper.  Iron at LOW heat for five seconds.  Breathe.

I refer to this as my diagnosable gingerbread house.


By doubling the dimensions, I had introduced engineering issues.  I needed weight bearing walls.The closet was designed for that purpose.  I made a double wall facing the living room.  But I failed to double the wall with the door.  Two by twelve inches, it was the first piece to break.  The pretzel sticks inside the closet hold it together.


Metaphor Alert -- Community

If I were to get philosophical -- and while I bent over this project, holding my breath and waiting for icing to turn to cement, I had plenty of time -- I would reflect that sometimes things or people are created that do not have the structural integrity to withstand the pressures to which they will be submitted.  Nevertheless, they can get by with a little help from their friends, even friends that brittle themselves, like pretzel sticks.  This is the essence of support groups.  Get into one.

Some of us are not particularly unstable, but we collapse under pressures beyond normal experience.  If we don't have to bear the weight by ourselves, we can make still our own creative contribution to the whole.  The fireplace wall fell into three places.  Twice.  It stood, once it received a full back brace.  The brace is not flashy.  It is not even visible, covered by the outside of the fireplace.  But it is essential.

This is the essence of community.  Christians call it the Body of Christ.  If the house were all ribbon candy, how would it stand?  If the house were all support, what would cover the kitchen floor?

Anyway, diagnosable.  The roof also collapsed, the weight bearing walls notwithstanding, because I pushed too hard while attaching it.  Be gentle with yourself, my friends.  The stronger parts can injure the weaker.  Self-restraint is especially important where you are strong.

But we can learn from our mistakes, and turn them into more creative opportunities.  The roof went for snacks to a bible study group.  I replaced it with a lighter version.  And then I broke one side again.  This time I finally listened to my spouse, and put up just half a roof, so people could look in on that nine patch quilt.  None of us has all the answers.  And sometimes irritating advice is good advice.

Even if it is irritating.

Another Cognitive Therapy Technique -- Dialectical Thinking

Even in the midst of this craziness, I kept aiming at sanity.  My mantra was Prototype, prototype.  The point of a prototype is to make as many mistakes as possible, in order to learn, and not make the same mistakes while doing the real thing.

I was making a lot of mistakes.  Boy, was I learning.

Dialectical thinking means that life is not divided into black and white.  One can hold a painful thought and a positive one in the same brain at the same time.  That and valium got me through.

I learned not to use a double barrel aged single malt scotch as a brace to hold up a wall while assembling, like the soup cans above.  The bottle was missing only as much as is pictured here before I made that particular mistake.  Sigh.

After mopping up the nearly full bottle of scotch and as much shattered glass as I could find, it was time, it was time to stop working on the prototype.  Well, after I built the fire in the fireplace.


Two hot tamales, cut on the bias, a couple little pretzel sticks and a sprinkling of ribbon candy crumbs.  The back of the fireplace is the inside of a mint Milano with the white frosting scraped off.

Like I said, diagnosable.

It wasn't finished.  It still isn't finished.  But the time for prototype was at an end.  The time for the real deal had begun.

To be continued...



all photos of gingerbread houses by Helen Keefe 
photo of scotch by Suat Eman

Saturday, November 20, 2010

Holiday Survival Tips for Loonies

While I am working on my entry for the Gingerbread Trail contest, here is a repeat from December, 2009.  I have reformatted and modified it slightly for Thanksgiving.  Happy Turkey! 


Ah, the holidays!  Time when far flung family members travel home and grow close around the turkey table.  Time to renew friendships in a round of parties and frivolity.  Time to go crazy?

There are stresses this time of year.  Routines are disrupted, people stay in crowded quarters, those who have reason to avoid each other are thrown together, negotiations between exes require professional mediation, alcohol is consumed in greater quantities, expectations for love and good cheer are bound for disappointment.  Loonies and normals alike need to tend to their mental health.

So Prozac Monologues supplies a handy holiday guide, with an assist from NAMI's Peer to Peer class and the University of Iowa Adult Behavioral Health department, covering the basics, planning ahead, mindfulness and quick getaways. 

