Return to Psychiatry?

I just got back from meeting with an advanced practice nurse (APN) for a psychiatric evaluation. I like her a lot: she was down to earth and personable. I felt like I could relate to her and trust her. She made a real effort to listen to me and ensure that her understanding of my history and current situation was accurate. She took the issues I’ve had with medications in the past seriously.

She screened me for bipolar and OCD, but hasn’t made an official diagnosis. First she wants to see the results of the blood work I had done when I went to see my primary care provider a few months ago. She also gave me a prescription to get a sleep study done to see if my problem might actually be sleep apnea or another sleep disorder. It could be that chronic lack of restful sleep has been keeping my brain from functioning properly and causing (or at least contributing to) my depression and anxiety symptoms.

Finally, she sent me home with a self-report measure to fill in over the 4 weeks between now and my next appointment. Every day I get to rate symptoms such as depressed mood, mood swings, irritability, food cravings, anxiety, sleep issues, difficulty doing things, and physical symptoms. There are spaces to mark day of the week and whether I have my period. As I complete it, I’ll be making a graph; it’s pretty neat.

Perhaps best of all, she agreed to talk with Wakana to coordinate my care. I guess time will tell how well they can work together to help me.

To be honest, I have mixed feelings about the situation. There’s a part of me that’s disappointed because I don’t have medication to take and either (preferably) gain relief from or complain about. It’s basically more of the status quo, at least until the data from the sleep study has been analyzed.

The rest of me likes that the APN is proceeding cautiously and trying to gather as much information as she can before prescribing drugs that may do more harm than good. She seems to be thinking about what is best for me as a whole person, not what will be the most convenient. It may take longer than I’d like before I have a treatment plan that’s truly effective, but hopefully I won’t have any more false starts and stops with medication. I may have found a keeper.

Listening to Myself – Part 3

I’ve been feeling much better since I wrote Listening to Myself – Part 2 about a week ago. I want to thank the people who reached out to me in response to that post: your support has meant the world to me. I’ve come to realize that I influence more people than I can possibly be aware of, often for the better… even in this time when I feel like I’m barely doing anything with my life. I may never see the whole, but I’m part of something important; something that needs me just as much as I need to remain a part of it. Connected.

I really needed to express what I wrote in my last post: feeling trapped, like I couldn’t express myself, like I needed some really big changes to happen or I wouldn’t feel like my life was worth living. Expressing those things – writing that post – was engaging in the very process of Creation that I felt cut off from. It was uncomfortable, and to be honest I feel guilty about the discomfort it caused others, but the very act of expressing those thoughts and feelings provided some of the relief I sought. It’s also helped me to start making some of the changes I need: volunteering, applying for jobs, spending quality time with Fox and Banji, creating art to enjoy the process, and starting to learn Tai Chi.

I’m so grateful for this space where I can express my most powerful, “dangerous” emotions safely. I’m so grateful for the people in my life who respond with concern and a desire to help however they can, without denying me my autonomy or pressuring me into silence.

I’ll admit my first instinct is to want to apologize for causing others – especially people I care about – discomfort and anxiety; sometimes it’s tempting to just take it all back and pretend to be “fine.” Let the machine run smoothly. But human emotions are important; they inspire us to do what is necessary for our individual and collective well-being. To say I “made” anyone feel a certain way is just plain inaccurate. I wrote a post expressing painful thoughts and emotions I couldn’t express anywhere else or in any other (safe) way. People read my post, experienced emotions (gasp!), and responded however they were willing and able at the time. That some responded with concern is nothing to feel bad about. It’s something to be celebrated! I’m part of a family; members of that family care about and do what they can to help each other through times that are more difficult, times of vulnerability.

Listening to Myself – Part 2

In Listening to Myself – Part 1 I quoted from posts leading up to my wedding last November. In those posts I had expressed feeling trapped and stifled, particularly in my relationships with Mom, Fox, and Fox’s family. Those feelings haven’t particularly gone away, despite efforts to improve communication.

I’ve been feeling suicidal again; Will Hall argues that feeling suicidal is not giving up on life, but needing significant change and feeling helpless to create that change. (Giving up on life would be going through the motions expected of us by society… interestingly enough, I expressed that view in my post, Giving In.) I need to figure out what changes I need, and acquire whatever help I need to make them happen, really soon. My mind’s come up with a specific way I could kill myself, and I have the means. It’s just a matter of will.

