Foucault, and stuff (this is a piece I wrote for a newsletter on social justice informed practice)

When clients come into my office for psychotherapy, they are usually focused inward, potentially seeking a diagnosis, and often asking “what’s wrong with me?” Yes, the majority of my clients are working through gender dysphoria or pursuing recovery from an eating disorder, and while these are indeed conditions I can diagnose, much of the work I do with folks is about exploring the ways in which structural oppression related to their sexual orientation, gender expression or race is causing distress, both directly and in its internalized forms. In other words, we shift from asking “what’s wrong with me?” to “why do I think something’s wrong with me?”

From a social justice perspective, one of the most insidious ways oppression in the form of patriarchy, misogyny, class bias and racism (among others) does its work is through internalization. When people internalize these structures of power and disempowerment, the self hatred and self doubt that ensue wreak all kinds of havoc in terms of beliefs that impact behavior and emotional experience, which then often leads to the development of some form of psychopathology. I vividly recall a professor at the Smith College School for Social Work stating: “The greater the oppression, the greater the depression” and I have seen this to be true over and over again in the lives of the people who walk through my office doors.

There was a time (and in some cases, that time is now) when people in my chosen profession, social work, were largely tools of oppressive structures. In the words of Michel Foucault: “The judges of normality are present everywhere. We are in the society of the teacher-judge, the doctor-judge, the educator-judge, the social worker-judge.” For example, as the majority of my clients are transgender or gender non-conforming people, many require authorization from me for their insurance companies that they are “trans enough” to receive gender affirming hormone therapies or surgeries. Many of these folks also experience profound depression and/or anxiety: how would you feel if your fate, your ability to live a life as yourself, was in the hands of an ostensible expert, deemed more expert than you about your own self-hood by virtue of their social position and capital?

My work, as a social justice oriented feminist relational psychotherapist, is kaleidoscopic. I work to support my clients in identifying the ways in which they’ve internalized oppressive structures. We work together to identify the ways they’re policing themselves and warping their sense of self through these lenses, and then we work to dismantle the problematic internalized beliefs that are setting them up for emotional distress and behavioral dysregulation. In other words, I sincerely look forward to a day when I become obsolete.

Advertisements

Coping isn’t a five letter word (it has six).

In my last post, I referenced having a long list of things to do to distract and calm myself “that I actually use.” While the list is personal, the concept and potentially some of my options are universal, and so I offer them here.

Marsha Linehan’s DBT manual features a list of “Adult Pleasant Events” in the Emotion Regulation curriculum, and I have often poked fun at the suggestion therein to chop wood, but the reality is that for the right person, that’s a great idea. When you’re overcome by either an overwhelming, extreme emotion or an intense urge to make what my preschool aged son calls “not a safe choice”, finding the right distraction, alternative outlet or self-soothing strategy is key to making it to the other side of the experience without making your life worse.

Before I get to my own list, there’s another DBT concept worth mentioning called Willingness, which is part of Linehan’s Radical Acceptance module in the Distress Tolerance portion of the DBT curriculum. Willingness is set in opposition to Willfulness, and it basically means you have to actually give recovery strategies an open-minded, whole-hearted chance. Example: refusing to try an alternative coping strategy because your special, special pain could never be helped by something as simple as taking a walk. That’s willfulness. Example: sticking to your commitment to actively engage in  15 minutes of a self-soothing strategy that sounds stupid and pointless at the outset before reassessing your desire to give into an urge to binge. That’s willingness. I’m not a huge believer in the magic of the cosmos, but I will say that the number of times I’ve gotten a phone call from a supportive friend at minute 14 of the aforementioned scenario is uncanny. In other words, it’s often not just the calming or uplifting properties of the strategy that gets you through, but rather, the shift in mindset to being willing to make space for recovery that makes the difference.

So, without further ado, here is my (partial) go-to list of Adult Pleasant Events. I’ve chosen my top few tried and true because this post is brought to you by a napping infant who is likely to wake up soon.

