Fortunately, key strategies can reduce and improve these symptoms. “The most important strategy is definitive treatment for the depression with psychotherapy and medication,” said William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

For instance, psychotherapy helps individuals become more aware of their cognitive symptoms, which can be subtle, Dr. Marchand said. It also teaches individuals specific techniques to improve their symptoms. And it helps clients gain a more accurate perspective on their illness.

“Because of the negative thinking associated with depression, there is a tendency to interpret symptoms as personal failings rather than as symptoms of an illness. A therapist can help one see things as they are – rather than through the distorting lens of depression,” Marchand said.

In addition to professional treatment, there are many strategies you can practice on your own to improve cognitive symptoms. Below are several techniques you can try.

Revise Distorted Thoughts

“I think it’s vital to teach any depressed individual how to ‘think happy,’” Serani said. Revising problematic thought patterns is key because they only fuel the fog and despair of depression.

“This approach definitely takes some time, patience and elbow grease, but once [it’s] learned, [it] enhances well-being.”

The first step is to monitor your negative thoughts, which you can record in a journal. A negative thought is anything such as “I’m a total loser” or “I can’t do anything right,” she said.

It’s also important to focus on how a negative thought affects your mood. By and large, it derails it. “Generally, [negative thoughts] will worsen mood, decrease hope and lower self-esteem.”

Next, challenge the reality of your thought, and replace it with a healthier one. Serani gave the following example: “Am I really a loser? Do I really do everything wrong? Actually, I get a lot of things right in life. So I’m not really a loser.”

Finally, review how each realistic thought affects your mood. According to Serani, it “leads to a healthier frame of mind. Now this new, healthy thought replaces the negative one and shifts mood into a less depressive place.”

Use Your Senses

“For helping with executive functioning skills for memory, focus and decision-making, I always recommend using your sense of sight, hearing and touch,” Serani said.

Technology can be especially helpful. For instance, you can set reminders for taking medication, attending therapy and running errands on your smart phone, computer or tablet.

If you don’t have access to technology or prefer pen and paper, Serani suggested placing brightly colored notes with reminders around your home and office. “Using touch to write will track the task more deeply into your memory and the visual cue to ‘see’ the reminder will help you keep your focus.”

Your sense of touch also can help when making a decision, said Serani, who uses this technique herself, “especially if I’m struggling with a significant melancholic mood.” She suggested a grounding practice, which “helps you be in the moment”: Place your hand on your heart, take a deep, slow breath and ask yourself the question you need to know. “Slowing things down and focusing on your sense of self can better help you make decisions.”

Take Small Steps

“Depression has a way of taxing you physical[ly], emotional[ly] and intellectual[ly], so taking smaller steps will help keep your energy reserve from burning out,” Serani said. Break down longer, more complicated tasks into bite-sized steps. This helps you “rest, refuel and re-attend [to your task].”

Have A Cushion

Therese Borchard, a mental health blogger and author of the book Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes, also struggles with cognitive symptoms from time to time. Whenever possible, she reduces her workload. “I’ve always prepared for days like that by working a little harder on the days I feel good, so I have a little cushion.”

Take Breaks

Because depression is so taxing on your brain and body, taking breaks can help. When she’s working, Borchard takes breaks every two hours, or “every hour if I’m really struggling.” Your breaks might include stretching your body or taking a walk around the block.

Be Kind To Yourself

“One of the most important things to do is remember not to be too hard on yourself if you still find you’re forgetful, have trouble focusing or making decisions,” Serani said. “Remember that you are experiencing a real illness.” Blaming yourself and losing patience only adds “to your already full plate.”

As Borchard noted in this piece on working from home with a mental illness, “When I was in the midst of my most severe depression, I couldn’t write at all. For almost a year…I try to remember that when I have a bad day where my brain feels like silly putty and I am not able to string two words together. I try to remember that courage isn’t doing a heroic thing, but getting up day after day and trying again.”

Goldstein describes mindfulness as “paying attention to something on purpose and with fresh eyes.” This is why mindfulness is so helpful. Instead of focusing on how badly we want the pain to stop, we pay attention to our pain with curiosity and without judgment.

This approach is very different from what our brains naturally do when we experience the physiological sensation of pain. Our minds typically launch into a litany of judgments and negative thoughts. According to Goldstein, we start ruminating about how much we hate the pain and want to wish it away. “We judge the pain, and that only makes it worse.” In fact, our negative thoughts and judgments not only exacerbate the pain, they also fuel anxiety and depression, he said.

What also makes matters worse is that our minds start brainstorming ways to soothe the pain. Goldstein likens this to the Roomba, a robot vacuum. If you trap the Roomba, it just keeps bouncing off the edges. Our brains do the same with scouring for solutions. This “creates a lot of frustration, stress and feeling trapped.”

Mindfulness teaches people with chronic pain to be curious about the intensity of their pain, instead of letting their minds jump into thoughts like “This is awful,” said Goldstein, also author of The Now Effect: How This Moment Can Change The Rest of Your Life and co-author of A Mindfulness-Based Stress Reduction Workbook.

It also teaches individuals to let go of goals and expectations. When you expect something will ease your pain, and it doesn’t or not as much as you’d like, your mind goes into alarm- or solution-mode, he said. You start thinking thoughts like “nothing ever works.”

“What we want to do as best as we can is to engage with the pain just as it is.” It’s not about achieving a certain goal – like minimizing pain – but learning to relate to your pain differently, he said.

Goldstein called it a learning mindset, as opposed to an achievement-oriented mindset. In other words, as you’re applying mindfulness to your pain, you might consider your experience, and ask yourself: “What can I learn about this pain? What do I notice?”

As Jon Kabat-Zinn, Ph.D, writes in the introduction of The Mindfulness Solution to Pain, “From the perspective of mindfulness, nothing needs fixing. Nothing needs to be forced to stop, or change, or go away.”

Kabat-Zinn actually founded an effective program called mindfulness-based stress reduction (MBSR) in 1979. While today it helps individuals with all sorts of concerns, such as stress, sleep problems, anxiety and high blood pressure, it was originally created to help chronic pain patients.

“In MBSR, we emphasize that awareness and thinking are very different capacities. Both, of course, are extremely potent and valuable, but from the perspective of mindfulness, it is awareness that is healing, rather than mere thinking…Also, it is only awareness itself that can balance out all of our various inflammations of thought and the emotional agitations and distortions that accompany the frequent storms that blow through the mind, especially in the face of a chronic pain condition,” Kabat-Zinn writes in the book.

Mindfulness provides a more accurate perception of pain, according to Goldstein. For instance, you might think that you’re in pain all day. But bringing awareness to your pain might reveal that it actually peaks, valleys and completely subsides. One of Goldstein’s clients believed that his pain was constant throughout the day. But when he examined his pain, he realized it hits him about six times a day. This helped to lift his frustration and anxiety.

If you’re struggling with chronic pain, Goldstein suggested these mindfulness-based strategies. He also stressed the importance of paying attention to what works for you and what doesn’t.

Body Scan

A body scan, which also is included in MBSR, involves bringing awareness to each body part. “You’re bringing attention to what the brain wants to move away from,” Goldstein said. However, instead of immediately reacting to your pain, the body scan teaches “your brain the experience that it can actually be with what’s there.”

You’ll find helpful videos with a three-, five- and 10-minute body scan on Goldstein’s website.

Breathing

When “pain arises, the brain reacts automatically,” with thoughts, such as “I hate this, what am I going to do?” Goldstein said. Though you can’t stop these first few negative thoughts, you can calm your mind and “ground your breath.”

Goldstein suggested simply breathing in slowly and saying to yourself “In,” and breathing out slowly and saying “Out.” Then you also might ask yourself, “What’s most important for me to pay attention to now?”

Distractions

A distraction can be a helpful tool when your pain is high (such as anything above an 8 on a 10-point scale), Goldstein said. The key is to pick a healthy distraction. For instance, it could be anything from playing a game on your iPad to focusing on a conversation with a friend to getting lost in a book, he said.

Mindfulness is an effective practice for approaching chronic pain. It teaches individuals to observe their pain, and be curious about it. And, while counterintuitive, it’s this very act of paying attention that can help your pain.

