Medication: Menace or Miracle?

Medications can be a valuable adjunct to therapy in helping to resolve some of the distressing symptoms clients experience. Low mood, perseverating thoughts, worry, and more severe symptoms like hallucinations or extreme mood swings, are usually very responsive to the correct psychotropic medication. And yet, I often find clients balking at a referral to a physician for an evaluation for medication. Like counseling and mental illnesses themselves, taking medication can be a stigmatizing experience. Clients worry they will become dependent on the medicine, or perceive that they are "weak" when they are unable to improve their symptoms with talk therapy alone. Sometimes clients voice a concern that their insurance premiums or job security could be threatened by a record of taking an anti-depressant or mood-stabilizing drug. Additionally, I've heard some clients voice a belief that adding a psychiatrist to their team of health providers somehow makes the clients look and feel "sicker." Some of these fears can be addressed by adequate education and debunking the myths associated with these treatment tools. Most of us can understand how a diabetic's pancreas stops producing insulin, and therefore, to maintain life, a patient will have to take insulin shots. When a person's thyroid begins underfunctioning, clients are usually willing to accept that they will be on thyroid medication for the rest of their lifetimes to provide their bodies with the chemicals necessary to keep bodily systems functioning well. And many people swear by daily multivitamins to supplement their bodies' needs for necessary elements and compounds that enhance health. Psychotropic medicines, however, are often viewed differently, despite the fact that they work in exactly the same way the aforementioned drugs do. Depression, anxiety, bipolar disorder, obsessive-compulsive disorder -- all of these illnesses share common ground with diabetes, cancer, and epilepsy: they are all biologically driven. Many mental health diagnoses are a result of too much or too little of a neurochemical in the brain. We may think that symptoms that largely are experienced or made evident in our emotions, feelings or energy level couldn't possibly be created by a biological problem. But the efficacy of psychotropic medications proves exactly that. When the dosage and type of medication is appropriate, the majority of clients taking these medicines will find their troublesome symptoms improve, sometimes dramatically. Accepting the biological, neurochemical origins of psychological distress can allow appropriate and effective utilization of medications that can greatly improve clients' quality of life.

Embracing the Humbug

From retailer commercials, to holiday movies and stories, we are deluged this time of year with images and messages of family harmony, abundance of gifts, treats and parties, and messages of good cheer and joy. But we all know reality can be a quite different experience. Many of us struggle with feelings of melancholy -- if not outright sadness and grief -- during the holiday season. This time of year, we feel the loss of loved ones, missed opportunities and the limitations from aging or illness in a most profound way. Sometimes, we even feel guilty or flawed because we can't seem to grasp the holiday spirit, despite our decorating/baking/shopping/carol-singing marathon of activities. I suggest we experiment with a paradigm shift this winter. Rather than force ourselves to feel jolly when we feel more like emotional Jell-o (shaky and transparent) what would happen if we gave ourselves permission to grieve our losses, to consciously choose to reminisce about those dear ones who will not be around our hiliday table this year? What would it cost us to be gentle and compassionate with ourselves and allow ourselves a holiday-free weekend unencumbered by party invitations, gift wrapping obligations and cookie-baking demands? After all, I'd wager that while some of our treasured traditions are built on generations of shared joyful experiences, others are crafted more from guilt and obligation. Do we REALLY have a genuine desire to have a freshly cut tree in the front window, even though the dog is likely to use it for a toilet, and we will be hoovering pine needles well into spring? Are we EXCITED to invite Uncle Harry to the Hannukah party, despite knowing the evening will end with Harry passed out in the hallway, like he's done the past 20 years? When my grandmother died some years ago, her baking traditions were assumed to pass on to me, her only grand-daughter. (Apparently, even in 21st-century Italian American families, grandSONS are not expected to bring anything to the holiday meal beside their appetites.) The thing is, Gram's honey-rum cookies are a b%+@! to make, and I never really liked the pizzelles, despite their pretty, lacy designs and cool waffle-maker-like baking appliance. I chose to let my sister-in-law take the honors for those recipes, and I bake the two -- and only two -- kinds of cookies I like. It was one small choice I made to avoid a weekend stuck in the kitchen preparing desserts I detest just so I could demonstrate a devotion to my Gram's memory. In fact, honoring my Gram is more evident when I choose to model her love for her family, or when I enjoy a glass of her favorite Chianti (which is also my own, thanks to Gram's introduction to the joys of the screw-top jug.) I will cop to still feeling a slight panic if I have to deviate from my extended family's decades-long history of producing typed, catalogue and photo-laden Christmas lists at the dessert table on Thanksgiving. And I've not yet developed the courage to tell my Mom it would be more convenient for my family if we could push Christmas breakfast back an hour or so. But come December 26th, I will risk my wife's displeasure and my son's eye rolling when I continue my lifelong tradition of lolling about the house all day in my pajamas. My wife is welcome to hit the mall for a frenzy of returning gifts and scoring after-Christmas deals. My son is free to keep a wide berth from my flannel-clad form. I have found that learning to honor the parts of the holidays that bring me joy -- and to avoid the ones that don't -- may be one way to ensure I'm able to add some cheer to everyone else's.

