At 11:17am today (5/19/13) my new nephew Oliver (Ollie) Charles Howe was born at 9lbs 4oz. and 20.4″. With the birth of new life in the family brings on a lot of thoughts, some good, and some are sad and bittersweet. My mom who passed away on February 8, 2012 was dying to be a grandmother. My niece Lorelai was born on September 9, 2011 and my mom was overjoyed, she was all ready for lots of baby sitting and good times with her first grandchild. Unfortunately she only got to enjoy her for 5 months before her passing. All I could think over the last 33 hours that I have been awake is how much my mom would have loved to have been there this morning, but I firmly believe she was there in spirit even though I think everyone who has ever lost a loved one would agree that it’s still not the same. Unfortunately this is how our lives work, we never know when our last day will come, but I will say this, my mom lived her life to the absolute fullest, she loved every moment of the 5 months she got to spend with Lorelai. One person dies, and another is born, it is the circle of life, sometimes it can seem cruel like in this situation but everything happens for a reason; for instance, when my mom passed, it forever changed my life and it brought me a second chance at life. I miss my mom more than anyone could ever know but I am thankful that she was able to teach me the most invaluable lessons about life. Everything is impermanent, our lives and our worlds are in a constant state of change, and we must live everyday as if it were our last. It was almost like my mom gave up her life in order to save mine. Before she died, I was a hot mess, but after learning these things through her death I am beginning to create a whole new life for myself. Of course I would give anything to have her back, but I know that it was her time. These thoughts don’t only apply to our human lives, it also shows itself in every living thing in the world. With the beginning of spring brings new life to nature, the flowers that my mom planted many many years ago finally came in bloom in the last couple weeks and it just reminds me of how my mom loved her flowers and when I see them blooming, I think of what it means to me. It means that another cycle has begun and just like the flowers, we have a new cycle starting in our lives through the birth of my nephew, and he was born the day after what would’ve been my mom’s 54th birthday. I don’t know if it’s possible but I have cried both out of sorrow and grief and also out of joy all in the same tears. It reminds me that we need to live our lives in such a way that when our time comes, our loved ones will not only shed tears out of sadness but also out of celebration. We need to create a life that can be celebrated. In the past 9 years I have attempted suicide more times than I can count but I am so very grateful that it just wasn’t my time because I can’t even begin to fathom the pain that my loved ones would’ve felt especially because up until about a year ago I wasn’t living, I was just existing. I can thankfully say now that I’m beginning to LIVE my life so that whenever my time comes it won’t only be a sad event but also a celebration.
When you forgive, you in no way change the past - but you sure do change the future. — Bernard Meltzer
This is the official ‘i care’ symbol. This is how it works:
Basically you reblog this, and your followers know that you care and that they can message you about anything anon or not and you will reply back or at least look at their message.
BUS Web Board An active and fairly recovery-focused forum for people who self-harm. British Association of Skin Camouflage Information on camouflage make-up for scars, including where to get these …
Many years ago, I took part in a CBT (cognitive behavioural therapy) group which was essentially eight weeks of learning how to challenge depressed thinking by doing a thought record. Although I have my reservations about CBT-style self-help and the way it’s used and abused by the NHS, this is one technique that has helped me get through episodes of depression. The theory behind it is that you can change the way you feel by changing the way you think, and for me, identifying the distressing but often irrational thoughts that are part and parcel of depression and finding a more balanced way of looking at things does help to lift my mood. The effect isn’t permanent – and the book this exercise comes from compares it to trimming back the weeds in your garden rather than pulling them out at the root – but as a short-term coping skill I find it very useful.
Thought records are supposed to help with all kinds of negative emotions, whether that’s depression, anxiety, anger or something else. Of course, if your thoughts are already balanced and rational then they’re unlikely to make a difference – not all negative emotions are a result of or linked to ‘twisted thinking’. I tend to use a thought record when I know or suspect my thinking has gone a bit screwy. I also find the first step can be helpful if I feel crap but don’t know why; it gives me a chance to understand why I feel the way I do and decide whether continuing with a thought record is appropriate.
Tip: It’s a good idea to rate your mood (e.g. on a scale of one to ten) before and after doing this exercise so you can judge whether it’s helped.
