Empty Spaces

FD is a doctor and when he tells me, it's okay, we can go out on the trails and ride, I take it as the word of the Old Mighty and fill up my tires.

The New York Times has a recent feature, Empty Places, I think it's called. There's also a place there with only stories, most pre-quarantine, but not pre-diagnosis. 

Here are mine. If you're from Chicago, you'll recognize them. It is truly eery, seeing so many empty places.

Von Steuben High School, empty

The river trail, Chicago

River trail, Chicago

Northeastern University, empty

Paranoia, schizophrenia, and shaking delusions

It can't all be about Covid-19.

The marvelous thing about being mentally ill is that you're oblivious to the news that affects everyone else. The thoughts and pictures in your head that have always been the enemy continue to be the enemy. So if you suffer from ideas of reference, if you believe that when you bring your phone to therapy that your neighbor will be able to listen in, well, you take the battery out of the phone. Merely turning it off isn't enough.

Is it even worth it to relieve people of their delusions? Won't they be replaced with others?

Not always.

This is such a lovely case that I can't help but share it. Details are changed to protect the identity of the patient.

The story:

He comes to me originally to diagnose what is wrong with him. He has noticed that he may have high functioning autism. He gets most of his news on YouTube.  A brilliant man, but entirely unable to function socially, the diagnosis makes sense. His psychiatrist treats him for bi-polar disorder, has not caught onto what we used to call Asperger's.

I don't even have to test him, can confirm from his oral history that he's not able to absorb social cues, that he can't put together the meaning of silence, when it is full of anger or merely just silence. To him it is angry. He thinks in pictures. He is always, always in need of direction, has no idea what to do, when. Misinterpretations abound, dominate.

Upon further examination, it is quite obvious that he has severe paranoia, and maybe that is the primary diagnosis. Maybe is is bi-polar, but maybe, more likely, a simple paranoid disorder. He doesn't hear voices or see things that aren't there. Nobody is telling him to do anything. He infers it all. (These are called ideas of reference). They, J. Q. Public, are out to make him miserable. The average man on the street wants to harass him. Even people in my waiting room-- when they gesture, it is about him.

You see, there is so much more that telling some people, It's not about you. Most of us get that. Some of us don't.

How to treat it? Not easy, especially if the patient is not taking the meds prescribed by the doctor for crippling anxiety. They make him feel stoned, tired, and dead. He'd prefer his anxiety, his sleeplessness any day.  And anyway. He sleeps.

We went with breathing, centering him on that. Nothing else exists, only the breath. Watch that, not your thoughts. Do not give them power. Do not show them you care. Be the Buddha, stronger, implacable. Indestructible. Above them.

Especially hard for someone like him, but doable. And if he can do it, we all can.

therapydoc

Part Four: Universal coping strategies from another country, Covid-19

My cousin and favorite rabbi/psychologist Dr. Peter Rosenzweig sent me this to post. He lives in Israel now where the virus is keeping everyone home, too.  Thank you Peter. Smiley face, hearts and all that to you and my wonderful cousin.
Here goes:

A mental health primer-for a pandemic

Understanding some basic facts about mental health is useful when we are all under such duress. As with improving physical health, our mental health can also be strengthened. Let’s divide this idea into two parts.

Part one: fear & stress

The current situation brings home how little is truly under our control. At times like this, it is helpful to have as much clarity as we can about what is given to us to do, and what is not. Often, when we are able to decide that certain things are not given to us to do, this allows us to ease expectations. This small step, can lower high stress to a level that is less emotionally taxing.

On this note, we should expect to be shaken by “fear thoughts”. Like a pulse or heartbeat, these thoughts, however uncomfortable, let us know that our instinct to survive is “operational”.

How we deal with fearful thoughts is part of the “abc”s of mental health. It is good practice to note the fear and to then let it go. This means employing distraction, or utilizing exercise or meditation to calm ourselves. A more relaxed body will often ease the mind. The goal is to avoid allowing a “first fear” thought to induce an ongoing state of fearfulness and alarm.

A state of alarm often produces moments of panic. Panic differs from fearful thoughts because it triggers the natural flow of adrenalin. This event shifts what began as a thought, into a physical change. Prolonged states of panic, lead to a state of “depletion”. This resembles the exhaustion athletes may experience at the conclusion of a hard fought game. Since the experience of depletion can feel the same as depression, it is useful to be able to distinguish one from the other.