I keep telling myself that if I straighten this place up it will be more pleasant to live in, but it doesn’t happen. Why? I keep telling myself I’ll feel better if I follow through on the summer course I’m registered to take in August, or the second composition contest I learned about, or planning the family celebration of my wedding… but it doesn’t happen. Why? I keep telling myself if I exercise and make better food choices I’ll feel better and be happier, but it doesn’t happen. Why? I keep telling myself that if I want to be a music therapist I need to practice my instruments and learn songs, but it doesn’t happen. Why?

Am I waiting for permission? From Fox? It’s not going to happen. It’s just not how he operates. It’s not how anyone operates.

I need to lead; I need to say, “This is happening now. Please help me.”

But I’m so tired. I stayed up at least an hour later than I should have last night because… I don’t know. He was on the couch with me, and I wanted to interact with him. But all the dialogue was happening inside my own head and I was falling asleep and he was trying to solve a puzzle on his phone. Moving so I could actually sleep took so much energy…

The alarm went off early this morning because we wanted to beat the heat and do the yard work Mom’s agreed to pay us for. He reset the alarm and went back to sleep. My mind continued the incoherent dialogue from last night and I kind of wanted to get up, possibly do something meaningful? I guess reading articles and watching videos about topics that are important to me, and commenting on them, is meaningful. I guess writing this post is meaningful. Right?

I feel like there’s so much inside me, but I can’t let it out. Some of it, like the irrational anger, isn’t safe to let out. Not in the form it wants to come out, anyway. Some of it, like the tears, is just more of the same old stuff I’ve been expressing over and over again, with no change. It doesn’t seem to be helping anything, so why bother crying? I think I may have figured out why I have these urges to cut myself; my emotions want to create a crack in my armor, a weak point from whence they can burst out. Or, if I can’t let them out, at least I can let something out…

Every so often I feel happy for a second, and I have to remind myself that it’s okay to feel happy. It’s okay to have energy. It’s even okay to act a bit silly. But it’s hard when the person you’re with can’t pick up on that and amplify it. I feel like I have to be depressed when the people I’m around are depressed. What, I have emotions? No, that’s impossible. I’m just a mirror for everyone else. I reflect whatever emotions they seem to be expressing.

I feel cut off from Creation – by which I don’t mean “nature,” though I could use some quality time with it that doesn’t involve getting sunburn, killing plants (“weeds”), or being terrified of yellow jackets. I mean I feel cut off from the process of Creation that is so important and sacred to humans, most religions attribute it to at least one of their deities. Music, art, writing, dance, building, gardening, political debate, bungee jumping, anything! I need something to do that creates something other than waste. I feel like all I’m doing is consuming: food, media, energy, money. My mind tells me I’m a waste of space and resources, and it has a point. What good am I doing by merely existing?

Hell, if I had a job I hated at least I could put part of each paycheck into my savings account and create… a savings account with a balance that increases periodically. That’s the thing: I could play music, write, draw, whatever… but would what I created be meaningful? Would anyone else care that I created it? Would it actually do anything?

4 Ways Parents Teach Kids that Consent Doesn’t Matter

The issue of consent has been a recurring theme on my blog, even though I haven’t always used that word to address it. (I’m using “consent” in a broader context than safe positive sex – an important issue in and of itself.) Whenever I’ve written about feeling like my wants and needs don’t matter, or my difficulty setting and enforcing boundaries, in a sense I have been expressing lack of consent in my relationships. defines consent as “permission, approval, or agreement; compliance; acquiescence” or “agreement in sentiment, opinion, a course of action, etc.” I’m concerned about the inclusion of “compliance” in the first definition because it is usually used in situations where a person, corporation, or other entity has power over an individual person, and the latter person is required to obey rules, regulations, etc. set forth by the former – or face some kind of undesirable consequence (e.g. being laid off, disciplinary action, fines, etc.). This definition does not reflect the meaning I intend to convey in my discussion of consent. The second definition, “agreement in sentiment, opinion, a course of action, etc.” is much closer to the meaning I intend; it implies or at least allows for equality among the people who are in agreement.

The thing is, I find it all too easy to express (and I often feel pressured to express) such agreement, even when I don’t agree or haven’t made up my mind yet. There are often times when I want something but only under certain conditions, which I may not feel comfortable expressing nor have the opportunity to express. There are also times when I don’t feel comfortable saying “no,” whether it’s because a) I don’t want to hurt the person’s feelings, b) I haven’t made up my mind yet and I don’t want that possibility to be gone forever, or c) my mother will give me a hard time if I say “no” and try to manipulate me into saying “yes,” so I might as well just agree to whatever she wants to get the interaction over with. (That last possibility is pretty much exclusive to interactions with my mother.)