The New Pioneers

I'm continuously amazed by the creativity, courage and resilience of transgender folks, as they carve a path through the unchartered world of transitioning between genders. We are a binary society: we are most comfortable with black and white, right and wrong, male and female. Transgendered clients don't fit easily into this "if not this, than that" mold. Who else has to consider which public bathroom to use? Who else fears for their personal safety based on whether they appear feminine "enough" to avoid a second glance from strangers? Who else has to worry that her newly legal first name doesn't match the gender box checked on a job application or a drivers license? The potential obstacles to everyday activities seem never-ending to my transgendered clients. Fear, rejection, frustration -- these emotions are constant companions to these brave souls who want, more often than anything, to simply fade into the background, to garner no more attention than any other person in the room. And yet, due to society's ignorance and rigidity, transgendered folks are barraged with discrimination, ridicule and regularly singled out for harassment and abuse. Insurance rarely, if ever, covers medical treatment beyond hormone replacement therapy. The economic costs of legal processes and employment instability can threaten the well being of even the wealthiest client. In the 15 years I've counseled transgender clients, I've not met a person who hasn't experienced suicidal thoughts, hopelessness and the loss of significant relationships as a result of their bodies not matching their internal experience of who he or she is as a person. As a culture and a society, we lag woefully behind in our efforts to understand, embrace and celebrate the gifts that transgender people can teach us about what it means to be male, to be female, to be human. To walk beside these extraordinary human beings is an honor, and a chance to witness people who are destined to change not only their physical selves, but also the course of history.

Survivor: The Isle of Holiday Celebrations

Television etiquette experts recently suggested routes to avoid potential family conflicts at our upcoming holiday celebrations. I had to laugh--my extended family celebrations don't end UNTIL there's a conflict a-brewing, just hopefully not involving firearms or flying crockery. (My mother still publicly mourns the death of her favorite gravy boat each time we sit down for Thanksgiving dinner). The (clearly) more civiled pros offered ideas like "focus on what the family is grateful for this year" or rehearsing conversation-diverting remarks designed to thwart Aunt Rita's criticism of cousin Jordan's green Rasta locks from evolving into a full-on family throw-down. "Avoid contentious topics" was another gem tossed out by the Etiquette Mafia. No talk of religion, politics, or sensitive social issues once the bird is on the table. Yeah, good luck getting my clan to sign on to that plan. What are we left with: should baby Jessica be enrolled in the Montessori school or the arts academy that requires child AND parent interviews? My family has had more heated debates over loyalty to the Sox versus the Cubs, or fake vs. real Christmas trees than about any political stance. Seriously, we suffered a decades-long cutoff when my uncle challenged my aunt's claim that Frank Sinatrs was the finest singer who ever lived. (To this day, I experience searing pain behind my eyes at the first bars of "My Way.") I can't imagine the stares of incomprehension I'd receive if I tried to whittle down the topics of "acceptable" dinner conversation. That act, in itself, would guarantee a few choice hand gestures in my direction. But, before you go thinking my family is a bunch of boorish, backwards heathens without the sense to come in out of a snowstorm, I maintain that we are also fiercely devoted to our -- and each other's -- kids; always willing to bring a meal or run an errand for a sick sister or nephew; and slavishly committed to a range of sentimental, heart-tugging rituals and traditions that brand our family as uniquely our own. This holiday season, I've decided to make one change, and like the church hymn says, "let it begin with me." Rather than dictate others' discussion parameters, or take responsibility to diffuse an insult from hitting its intended mark, I've decided to approach this year's festivities with an energy of openness. All the rules and recommendations, ultimately, come from a place of fear and anxiety, and we all carry enough of that baggage already. Sure, gathering around the table is akin to an open invitation to fisticuffs in my families' domiciles, but I doubt I help the process when I approach my family girding for the worst. I can't change them, and I'm not respecting their autonomy when I try to run interference. But perhaps, stepping across the threshold with an air of positive anticipation and joy at our motley gathering, rather than adopting the protective stance of a defensive lineman, may alter the course of the evening's energy for the better. Still, I'll probably choose the seat closest to my older brother: his bodybuilder girth is good cover if the salad plates go flying.

The Scars of Self-Injury

Few of us can imagine inflicting the kind of physical pain and damage that self-injurers inflict on their own bodies. For many people, the concept of self-injury is as foreign as imagining picnicking on the moon. But in our counseling rooms, we see the reality of self-injury far too often. Cutting, burning, poking, slapping -- these violent behaviors can be regular occurrences in the lives of some of our clients. What would drive someone to hurt him- or herself? Isn't self-injury just a bid for attention? Is there a difference between self-injury and suicidal ideation? Loved ones of those who self-injure struggle with these questions. And while the specific instigating factors behind one's self-injurious behaviors are as varied as the individuals themselves, some commonalities can be noted. People who hurt themselves often engage in an addictive-like relationship with this behavior. They initially find some sort of emotional relief -- either in the form of distraction or a sense of release from psychic pain -- from the harming behavior. Later, either due to a lack of appropriate coping resources, or the relative speed with which self-harm usually provides relief, the person continues to use these actions to deal with more distressful life situations over time.