Part two: sadness and depression

Just as we should not be surprised to have fearful or morbid thoughts, we can also expect to feel sad. On some level, we have all lost some part of what our lives looked like prior to the outbreak of this pandemic. Feeling loss and sadness allows us to grieve. Although no one enjoys grief, the ability to grieve losses is a cornerstone of mental health.

Whereas “clinical depression” is a psychiatric problem that is eased by medication, grief-related sadness typically cycles through when we are able to identify and accept the loss for what it is. A shift from grief to gratitude for what we are able to maintain, is a basic part of practicing good mental health.

Lastly, being able to help others is a valuable human capability. It is also a reliable mood changer. The experience of actually helping another person is a useful way to manage the feelings of helplessness that are part of contending with this pandemic.

Snapshots: Corona

Remember this feature, Snapshots? 
I don't, not well, but somehow remember that it was a feature of this blog. 

So here goes. This will be quick. Just two stories, never happened, entirely made up.  

(1) A New Meaning to Vulnerability

After seeing a few patients face to face in the office last Monday, I knew it had to end. It's just a bad idea. It was fortuitous, too, getting an email that afternoon from the academic institution that keeps me on as an associate research professor. The email tells me that Blue Cross Blue Shield is now paying for phone and video-chat visits. Bill and use the usual codes. Don't abandon your patients in these difficult times! 

I forward it to a few colleagues. It's about time, we all grumble. Getting paid for virtual sessions had seemed an impossibility only a few weeks ago. It takes a plague.

So I send texts to patients: Call me. FaceTime me. Use WhatsApp, Zoom. I don't care. But don't come in.

They're fine with this, except for those who do not trust the airwaves.

Then I get an unexpected response.

"I'm sitting in my car sobbing. I just spoke to my doctor. Yes. Yes, call me on Wednesday."

JUST SAW THE DOCTOR AND HE'S SOBBING?

This is not a woman known for sobbing. Naturally I cannot wait and call her immediately but she doesn't pick up. I text and give her a time today. My four pm has cancelled. She texts back. "That works. Thank you."

This is a physically challenged person. On an average day she suffers, really suffers. It is hard to be her, and my personal feelings, like those I have for most established patients, are almost raw, so deeply caring whenever I think about what she's gone through. And she's young. To think that she might have coronavirus terrifies me. Could she beat that too?

We talk. She's fine. She wasn't, but now she is. She was upset because the doctor ordered her to be in quarantine, and she runs a huge  business, hundreds depend upon her to be there, to make decisions. And there will be the layoffs.

Not everyone, at that point, had to self-quarantine, and those of us who can work at home did that. But not everyone can just stay home.  She is freaked about the business, that it will tank.

And all I can think is: Dude, I've already been to your funeral. More than once. You will recover financially, Please G-d. Stay away from people. That's the only advice I have in the moment: self-isolate. Please. Just stay away from people. And breathe.

(1) Why Sometimes I Think I Married a Crazy Person

It is Shabbas, so we don't use the phone. But FD is a doctor and there is no Shabbas for him, he's exempt from Jewish laws. Saving lives is much more important, according to our rabbis.

We have finished eating a late lunch and are clearing the table. He's paged and walks away to make a call. He returns with his hat on his head.

"I have to take a little walk."

"Where are you going?"

"I have to see a patient."

"Why?"

"I have to tell him some news."

"Can't it wait until after Shabbas?"

No.

Understand. I am not a dependent, needy spouse who can't be alone. I like to be alone. We're together enough. We're apart enough. This isn't about me cramping his style.

"It can't wait."

"Why?"

"I have to deliver some bad news."

"Why can't you do it on the phone?"

"He won't answer the phone. It's Shabbas."

"Right. But why can't it wait."

"He tested positive for Covid-19."

Short pause.

"Who is it?" (not that he would tell me, but a girl can try)

"You don't know him."

"You are not going there."

"I have to go."

"You are not going inside that house!"

"I won't go inside the house."

"You promise?"

"I promise."

"You're crazy. Don't you dare go into that house."

It is bad enough, I tell him, that he tests these people. It is bad enough that he hasn't retired, left this practice. But he leaves to see a man and tell him that although he seems healthy, that he has coronavirus, Corona-19.

Did you know that there are several types of coronavirus? This is why they call it 19, because it presented in 2019. About six weeks ago FD had a case of a different coronavirus. That patient was very sick, too, hospitalized. FD started to cough, sure that he probably caught it. I kept my distance. His case, if it was corona, was very mild. Are we having fun yet?