Expressing agreement when one feels pressured or coerced into doing so, or when one is afraid not to do so, is not consent. Definitions of consent in the realm of safe, positive sex emphasize that the person giving it must be “free,” “willing,” “active,” and “informed;” the best definitions encourage clear verbal communication.

In her article on Everyday Feminism, Shannon Ridgway encourages the person seeking consent to also consider the other person’s nonverbal communication:

  • Look for visual clues – Does the other person seem excited or happy? Are they smiling? Or do they seem scared or unsure?
  • Check body language – Is the other person seem to be in a positive mood or have high-energy? Or do they seem tense and uncomfortable?
  • See if they’re engaged in the sexual act – Is the other person proactively kissing or touching you? Or are they still and only move if you ask them to?

And lastly and most importantly,…

  • Just ASK and watch for if the answer is said with fear or joy. If it’s a “yes” said in a small or fearful voice, wait before progressing and find out what’s going on.

As much as I would love for the people who are closest to me to apply the above guidelines whenever I seem to be agreeing to something, I can’t rely on that for my own safety and well-being. At best, I can show them the guidelines and ask them to consider the above questions, then follow up with me if something seems amiss. Whether they’re willing to try or not, they might not always be able to read and respond to my nonverbal cues. We all make mistakes.

I need to ask these questions of myself, before expressing agreement or willingness to do ______. Am I excited about this possibility? Or do I feel unsure? Is there any tension or discomfort when I think about ______? Do I proactively take steps to make sure ______ happens, or do I only move when asked? Do I feel pressured to agree to ______? What would I choose if I could choose freely? What questions or concerns do I have? Do I need more time to consider? What can I say right now, besides “yes” or “no”?

To be honest, I tend to be painfully aware of my responses to these questions, even if I’m not consciously asking them per se. (I still think it’s worth reminding myself to ask and answer them, though.) The true difficulty I face lies in acting on them (e.g. expressing disagreement or uncertainty), largely because I have been raised to believe that my feelings, opinions, desires, and needs matter less than those of other people. I don’t think my parents, other caregivers, and family members intended to convey that message; they just didn’t understand how their actions might affect me. They were coping (often poorly) with their own problems. And yes, at times they were too focused on themselves to consider my needs. Without knowledge of alternatives, they were repeating the lessons they had been taught, the imperfect ways in which they were raised… even when they meant to do what’s best for me.

It hurts.

But there is hope in that pain. For one thing, it’s easier to forgive them for the mistakes they made, knowing that the pain they caused me was unintentional. Then I don’t have to waste energy being angry or resentful and can instead focus on taking better care of myself. I also don’t have to blame myself, but can instead ally with myself to make sure my needs are met, my opinions heard, etc. going forward.

And I have access to resources that were not available to the people who raised me. This whole post was inspired by a video I wish my parents could have watched when I was a young child. I can’t bring it back through time, but I can use it as a tool in my own healing and incorporate its messages into how I parent my own (someday) children. I hope others will find it to be a valuable resource as well.

(content note: includes mention of sexual and other abuse; quotes potentially-harmful things parents may say to their children)

watch on YouTube: “4 Ways Parents Teach Kids that Consent Doesn’t Matter” by Parenting Gently

Marriage Counseling

If I was “better” (“normal” and/or hypomanic) when I wrote some of my most recent posts, I have since crashed back into a depressive state. One major trigger was working on my entry for a composition contest for a few days straight (getting minimal sleep), then having the results be completely out of my hands. I’m not even sure they received it because they didn’t send me any confirmation. I’m thrilled with how the piece came out and I’m very proud of it and I can’t wait to share it with the world! The trigger is the lack of response – any response, even just an acknowledgement that I submitted an entry. I hate not having any control over the outcome, especially after working so hard on something! I don’t even know how long I’ll have to wait.

Another major trigger was coming home (from visiting with Banji) to a cluttered house, trouble sleeping, chronic pain (that contributes to trouble sleeping), and the same codependency issues I’ve been having with Mom and Fox. This environment really isn’t good for me.