  • Leave my current space. Like it’s on fire. I have often found that making the choice to leave the place where I’m upset or triggered opens a fresh perspective. Sometimes this means going outside for a walk, other times it means going into my mother-in-law’s bathroom to cry with the sink running.
  • Serenity (it’s an essential oil blend, not an ephemeral concept). Because the olfactory nerves terminate near the amygdala in the brain, scents are highly evocative of emotion and memory. I have found that Serenity consistently evokes feelings of peace and contentment for me, as well as now being associated with memories of previously having coped well.
  • Making and drinking a cup of tea (usually decaf jasmine green because it reminds me of my sister). This one is multi-faceted. A watched pot never boils, and I use that to my own advantage and stand with the kettle while it heats, which forces me to slow down and opens an opportunity for mindfully observing my thinking. The warm steam and aroma as the tea steeps offer a soothing sensory experience, and also evoke memories that calm and uplift me. 
  • Drinking 20 oz of cold water out of a Mason jar. The Mason jar evokes memories of the supportive friend who first introduced me to the joys of vintage jars, as well as humorous ones of the various clients who have seen my jar and accused me of drinking moonshine in my office. The coldness of the water forces me to slow down and pay attention because I’ll be rewarded with brain freeze if I don’t. Also, I associate water with cleansing, which can work as a metaphor in moments where I’m working through a difficult emotion like shame or toxic anger.

Just drink a glass of water and your eating disorder or depression will be cured forever! sounds like an obnoxious article in a self-help magazine, but it’s not the strategies themselves that do the heavy lifting. Yes, it’s useful to find strategies that speak to you and tap into your particular set of memories and preferences, but the real magic comes with cultivating willingness to employ them.

All or Nothing.

In case my clients hadn’t mentioned it enough this month, an excellent article about “All or Nothing” thinking showed up in my inbox a few days ago that sealed the deal on me writing about this topic.

For the uninitiated, All or Nothing thinking goes something like this: “I just ate x, which was not on my strict list of safe foods for my special and restrictive New Year’s resolution diet, and therefore I have ruined my day and I’m going to eat several more servings of x, as well as anything else I happen to encounter that is off-limits.” Other variants include the belief that an A minus is a bad grade, and since you just got one, you’re never going to do your homework again because what’s the point if you’re just going to fail, or that because you did not get this particular job, you are clearly unemployable and are never putting yourself through the humiliation of sending out a resume again.

There are a lot of problems with this kind of thinking. As my handy-dandy examples suggest, one of the most significant is that it tends to lead to quitting, inertia, anxiety, depressive thoughts and other totally fun experiences. The actions that flow from All or Nothing thinking are usually the opposite of effective. Otherwise known as ineffective.

Let’s take our poor sad friend on the All or Nothing diet who has “cheated” or “failed”: she’s really extra screwed because the rules of her diet were written by All or Nothing thinkers to start with, but beyond that, if the goal of the diet was to, for example, eat fewer treats, then responding to eating a treat by deciding she has failed and eating a whole bunch more treats is pretty counter-productive.

Here’s an alternative. (And for the sake of argument, let’s say it’s reasonable that the dieter has decided her health or self esteem or chronic headaches or whatever it is would be ameliorated if she ate fewer treats.) Rather than taking the All or Nothing path of deciding that all treats are off limits at all times forever (and therefore if she has one, she is a failure, and off the diet, and should “take advantage” of already having “ruined the day” and squash in as many treats as possible), she could think a more helpful, more effective thought. Something like “I’m going to pick one treat per day to really savor and enjoy to support myself in eating fewer treats overall. If I have a moment or day where I eat more treats, I’ll use that as a learning experience to see if there are any ways my plan needs to be adjusted.”