Both parents need to nurture children. Healthy parenting helps the grown child be his or her own best mother and father. A child must not only feel loved, but also that he or she is understood and valued by both parents as a separate, unique individual and that both parents want a relationship with him or her. Although we have many needs, I’m focusing on nurturing emotional needs.

Emotional Needs

In addition to physical nourishment, including gentle touch, care, and food, emotional nurturing consists of meeting a child’s emotional needs. These include:

• Love
• Play
• Respect
• Encouragement
• Understanding
• Acceptance
• Empathy
• Comfort
• Reliability
• Guidance
• The importance of empathy

A child’s thoughts and feelings need to be taken seriously and listened to with respect and understanding. One way of communicating this is by mirroring or reflecting back what he or she is saying. “You’re angry that it’s time to stop playing now.” Instead of judgment (“you shouldn’t be jealous of Cindy’s new friend”), a child needs acceptance and empathic understanding, such as: “I know you’re hurt and feel left out by Cindy and her friend.”

Empathy is deeper than intellectual understanding. It’s identification at an emotional level with what the child feels and needs. Of course, it’s equally important that a parent appropriately meets those needs, including giving comfort in moments of distress.

Accurate empathy is important for children to feel understood and accepted. Otherwise, they may feel alone, abandoned, and not loved for who they are, but only for what their parents want to see. Many parents unwittingly harm their children by denying, ignoring, or shaming their child’s needs, actions, and expressions of thoughts or feelings. Simply saying, “How could you do that?” may be felt as shaming or humiliating. Responding to a child’s tears with laughter, or “That’s nothing to cry about,” or “You shouldn’t be (or ‘Don’t be’) sad,” are forms of denying and shaming a child’s natural feelings.

Even parents who have sympathetic intentions may be preoccupied or misunderstand and misattuned to their child. With enough repetitions, a child learns to deny and dishonor natural feelings and needs and to believe that he or she is unloved or inadequate.

Good parents are also reliable and protective. They keep promises and commitments, provide nourishing food and medical and dental care. They protect their child from anyone who threatens or harms him or her.

Tips for Self-Love & Self-Nurturing

Once grown, you still have these emotional needs. Self-love means meeting them. If fact, it’s each person’s responsibility to be his or her own parent and meet these emotional needs, irrespective of whether you’re in a relationship. Of course, there are times you need support, touch, understanding, and encouragement from others. However, the more you practice self-nurturing, the better your relationships will be.

All of the things a good mother does, you have the superior capacity to do, for who knows your deepest feelings and needs better than you?

Here are some steps you can take:

• When you have uncomfortable feelings, put your hand on your chest, and say aloud, “You’re (or I’m) ____.” (e.g., angry, sad, afraid, lonely). This accepts and honors your feelings.
• If you have difficulty identifying your feelings, pay attention to your inner dialogue. Notice your thoughts. Do they express worry, judgment, despair, resentment, envy, hurt, or wishing? Notice your moods. Are you irritable, anxious, or blue? Try to name your specific feelings. (“Upset” isn’t a specific feeling.) Do this several times a day to increase your feeling recognition. You can find lists of hundreds of feelings online.
• Think or write about the cause or trigger for your feeling and what you need that will make you feel better. Meeting needs is good parenting.
• If you’re angry or anxious, practice yoga or martial arts, meditation, or simple breathing exercises. Slowing your breath slows your brain and calms your nervous system. Exhale 10 times making a hissing (“sss”) sound with your tongue behind your teeth. Doing something active is also ideal for releasing anger.
• Practice giving yourself comfort: Write a supportive letter to yourself, expressing what an ideal parent would say. Have a warm drink. Studies show this actually elevates your mood. Swaddle your body in a blanket or sheet like a baby. This is soothing and comforting to your body.
• Do something pleasurable, e.g., read or watch comedy, look at beauty, walk in nature, sing or dance, create something, or stroke your skin. Pleasure releases chemicals in the brain that counterbalance pain, stress, and negative emotions. Discover what pleasures you. (To read more about the neuroscience of pleasure, read my article, “The Healing Power of Pleasure”.)
• Adults also need to play. This means doing something purposeless that fully engages you and is enjoyable for its own sake. The more active the better, i.e., play with your dog vs. walking him, sing or collect seashells vs. watching television. Play brings you into the pleasure of the moment. Doing something creative is a great way to play, but be cautious not to judge yourself. Remember the goal is enjoyment – not the finished product.
• Practice complimenting and encouraging yourself – especially when you don’t think you’re doing enough. Notice this self-judgment for what it is, and be a positive coach. Remind yourself of what you have done and allow yourself time to rest and rejuvenate.
• Forgive yourself. Good parents don’t punish children for mistakes or constantly remind them, and they don’t punish willful wrongs repeatedly. Instead, learn from mistakes and make amends when necessary.
• Keep commitments to yourself as you would anyone else. When you don’t, you’re in effect abandoning yourself. How would you feel if your parent repeatedly broke promises to you? Love yourself by demonstrating that you’re important enough to keep commitments to yourself.

A Word of Caution

Beware of self-judgment. Remember that feelings aren’t rational. Whatever you feel is okay and it’s okay if you don’t know why you feel the way you do. What is important is acceptance of your feelings and the positive actions you take to nurture yourself. Many people think, “I shouldn’t be angry (sad, afraid, depressed, etc.). This may reflect judgment they received as a child. Often it’s this unconscious self-judgment that is the cause of irritability and depression. Learn how to combat self-criticism in my ebook, “10 Steps to Self-Esteem,” available in online bookstores.

I did not read the foreword or the praise-filled blurbs in the front of the book before reading it myself, as I did not want to be swayed one way or another. Instead, I tried to dive in with a somewhat skeptical yet mostly open mind, with the knowledge of my own many failed attempts to adhere to or complete a 12-step program successfully. But when I laid the book down, after soaking up every word and working through every exercise, I thought, Finally! Someone gets it.

Sacco, an adjunct professor of psychology, pulls back all of the recovery/12-step jargon and red tape, and gets down to the bare bones of what is a “must” in order to experience freedom from addictions and habits that control one’s life. He details the core issues that have to be addressed and gives practical, real-life applications that can be implemented immediately. His plan does require an attitude of desire for a better life and a belief in a higher power, whatever or whoever that may be for you. Most important, he gives a real sense of hope, instead of a long list of tasks to complete. He suggests that choosing which aspects of recovery programs work for you, rather than making oneself abide by every single instructed step, can lead to greater success. 

This is crucial when speaking to people who have tried and failed before and want only to be successful in kicking the monster called addiction. Hope is rare in the addict’s world. And sometimes a to-do list of meetings (30 meetings in 30 days for the first month) filled with people one doesn’t know or trust can be overwhelming. It may even be the first step towards another failure if an addict isn’t ready socially or emotionally to jump into a public forum.

I am a recovering addict myself. I spent numerous years living with an overwhelming feeling of failure in regard to my attempts to get substance free. I spun my wheels, so to speak, trying to do what I was told and trying to complete the steps I was advised to complete. Unfortunately, I had neither the maturity nor the appropriate knowledge of a higher power required to make a full recovery. And the failure that occurred time and time again prevented me from realizing that I was capable to succeed in this area.

The author begins his book by explaining the foundation of his plan—the one that can supposedly help one overcome addiction and bad habits in 30 days or less. Sacco posits that three things will need to be addressed in order for true health and recovery to be attained. Together, they form the psycho-social-spiritual. Respectively, they are mental health and well-being (psycho), social well-being (social), and belief in God, a higher power, or the universe (spiritual). He shows how all three work independently, as well as how they become dependent on one another.

He breaks the book into three sections as well. The first contains the components of what an addiction is and why it continues to exist and fester. In the second, he discusses how we, individually, may contribute to the manifestation of an addiction. And third, he presents 30 days of “intentions” to work into one’s daily life. He purposely chooses the word “intentions,” as opposed to “affirmations,” he tells us. His careful choice here is to encourage “active choosing” and “powerfully expecting” outcomes. This is based on his belief that “active choosing” engages the mind to learn on one’s own terms and not be at the whim of whatever garbage flows in. And the act of “powerfully expecting” is believing something will come to pass. It demonstrates our confidence in our own beliefs and abilities, he says.