Fox and I have been working on our communication; I’ve been practicing being more assertive and he’s been trying to encourage that while also making efforts to interact and create a healthier environment for us to live in. There have been days when he’s been out of the house helping people he knows with odd jobs to make some money. I haven’t made the best use of that “alone time,” but I have appreciated it; time alone in the privacy of my own home is vital to my emotional well-being. We’ve been able to enjoy our time together and support each other and even share moments of wonderful intimacy. We’ve also been making an effort to spend time with our friends, which helps a great deal. There are times – such as today – when I think that our relationship is actually just fine; if only we had jobs and didn’t live with my mother and could get a good night’s sleep, I’d be very happy with him.

But frustration, lack of motivation, and lack of energy often get the best of both of us. Sure, I could clean the house or apply for jobs or practice the skills I need for my career, but it seems pointless. The house will get messy again and chances are I won’t get the job. Why would anyone want to hire me, when there are scores of other qualified job-seekers out there who are cheerful and have more relevant experience? I haven’t done anything worth putting on my resume (except perhaps for this blog, but I need to keep it anonymous) for the past three years!

My mother isn’t helping. Instead of encouraging me when I told her about the composition contest, she said it was a “big dream” as though I was wrong to think I had any chance of winning it, or even for wanting to enter it. More recently, when she called and I told her I was working on my resume, instead of supporting or encouraging me or hanging up so I could focus on it, she started gossiping. Apparently I’m not allowed to have times when I don’t want to be disturbed – which would be a serious problem anyway and gets extra awkward because I’m married… It’s very frustrating. She tends to want to talk when Fox and/or I are in the middle of something; if I ask her to leave us alone she feels hurt; if I take the time to talk to her, Fox tries to help me end the conversation in a timely manner – which gets very awkward and leaves all three of us feeling unhappy. I feel like I’m constantly being undermined. (So does Fox!)

I suppose part of the problem is that I want approval from Mom – particularly when I make the effort to find a job so I can stop being financially dependent on her, a situation she has expressed dissatisfaction with and concern about! But I’ve lived with my mother my whole life; I should have learned by now that nothing I do will ever be good enough for her. I could do the Biggest Bestest Thing Evar and she would criticize me on my looks or complain that I left my socks on the floor or complain about something Fox did or insist that I listen with rapt undivided attention while she described in intimate detail everything she had for lunch that day. It’s like there’s a fog around her head – at least when it comes to me. Every so often the fog lifts and she can be happy for me or support me or even listen to me, but the majority of the time I’d be better off if I didn’t exist. I guess, what I’m trying to say is: if I didn’t want approval from her, then these behaviors would still be annoying, but they wouldn’t wreak such havoc on my self-esteem.

Which brings us to today. Fox and I had our first marriage counseling session. I wasn’t particularly thrilled. It was at the same practice where my psychiatrist at the time interrupted me in the middle of saying I was suicidal to take a phone call from billing – but they’re the only place in the area that takes our insurance where we were able to make an appointment. They made Fox fill out paperwork before the licensed marriage therapist could see us; Fox wasn’t feeling well so he was becoming confused by some of the questions and frustrated with others. When I asked if they needed anything from me they said “no;” I felt as though they thought I was being overbearing. Eventually I realized they perceived Fox to be the client and I just so happened to be there with him. The therapist seemed surprised that we both wanted to participate in the session, even though Fox had explicitly requested marriage counseling.

To be fair – especially since I’m viewing the world through “depression goggles”* – the therapist was professional and made an effort to hear and reflect both our perspectives as equally as possible. We both liked his focus on depression as “lack of energy” rather than as a medical condition that requires diagnosis and medication. He asked good questions that helped me clarify my thoughts on an issue that’s important not only to our relationship but also my own safety. He expressed willingness to help us work through whatever we needed, without judgment.

* (“depression goggles” = the tendency to overemphasize the negative and interpret neutral stimuli as negative that is characteristic of depression)

The therapist also gave us something new to work with, even though it was a very short session: he asked us what our vision is for our relationship and the life we want to create together. I focused on the here-and-now: here and now (or, at least, in the very near future), I want our relationship to be a mutual source of support and comfort. Fox focused on the distant future: many decades from now, he wants us to be old together surrounded by our children, grandchildren, and possibly even great-grandchildren. I think we each also want what the other expressed wanting, but to be honest the focus on being old kind of scares me: I want to focus on living my life, not where I’ll be near the end of it.