The Basics of Holiday Family Survival 

Keep to your routine as much as possible.  If you can't eat like you do at home, get at least one nutritious meal every day.  If your family of origin is a little whacked, and your root chakra could use some assist, concentrate on protein (meat, fish, tofu, beans), root vegetables (carrots, beets, onions) and red stuff (beets, strawberries, cranberries, cherries -- jello does not count.)  Don't go to parties without some protein already on board.  At the buffet table, carrots.  Skip the dip, limit your lipids.  You will sleep better for it.

Remember Lloyd Bridges in Airplane?  The holidays are probably not a good time to stop sipping, smoking, snorting, sniffing...  You get the idea.  On the other hand, ultimately substance abuse is a greater hazard than help in negotiating tricky family dynamics.  So keep it under control.

Sleep -- not so easy if you get the couch in the family room.  Borrow somebody's bed for a nap.  If you anticipate a problem, I'm all for an occasional pharmaceutical assist, as an alternative to the straight jacket, which is where you may be headed if you don't get good sleep. This is true for everybody, essential for people with bipolar.

Safety -- no, you do not have to hang around anybody who is abusive.  If that is an issue, have your escape plan ready, your keys and your credit card in your pocket, your alternative crash pad arranged.

Oh, and water -- with all your meds, you are probably supposed to push water, as it is.  Even more so in the dry winter air.  Even more so when dehydration can be mistaken for hunger, leading to more cookie consumption, requiring more water.  Especially even more so with greater alcohol consumption.  Be kind to your liver.  Drink water. 

Plan Ahead

Many a family feud could be short circuited with some conversation ahead of the storm.  Which chores does the host want or expect help with?  Which chores does the guest want to volunteer to do?  In any relationship, 50/50 does not work.  You have to give at least 65.

Is there any tradition, activity, food, game that will blow your anterior cingulate cortex if it doesn't happen?  Take some responsibility for it.  Laugh about it, and let people know what it is.  And if it doesn't happen, well, that will give you material for your next therapy appointment.  You already know what your therapist will say, don't you.

How many events are planned?  Which ones can you skip?  Is there room for negotiation?  What would you like to do in a group?  When will you want to go off by yourself?  When will the one who abused you as a child be around?  Where will you be instead? 

What are your needs?  What are others' needs?  Talk to each other.  Listen to each other.  Remember, there is no Norman Rockwell Thanksgiving, except for one painting.  Which is still under copyright protection.  Which means you can't replicate it.  This is art, people.  It is not your family, and not mine, and not anybody else's, either.  Give yourself and your family a break.  Your relatives, your turkey and pie are infinitely more interesting, anyway. 

Mindfulness 

"I am here, this is now."  That is my chant, accompanied by some deep breathing, calling me out of the unhappy past and the uncertain future.  Look up, listen up, and notice.  You don't have to participate.  Just notice.


When things get especially bleak for me, I go outside, regardless of weather, and try to replace the running voices in my head with a minute description of what I see around me.  "There is a little girl.  She has pink leggings on.  Her hair is in ponytails on either side of her  head.  The woman is pushing the stroller.  The tree is a pin oak and still has its leaves.  The passing car is a Volvo.  We used to have a Volvo.  It always... -- no, that's the past.  Come back to the present.  This Volvo is dark green..."  You get the idea.

When you can't get outside, like during dinner, become an anthropologist.  Who are these people?  What do they think?  How do they treat each other?  What are their eating habits?  What happens after three beers?  You are not responsible for any of it.  You do not have to stop what you don't like.  You don't even have to like or not like.  You are simply an observer.

Mindfulness is a practice.  Practice is what people do when they want to get better at something.  Remember, if you can't pull off mindfulness every time you need it, that's okay.  You just keep practicing. 

Quick getaways 

There is one more thing you need, some handy lines to get you out of the inevitable spot.  Let's see how many of these you can anticipate.