He returns in a half hour to tell me they spoke through the screen door, glass in lieu of screens. We live in Chicago. It is still cold. Yesterday the temps were in the 20's.

I look deeply into FD's eyes. Because he cares about them, too. He cares about his patients, too. And there are times, there really are some people, who can't do it by phone.

therapydoc

Covid-19 Part Three: Coronavirus and Breathing

Breathing

The coronavirus gives breathing new meaning. I have a theory about it.

A week ago my most anxious patients had their symptoms under control. They would come in (yes, that was dumb on my part, seeing patients face to face, but we were five feet apart) or we used an app to discuss life, stress, relationships, work, play. We discussed everything but the novel coronavirus. Which is remarkable.

Everyone else, normal people, totally freaking out.

I attribute the absence of panic, the practical superior attitude of my anxious patients to therapy. They breathe, they work their muscles, all of the CBT we teach in this gig. They work the program.

But that was then, back in the first week, and now no one is absolutely cool. In the past couple of days everyone has talked of nothing else-- only quarantine and contagion, whether or not it is too late, who is sick.

Me, too. I panic too. Whatever anxiety we held in abeyance, denial, for as long as we could, well, we have officially lost it, along with our money. And the fear of dying, our worry about loved ones. It has us, even the most Zen among us. More than an eyebrow is twitching.

Therapists wonder if there will be a suicide epidemic. Money matters to everyone.

I had this theory that if we got sick we could still ignore it, not judge it, could distract with all kinds of things, hobbies, etc., breathing (the way the yogis do). But no! That won't work if we can't breathe,  if we can't exercise, can't get out of bed, which is what happens when we have pneumonia.

So that theory, watch it disappear. Coping is going to be hard.  All we have left are our usual devices, if we get sick.

We should call our doctor, On the telephone a primary care physician can tell us if we need to be examined or should go to an emergency room. Telehealth is covered by most insurance. Check that out before leaving home.

But if sick, and our anxiety is getting in the way of a good time, there are the following exercises to consider, standards in your average therapydoc's toolbox. To me it really is all about breathing and distracting, being creative and thinking less. But here are 2 suggestions.

I.

Visualization techniques are nice. Focus on encouraging antibodies to make an appearance, come out to play, those little packmen in your bloodstream that eat up foreign cells. Order them to gobble up corona cells.  Mind games are free. You can play if you have the virus, or even if you don't.  

II.

Focus on your breath. The method I teach my patients is just that, focus on  your breath. We all breathe anyway, so we may as well be mindful about it. Some people, when they get anxious, literally stop or slow it down. And we need it.  

There are 2 nice ways to go about about this.

1. Just as we attend to a throbbing paper cut, or anything else that our body ego seems to notice, like that nasty feeling we get gastro-intestinally when things don't move, pay attention to the air coming into the mouth, the nose, flowing into the body.

• Put your hand on your heart, notice your chest rising and falling in sync with your inhaling and exhaling. That's the power of breathing.
• Find your breath, either in the nose or mouth. Mentally attend to it, just watch, feel it, that and nothing else. If it is easier you can watch something while focusing on your breath, a nice picture perhaps, or a video of the sea, but it is the flow of your breath you care about, the wave of air that refreshes the body and the mind.
• Once you have found your breath, watch it for as long as you can. One minute is great. Three minutes, fantastic. A few times a day? Amazing.
• If you've been breathing through your nose, switch to mouth breathing and notice as air glides onto the roof of the mouth and the tongue, the teeth. Then as it disappears, goes where it is supposed to go, your chest rises.
• If you're breathing through your nose, feel the mucous membranes respond. They may feel cold. Watch as air carries inward to do the work of life.
• You don't have to do anything other than watch the show. You don't have to count, don't have to breathe more deeply. Just watch what is going on without any effort on your part. That's the ticket. It forces us to get greedy, to want more air, just doing that, and we'll inhale more deeply to comply.

There. You have mastered this.  You can and should turn to this fabulous, accessible, G-d given technique that actually works whenever there's a need to reduce anxiety, even depression. Practice it when you aren't anxious or depressed. Do it driving, do it doing dishes, do it while listening to your mother rant at you on the telephone to STAY HOME DURING THE CORONA CRISIS.

Alternatively.

2.  The balloon technique. 

 Notice the breath, your inhalation. After a few unscripted breaths, try to intentionally bring the breath to your belly, to fill it up like a balloon. You can even push your stomach muscles out to do that. Fill it up. Once full, suck in a bit more air and hold your breath 3 seconds.