Sacco, a former private practitioner in the areas of relationships, criminal psychology, addictions and mental health, writes in a no-nonsense, straightforward manner that is easy to understand, even if one is not very fluent in psychology terminology. He acknowledges that everyone is different and that not all types of therapies or treatments work for everyone. Some of the more popular therapies for addiction  are biased, however, requiring a commitment to the so-called full process. For some, this can be a recipe for failure. The message conveyed in this book is that you can take it all or take just the parts you need, depending on where you are psychologically, socially, and spiritually.  It is a buffet of options—and, ultimately, your rate of success begins and ends with you.

After reading the book, I am no longer a skeptic. I believe this is a process that can and does work. Reading it, you will begin to understand how your past and the negatives associated with it can be what keep you stuck in the mud of misery. You will also come to understand and learn about sweet acceptance. And in the middle of all of this, you will find what you have been looking for: peace of mind.

Right Now Enough is Enough!: Overcoming Addictions and Bad Habits for Good in 30 Days or Less!
Booklocker.com, January, 2013
Paperback, 254 pages
$18.95 

Ego is the bad guy here, a brimming pool of selfishness, spite, defensiveness, emptiness, and whatever negative term you want to add. We have to transcend ego to get to Spirit, which is pure happiness, Mutchler tells us. This is essentially his book’s thesis, with some explanation of the mechanisms he encourages the reader to use to get from ego to Spirit. We live in “uncertain times,” he says, and this makes us feel isolated and competitive. We look for answers outside of ourselves when we should look within and go back to where we come from — which, apparently, is Spirit.

Spirit, as defined in the book, is equivalent to pure consciousness and comes from a single source of divine energy. Ego, on the other hand, is limited consciousness, because it’s not who we are. In the author’s words, “Consequently, and over time, an ever-widening gap has developed between who we are—ego—and who we really are—Spirit. The result is a growing state of tension for humankind that makes life stressful, disconcerting, and oftentimes miserable.”

The explanation of Mutchler’s perspective begins with the Big Bang, and tries to connect quantum physics to human consciousness. There are also brief descriptions of  different types of subhuman consciousness, including material, plant, and animal, presumably meant to set the stage for human consciousness, the main topic of the book. Consciousness, however, is not something the author wants to break down. He tells us: “But remember, consciousness is purposely not defined in this discussion. To define anything is to limit and confine, and we want to do neither. We want simply to stay open to what consciousness is and let our understanding of it unfold as we work our way through its various levels of expression.”

Considering that science started with classification and definition, the above statement is a little startling.

The word ego, meanwhile, is derived from the Latin for I, and in Freudian theory was the arbiter between Id and Superego. In popular usage it refers to a heightened sense of self importance. But according to Mutchler, these are all mistaken concepts. Instead, he defined ego as a “state of consciousness.” Yet since he won’t define consciousness, we’re left without all the information we need. Is he saying that ego is consciousness, and consciousness, ego?

Whatever this ego-consciousness is, it isn’t a positive thing, he tells us in subsequent chapters. It makes us claim superiority to quell our unconscious sense of inferiority. It makes us project blame on others, and thrives on suffering and bad news. It’s judgmental, acquisitive, and entitled. It’s a jealous, envious drama queen that will do anything to survive.

In the next section, the combat between ego and Spirit takes on Manichean dimensions; it’s clearly evil versus good. Ego consciousness is likened to hell with almost unlimited destructive powers. “Collectively ego consciousness threatens to destroy mother earth and her ability to sustain us,” Mutchler writes. Love is Spirit’s weapon in dealing with the ego. In the author’s words, “ ‘Talk’ to your ego, assure it that dying isn’t necessary. It needs only to transition to another state of being….”

Being aware of ego is, Mutchler writes, the way to transition. How to do this? Look for situations where you feel upset, the author says, as ego thrives on suffering. “Each time you notice ego intruding into your thoughts, behaviors, or emotions,” he posits, “you are stepping directly into the world of Spirit.” As ego recedes, you become more open, friendly, moral, and ethical. If you spot ego in others, he says, you’re less judgmental.

The most useful part of the confused book, therapeutically speaking, focuses on how we describe our ongoing lives to ourselves. This section is very much in tune with contemporary cognitive therapy. The author states that there is a language of the ego and a language of the Spirit. Ego language is deeply ingrained and has been with us all our lives, though it is not the original cause of our suffering. This so-called ego language, Mutchler writes, “plays a large role in sustaining ego consciousness and perpetuating human suffering.” A few examples from a long list of words is “Disgrace, Regret, Shame, Worry.” Spirit language on the other hand is positive, life affirming. It includes “Peace, Joy, Happiness, Harmony.”

Awareness of our ego language and changing it is, according to the book, a major means of moving from ego to Spirit. To this end the author provides pages of judgmental adjectives and their less judgmental alternatives.

After all of this, the final section of the book, called “The Choice Is Yours,” talks about death in the style of a Hallmark condolence card.

The essential message of Beyond the Ego can be reduced to one line: Be less selfish and you’ll have a happier life. The book’s most salient aspect is the focus on language as a means of perpetuating unhappiness. But it is not a real behavioral science book, and leaves too much out.

Beyond the Ego: Where Love, Joy, and Peace of Mind Await You
Balboa Press, 2012
Paperback, 208 pages
$14.99 

1. Everyone has challenges.

Clinical psychologist Christina G. Hibbert, PsyD, wants readers to know that they’re not alone in their struggles. “We all have challenges. Even as I sit in my chair helping [a client], I have challenges too. It hurts me to see clients feeling like they’re the only ones on earth who ‘need therapy.’”

Therapist Joyce Marter, LCPC, agreed. She believes that our struggles are simply “part of the human condition…[E]verybody struggles with issues related to self-esteem, identity, navigating relationships, coping with various life traumas, managing stress or challenges in creating the life we want, personally and professionally.”

2. Everyone can benefit from therapy.

Therapy is a healthy and proactive approach to dealing with challenges, Marter said. “A therapist is like a personal trainer for your mind. I believe we can all benefit from therapy at various points in our lives and see it as a preventive and routine form of health care.”

3. Seeking therapy is courageous.

It’s a common myth that therapy is for weak people who can’t fix problems on their own. “I think of therapy as making use of all the tools at one’s disposal to manage negative emotional symptoms and maximize strengths and fulfillment,” said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens. “People willing to delve into their own psyches are … actually quite courageous.”

4. Therapy helps you navigate life.

You can apply the skills you learn in therapy to any area of your life, according to Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression. “It really doesn’t matter if you go to therapy for anxiety, depression, to lessen obsessions, to quit smoking or to learn how to parent – whatever the reason – the techniques of self-reflection and thought-changing are involved in all.” In fact, she said, many people consider therapy to be the most meaningful and valuable experience of their lives.

5. Therapy is a process of self-discovery.

“To my thinking, therapy does not need to be an excruciating experience. Sometimes I think we do therapy itself a disservice when we call it ‘work.’ For my clients, I like to think of their therapy as a process of self-discovery, more joyous in the end than painful,” Duffy said.

6. Therapy isn’t about blaming others.

“Some people think therapy is about blaming their parents or their life histories for all of their woes,” said Marter, also owner of the counseling practice Urban Balance. Therapy is actually “about honoring those experiences and then taking full responsibility for your life from here forward.” She shared Wayne Dyer’s quote: “Everything you do is based on the choices you make. It’s not your parents, your past relationships, your job, the economy, the weather, an argument or your age that is to blame. You and only you are responsible for every decision and choice you make.”

7. Therapy is a place to say and ask anything.

“Therapy isn’t the place to put your best foot forward and try to convince the therapist that you have it all together,” according to Ryan Howes, Ph.D, a clinical psychologist and author of the blog “In Therapy.” Instead therapy is a space to be fully and authentically yourself. Bring everything from your daydreams and fantasies to your harsh opinions and random thoughts, he said. “A skilled therapist will work to understand these impulses and beliefs without judgment and help you make sense of them. Save the pleasantries for the outside world, and let your raw, real thoughts and feelings out here.”

The same is true for asking your therapist questions: If there’s a question you’d really like to ask about your treatment or therapy in general, ask away, Howes said. “If the therapist doesn’t want to answer, let them explain why and how not answering benefits you in the long run. If you’re not satisfied with the answer, let them know.” He noted that therapy is a relationship. “Therapists should be experts at setting boundaries and working through relational issues in a constructive way.”