Take a sheet of paper and divide it into four columns. In the first column, write down all the negative, distressing or anxiety-provoking thoughts that are going through your head.
If you just know you feel bad and are not sure what you’re thinking, these questions may help:
- What was going through my mind just before I started to feel this way?
- What does this say about me? What does it say I can/can’t do?
- What does this mean about me? My life? My future?
- What am I afraid might happen? What is the worst thing that could happen if this is true?
- What does this mean about what other people might think/feel about me?
- What does this mean I should/shouldn’t do?
- What images or memories do I have in this situation?
Source: Overcoming Weight Problems by Gauntlett-Gilbert and Grace
Read through your list of thoughts and circle the one you find most distressing. This is the thought you’re going to challenge. (You can always repeat the exercise for other thoughts later if you like.)
In the second column, write down all the factual evidence that suggests your circled thought is true. Be as specific as possible, and only include facts, not opinions. For example, if your friend Sally said a particular dress made you look a little fat, don’t write, “I look fat” (this is just Sally’s opinion). Don’t write, “Sally says I look fat” (this is overgeneralising). Write something like, “Sally said I looked a little fat in the green dress.”
Here’s an example from one of my own thought records:
Thought: I’m a useless, weak, pathetic person who can’t cope with ordinary life.
Evidence for thought: I only managed about 2/3 of the work I should have done today.
I couldn’t concentrate well and didn’t notice several typos – I’m not sure I did a good job.
The house is a mess.
I haven’t cleaned out the guinea pigs for 2-3 weeks.
The broadband company made a mistake with my bill months ago and I still haven’t contacted them about it.
I feel like I can’t cope and want to hide.
In the third column, write down any factual evidence that suggests your circled thought is not 100% true. To do this, you can ask yourself the following questions:
- Have I had any experiences that show that this thought is not completely true all the time?
- If my best friend or someone I loved had this thought, what would I tell them?
- If my best friend or someone who loves me knew I was thinking this thought, what would they say to me? What evidence would they point out to me that would suggest that my thoughts were not 100% true?
- When I am not feeling this way, do I think about this type of situation any differently? How?
- When I have felt this way in the past, what did I think about that helped me feel better?
- Have I been in this type of situation before? What happened? Is there anything different between this situation and previous ones? What have I learned from prior experiences that could help me now?
- Are there any small things that contradict my thoughts that I might be discounting as not important?
- Five years from now, if I look back at this situation, will I look at it any differently? Will I focus on any different part of my experience?
- Are there any strengths or positives in me or the situation that I am ignoring?
- Am I jumping to any conclusions that are not completely justified by the evidence?
- Am I blaming myself for something over which I do not have complete control?
Source: Mind Over Mood by Greenberger and Padesky
You might also find it helpful to look at the Ten Forms of Twisted Thinking (which help you spot flaws in your negative thoughts) and Ten Ways to Untwist Your Thinking for further ideas.
Thought: I’m a useless, weak, pathetic person who can’t cope with ordinary life.
Evidence against thought: Depression is an illness. It’s recognised as a disability under UK law.
I did do some housework yesterday and at the weekend.
I give the guinea pigs a loving home.
I know many people with depression who deal with these problems and I don’t think they’re pathetic, weak or useless.
People in my support system are impressed by how much I’m getting done despite the depression.
Many people get behind on housework etc and I wouldn’t say they’re not coping with life.
I’ve been busy with work, Sirius Project and driving lessons.
I can cope with work fine when I’m not depressed.
I’m under extra stress with the housework at the moment because of my partner’s RSI.
I may not be on the best meds for me right now.
B says I come across as someone who makes every effort to deal with problems and work at it.
I’ve helped myself cope by being open with my employer about my depression.
I’m putting a lot of effort and energy into my recovery right now and have developed new ways to help myself.
What if your thought is true? Before you come to this conclusion, I would recommend asking someone you trust for their opinion. However, sometimes a distressing thought can be accurate – for example, if you’re in serious danger of losing your job and your thought is, “I could get fired!”