Most of us can recall a moment of self-loathing or a period of hopelessness in our histories. For those who self-harm, self-hatred, a sense of continuous personal failure and a fear of relinquishing the tool that has brought them relief are constant companions. And while the behavior can appear dramatic and attention-seeking, self-injury is rarely a casual choice by the individual. Due to the addictive nature of the dynamic, someone who hurts himself can quickly become reliant on this maladaptive coping skill. We can understand someone getting a sense of relaxation, increased well-being, a distancing from their problems, by drinking alcohol. Tobacco smokers often report feeling instantly calmed and/or energized, not just from that first puff, but even through the rituals of igniting their lighter or smelling the sulphur of a dying match. Similarly, self-injurers can experience a lowering of stress via the habit of self harm.

People who self-injure are at a higher risk of suicide, not only due to their struggles with depression and hopelessness, but because the risky behaviors associated with self-harm could inadvertently creat a risk to one's life, even if she isn't intending to end her life. Self-injurers have mistakenly nicked a major vein or artery, causing them to hemorrhage before help could be obtained. Some wounds can get so infected they can lead to sepsis, a potentially life-threatening blood infection.

The treatment for self-injury almost always involves a holistic approach, including individual therapy, medication, group therapy to teach skills like stress management, frustration tolerance, emotion regulation and appropriate self-care. Centering skills like mindfulness and meditation are other helpful tools that can help clients to learn to manage their painful life experiences without resorting to self-harm. Occassionally, hospitalization is necessary to ensure an individual's continued safety.

Self-injury is always a sign of deep distress and a loosening of one's ability to manage their pain in effective ways. But clinical and medical intervention can help these clients regain control of their lives, and offer a path of hope and recovery into a life marked by positive self regard, rather than haunting scars.

The Gifts in Gratitude

November is marked by colorful leaves, falling temperatures, an abundance of turkey-related products at the supermarket and the varied modes giving thanks takes. Recently online, I've seen groups of people daily enumerating the things in their lives for which they are grateful. From sentimental to sublime, folks are counting their lucky stars for their spouses, a warm home to return to after a busy day, a full refrigerator, health and autonomy, even a close parking space at the crowded Target on a rainy Saturday. These sentiments are not meant to be a Pollyanna approach to dismissing or minimizing the suffering that goes on in our world everyday. Rather, they are a reminder that there is, indeed, a yin and yang to our lives, times when we are deep in shadow countered with periods of lightness and grace. Being conscious of our blessings will never negate the losses and sadness that mark some days. But those bright spots do provide us with an opportunity to connect with grace, to be reminded that good and love and hope are around us if we choose to look for them. Some days we may need to look long and hard to find the glimmers of sweetness. They may appear hidden deep in the loam, barely visible save for the one small glint that we catch only if the light is right. Or they may appear as evident as a gold star on a spelling test. Resilience is found in remembering to grasp the good, risking the reaching. By training our eyes to view life through the lens of gratitude, we discover, like the many-hued leaves at our feet, gifts unending.

Hiding in Plain Sight

My wife took our son Halloween costume-shopping over the weekend. They kept me in the loop, messaging me photos of themselves in all kinds of getups: as Wild West Cowboys, chefs in aprons and torques, spooky witches complete with brooms and black hats. They seemed to favor the masks, though-- political figures, celebrity faces, spooky goblins. In the pictures, the masks were so detailed and enveloping that I didn't know whether my wife or my son was the model. He finally settled on a creepy clown mask, which he customized at home with gruesome splashes of fake blood. In his mask, my son could be anyone, a stranger I'd never know or a neighbor down the street. Kind of unnerving to think about. But not all that different from the masks we wear everyday. Whether its the confident face of a businessperson as we enter a sales meeting, or the calm expression we adopt to ease the tantrum of a wailing child, we may adopt different faces to fit the range of experiences that fill our day. And certainly, many of those masks are truly functional, moving us forward or producing a benefit in the end. When we approach our child's teacher to discuss a failing grade, we're most likely to experience a positive outcome from that interaction if we approach the teacher with an expression of openness, seriousness and concern rather than with the outrae we may be feeling beneath the surface. Or if we are considering asking the boss for a raise, we're better primed for success if we enter his office with a pleasant affect and energized demeanor, even if we are fearful about the rumors of layoffs or frustrated by a coworker not pulling his weight. But, just as easily, we may find ourselves adopting a mask that holds us back from taking risks, connecting, or speaking our truth. I've seen couples "put on their best face" for each other, trying to avoid painful losses or minimize the chance of conflict. Similarly, I've worked with teens whose masks of bravado and insolence hide the deep pain of rejection and the fear of failure. But only through authenticity can another truly know And empathize with our experience. We may think its kinder to "smile and nod" when asked for our honest opinions, but we may actually be communicating subtle disrespect by giving someone less than our real truth. Manners, grace and politics will always have their place. But showing the world our true selves is a courageous choice that can bring us closer to one another, and build connections with the potential for deeper intimacy, for a truer knowing of each other and ourselves. That's a treat that will last through countless seasons.