8. Therapy doesn’t end as soon as you feel better.

Jeffrey Sumber, M.A., a psychotherapist, author and teacher, wishes that people knew that improvement doesn’t signal the end of therapy. “So often, folks begin to feel the shift within themselves, their patterns change, their mood improves, and they terminate treatment only to find themselves in a similar situation down the road.” That’s because those shifts are a mark of progress, not proof of a cure.

“The counseling process is multi-layered and the feelings of renewed purpose and lifeforce that accompany the internal shifts we make are actually there to help propel us forward so that we feel this way every day on our own. I wish people took the signs of improvement as a confirmation that treatment is helping, not over.”

9. Don’t compare your insides to others’ outsides.

“I often hear clients pathologize themselves and suggest that most other people are functioning at a higher level in various aspects of their lives,” Marter said. In reality, however, “we are all dealt a different hand of hardships and blessings. Therapy is a place to help you think through how you want to play your hand.” In fact, she’s seen “people overcome great adversity and others squander great blessings.”

10. Your thoughts dictate your feelings and behavior.

Marter cited Gandhi: “A man is but the product of his thoughts.” This is why it’s so helpful to pay attention to the things you say to yourself and shift your perspective to more realistic, empowering thoughts. “Through therapy, we can let go of negative or irrational thinking and promote positive thinking and a practice of gratitude that will attract more positivity into our lives,” Marter said.

11. Acceptance isn’t limiting; it’s liberating.

“Don’t get me wrong, there are times when we need to keep striving, pushing, and holding out hope for better health, better careers, or healthier relationships,” Howes said. However, many individuals end up wasting their time and energy wrestling limitations they can’t change, instead of focusing on the things they can alter. According to Howes:

We need to accept our age. We need to accept many physical and mental illnesses and addictions. We need to accept the past. We need to accept others as they are. This isn’t to say we need to like it, or that we can’t work to make the best of each of these entities, but we need to relinquish the idea that we have any power or responsibility to change them. Once people realize they can accept instead of fighting things beyond their control, they realize they have much more time and energy for things they can impact.

12. You are worthy. Whether her clients come in with depression, anxiety, relationship problems or parenting concerns, Hibbert believes that, at the core, they’re all struggling with the same thing: “an inability to comprehend and feel their worth.” She’s also seen this with friends and family and experienced it herself. “I’ve had to work very hard to discover my own self-worth.”

She wishes people truly understood that “they’re more than how they feel, what they do or say, and what they think. Deep down, we are each of infinite worth.” Connecting to our self-worth is “the key to living a life of meaning, abundance and joy,” said Hibbert, also a women’s mental health, postpartum and parenting expert. (She talks more about self-worth in this piece.)

13. Life requires balance.

Howes noted that while the idea of balance is cliché, he’s also seen the damage of living in extremes. “People who work too much, party too much, spend too much time online, exercise too much or let themselves become consumed by their relationships will face the consequences of a life out of balance.” The skills for achieving moderation are challenging yet critical to learn, he said.

14. Growth and progress are not linear.

“We all go through setbacks, relapses or regressions in life as a normal part of being human,” Marter said. Experiencing a setback doesn’t mean you’re back to square one. Instead, this is an “opportunity to learn, get back on the saddle, grow and move forward. Life is a process of ebbs and flows.”

15. Work on the inside.

According to Marter, “Some people are waiting for external factors such as a relationship, a job, a perfect body or a fat bank account to make them happy.” Instead, the key is to work from the inside out. She cited Eckhart Tolle: “If you get the inside right, the outside will fall into place.” Marter added: “Therapy is a place to explore your greatest gifts and align your life with those so that you will achieve all you desire personally and professionally.”

This is a fascinating book for those who want to think about and remember more useful information. It combines some common-sense advice with the author’s experience in the field of cognitive science. While I didn’t find every point helpful, there is much to like.

According to Markman, smart thinking is “the ability to solve problems using what you already know.” That sounds simple, but the book explains how we can put better information into our brains and then get better at recalling that information. As a result, we become better thinkers. That’s an appealing idea.

Markman’s formula goes something like this: We should develop a habit of acquiring high-quality knowledge which we then apply to problem solving. It doesn’t seem to be the author’s intent to present startling new methods, but rather to use his knowledge of how the mind works to give us basic ideas to improve our thinking. This can mean thinking outside the box, which is hardly a new approach. Or, applying what we know from one field to a totally different one to arrive at a solution.

Markman spends a chapter or more on the topic of habits. He suggests that if we develop good learning habits, we make it easier for our brain to think. This in turn relieves mental stress and preserves energy for more challenging tasks. We likely haven’t thought a lot about how much energy we use in thinking, but Markman wants us to understand that we use mental energy in much the way we consume physical energy. When we are in our comfort, or habitual, zones of working with familiar subjects, thinking seems to come easily and without much stress. So, he posits, our goal should be to make more subjects familiar ones.

For instance, are you able to move about a room in the dark? If so, that’s because you have made it a habit to maneuver around furniture and other objects by making a connection between an action (your movement) and an environment (the room). When we make that connection in other learning situations such as a classroom or meeting room, it helps our brain to retain the information.

That example works well. But much of Markman’s discussion of other types of habits, such as smoking or overeating, is belabored. They aren’t bad suggestions; it’s just that we have read these ideas in many places before. Still, a helpful tip from the book is that if we want to change or drop a negative habit it works better if we replace that habit with a good habit. Markman adds that keeping a diary can be effective for some people.

I felt the most helpful and interesting discussion was on the subject of memory. Markman suggests that because our memory has capacity limits, it is important to take in information in a smarter way in order to retain more valuable knowledge. He uses a concept called the “Role of 3” to make his point. Even though there may be a lot going on around us, we are capable of absorbing only about three aspects at a time. Further, what we retain in long-term memory is even less detailed. For example, can you remember an early childhood birthday? Being honest, you may recall that there was a party that likely was in a home you recall and likely included certain friends. But you can’t recall much detail with certainty, including how you felt about it. Markman’s bottom line is that if you are having trouble remembering something, you did something wrong on the intake end.

Being aware of the Role of 3 can also be used to our advantage when we are delivering information, as we might in making a presentation or while teaching. We may want to tell our audience or colleagues everything we know, but this could result in their retaining the less important information. It’s better to stick to three main points. In fact, the author repeats common speakers’ advice: Tell them what you are going to say; say it; then tell them what you said.

Markman also says that we miss much of what is right in front of us. He calls it “change blindness,” explaining that although our eyes may be constantly scanning our surroundings, we only notice a small part of what we are scanning. We see examples of this when witnesses to a crime have difficulty describing the perpetrator with much detail, or describing accurately.

The book also claims that it is easier for us to learn new information that is related to something we already know than when it is a totally new topic for us. We can accept this as likely and use this to make us work harder when we are in new learning territory.

Why do we even want to become smart thinkers in the first place? Why not! It can help us in school at any level; in work and careers; and in social interaction. In showing us why we think the way we do, Markman’s book is a useful one, even if not every point is fresh. And if some of his suggestions seem to take too much effort or seem too challenging, we can still learn how to be more alert to what we absorb—and hopefully become more interesting people as a result.

Smart Thinking: Three Essential Keys to Solve Problems, Innovate, and Get Things Done
Perigee, Penguin Group, December, 2012
Paperback, 272 pages
$15

“I really enjoyed playing with the idea of ‘who are we without our memories’? Do you make the same choices? Do the same things make you happy?” – Allison Winn Scotch

Imagine waking up one day without your memory. Your history is depleted, and the only stories that you hear about yourself and your past are strung together from others’ perceptions. How do you even begin to maneuver your way through that kind of maze? Allison Winn Scotch’s well-written novel, “The Song Remains The Same” explores those complexities, along with the significance of confronting where you came from.

Nell Slattery survives a tragic plane crash and awakes in the hospital with amnesia as a result. Her memory loss could be due to critical brain damage, or to her brain shutting down from the severe trauma, likened to a protective shield of sorts. Nell’s now on a quest to find out who she is and seek out the missing pieces of her life, without a foundation that she can remember and draw upon.