There you are, being an anthropologist, mindfulnessing away.  And Uncle You Know Who turns to you and says...  What will it be this year?  Health care?  Sarah Palin?  What he thinks about all this therapy you're doing?  He knows your triggers like the back of his hand, because he trips them every year.  Well, write this one down on the back of your hand, "That's very interesting.  I'll have to think about that."  That one can get you out of all kinds of arguments.  Sometimes it even gets my therapist off my back.

Or there you are, seated next to the cousin you haven't seen since she tried to drown you in the pool when you were kids.  Remember, you are here, this is now.  Try, "Seen any good movies lately?"  It matters not a whit if that line is a dud, because it sets up your next line, "What do you do with your time nowadays?"

Then there is the open-ended "How about them Hawks?" Or Vikings, or whatever.  Do a little research ahead of time, so you know a team near the person you are addressing.  For the sport challenged, here is a starting point: it's football season.  And if that line is a dud, follow with... are you with me yet?...  "What do you do with your time nowadays?"

When you want to escape the person or the room, there's:  "Excuse me, my drink needs more ice; I'm going out for a smoke/some air/to make snow angels;" and, "Do you know where the bathroom is?"

And when you have had your limit: "I really must go.  Thank you so much for dinner.  Happy Thanksgiving."  With a normal host, I mean really normal, not undiagnosed normal, you don't need to explain anything.

If the host is in the "undiagnosed " category, then try: "My puppy/probation officer/Nurse Ratchet is waiting up for me."  Or, "I'm sorry, suddenly I'm feeling flu-ish."  You can play the flu for all it's worth this time of year.  Or even, "Oops, my meds are wearing off.  Gotta go!"

Sometimes a simple "I'm outa here" works.

Make yourself a crib sheet, and these few lines will help you navigate a wide range of social situations.

Do you have anything else you want to recommend to fellow readers?  Make a comment!

Families -- you gotta love 'em.  At least you can laugh.  It works better if you do.  Happy Holidays!

Our (Almost Traditional) Thanksgiving Dinner photo by Ms Jones and licensed under the Creative Commons Attribution 2.0 Generic license
Sleep and his half-brother death byJohn William Waterhouse 1874
photo of dirty dishes by User:Mysid and in the public domain
Autumn by Vincent Van Gogh
photo of Margaret Mead by Edward Lynch, given to the Library of Congress

Friday, November 12, 2010

Hope and the Play of the Week

I am up to my earlobes in ribbon candy, pretzels and gingerbread right now, a holiday project gone diagnosable.  I have been working for several weeks now on the prototype of a gingerbread house that is yet to come.  If this one stands.

I hope I can post pictures of the finished product.  They could go in my file.

Meanwhile, I have scavenged a video from a Facebook friend.  It reminds me of my very favorite poem in the whole wide world.  My congregations know it by heart, they have heard me preach it so often.

Listen to the mustn'ts, child.  Listen to the don'ts.
Listen to the shouldn'ts, the impossibles, the won'ts.
Listen to the never haves then listen close to me...
Anything can happen, child.
Anything can be.


Come to think of it, the gingerbread house, the poem and the play of the week all have this is common.  They are matches, held up against the darkness.



Here's hoping you some light.

Thursday, November 4, 2010

Weighing Costs and Benefits Part V -- Down and Dirty Algorithm

SE + NE + $$$ + STG + TR = STC.

E#PT X NSR = STB.

STB TO STC = ODDS OF SUCCESS


There it is, the Prozac Monologues Down And Dirty Algorithm, to weigh your costs and benefits for medication or any other treatment for any mental illness, or any other medical condition, for that matter.  Click on the first and second lines.  They will take you to the posts that develop the formula.

Can you believe we finally made it?

We started with the:

Manifesto of a Lab Rat. 


I am a Lab Rat.  Yes, I am.

The Manifesto begins there.


It continues: 
 
If I am a lab rat, I will be a free-range lab rat.

What I mean by free-range lab rat is this: 

I insist that I contribute more to this enterprise than my body.

Your doctor tells you to weigh your costs and benefits, but gives you no way to do so, other than insufficient information + gut + desperation = noncompliance, if you don't come up with the same answer as your doctor.

What we need is an algorithm: logical rules that we can apply to objective data to solve a problem.

This algorithm does not exist.