If this is the case, instead of trying to challenge the thought, it can be more helpful to take practical steps to address the problem. You might want to discuss your concerns with your boss, start looking for other jobs, come up with a plan for how you’ll cope financially, and so on. You can find more advice on problem-solving techniques on page 9 of this PDF booklet.
In the final column, try to come up with some “alternative” or “balanced” thoughts that are more factually accurate than those in the first column. These should take into account all the evidence you’ve just gathered. You can ask yourself the following questions:
- Based on the evidence I have listed, is there an alternative way of thinking about or understanding the situation?
- Write one sentence that summarizes all the evidence that supports my thought and all the evidence that does not support my thought.
- Does combining the two summary statements with the word “and” create a balanced thought that takes into account all the information I have gathered?
- If someone I cared about was in this situation, had these thoughts, and had this information available, what would be my advice to them? How would I suggest that they understand the situation?
- If my thought is true, what is the worst outcome? If my thought is true, what is the best outcome? If my thought is true, what is the most realistic outcome?
- Can someone I trust think of any other way of understanding this situation?
Source: Mind Over Mood by Greenberger and Padesky
And here’s my example:
Thought: I’m a useless, weak, pathetic person who can’t cope with ordinary life.
Alternative thoughts: I’m finding “ordinary” life quite hard to cope with right now, but this is understandable given I’m depressed. It’s not a judgement on me as a person.
I’m not weak – I’m actually working very hard on recovery!
If there is any truth to your circled thought and it requires some kind of action, I also like writing a brief to-do list in this column. For example, “I am in danger of losing my job, but I can improve my situation by taking the following steps…”
This exercise is a simplified version of the technique described in the book Mind Over Mood by Greenberger and Padesky.
You’re trying really hard not to self-harm. You’ve thrown away your blades, used the alternatives, and you’re getting help to deal with your underlying “issues”. You’re drawing on willpower you didn’t know you had and you’ve managed to go for longer than ever before without hurting yourself. Then something happens to trigger you, or maybe you just can’t keep up the effort any more, and you end up self-harming again. Does this mean you’re beyond help? Should you give up trying to get better?
Not at all! Many experts on addiction believe that relapsing is actually an important part of the recovery process. Every time we relapse, we learn more about what triggers us. By thinking about how the relapse could have been prevented, we learn new things to try on our path to recovery. Relapse can also help keep us on our toes: sometimes when we haven’t self-harmed in a long time, we assume we’re “better” and no longer need to go to therapy or take our meds or keep using self-help techniques. Sadly, this is not always the case, and relapse can serve as a useful reminder.
There are two important things to do if you relapse. The first is to keep the incident in context – don’t give up hope or lose sight of your achievements. The second is to learn as much from the experience as you can and use this information to help you recover. This page also gives some advice on how to prevent relapse in the first place.
Tips for Preventing Relapse
Build up a good support network. Many people (including doctors!) tend to assume that if you’re no longer self-harming, your problems are less severe and you no longer need as much help and support. In fact, your underlying problems (e.g. depression) may still be there and you may need extra support, not less, to help you cope without SI. Make sure everyone you would normally get support from knows about this. Try to find as many sources of support as you can (friends, family, health professionals, helplines, internet forums and chat rooms, self-help groups, etc). This avoids putting too much pressure on any one person and means you’re less likely to be “caught short” when someone’s unwilling or unavailable.
Try to improve your mental health overall. Don’t just focus on simply “stopping” – self-harm is a coping mechanism and if you want to live without it in the long term, you’ll probably need to find other ways of coping and tackle the issues that caused you to SI in the first place. Otherwise, you might find you can go for a while without self-harming but then “explode” and hurt yourself worse than normal, or you might find you turn to other unhealthy ways of coping such as starving yourself or drinking too much.
Don’t worry if you can’t stop thinking about self-harm. This is fairly common, especially if self-harm has played a big role in your life up until now, but the thoughts should get less frequent with time. Secret Shame’s Dealing with intrusive thoughts after stopping page gives some suggestions on how to cope with this.
Keeping Relapse in Context
When you end up self-harming, it’s easy to feel that the weeks or months when you abstained don’t count any more. This isn’t true! If you went for six weeks without SI, that’s an achievement which nothing can take away. You’ve proved that you can cope for that long without hurting yourself, and if you learn something from your relapse, hopefully you can go for even longer next time. So don’t beat yourself up about it too much.