Before the accident, her marriage was treading on thin ice and layers of emotional pain were present within. She was 13 when her father died; he was a renowned artist who struggled with his mental health, ultimately becoming a recluse. With so many voices in her ear (including her mother, sister, husband and friends) about various events and relationships, Nell must sift through the information and uncover the real version of the truth.

“The book shifts perspective a few times so the reader can see just how unreliable her friends’ and family’s perspective is,” Scotch said in a 2012 interview on Rosie Molinary’s blog site. “You realize (I hope) that no one is malicious or has malicious intent, they’re just all trying to muck their way through a terrible situation.”

One of my favorite excerpts stems from the heart of Nell’s road to discovery. “Maybe I have gotten a hell of a lot better, and I’ve only been holding on to my amnesia because I’ve been working hard to avoid the alternative. The memories. The journey. But I am standing here now, strong, capable, and perhaps it’s time to accept where I’ve been, what I’ve gone through and what comes next.”

In the final stretches of The Song Remains The Same, it seems apparent that even before Nell lost her memory, she was so swallowed up and defined by her pain that she lost sight of what she was about. However, right before the crash, she had begun making particular choices to find a way back to herself, even if scars still remained. Furthermore, as she battles with amnesia, she learns new lessons as well, forgiveness topping the list.

The novel brings to the surface age-old questions, such as whether people can change. Based on descriptions from those around her, Nell doesn’t envision herself to be the person she was, but as she embraces a new, clean slate, she constantly wonders if people really can be different than who they were. Perhaps people will always hold onto their essence, while they continue to grow and evolve. Regardless of whichever camp you buy into, Nell is an introspective protagonist who will grab readers’ attention.

In addition, Scotch emphasizes the importance of the past. Nell is able to uphold a sense of emotional memory through listening to music (a favorite playlist was compiled that induced triggers or childhood recollections) and learning to free associate in therapy. Through these mechanisms, she’s able to hone in on intuition and conjure imagery that relays an honest portrayal of what previously occurred.

I find that the “live in the moment” motif is often preached, and while that’s valid and insightful, the past doesn’t cease to exist, for our histories are still relevant. It must be surreal to place yourself in Nell’s shoes (or someone like Nell in real life), who must press on without prior experiences, or wounds that aren’t understood.

When Rosie Molinary asked Scotch about her inspirations for this “fairly dark book,” she responded openly about what drives her storylines.

“There must be something about me that loves to examine the underbelly of what makes people tick – and what makes us both loyal and disloyal,” Scotch said. “Certainly in my own life, I’ve had experiences of betrayal – fortunately, nothing like what Nell has gone through – and I guess they must have stuck in my subconscious. Also, I always love exploring characters who go through something difficult and find a way to make it out the other side.”

The Song Remains The Same is absolutely worth your time; it showcases complex themes, while executing a thought-provoking narrative — Allison Winn Scotch knows what she’s doing.

Of course, feeling trapped is a state of mind. No one needs consent to leave a relationship. Millions of people remain in unhappy relationships that range from empty to abusive for many reasons; however, the feeling of suffocation or of having no choices stems from fear that’s often unconscious.

People give many explanations for staying in bad relationships, ranging from caring for young children to caring for a sick mate. One man was too afraid and guilt-ridden to leave his ill wife (11 years his senior). His ambivalence made him so distressed, he died before she did! Money binds couples, too, especially in a bad economy. Yet, more affluent couples may cling to a comfortable lifestyle, while their marriage dissolves into a business arrangement.

Homemakers fear being self-supporting or single moms, and breadwinners dread paying support and seeing their assets divided. Often spouses fear feeling shamed for leaving a “failed” marriage. Some even worry their spouse may harm him- or herself. Battered women may stay out of fear of retaliation. Most people tell themselves “The grass isn’t any greener,” believe they’re too old to find love again and imagine nightmarish online dating scenarios. Also, some cultures still stigmatize divorce.

Unconscious Fears

Despite the abundance of reasons, many of which are realistic, there are deeper, unconscious ones that keep people trapped – usually fears of separation and loneliness. In longer relationships, spouses often don’t develop individual activities or support networks. In the past, an extended family served that function.

Whereas women tend to have girlfriends in whom they confide and are usually closer with their parents, traditionally, men focus on work, but disregard their emotional needs and rely exclusively on their wife for support. Yet, both men and women often neglect developing individual interests. Some codependent women give up their friends, hobbies, and activities and adopt those of their male companions. The combined effect of this adds to fears of loneliness and isolation people envisage from being on their own.

For spouses married a number of years, their identity may be as a “husband” or “wife” – a “provider” or “homemaker.” The loneliness experienced upon divorce is tinged with feeling lost. It’s an identity crisis. This also may be significant for a noncustodial parent, for whom parenting is a major source of self-esteem.

Some people have never lived alone. They left home or their college roommate for a marriage or romantic partner. The relationship helped them leave home – physically. Yet, they’ve never completed the developmental milestone of “leaving home” psychologically, meaning becoming an autonomous adult. They are as tied to their mate as they once were to their parents.

Going through divorce or separation brings with it all of the unfinished work of becoming an independent “adult.” Fears about leaving their spouse and children may be reiterations of the fears and guilt that they would have had upon separating from their parents, which were avoided by quickly getting into a relationship or marriage.

Guilt about leaving a spouse may be due to the fact that their parents didn’t appropriately encourage emotional separation. Although the negative impact of divorce upon children is real, parents’ worries may also be projections of fears for themselves. This is compounded if they suffered from their parents’ divorce.

Lack of Autonomy

Autonomy implies being an emotionally secure, separate, and independent person. The lack of autonomy not only makes separation difficult, it naturally also makes people more dependent upon their partner. The consequence is that people feel trapped or “on the fence” and wracked with ambivalence. On one hand, they crave freedom and independence; on the other hand, they want the security of a relationship – even a bad one. Autonomy doesn’t mean you don’t need others. In fact, it allows you to experience healthy dependence on others without the fear of suffocation. Examples of psychological autonomy include:

1. You don’t feel lost and empty when you’re alone.
2. You don’t feel responsible for others’ feelings and actions.
3. You don’t take things personally.
4. You can make decisions on your own.
5. You have your own opinions and values and aren’t easily suggestible.
6. You can initiate and do things on your own.
7. You can say “no” and ask for space.
8. You have your own friends.

Often, it’s this lack of autonomy that makes people unhappy in relationships or unable to commit. Because they can’t leave, they fear getting close. They’re afraid of even more dependence – of losing themselves completely. They may people-please or sacrifice their needs, interests, and friends, and then build resentments toward their partner.

A Way Out of Your Unhappiness

The way out may not require leaving the relationship. Freedom is an inside job. Develop a support system and become more independent and assertive. Take responsibility for your happiness by developing your passions instead of focusing on the relationship. Find out more about becoming assertive in my e-book, How to Speak Your Mind — Become Assertive and Set Limits.

Some individuals experience a decline in mood with a sense of loss, he said. Others experience a loss of interest or pleasure in activities they previously enjoyed. Still others experience “an increased irritability, impatience or lower tolerance for the normal stresses of daily life.”

Chronic pain also creates many stressors, which can lead to depression, said Beverly Thorn, Ph.D, Clinical Health Psychology Professor and Chair at The University of Alabama whose research focuses on painful conditions. Chronic pain interferes with a person’s daily functioning. It lasts at least three months, more days than not, she said.

“People might be unable to work or work the way they used to.” Consequently, they might have financial problems, and a new role in their family. Patients have told Thorn that not being the main provider has made them feel worthless or like they’re not contributing to their family unit.

Treating Both Conditions

It’s important to treat both chronic pain and depression, Kerns said. “Many people with pain and depression say things like ‘If you had my pain you’d be depressed, too,’ or ‘If you would treat my pain, I wouldn’t be depressed.’ However, reducing pain doesn’t necessarily reduce symptoms of depression, he said.

That’s why Kerns suggested people work with providers who treat each condition (instead of an either-or approach). Some studies suggest that a collaborative and integrative approach is best. This study published in the Journal of the American Medical Association found that a course of antidepressants followed by a pain self-management program improved both depression and pain.