So as an interested party, a very interested party, given that my body is the test tube, I decided that my contribution to this chemistry experiment would be the algorithm.

The problem we want to solve is this:

Do I Want To Put These Chemicals Inside My Body?

This task has continued over several posts this fall, interspersed with a few sick leaves and vacation days.  Click on costs and benefits to follow the whole development.  (The first post is at the bottom, dated August 19, 2010).

What To Do With The Algorithm

The resulting algorithm can be applied not only to the chemicals you put in your body, but any other form of treatment as well, talk therapy, aerobic exercise, yoga, Chinese medicine, acupuncture, even aroma therapy, should you choose.

You can compare the results of the cost/benefit analysis of different treatments, and do the same with various combinations, when you can find the numbers.  Which admittedly, you cannot for any of these that do not get Blue Cross Blue Shield reimbursement.

There are numbers out there for talk therapy and aerobic exercise.  But doctors do not usually use the word therapy for anything other than chemicals or electro-convulsive therapy (ECT) or any of those new-fangled electrical interventions.  That is the context in which you are told to weigh your costs and benefits.

For the most part, I have used antidepressants as examples.  One out of every ten people in the United States is taking them right now.  So this would be the most common application, among psychotropic medications.

It was helpful to look at chemicals as I developed this algorithm, because they are the form of treatment with the greatest costs and greatest variety of costs:





dizziness and confusion,





insomnia and fatigue,



weight gain, irritability, sexual dysfunction,  irritability.




So this is what you do when you use the algorithm to weigh your costs and benefits -- you compare two numbers, STC (Short Term Costs) and STB (Short Term Benefits).

And how do we get those numbers?

Remember,

SE + NE + $$$ + STG + TR = STC.
E#PT X NSR = STB.

The abbreviations increase the confusion quotient, and thus make it look scientific.  Here is a translation:

Side Effects (SE) plus Not Effective (NE) plus Money ($$$) plus Stigma (STG) plus [lack of] Trust (TR) are your costs (STC).  These costs are based on the reasons people give for discontinuing their medication.

Efficacy Given The Number of Present Trial (E#PT) times How Many Would Not Experience Spontaneous Remission Unless They Took the Medication (NSR) are your benefits (STB).

Did you like my illustrated tour of the previous posts?

And Where Are We Supposed To Get Our Data?

They ought to be provided to you by your doctor, who has told you to weigh your costs and benefits.  Except for money, stigma and trust -- you have to come up with your own odds that you will quit taking your medication because you can't afford it, you are afraid for your reputation, or you do not trust your doctor.

They ought to be provided to your doctor by the drug reps.

But they are not.

So you have to do your own research.

I think the algorithm would make a fabulous app.  The numbers could be regularly updated, from the latest research by scientists not funded by the companies that sell these chemicals.

I claim copyright, by the way. 

Long Term Costs And Benefits Are Missing

Notice that I refer to short term costs and benefits.  Some will object that I left out good reasons to take meds: the difference that meds make to how quickly another episode occurs (relapse rate), how long various approaches take to work (time to remission), how medications affect things like brain mass, suicide risk.

Others will object that I left out good reasons not to take them: the possibility that medication might accelerate the natural progression of the disease, the possibility that the diagnosis is off and you will flip into mania or hypomania, liver damage, the consequences of weight gain, such as heart disease and diabetes, suicide risk.

Someday I will do a post or two on that suicide risk issue.  There is a lot to say about that.

Well, this algorithm is complicated enough and took five posts already.  This one has that i-Pod potential.  The one that includes all those other issues will take more gigabytes.

STC versus STB give you the odds.

Once more I repeat, they do not give you your decision.  There are additional personal factors that influence or even override logical rules, objective data, and problem solving.

Personal Factors:

You have used up your sick leave, your vacation time and your family leave for this year and next, and your boss will fire you if you don't start taking meds.

Your wife has issued a similar ultimatum.

You can't get out of the loony bin any other way.

You are desperate.

You have the knife to the wrist.

Like I said, it is your decision.  I am merely your humble servant.  Who does occasionally buy a Powerball ticket.