Remind yourself of your achievements so far. It can help if you write these down. How long did you go without self-harming? Were there any times you wanted to SI or came close to doing it but didn’t? If there were any extenuating circumstances that lead to your relapse (for example, something unusually distressing happened to you, or you didn’t have your usual support) remind yourself of these too. (They will also be useful when it comes to learning from the experience.)
If you keep track of exactly how long it is since you last self-harmed, try not to think of yourself as being back at square one. You have still achieved something, and you can learn from this experience. It might help to tell yourself something like, “I’ve only self-harmed once in the last six weeks,” rather than, “It’s only been a day since I last self-harmed.”
Learning from Relapse
Think about exactly what happened that lead up to you self-harming. You might want to ask yourself the following questions:
Now ask yourself if you could have done anything differently that wouldn’t have resulted in you self-harming. Alternatively, are there any changes you could make now to prevent something similar from happening in future? Focus on the things you can do and be realistic – for example, if the person you usually turn to for support wasn’t available, accept that this is going to happen sometimes and try to widen your support network.
Remember, the idea isn’t to beat yourself up about the things you did “wrong”. It’s OK to make mistakes, and not everything that contributed to you self-harming will have been your responsibility or under your control. The idea is just to learn what you can from the experience, look at what you could have done differently, find better ways of coping with the stuff you can’t control, and don’t give up hope!
This entry may be triggering or difficult to read for some people.
Self-injury behavior is something that is more common than many people realize. (In one study by researchers at Brown University of high school students, 46 percent had injured themselves in the past year on multiple occasions.) It is often misunderstood, not just by the lay public, but also by the mental health professionals who ostensibly should know what self-injury it is and how best to treat it.
Self-injury is used by people as over-drinking is used by others — to drown out emotional pain with something else. In the case of self-injury, that something else is physical pain. It focuses your attention and takes your mind off of your emotional pain, if only for a little while.
Cutting is the most common form of self-injury — making skin-deep cuts on one’s arms, wrists, or less noticeable areas on one’s body. The cuts are not meant to cause permanent damage or harm, nor are they meant as a suicidal gesture. The cuts are the means to an end themselves — they provide a source of immediate but non-serious physical pain (as long as they are allowed to heal cleanly). Other forms of self-injury include burning, or keeping old wounds open or inviting infection in them to keep them painful.
The people with the most severe self-injury behavior often can think of little else as they go through their day — it becomes something more than just a way to deal with emotional pain, it becomes its own obsession, as it did with Becki, a person who self-injured and is profiled in an article that appeared online inNewsweek last week:
Becki describes it as an obsessive battle, and one she often lost. At her worst, she says she spent every hour living and breathing self-injury. She dreamed about it. She’d think about it at school. She bought every book published on it. She searched for self-injury Websites, and compiled what she found into a 13-page Website of her own. “I was cutting 10-plus times a day, and still, if I didn’t do it, I would feel like I was missing something,” she says.
Newsweek‘s article is a fairly good read on self-injury and self-harm, describing what self-injury is, using Becki as a case study, and brings us up-to-date on treatment options and the latest research into self-injury. If nothing else, it helps bring this behavior out into the open more, helping people understand that it is not something that one should be ashamed of and that it can be treated.
As the article notes, self-injury isn’t recognized as a mental disorder by itself. But that doesn’t mean it can’t be treated. Treatment usually is done through psychotherapy, and focuses on helping the person identify their own triggers for self-injurious behavior, and find alternative methods for helping them deal with the emotional pain in their life.
As you can see from this issue’s lead article, SSRIs help alleviate core PTSD symptoms, but hardly roar by the placebo response rate in clinical trials. And anytime the placebo effect is this robust, you can predict that psychotherapy will be very effective. This is certainly true in the world of PTSD.