After the session, I asked Fox if he was willing to compromise by focusing our vision on the near-ish future, say 5 to 10 years from now. We both agreed that we want to be employed, have our own house, and have children; we may not agree on all the details but those will be largely dependent on the realities we face as we work toward these goals (e.g. what houses are available within a reasonable commute of our workplaces and/or the community where we choose to live). I’m hopeful that having a shared vision of what we want to achieve together – that we are both comfortable with – will help us in our everyday interactions and therapeutic work.

So what bugged me? Well, there was the paperwork and not being perceived as a client; I was very concerned that the therapist would take Fox’s side in any areas where we might disagree. Near the end of the session the therapist had to do more “paperwork” – asking Fox a series of questions and marking his answers in a form on the computer. At one point he paused to encourage Fox to purchase a nutritional supplement from a website that would generate revenue for a nutritionist he knows. That seemed kind of sketchy.

The therapist had to rush the “paperwork” because there was another client waiting – which wasn’t too big of an issue given Fox’s current mental health, but could have been very problematic if Fox had been feeling suicidal or engaging in self-harm. Those aren’t exactly the kinds of issues one can effectively address in the last minute or so of a session, and I imagine (based on my own experience) that a lot of people who feel suicidal or engage in self-harm would be uncomfortable answering those questions honestly, given the situation. These are complex issues that need to be understood from the perspective of the person experiencing them, not binary conditions that can simply be marked present or absent. I don’t mean to come down too hard on the therapist because he was probably just doing what’s required of him, but I do have a bit of a bone to pick with whoever designs and requires these questionnaires.

Finally, the therapist’s body language concerns me. Fox suggested that he might have just been tired and I’m willing to give him the benefit of the doubt, but he broke all the rules I learned at the undergraduate level about how to use body language to help clients feel comfortable and listened to. He slouched, he looked bored, he crossed his legs. At one point his body language clearly indicated that he was very uncomfortable with the topic we were discussing – which concerns me because we need someone who can support us in navigating its impact on our relationship. He hunched his shoulders, looked at the floor, and oscillated in his chair – avoiding eye contact – when he said he was willing to help us address the topic. I didn’t feel safe – kind of like how a mountain climber wouldn’t feel safe putting their weight on a support that shifted under pressure. I’d prefer if he had said he wasn’t comfortable addressing the topic but could refer us to someone who could, or he needed time to do some research, or if there was otherwise some connection between his verbal and nonverbal communication in that moment.

Unfortunately, we’re very limited in our ability to seek help elsewhere. Most of the licensed marriage counselors we found in the area in our network are part of this same practice! The ones that aren’t part of this practice never got back to us; we have no reason to believe they would if we were to try again. And even if they did, it could be weeks or even months before we could have our first appointment! If we want professional help working on our relationship, we need to make the most of what we’ve got.

Take Women’s Health Care Out of Employers’ Hands: The Hobby Lobby Problem and the Single-Payer Solution

I really love the underlying point made in this post: “healthcare is an essential and public good.” In the US there’s too much focus on individual economic growth; I find it kind of terrifying that healthcare is a for-profit sector people (well, the small percentage who still have extra resources) can invest in for their own private economic growth. This article is great because it reframes healthcare as something we all as citizens can invest in for the health and well-being of ourselves and each other. That’s what a single-payer system should ultimately be: not putting healthcare in the hands of a nameless, faceless “government” that is ultimately run by big business… but taking it out of the hands of big businesses (including private, for-profit insurance companies) and back into the hands of we, the people.

Continuing the antidepressant debate: the clinical relevance of drug-placebo differences

So, basically, taking an antidepressant is no better than taking a placebo… actually it’s worse because the antidepressant is more expensive and can have nasty side effects.

Joanna Moncrieff

German psychiatrist, Stefan Leucht and colleagues, have produced another really important paper (1). The results indicate that the small differences usually found between antidepressants and placebo are far below the sort of differences that would be clinically detectable or meaningful.

Leucht et al have conducted the first thorough, systematic attempt to provide some empirical evidence about what constitutes a clinically meaningful difference in scores on depression rating scales, such as the Hamilton Rating Scale for Depression. Although the study did not set out to explore antidepressant effects, these are the scales that are used to assess the efficacy of antidepressants in placebo-controlled trials. In 2004, the National Institute of Clinical Excellence declared that a Hamilton score difference of three points was clinically significant (2). This estimate seems to have been plucked out of the air, however. At least the Institute never provided any explanation of what it was based on…

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