Now, if she eats an extra treat, she hasn’t failed, she has stumbled upon a piece of data that is a total gem because it’s going to help her figure out a more effective plan e.g. “Oh, I see that it’s not a good idea to eat my special treat when I’m distracted by paperwork because I won’t really savor it and I’ll be more likely to want more. Excellent! Good to know.” (Her therapist might have had to support her in re-framing things that way, but hey, it’s cool to ask for help.)

Similarly, with the A minus, and the job that doesn’t pan out, if the goals are academic success and employment, and the disappointment is a perception that these outcomes might not work out, quitting all together is only going to take our All or Nothing thinkers farther away from their goals. (Also, an A minus is a really good grade, and perfectionism is very All or Nothing.)

All or Nothing thinking isn’t logical by it’s nature because it’s usually driven by a strong emotion (shame, fear, remorse, despair, euphoria), which is the primary way to identify that you might be in the throes of it. Any action that you’re drawn to while experiencing a strong emotion is suspect, and worth putting through the All or Nothing test. And wouldn’t you know it: Mindfulness helps here. Holding awareness of your emotional state provides the opportunity to catch yourself in those heightened moments when you’re vulnerable to distorted thinking, which provides you with the opportunity to review your thoughts and action plans before tumbling down the All or Nothing rabbit hole.

Like so much of what I recommend to folks, this is hard work, but it’s a way easier path than holding yourself hostage to a cycle of unrealistic standards and constant feelings of failure. At least, I think so.

Everyone is TOTALLY FREAKING OUT ABOUT HOLIDAY COOKIES.

This morning, I got an email from one of my favorite nutrition writers, John Berardi of Precision Nutrition, which sounded an awful lot like what I’ve been saying to clients for the last few weeks when they come to me TOTALLY FREAKING OUT ABOUT HOLIDAY COOKIES. These are stressed people. Seriously unhappy people. Not exactly holiday cheerful. Because COOKIES. I had people TOTALLY FREAKING OUT ABOUT HOLIDAY COOKIES starting in early November, and I will continue to hear about COOKIES well into January. I’ve shared Dr. Berardi’s words below, but first, my take on this state of affairs.

As evidenced by my egregious use of capital letters, these are high volume, high intensity, high anxiety, high angst concerns. And I’m not trying to be mean about it: people are seriously suffering, and it’s very real. The problem is that we’re talking about cookies. In my mental landscape, a cookie is a palm-sized (or smaller, like those little round ones with the nuts inside and the powdered sugar – I love those) baked good that takes one to three minutes to eat depending on the size. However, for my friends of the freaking out, COOKIES are stomping through their mental landscapes crushing hopes and dreams like Godzilla having a very bad hair day.

The fear is real. It’s real, but it’s also a construction and a self-fulfilling prophecy. If a person starts thinking in November about how hard it’s going to be not to eat a certain food item in two months, and keeps thinking about how “bad” that food item is, and how she can’t control herself around that food item, it gives the damn thing an enormous amount of power. (It also ruins her November.) COOKIES are going to destroy her, she’s sure of it, and ensuring it. And of course, when late December rolls around, she’s going to eat them. How could you not eat something you’ve been debating about for two months? Will she enjoy the cookie? Survey says no. Because the minute it reaches her mouth, she’ll already be berating herself for how weak and bad and lazy and gross she is to have been subjugated by a COOKIE, rather than savoring its tasty flavor, reflecting on the family heritage the recipe represents or something else, you know, nice.

Because holiday cookies are nice. That’s about it. Some are tastier than others, some have memories associated with them, and some are kinda lame and taste like their cardboard box. But they really, really are a pretty minor, albeit pleasant, occurrence if you treat them as such.