The most well-studied therapy isexposure therapy, in which patients are encouraged to confront their demons in various ways in the hopes that this will gradually desensitize them to their symptom-inducing power. In this technique, therapists guide patients through a process of imagining and recalling the traumatic event (“imaginal exposure”), and they help patients come up with strategies allowing them to expose themselves to the feared place or situation (“in vivo exposure”). Sometimes, this means that the therapist will actually accompany the patient, for example, to the street where the assault occurred, doing “guerilla psychotherapy” where it needs to happen the most. (See this issue’s interview with Dr. Edna Foa for more information on a particularly effective version of exposure therapy.)
Anxiety management programs focus on teaching patients a range of coping skills to help them calm themselves when they experience PTSD symptoms. Most famously, these techniques include good old relaxation training, but creative therapists will add controlled breathing exercises, distraction techniques, positive imagery, and even some cognitive therapy.
There’s always straight-ahead cognitive therapy, in which therapists help patients identify dysfunctional thoughts and attitudes that may have been engendered by the trauma, guide them in challenging these beliefs, and then help them to replace them with more realistic cognitions.
No brief survey of PTSD therapy would be complete without mentioningEMDR (“eye movement and desensitization reprocessing”), a technique that raises everyone’s “hokeyness” antennae but appears to be effective nonetheless. The technique was developed by psychologist Francine Shapiro as a result of a personal experience: as her eyes tracked something that was moving back and forth rapidly, she realized that an upsetting thought that was preoccupying her had gone away (Shapiro and Forrest, EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma, New York: Basic Books, 1997). In EMDR, the therapist has the patient recount or remember the trauma while having the patient track side-to-side movements of the therapist’s finger. A bit of cognitive therapy is typically thrown into the mix, with the therapist helping the patient replace negative with positive self-beliefs (Shapiro and Maxfield, J Clin Psychol; 58:933-946).
Yes, these abstract explanations of therapeutic techniques are always a bit mind-numbing. So let’s get to the bottom-line: Are they effective, and how do they stack up against one another, and against meds?
This article originally appeared in The Carlat Psychiatry Report — an unbiased monthly covering all things psychiatry.
Want more, plus easy CME credit?
Exposure therapy, stress inoculation training (a version of “anxiety management”), and cognitive therapy all appear to work better than the typical waiting list control group, and all three techniques are essentially equivalent when compared head-to-head (J Clin Psychiatry 2000; 61[suppl 5]:43-48). Of the three, exposure therapy may be the easiest to learn how to do, so one could argue that this would be the best of the lot to focus on if you intend to do much therapy with PTSD patients.
EMDR has been studied in controlled trials (J Consult Clin Psychol 2001; 69:305-16), and appears to be superior to waiting list. A big controversy among those who follow these issues is whether the eye movement part of EMDR is actually superfluous. The definitive meta-analysis of 34 studies of EMDR cited above reported that “no incremental effect of eye movements was noted when EMDR was compared with the same procedure without them.” This suggests that EMDR is simply a collection of traditional exposure and cognitive therapy techniques with eye movements thrown in for kicks, but there are many very devoted practitioners of EMDR out there who would have TCR quartered and roasted for saying so.
How does therapy compare to medication for PTSD? Sorry, there have been no head-to-head clinical studies of this. The closest we’ve found is a meta-analysis concluding that therapies tend to have larger “effect sizes” (which is equal to drug effect minus placebo effect, adjusted for the relative precision of whatever rating scale is used) than meds (Clin Psychol Psychother 1998; 5:125- 144), but this was published in 1998, before the big SSRI studies were done. It would certainly seem likely that a combination of therapy and medication would be better than either one alone. In fact, in this month’s interview, Dr. Edna Foa describes a study indicating that adding CBT to Zoloft enhances response, but this research has not yet been published.
TCR VERDICT: Get them into therapy! (Along with your favorite med)
Depression is quite complicated. It entails a host of symptoms that perplex even the savviest therapist. Depression is even more complicated in children and men because the expression of symptoms is not as clear-cut for them as it is for others. Nonetheless, depression is one of those “diseases” that requires a compassionate, caring, knowledgeable, and understanding individual to identify it. Families, caregivers, and friends who suspect a loved one experiencing depression ought to know that depression can entail lots of symptoms. Sadly, many people believe depression is a sad mood, bad mood, or negative thinking that can be overcome through will power. This is not always the case. Depression often requires treatment.