If you haven’t yet, consult a pain specialist for a treatment plan, along with a mental health specialist for a proper evaluation and treatment for depression, Kerns said. It’s also important to communicate regularly with your providers and pay attention to changes, Thorn added.

When to Proceed with Caution

One of the biggest challenges of treating both pain and depression is that feelings of helplessness and hopelessness lead people to try cures that are ineffective and even damaging, according to Kerns. “Continued doctor-shopping is problematic.”

Also problematic is pursuing more and more aggressive pain interventions, which he said only reinforce the “sense of helplessness and hopelessness and demoralization.”

Opioid medication is another concern. According to Kerns, there’s very little evidence that opioids are helpful for chronic pain. Instead, there’s “abundant evidence of the potential harm of long-term opioid therapy.”

For people with pain and depression, “who may be vulnerable to pursue these kinds of interventions,” it’s best to be cautious. Most experts “argue for very limited use of pharmacological agents and support education, encouragement and judicious use of non-opioid, over-the-counter [medication],” along with a healthy lifestyle and self-management techniques, he said.

How Psychotherapy Helps

Experts used to think that the amount of pain a person felt was equal to the amount of damage in their body, Thorn said. Today, however, we know that our thoughts and emotions can influence the perception of pain, making it much worse or less intense, she said. Psychotherapies, such as cognitive-behavioral therapy (CBT), harness this concept “by re-teaching your brain.”

Research has found that CBT is highly effective for managing both pain and depression. (“Some of the strongest evidence supports CBT,” Kerns said. But he also noted that other therapies such as behavioral activation and Acceptance and Commitment Therapy show promise.)

For instance, CBT teaches individuals to pay attention to their thought processes, which can maximize or minimize pain. Thoughts like “This pain has ruined my life, and there’s nothing left to be done,” negatively affect your emotions and behaviors, said Thorn, author of Cognitive Therapy for Chronic Pain: A Step-by-Step Guide. They also make you more likely to get depressed and withdraw. Plus, “If you feel like there’s nothing you can do, you won’t do anything,” which is “really dangerous for someone with chronic pain.”

For instance, one of Thorn’s clients, who has lower back pain, kept saying that his spine was disintegrating because his MRI showed some damage. Thorn asked him how this thought was affecting his emotions and behavior. “It makes me panic, and I’m afraid to do anything.” This thought also spiked his blood pressure, breathing and heart rate. Thorn suggested he find another perspective that’s more realistic and less of an emotional noose. He came up with the following thought: “There’s still some damage to my spine, but no amount of surgeries will help that damage. [However] it is the kind of damage that would be helped with muscle strengthening.”

Today, Thorn’s client plans to work with a physical therapist to strengthen his muscles. “As soon as someone has an empowering thought, they start to feel like they have a little bit more control over their life,” Thorn said. “His spine is damaged. He’s had three surgeries. But does he have control? Yes, he does.”

Paying attention to your thoughts is especially helpful when your pain level rises. For instance, Thorn suggested asking yourself, “What just went through my mind? What am I saying to myself?” If you become aware of a negative thought that’s emotionally laden for you, “stop, breathe and then consider your options.” This helps to interrupt your reflexive reactions, such as lashing out at yourself or your loved ones. It helps you choose a different path, and reminds you that you have more control than you think you do, she said.

In CBT, along with other therapies like behavioral activation, clinicians also help patients discover the kinds of physical activities they can engage in without exacerbating their pain, Thorn said. They also help them make realistic goals and manage defeatist thinking.

For instance, a person who used to run 10 miles might be able to walk for a few minutes today. They might easily think that such a minor activity isn’t even worth it. However, as Thorn said, walking for 5 minutes several days a week adds up. Soon you might be able to walk for five days, and so on. “That kind of gradual increase will build on itself.” Plus, regular physical activity helps to improve mood and energy levels.

Living with chronic pain can be especially debilitating. It can lead to or exacerbate clinical depression. Fortunately, these conditions are highly treatable. The key is to seek treatment for both, and to remember that a fulfilling life is absolutely possible.

Further Reading

Thorn and Kerns both recommended the book Managing Pain Before It Manages You by Dr. Margaret A. Caudill. Kerns suggested John Otis’s Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook.

Also, these are excellent organizations: the American Chronic Pain Association, led by people with chronic pain, and the American Pain Society, Kerns said.

Have you seen that bit of dastardly magic happen in your life? You start the week with three priority-related tasks; by Monday night, you haven’t completed any of the original tasks and, somehow, your to-do list has more than quadrupled. You didn’t sleep the day away. You were actually working. So why isn’t the list shorter?

Enter Elizabeth Grace Saunders.

The 3 Secrets to Effective Time Investment may be the answers to your time-/work-related prayers. As a time management coach, Saunders is the founder and CEO of Real Life E, a time-coaching company that strives to empower their clients through a “schedule makeover” coaching process and various training programs. With a list of clients to back up her claims, Saunders’s method is straightforward and seemingly very helpful.

Throughout her book, Saunders provides “mental shifts” to help readers adjust their thoughts in a direction that will foster productivity, confidence, and positivity. She also includes action steps to move progress forward and journal exercises at the end of each chapter to give the reader the opportunity to meditate on the various crucial points.

Saunders addresses the importance of time investment, goes over the kinds of crippling emotions that stall productivity, and provides a series of mental exercises meant to empower and build confidence in the reader. She provides both “key mental shifts” and “essential actions steps” to combat and overcome emotions that can hold us back. For example, regarding the emotion “overwhelm,” one of the action steps is “allocate time carefully.” In this step, Saunders explains that the reader should not just determine what they need to do but also determine how much time to allot for each to-do item. One of the key mental shifts for “overwhelm” is:

Harmful thought: “I must do whatever it takes to keep up with my environment.”
Helpful thought: “I can choose to modify my environment and my response to my environment so that I feel comfortable with the pace and quantity of what is asked of me.”

This breakdown is helpful, but the so-called secrets alluded to in the title are the real meat of the book. Simply put, the three secrets are:

1) Clarify action-based priorities
2) Set realistic expectations
3) Strengthen simple routines.

These may seem rather straightforward, and there may be a few people who believe that those three lines are enough to give them the tools to implement effective time management. Do not be fooled. Saunders delivers these simple statements and then elaborates on their importance and how to successfully implement them. She also addresses potential roadblocks to the implementation of each step.

Saunders does a great job of looking at routines. She provides a step-by-step guide to developing your own set of simple routines. This section also includes references and notes to available templates on her blog, such as her “Simple Project Plan Template.” She also recommends other sites that can help, such as Harvest (www.getharvest.com), iDoneThis (www.idonethis.com), and Basecamp (www.basecamp.com).

Perhaps it was timing or perhaps it is because I love resources that help me get my life more organized and productive — but regardless of what it was, I absolutely loved The 3 Secrets to Effective Time Investment.  Although I have not yet taken the time to completely implement the book, I did actively participate in the exercises and journaling throughout my read. I am already planning on rereading the book more slowly and starting to implement the steps. I have recommended it to almost everyone I know who could potentially benefit from it — and that is basically everyone I know.

The 3 Secrets to Effective Time Investment
McGraw-Hill, December, 2012
Hardcover, 256 pages
$22.00

Perry begins with an assumption that we already have mental balance, but that we need tips to maintain it. While that assumption may be false for some readers, her book is still a useful tool. And although some of her ideas are not new, they are worth hearing again along with her more original suggestions.

Perry explains that most of our brain development occurs by age five. Our earliest experiences help to explain why we are who we are. She writes that while we will not remember all of our childhood influences or the people who created them, we can learn to recall and think about them in ways that will lead us to better mental health.

Many of our childhood experiences were positive and helped us to learn to process our feelings in a mature way, or helped us feel good about ourselves, Perry writes. However, we also had experiences that were confusing or undesirable that may have had a lasting effect on us. Perry advises that we process our feelings differently when it comes to the latter, in order to eliminate their negative impact.

This is a reasonable suggestion, but in reality, I found it very difficult to segregate individual events from years ago, let alone to identify their impact on me or how I felt about them. Just sitting with Perry’s book and one’s memories isn’t quite enough.

Perry also explains that there are essentially two types of insanity. At their extremes, they are chaos, which occurs when we careen from one chaotic situation to another, and rigidity, which occurs when we repeatedly react to experiences with outdated and negative responses. We want to avoid either extreme by being in touch with our sensations and reacting positively to what happens.