Try this mindset on for size: Imagine yourself not thinking about holiday cookies until you’re actually faced with a plate of holiday cookies, perhaps at a party, perhaps on the table in the break room at work. Like, how you don’t think much about getting an oil change until it’s time to get an oil change. Now, assess the plate of cookies. Do you like this kind? Were they prepared by someone special? Are they appealing? Now, assess your level of hunger and your emotional state. Are you fairly full because you just ate a satisfying meal? Are you starting to feel that little nudge in the tummy that suggests it might be snack time soon? Are you bummed out and overwhelmed, or perhaps feeling a little festive? If you’re not too full, and not in an unpleasant emotional state where you’re more likely to be self-medicating than enjoying a treat, and there are cookies on the plate that are truly appealing to you, select the cookie that looks the best and eat it.  Feel free to take a bow.

Then walk away. Because you are not the cookie you just ate. You’re a mature adult human who, on occasion, when the moment is right, chooses to eat foods from the “treat” category because they are fun and nourishing in their own way. You’re not going to get fat. You’re going to get awesome. Because when COOKIES become just cookies, you get the power back, and you get to spend a lot more of your life thinking about other things that are a lot more interesting. Like, what to get your mother-in-law for Christmas. Or world peace. Or really anything.

(And, as a side note, if you are maybe still a little worried about the cookies: you’re much more likely to overeat the things if you treat them as a diet smashing super power, rather than a moderately enjoyable sometimes treat, because that’s how the restrict, binge, rinse, repeat cycle works. I promise, promise, promise you that you will eat fewer cookies if you allow yourself to enjoy them now and again than if you try to avoid all baked goods for two months and then go to your Nana’s house on December 25th.)

Now for the other guy’s take on things:

“My three little ones have been helping my wife and I with the usual chores: decorating the tree, creating cards with construction paper, preparing canned food donations for the local food pantry, and…making delicious cookies. But before you ask for my killer “healthy” cookie recipe, I have a confession: We’re not making not some low-fat, gluten-free, protein-packed, artificially sweetened, possibly-hiding-beets, “healthy” version of a cookie. Nope, we’re making the REAL THING. The kind of cookie that contains butter, sugar, and flour. The kind of cookie where you want a tall glass of milk to help wash it down. The kind of cookie most “nutrition experts” will tell you to avoid completely this year… Just dip some kale leaves into lemon juice with a splash of stevia and it’s exactly the same thing.

Anyway, when people learn that my family and I sometimes make treats like cookies…or go out for ice cream…or don’t eat 100% protein and vegetables all the time…they get a little confused. “But isn’t Precision Nutrition all about eating good foods and avoiding bad foods?” The answer, I’m proud to say, is no. Precision Nutrition is NOT all about eating “good” foods and avoiding “bad” foods. (I don’t even like those labels.) In a minute, I’ll share what Precision Nutrition is really about. But first I’m going to encourage you to enjoy some sort of cookie, cake, or cocktail this holiday season, too. In addition to songs, and friendship, and holiday cheer…

You see, every time you choose to eat one thing over another, you’re voting for what’s really important to you right now. Of course, you may not realize you’re doing that. But every decision IS a calculation. Of what really matters to you, in that moment. So, with the holidays here for most of us, what DOES matter to you right now?Is it… Feeling good? Connecting with loved ones? Truly nourishing your body? Feeding your soul? Remembering your heritage or family traditions? No judgement here. YOU get to decide your priorities. And  sometimes other things SHOULD win out over “nutrition”.

So I’m not here to tell you what to do, think, or feel. Or to make you feel guilty, ashamed, anxious, or deprived. Instead, I’m here to help you think through the question. To help you choose more consciously, with awareness and intention… Because shortbread and latkes taste great when made with love and shared with friends and family. They just do. And, while some people in fitness have a hard time with this notion, I think that feeling good is part of enjoying life and being healthy…

Here’s my first prescription: Enjoy a real cookie or two this holiday season! Or some other thing you enjoy but think is “off limits”. Just do it consciously, mindfully, and – as we teach in our coaching programs – slowly. Instead of scarfing it down and waiting for the guilt, taste what you enjoy. With intention. Then move on…

But even if you’re not ready to embrace this mindset yet because restricting is your only way to feel in control… Because you can’t believe that enjoying certain foods guilt-free is possible… Because you’re stuck in the middle of a nasty cycle of restrict, collapse, guilt, repeat… My family and I will still share some laughs, shed some tears, and nosh a few cookies this holiday season. We might even raise a glass of egg nog in your honor. Because, around here, we know that connection, love, and enjoyment CAN exist while working toward better health together. And we’re hoping that somewhere along they way you’ll discover the same thing.”