I have always assessed depression by looking for 3 major defining features and you can do the same:
I often refer to depression as dark colored glasses. Depression causes people to see the world through dark and faulty lens. You can never really see the truth for the darkness. If the “darkness” persists, an individual can become numb to life around them and begin to lose the ability to feel present, engaged, or included in life. The human mind just simply checks-out.
What do a 45-year-old professor, several well-educated parents, a retired psychotherapist, a concerned husband, and a college student all have in common? These are people suffering–or intimately connected to someone suffering–from clinical depression who didn’t know it.
How, in this day and age, with so much information available, is it possible that depression can still go undiagnosed and therefore untreated? Perhaps this is part of the reason why the blog “Depression Part Two” on Hyperbole and a Half just went viral (besides how extraordinarily creative it is). Here are some reasons why smart people can miss the signs of depression:1. Depression can creep up on you.
Not all depression is so severe that you can’t stop crying or get out of bed. For many people, the feelings of sadness manifest as a growing disinterest in life’s activities. What used to be fun or interesting seems unimportant or shallow. You don’t feel like going to your friend’s birthday party so you make up an excuse. You feel bored by the books or TV shows that used to appeal to you. You don’t notice how, little by little, you are pulling back from others, spending more time alone, locked in your room.2. Depression seems to be a logical response to life’s challenges.
Since depression often worsens or can be triggered by loss or stress, you figure that you are responding appropriately to what is indeed a painful time in your life. You may have broken up with a boyfriend, had difficulties at work, done poorly on a school assignment, or moved away from a supportive environment. When you don’t snap out of it, even when your life circumstances appear to get better, you don’t realize that your negative mood state has persisted for months or even years.3. Some depression manifests as extraordinary irritability rather than sadness.
One of the most commonly misunderstood or overlooked manifestations of depression is hypersensitivity or irritability. People around you tell you that you are constantly cranky. You seem annoyed (and feel annoyed) at every little thing. People or activities that you didn’t like before become intolerable. One of my clients, Sally, upset her husband and kids because she yelled at the TV announcers and seemed critical and judgmental about everything. Only when I inquired about whether Sally might be depressed, did she realize that she was sleeping an inordinate amount of time and no longer had any appetite. She never felt sad, just incessantly irritable.4. Some depression manifests as extreme anxiety.
Many people do not realize that anxiety is a frequent companion of depression. Mark, a local college student, came to see me because of paralyzing test anxiety and social phobia. Since he did not feel sad and never cried, Mark attributed all of his problems to his fears. Only after a thorough assessment that revealed his gradual weight gain since high school, his difficulty with sleeping, his growing disinterest in sports (which had been his passion), did Mark realize that his anxiety was one of many symptoms of his depression.5. If you’ve been depressed your whole life, it just seems normal.
I worked with Randall, a 54-year-old math professor, who never said a word about being depressed. He had even had bouts of suicidal thoughts on and off since he was a teenager. Randall’s mother was chronically unhappy, and his father was an alcoholic. Surrounded by a family of unhappy people, this client thought of his mood state as normal. It never occurred to him that he might learn to treat himself more generously. To be happy was unthinkable in Randall’s world.6. You have been raised to be stoic in the face of any form of pain.
Justina came into therapy because her child was having problems adjusting to school. She insisted initially that everything was fine in her life. It was only when her son told her that he was afraid to go to school because he thought his mom might hurt herself that Justina began to talk about how difficult it was to get out of bed every morning. As we talked further, she described her upbringing in a highly religious family where she was not allowed to complain. Her parents taught her to be grateful for her privileged life in a world where others suffered from poverty and religious persecution. Justina’s shame about what she saw as her personal weakness had kept her from talking about how badly she felt.7. You feel hopeless, believing nothing will change how you feel.
Another group of people just soldier on, convinced that there is nothing anyone could do to help. Since depression causes people to withdraw from life, to stop reaching out to others, and to be immobilized by insecurity and anxiety, the idea that their misery is unchangeable becomes a self-fulfilling prophecy. The very things that loved ones do to try to help–telling the depressed person to exercise, go out more, drink less, and look at the bright side–are the very things that the depression makes impossible.