How Does The Algorithm Work?

Let me give you a personal example.

When I first took Prozac, Eli Lilly's website said that it had helped 70% of the 55,000,000 who had already taken it.  I didn't know anything about spontaneous remission or the effect of which trial this was.  So STB = 70.

Meanwhile, none of the side effects (SE) reported went above the 15% range; the odds that it would not be effective (NE) were 30 out of 100; it was already generic, and I could afford it ($$$); stigma (STG) was not an issue for me; and I had total trust (TR) in my doctor.  So STC was 15 + 30 + 0 + 0 + 0 = 45.

That meant (with the information I had) that the odds for Prozac were 70 to 45 in favor.  And I could put off therapy.  No brainer.

Next up -- actually, five keep trying's later, we had moved on to a psychiatrist who prescribed Effexor.  Crazy Meds says: for deep, despairing clinical depression that needs to respond to the standard tweaking of the three most popular neurotransmitters, Effexor XR (venlafaxine hydrochloride) often pulls people out of the abyss.  By then, the deep, despairing abyss -- that would be me.

My doc said I get good results from Effexor.  She didn't say how good results translated to a number,.  (That's case studies, by the way -- not research.)  But she did tell me to weigh my costs and benefits.  By then I knew that most antidepressants have about the same effectiveness level, which I took to be around 40%.  I didn't know it mattered that I was on my sixth go round.  Odds for benefit, STB = 40%

She also gave me the usual side effects, because I asked.  Since insomnia was a major issue for me, and we had run through a number of sleep aids, she said that the insomnia risk (SE) was 15%.  Not effective odds (NE) would come in at 60 out of 100.  Since she didn't ever answer phone calls, and I knew I couldn't stop this med without help tapering off, and I was wary of her by now, I grilled her on how to discontinue without her help.  Trust, lack thereof, (TR) was in the 40% range.  STC was 15 + 60 + 40 = 115.

With Effexor, my odds were 115 to 40 against.  Not so good this time.  However, desperation overcame gut instinct.  So I kept trying.

The rules of the algorithm work, but the results are only as good as the objective data.  What if I knew then what I know now?  Without going into the whole story, and by tweaking numbers actually available: 

Prozac -- 

STB = 40 (E#PT) X .8 (NSR) = 32.
STC = 30 (SE) + 60 (NE) + 0 ($$$) + 0 (STG) + 20 (TR) = 110. 

110 to 32 against.  I still had issues with therapy (nothing to do with any therapist I have ever known, by the way).  And being over-educated, I am on the compliant side.  So I would have given it a shot. 

Effexor --

STB = 10 (E#PT) X .8 = 8.
STC = 34 (SE) + 92 (NE) + 0 ($$$) + 0 (STG) + 95 (TR) = 221.

221 to 8 against.

The numbers for Effexor come from the STAR*D study, and were available at the time I started taking it.  But I didn't know that.  STAR*D's original conclusion was that after two antidepressants have been tried, subsequent results are dismal, and more research for better medications should be a priority.

Since then, a jillion articles have been written about how STAR*D was a lousy research design that cooked the books in way favor of the chemicals at every step, starting with the selection of subjects.  Click here for my posts that reference STAR*D.  But Google it for for what the scientists say.

Anyway, 221 to 8 against -- I would have given it a pass.  Even I could tell the books were cooked.  And I got so much better after I went off it.

And So The Manifesto Of A Lab Rat Concludes

Of course, your results may vary.  Just remember, it's your test tube.




flair from Facebook
Photo "Tired Man" by graur codrin
Photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
i-Pod family photo by Matthieu Riegler, licensed under
the Creative Commons Attribution 3.0 Unported license.png
photo of Warren G. Harding in public domain
photo of woman pointing taken by David Shankbone,
used by permission under the Creative Commons 
Attribution-Share Alike 3.0 Unported licence and modified
photo of prozac by Tom Vasco and is licensed under
photo of effexor by Parhamr who has placed it in the public domain
photo of John LeCompte of Evanescence by Samuel Lang,
permission to copy and modify granted under GNU Free Documentation License