Exhale slowly, imagine that balloon deflating. Stretch out the exhalation for as long as you can, and when you're out of breath, hold that pose for a moment.

Repeat.

To your health,

therapydoc

Oy vey, we're all gonna' die

Oy, Vey, We’re All Gonna’ Die

When my brother and I were young we would stay with my grandparents for a few hours after school. As we left my grandmother would bless us. 

"You should live and be well," she said. 

Powerful stuff, that. 

I can't remember if she put her hands on our heads while saying it— it's been a long time— but I have a vague visual memory of her face, her mouth, and her housedress. We are at her front door, leaving with our mother to go home for dinner. Gramma says these words, “You should live and be well.” Every. Single. Time.

What, from her own experience? Did she watch people die? Or did the words come from her grandmother’s hands?  Gramma passed away at 91.

But, as we say in my tribe, most of us are not on her madrayga. (rhymes with ha-tray-la). It is the Hebrew word for step or level. She and my grandfather only survived a pogram because the Czar let the Jews go on Yom Kippur, assuming they could afford the passage to America.

At the end of our visit, when my patients ask how I'm doing, I sign off by joking;

"Oh, you know. Just waiting to die." 

It always gets a laugh. It's the elephant in the room. I'm older than my grandmother had been when she blessed us. I'm in that vulnerable demographic. And people die from this virus.

I can say what I want about how healthy I am, how fit, how I can breathe as well as your average yogi-in-training (swimming for years has served me well), but to be honest, in my most rational heart of hearts I ask:  Am I, though? Will it be enough? What about that bronchitis last year?

But hopefully, yes, it is. And quarantine should help. So I tell them: You’re not in the office. I’m in WFH, work-from-home. We’re good. I’m not afraid (yes, I lie! I lie all the time!). We’ll get through this. 

In my community I'm not feeling the optimism. Like the rest of society they are hoarding food, and it is worse because of Passover. Passover has always been a time for making sure there is enough food that has no chometz, leaven. Passover preparation moves the needle for the rational and the anxious alike. Everyone is in the same rush to get ready. But we can’t even rush about from store to store as we once did, hunting down what we need for the holiday.  And we don’t like sending our children.

But back to the catastrophic expectation. Those of us who aren't worried about running out of food so much as dying think: It's that six degrees of separation thing. That's what triggers the fatalism. We know someone who had contact with someone, who had contact with someone else—  who tested positive!

Sometimes it's only two degrees of separation. But those words, tested positive, are foreboding, no matter how many degrees away.

As in, You’re next. 

When my sons were about 14 they were in Yeshiva, the local Jewish high school. Faculty and students did not speak Yiddish, not usually, but Yiddishisms can be heard in the hallways and these trickled home. My adolescent twin sons came home one day singing a Yiddish song they had translated to English.

Oy vey, we're all gonna' die.
Oy vey, we're all gonna' die.
Only Torah and only mitzvahs
Are gonna help us now.

The tune is catchy. My partner and I just recorded it, if anyone’s interested.

The boys had been learning a tractate of Talmud Berachot (A gemarah, legal book. Parsing it out berach rhymes with prof, chot with moat, hard ch) 

Again this is my recollection. Within the holy book we find the words, we're all going to die. It is something the rabbis talk about.

I'm sure I responded to the kids by saying  You don't need to be a talmudic scholar to know this. 

And yet, they sang the song over and over again, laughing until they cried. It is one of those tunes, quite frankly, that becomes an ear worm, catchy, contagious.  Pun intended.  

File singing, and yes, facing the catastrophic expectation, under Coping.

You should live and be well,

Linda Freedman

*mitzvahs  The good deeds commanded by the Old Mighty (my grandfather’s name for his Higher Power. There are 613 mitzvot in the Torah. 

PS   I'd be remiss if I didn't suggest this post by a blogger at Chabad.org.  (They would appreciate the song)  Check out 10 Things I've Learned About Life in the Midst of the Corona Crisis

Covid-19 Part One

This before we were ordered to stay home.

Like many people these days, I listen to podcasts. But they don't hold my interest very long, not unless there's something to learn from them. My tastes lean to rabbis, and people who have done research. A rabbi who teaches in a university, one who doubles as a professor, well, it doesn't get any better than that. 