Just a spoonful of sugar makes the medicine go down.

I’ve been thinking a lot about medication lately. (Also working overtime to buffer my family financially for my upcoming maternity leave, hence the sparse postings.) (Further parenthetically, I am not, to be clear, a prescriber of such, nor do I believe that psychotropic medications work for all people in all mental health situations.)

I’ve noticed that the people I see in treatment tend to fall into several camps. The first group believe that medication is the most important part of mental health treatment, and if they don’t feel “normal” yet, then they just haven’t found the right pill at the right dose. These folks tend to get frustrated the minute I mention the word “process” in relationship to their wellness, or suggest that the choices they’re making or the beliefs they have might be contributing to feelings of being less than well. Obviously, I’m biased towards thinking that my professional output leads to effective outcomes, but these folks and I don’t tend to do very well together.

The second group of people I see are highly medication resistant, either because being diagnosed and prescribed a medication feels stigmatizing, or out of fear that the medication will in some way fundamentally and/or irreparably alter their personality or state of being. While resistance to therapy is not a problem here, I have found that people in this camp hit impasses as well because their symptoms interfere with their ability to act on insight and new learning sufficiently to make serious headway.

Historically, I have not found myself to be particularly effective in convincing folks in either of these groups to budge towards the middle path, but, in an interesting twist of fate, my pregnancy has provided me with some rather powerful talking points.

The story goes like this: up until my late husband’s suicide, no one in my circle of wellness helper types had ever recommended medication to me, which is a mystery I’ll leave for another time, but that probably has its roots in my particular cultural location. Regardless, things got sufficiently squirrelly in the aftermath of his death that I ended up with a referral to a psychiatrist. We tried me on a few different medications over the course of a year or so, all of which I “felt” in various ways in terms of both their impact on my mood and various physical symptoms, until both the psychiatrist and I agreed that we’d landed on an antidepressant and a take-as-needed for supremely anxious moments combination that was the most helpful with the fewest annoying side effects.

And then I got pregnant, and had to drop it all so the baby didn’t get a cleft palette and a heart defect, which was a sacrifice I was (hopefully obviously) willing to make.

But now, I have my symptoms back, and it’s giving me a very useful perspective on what medication does, what it does not do, and why I probably would have been a lot easier to live with, both as myself and in relationship to others, if I had gone on medication about a decade and a half sooner.

When I went on the medication, I had a basic hunch as to what was different, but mostly I just knew that I felt better, and that better was good. Now that I’m off, I have been able to pinpoint exactly what has come back: there are a set of experiences, the most salient being this state I get into for about 24-72 hours at a time in which I’m tense, irritable, sad, afraid and just super negative, that immediately reemerged off the medication. It didn’t change who I am, or how I think, or my beliefs. It just eliminated that particular mood experience from my life.

What’s further interesting is that I can now look back on my life and identify when it was that this particular state started coming over me, either sporadically, or for months at a time, and say AH HA! That was a brain state, the kind that medication can shift. That wasn’t “me”, which is what I used to think. On medication, no cloud of icky. Off medication, clouds of icky are in the forecast every few weeks.

In defense of my non-pill-prescribing-profession, I’ve been using mindfulness, a variety of coping skills including talking with my partner about how this is a transient state, cleaning random things, and baking a lot of whole grain muffins (the most recent batch were banana chocolate chip), to get through since I don’t have the medication tool at my disposal these days, but I never thought I’d say that I was looking forward to getting back on medication (in, like, two years when daughter has been born and is finished breast-feeding).

And I am.