Meanwhile, Perry posits, there are four cornerstones to sanity: self-observation; relationships; stress; and personal narrative. By regularly evaluating these four areas, Perry says, we can gain and retain a saner outlook.

Through self-observation, she suggests, we can examine on a daily basis how we are feeling about what is happening to us. This observation should be non-judgmental, and should cause us to be responsible for our reactions rather than feel that we have no control over them. Perry provides a “grounding exercise” to help with this. As we evaluate our feelings, we may consider either how we think others see us or how something feels internally. I found both approaches to be helpful. She suggests that keeping a journal, meditating, or praying can also help.

Perry’s second point is that having good relationships helps us to stay sane, citing examples of how faulty relationships, or having too few positive relationships, can be detrimental. This is certainly not a new idea. Still, reading Perry’s take may help us to look more closely at our relationships and motivate us to make changes where we can do better.

Both positive and negative stress affect our sanity. This is the third area Perry discusses. Obviously, we know that positive stress should be embraced because it stimulates us, and that negative stress should be managed or eliminated. We should seek positive stress that is mental, such as new opportunities or challenges at work, and positive stress that is physical, such as a good workout. This is old news—and we usually recognize when we are under exceptional negative stress—but still a helpful reminder to pay attention to how our experiences may be affecting us.

Finally, Perry’s fourth cornerstone is personal narratives: the stories we tell ourselves or that others tell us, or that we have read or watched on television. Because we often subconsciously embrace these narratives, they help to define us—but when they are negative, Perry writes, we must edit or change them to regain our balance. She encourages us to look for the good news in these stories because, she believes, optimism gives us a better outlook than pessimism.

Some might argue with this simplified view, however. Rather than taking this approach, I find that narratives help me more when I check my reactions or feelings against the people in a given “story.”

Perry provides a series of exercises intended to help us experience the four cornerstones of sanity. These are mostly common-sense activities, but can still be useful. Just as a therapist would encourage and expect a client to work on areas that may bring about improvement, the author expects the reader to do some of the same. The unfortunate shortcoming, of course, is that with a book, a reader has no way to get professional feedback on his progress. However, if we intuitively feel when we are not in balance, it can help to try some mental exercises on our own.

This is an easy book to read, and a second reading may uncover new insights. Too often we read advice in a self-help text, agree that it makes sense, and then go about our busy and stressful lives as though we never read the book. To make this one worth our time, we must pay attention to these ideas in a thoughtful way and then follow Perry’s suggestions. For instance, reviewing what happened at the end of each day and how we reacted to it helps us to make positive change. As Socrates tells us, “the unexamined life is not worth living.” Perry gives us direction. We may not want to follow every suggestion, but can probably find some that feel comfortable.

How to Stay Sane
Picador, December, 2012
Paperback, 192 pages
$16.00

But it’s actually not uncommon for the first treatment to be unsuccessful. In fact, about 40 to 50 percent of people don’t respond to the first antidepressant they’re prescribed, according to Jonathan E. Alpert, M.D., Ph.D, the associate director of the Massachusetts General Hospital Depression Clinical and Research Program and co-founder and co-director of the Depression and Anxiety Group Practice.

Still, the people who stick with treatment do get better. So there is hope – real, tangible hope. Below, you’ll learn why treatment might not work, along with what you can do and how you can advocate for yourself.

Why the First Treatment Doesn’t Work

There are many reasons why the initial treatment doesn’t take. Here’s a selection.

Incorrect diagnosis. The treatment might be ineffective because the person doesn’t have depression in the first place. For instance, medical illnesses such as hypothyroidism can look like depression. Hypothyroidism produces significant fatigue, lack of motivation and difficulty concentrating, Dr. Alpert said.

A person might have another psychiatric disorder such as bipolar disorder. “On average bipolar disorder takes 7 years to diagnose,” said Kelli Hyland, M.D., a psychiatrist in outpatient private practice in Salt Lake City, Utah. Or an individual might have a personality disorder, which doesn’t respond to medication, she said. (In fact, “medication is often contraindicated.”)

Even if the diagnosis is correct, medical conditions can blunt the effect of antidepressants, Alpert said.

Stressors. Sometimes, the person is “living in an untenable situation,” Alpert said. So it doesn’t matter how well the antidepressant is working because the individual is still surrounded by stress – either at home or at work – that needs to be addressed, he said.

Adherence. Some people might stop taking their medication because they’re concerned that it’s habit-forming, addictive or a crutch, Alpert said. Other individuals might stop because they actually feel better. But, as he said, “Once someone responds, they need to stay on medication for a minimum of 6 to 9 months to ensure they don’t have a rapid relapse.”

Another reason people stop taking their medication is side effects, such as nausea, diarrhea, sexual dysfunction or weight gain, he said. (“Many of these side effects can be addressed by switching to a lower dosage or a different antidepressant or sometimes by prescribing a second medication that helps alleviate the side effect.”)

Alcohol or drug use. “Alcohol and drugs interfere with antidepressant response,” Alpert said. Even having a beer or glass of wine at night can mess with your medication, Hyland said.

Other medications. Hyland noted that other medications, such as steroids and hormones, can interfere with antidepressants. (Being perimenopausal or menopausal also can affect efficacy, she said.)

Sleep problems. “I tell my patients that if you’re not sleeping, we can take medication ‘til the cows come home,” Hyland said. “Insomnia exacerbates mood, anxiety and coping.” Treating an underlying sleep disorder or trauma is important, she said.

Severity of illness. With moderate to severe depression, people often do best with medication and therapy, Hyland said. And sometimes two or three medications aren’t enough, she said.

The Next Steps

If your first ineffective treatment was medication, there are several ways physicians proceed. Alpert begins by examining the reasons the medication didn’t work. If he can eliminate the above as culprits, he might increase the dose of the medication. He also might switch the patient to another antidepressant within the same class (such as switching from one selective serotonin reuptake inhibitor, or SSRI, to another). He then might choose a medication from another class.

Another technique is to add a medication to augment the effects of the initial antidepressant, “especially if there is some evidence of a partial response,” Alpert said. In other words, if a person thinks they’re about 20 percent better and they’re tolerating the medication well, the doctor may prescribe a second antidepressant that works on a different mechanism of the brain, he said. An example is combining an SSRI, which targets serotonin, with Wellbutrin, which works on dopamine and norepinephrine.

Physicians also might prescribe an atypical antipsychotic, such as Abilify or Seroquel, to bolster the effects of the original antidepressant, Alpert said.

Psychotherapy, including cognitive-behavioral therapy and interpersonal therapy, is highly effective for treating depression. Therapists help clients learn about their illness, cope with stressors in their lives, identify and change dysfunctional thinking, and take action to get better.

If you’re only taking medication, seeing a therapist can be tremendously helpful. (If you’re solely working with a therapist, it’s also possible that you might need medication.)

Somebody, somewhere, declared April to be Autism Awareness Month. I’m all for it. We need to be more aware of it so that children are diagnosed early and accurately to make sure that they get the treatment they need.

What is Autism?

Autism is a neurological disorder that usually becomes apparent by the age of 3 if people know what to look for. Part of the problem in diagnosing autism is the wide range of possible behaviors and abilities. However, there is usually a distinct pattern of significant impairment in three major areas:

• Impairment in reciprocal social interaction. Children who are on the autism spectrum don’t get the give and take of conversation and sharing of experience. Even when very little, neurotypical kids will point to things that interest them so that others will see it too. They will babble back and forth, imitating conversation. Autistic kids seem to be in their own world, uninterested in sharing it with others or unable to understand that other people aren’t as interested as they are in their obsession of the moment. Higher-functioning kids with autism may come off as rude, clueless, or self-centered because of their apparent inability to read what is socially appropriate at any given time.
• Impairment in communication skills. Their language may be unusual, stilted, or limited. High-functioning kids on the spectrum may have large vocabularies but may use words incorrectly or idiosyncratically. Lower-functioning kids may not speak at all.
• Presence of stereotyped behaviors, interests, and activities.Spinning, flapping, and finger-flicking are common in young kids and even in some autistic adults. Many rock to comfort themselves. Children may develop an intense obsessive interest in just about anything. I’ve known kids who are walking encyclopedias about pirates or fishing or who know every detail of every one of the Star Wars movies. They can talk for hours about their “thing” but are unable to have even a brief conversation about almost anything else.Some of the more disabled kids with autism I’ve known have been obsessed with things such as different kinds of tires, ceiling fans or string. They are happiest when they can watch or play with their particular interest. High-functioning autistic adults may become experts in arcane academic or technical areas, again to the exclusion of almost everything else.