All that to tell to quote from a prodigious podcast: Rabbi Dovid Katz on Jewish History Rabbi Katz almost always prefaces his conclusions by saying, 

Hey, that's just my opinion. Seriously. Just my thoughts on the topic, the matter at hand, what we're talking about here. Really. You know what I mean? My opinion. You understand. It's just my thinking. 

In other words, take it with a grain of salt, form your own opinions. You're welcome to go elsewhere, consult another rabbi, another historian. 

So that's the caveat here, too. Just my opinion. 

nobody's swimming lately

  Today I went to the pool and guess what? Nobody there! Nobody. Except one woman singing in the locker room. She said that people had been there earlier, but now they're gone.

She sang well. She seemed happy. And I, too, leaving the facility an hour later, felt pretty happy walking home.

That was today. Yesterday, as the news breaks about the virus, mass hysteria, fear of contagion, pressure to flatten the curve. All this for a virus, FD is quick to tell me. It feels like gloom and doom, the world is coming to an end.  Any money we thought we had? CRASH!

Coping skills are the order of the day. And all I can think is, ignore, ignore, withdraw, retreat, go into emotional-mental quarantine. When people panic, be the best therapist you can be. Don't. And tell them,

Life goes on. Stay in the moment. Feel reality, feel the present. Love it.

That's it, that's the mantra. Live life as is. Don't focus on Covid-19, unless it is to somehow lift others up. Don't bring people down. Like most things we fear, the virus has much well-deserved power. But there will be an end to it.  (Again, my opinion, what do I know?)

A steady diet of attention to this thing will, no question, bring us down. And yet, there is no escaping that, most likely. We will have to attend to it, we will, and we will all commiserate. We are, for once in a century, all in the same emotional boat.

The object is to stay up. Rally whatever serotonin we can. Stretch.

Because for most of us, as the Beatles sang many years ago,

Oh blah di, o blah dah. Life goes on bra.  Al la la la life goes on. 

We have choices. We can stay in the moment, live our lives in some happy fashion, and connect with people electronically (because, no doubt, the pool will close). The moment is different for everyone, but it is our prerogative to stay here, to feel it. Or we can future trip and worry.

As the rabbi might say, Therefore, choose life.

But that's just my opinion.

therapydoc

  

Covid-19 Intro

Time to resurrect the blog. There's a pandemic going on. People are anxious, not that anyone can blame them. What would a therapist have to say about it?

We could go into the various types of anxiety disorders, agoraphobia, generalized anxiety disorder, panic disorder. There's the fear of contagion, health obsessions. Hypochondriasis. Easily suggestible disorder (made that up).

Obviously obsessive-compulsive disorder. 

But let's talk about me. 

Let's say a person is still going to the health club or swims every day. Does she have a gambling disorder? The virus hasn't yet hit Chicago, but it is in Illinois. Just saying.

In my family no one would argue that we have genetic and experiential programming to lean toward anxiety. We're set up. We catch it from anything. 

So really I should be flipping out about the coronavirus, Covid-19, but I’m not. And it helps that FD is not. He had a patient with another type of Coronavirus, not 19,  who was very sick. We're hoping because of that we are both immune.

He treated it like he treats sick people and the patient is fine. 

Strangely enough, perhaps the most anxious/OCD person that I know isn’t flipping out either. I saw him yesterday and we talked about everything but coronavirus and it was liberating, at least for me. Him, too, one can hope.  (There's much to be learned from his therapy and why he is not freaking out. We'll get to that in another post).

Everyone at my office is talking about this, at least right now, no matter what the presenting problem: depression, anger, grief, anything. My mix is quite concerned about coronavirus, if not particularly freaked. We could talk about this phenomenon the entire visit. 

What is there that someone like me could add to the conversation that hasn’t been said already? Because frankly everything has been said. Am I right? 

Fact is, there is a lot to talk about. We want to know about the progression of the disease; we want to know if we are at risk; we want to know if we can travel; we want to know if we can send our children to school, if we should go to work, if we can go to work. Must we disinfect every doorknob, and on, and on, and on. Because of all of that, we do need to listen to the news; we have to get updates from television, email and social media. 

Every mention Covid 19 is triggering whatever latent fears. Our anxiety is triggered, if only a tad more. 

You would think that all this flooding would help, but it doesn’t! So what does?

I can't go into it now. They're picking me up downstairs and it isn't nice to keep people waiting. But let's say this. Let's stay present. And make the present good, happy. Do those kinds of things. 

And breathe. Any old way. More on that later.

Wow, it's good to be back. 

therapydoc