  In addition, many of these children show sensory processing disorders. They can be intensely over- or under-sensitive to sensory stimulation (lights, sounds, smells, or touch). Some are unable to stand the buzz of fluorescent lights or the smell of certain foods, the sensation of certain fabrics or changes in temperature, to name only a few examples. Some have a very high tolerance for pain. (A school program called me recently because a teenaged girl seemed to feel no pain when she pulled off fingernails.) Some can’t manage any discomfort at all. I know one preschooler who walks on tip-toe whenever he is barefoot because he can’t tolerate how grit feels on his feet.

Autism is associated with a known medical condition in only 10 to 20 percent of cases. It is thought to be genetic since 60 to 90 percent of identical twins both have it while in fraternal twins it is less than 5 percent. As yet, there is no genetic test or brain scan or medical test to use for diagnosis. We rely on observation and the experience of professionals.

Why Does the Prevalence Rate Keep Growing?

In my professional lifetime, the odds of a child having autism have kept growing. In the 1970s, the statistic worldwide was 4 in 10,000. Between 1985-1995, the number tripled to 12 in 10,000. The rate was estimated to be 1 in 155 by 2002; 1 in 110 in 2006 and 1 in 88 in 2008. Some studies are now suggesting that it afflicts 1 in 50 kids in the U.S.

What happened? Partly it’s about a change in the acceptance of autism as a genuine, distinct disorder. Partly it’s due to a change over time in the description of criteria and the number of criteria that need to be met to make a diagnosis.

When I was in graduate school in the early 1970s, we were using the DSM-II. Autism isn’t mentioned except as a subset of childhood schizophrenia. Frankly, back then, I’d never heard of it. When DSM-III came along in 1980, a section on infantile autism was added and the first effort was made to delineate criteria. It took until the DSM-IIIR in 1987 for autism disorder to appear with a well-articulated set of 16 criteria, 8 of which had to be present to warrant a diagnosis. By the time the DSM-IV (1994) and DSM-IVR (2000) came out, the number of criteria had been reduced to 12, with 6 being needed for a diagnosis. With each succeeding edition, mental health professionals became more aware of autism as a possible diagnosis.

At least some of the increase in prevalence is due to that awareness on the part of professionals. Some of it is probably because kids who at one time might have been diagnosed with psychosis or retardation or hyperactivity are now being assigned the diagnosis of autism. And some of it is due to the fact that parents and teachers have become much more attuned to the possibility that a child is on the autism spectrum, so evaluations are occurring at a much earlier age. Finally, it’s possible that there is something going on in our environment or in genetics that is causing an increase in the disorder. That last one remains a mystery.

What if You Suspect Your Child Has Autism?

With the increase in autism prevalence and awareness has come an increased sophistication in screening. A diagnosis of autism is rarely assigned before 15 to 18 months of age. If by then you suspect that your child isn’t developing as he or she should, you can first go to one of the many websites that have quizzes and checklists for the symptoms of autism for the age of your child. But please don’t go on the results of those websites alone. There are many reasons why a child may not be keeping up with peers. It’s just a good, if crude, first effort.

The next step is to ask your pediatrician to take a look at your web-based checklists and to decide if a referral to an autism screening team is advisable. There are early childhood interventions (EI) teams all over the U.S. who can make a more refined diagnosis and who can offer treatment if it is needed. If there is no EI team nearby, there is probably a diagnostic team in a mental health clinic or children’s hospital near you. An accurate diagnosis is essential. Diagnosis is what determines what types of treat may be the most helpful for your child.

Early Intervention Matters

There is no cure for autism but when children get intense and appropriate treatment early on, preferably before age 3, many can and do learn compensatory skills. Excellent programs provide physical, occupational and speech therapy as well as coaching in social and language skills for the child. They also provide coaching and support for parents so they can reinforce and continue the treatment at home. If there is no comprehensive program nearby, there is often a resource center connected with a school or with a medical center that can help families get the services the child needs.

Before reaching a tipping point, people often are able to balance known or unknown ADHD challenges with strategies they may not have even realized they were using. They had been able to adapt and cope well with their symptoms. Their symptoms may not have interfered with their functioning, so that they avoided an official ADHD diagnosis.

But for some reason a life change — a job promotion, relationship change, school change, or myriad other things — renders the current strategies ineffective. Over time there is a sense that things are no longer going well and in fact, life seems to be falling apart in a big way.

Here are some life situations that could be possible tipping points::

1. New problems at school.

Often, when higher elementary or middle school hits, students begin unraveling. They experience more responsibility in juggling multiple classrooms, more homework and larger classes. Suddenly it seems like nothing is working anymore. They can’t get things done that they want to get done, everything becomes chaotic, things start to come undone. Their schoolwork starts to suffer; they may have trouble concentrating in class, forget to hand in homework or start to experience difficulties with old friendships.

Often, no one recognizes these warning signs as being ADHD-related because the students previously had managed or were able to compensate for their challenges. Parents and educators start to feel helpless when a previously successful student seems to become unmotivated. Students are told they just need to try harder. Everyone is unsure how to get the child back on track and the students begin to feel stupid, lazy and incapable.

2. Inability to cope after significant life changes.

Some people with ADHD experience their first tipping point after a significant life change, even a positive one such as getting married or moving into a new home. These major life celebrations are anticipated with great joy, but often may be a change that tips the balance. Perhaps you’ve been able to balance your own life and your own schedule and where you put things up until now. But then you get married and now your spouse has a different way of doing things or expectations of the way things should be organized that differ from your views. That’s not to mention having to deal with the extra stuff in your space.

Slowly you notice that things are not working as well as they had before, and because this is supposed to be the happiest time of your life, you think there must be something wrong with you — right? Wrong! Significant life changes such as getting married, having another child or moving homes often can upset an unknown balance.

3. Unable to transition successfully into a new role at work.

Up until your “tipping point” you have been performing really well in your job — so well, in fact, that you are promoted. Slowly you may start to notice that you are not doing this new job as well as everyone expected, and you begin to isolate yourself, dread going to work and may eventually get fired.

What happened? You reached your tipping point. Not because you didn’t deserve the job, but because changes in work often come with changes of staff, support, work space, etc. that throw you off.

4. Change in family dynamics.

If you find yourself with new responsibilities and changes in your family, such as taking in an elderly parent, adding members to your family, or getting a new roommate, the additional responsibilities, change in routine and stress can gradually sink in and leave you overwhelmed and unable to cope as you have previously. It is so easy to begin to think you are a terrible mom, unfit for the responsibilities of a family or that you may be destined to live alone.

It’s not you. You were thrown off-balance, and your ability to compensate for your ADHD with your old routine, structures or systems is no longer working. But instead of seeing the truth, that it isn’t anything you’ve done wrong, or knowing that you can fix this, you’re filled with undeserved guilt and shame.

5. Physical injury.

People often experience their tipping point when an ADHD-management strategy such as exercise decreases or activity level changes. Unbeknownst to many people with ADHD, participation in sports or daily exercise provides some additional dopamine to our brain and helps to create structure and routine in our lives that help to better manage ADHD symptoms.

Tipping points are common for high school athletes who have earned success not only in their sports but academically, only to go off to college and experience failure for the first time. Without the rigorous physical training and structure of high school, they begin slowly to fall apart. Another common tipping point for people with ADHD is when they have experienced an injury and have to decrease their activity or exercise level. This change in routine and absence of daily dopamine boosts can challenge previous steadiness, energy levels and ability to focus. Life begins to wobble.

As you can see, there are many reasons, often beyond your control, that might lead you to your tipping point. A tipping point means that you are at a crossroads. You have a choice which way you will react. You can continue down that path to chaos and overwhelm, or you can get restructured and relearn ways to to cope and get back on track.