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“Nothing in life is to be feared but understood”- Marie Curie.

Once in a while I get an email from a Spo-fan (or somebody like one) wanting to hear about anxiety, more specifically, what to do about it. I spend a lot of my working day addressing this issue. You would think the patients who are most challenging to work with would be the folks with mania or psychosis or depression. It is not so. It is the anxious ones that are the most challenging to work with as they are often literally and figuratively in a panic, seeing things as urgent if not catastrophic. It is a challenge not succumb to their anxieties.

So here are some tips for thems dealing with anxiety.
Pay attention, people pay me big bucks for this sort of stuff.

The emotion of anxiety is part of our physiology; it is there for a reason. We are the descendants of those who got tense and vigilant when they encountered something or someone dangerous or unfamiliar. The folks who shrugged off that funny-sounding noise from behind ended up as prey, not as parents. Our inner brains remain wired to react to new things/others with anxious trepidation. Alas, Babylon! These inner-brain parts don’t discriminate. An angry tiger pushes the same buttons as does an angry boss. Thus, it is normal to have anxiety; it pops up before our frontal cortexes kick in with a more relational reaction “hey, this isn’t a tiger! Cool it down there!” In summary: anxiety is not the enemy. Anxiety is a team member, one you really don’t want to live without. Anxiety is just not a good team leader. Anxiety makes a good servant but a lousy boss. I tell my patients to quit looking at anxiety as maleficent alien life form or an omnipotent enemy.

You may not be able to stop becoming anxious when something happens, but you can do something about how you react to it. Anxiety can feel intense, overwhelming, and ponderous, but it is nevertheless a treatable condition. What I mean by this is getting anxiety (acute and chronic types) down to a dull roar. Thems who are anxious often want anxiety not to be happening at all. They see it as a black/white on/off emotion: either not there or at a 10+ level. For those with chronic anxiety, approach it like any other chronic condition. One learns to live with it and not let it dominate your life. C.G. Jung said when you try to eradicate something it just comes back to dominate you worse than ever.

Emerson said “always do what your are afraid to do” – good advice for thems who are anxious. It is understandable that when faced with something that evokes anxiety we want to do a 180 and avoid it. If we persevere and practice what we fear, we realize ‘it wasn’t that bad’. This builds familiarity and confidence – and anxiety ameliorates. This needs to be done in steps called ‘desensitization’. I am presently working with a patient who has developed an anxiety to drive. She is practicing merely driving around the block in her familiar neighborhood, knowing if she becomes anxious she is only a few minutes from home. As she grows OK with this she will go out longer and farther, and eventually to highway driving (during a quiet time of the day).

I’ve trained myself whenever I get anxious about doing something, I pause to remember literally everything I like doing now started this way. Give it a try, knowing I will bungle/be anxious but survive and perhaps keep going.

Most folks tell me their anxiety is about the ‘what-ifs’ of life and the consequences of these scenarios.** At the heart of it all is fear of the unknown.

When patients tell me they are ‘frozen with anxiety’ I give them my spiel to pick a direction and start. “But how do I know if it’s the right thing and what happens if it fails?” You don’t really. How do you know anything about the future, no matter how you try to control for it by avoiding anxiety-evoking actions? If you want to improve your life you have to embrace uncertainty and allow anxiety to be. It’s not comfortable. You have to get comfortable with being uncomfortable. In this paradox the tyrant anxiety diminishes and becomes no longer the master. This is the true notion of head shrinking.

*These words are often interchangeable. To straw split, worry is the mental matter and anxiety is mental with physical components. I may worry did I leave the stove on; if I am having palpitations, tremors, dyspnea along with the worry, this is anxiety.

**Counseling/therapy often works with these ‘worse-case’ scenarios. How likely they are to happen, and how bad would it be really if it did happen. Often that anxious matter (like going to a party of strangers) may be not comfortable but hardly the ‘everyone will look at me/laugh at me/judge me” and I will be wiped out” that is feared.

Writing is challenging after an entry like yesterday’s. Most of my scribblings are attempts at Attic wit, and I am not feeling much of that today. However, I know Warrior Queen would want me to persevere – especially on a Saturday night when she held court as DJ for the weekly blogger dance over at her place.  Here is one I wrote earlier this week. Spo

The Tuesday after Memorial Day sees the most august return of Urs Truly to face-to-face appointments.  Before the pandemic, my work week consists of two places: “The Phoenix Office” and “The Mesa Office”. I go to the latter on Tuesdays and Thursdays, so my first ‘back to work’ day as it were will be in the faraway Kingdom of Mesa.  I have not set foot in that office in over a year. I know this as my space is for a ‘zoom’ appointments for thems needing to come in for their on-line appointments while I am working at home.  Many have pointed out the wall calendar is says it is April 2020. *

Someone proposes I drive there tomorrow and give the space a good washing.  For the past year, the patients were at my desk, working the computer and mouse. Last week I sent an email to the House Manager, asking her to provide the names of who works there. I don’t remember. Some of the staff I haven’t seen in a year, and a few have shifted roles (and rooms) and there are new people I haven’t met but only know by group email.  Imagine Urs Truly showing up and not remembering who is who!  Oh the embarrassment.  The only one I remember is The Billing Lady, to whom I report daily on the number of ‘no-show’ appointments.  I think she stayed in the same room.

I am curious to see if patients and staff will be wearing masks. I sure hope so. You bet your knickers I am wearing mine. I wonder if patients will find this comforting or upsetting.  Most of The Mesa Minions work in enclosed rooms without space for social distancing.

The reactions of the patients to this homecoming range from rejoicing to outrage.  Many hate zoom appointments;  coming in to the office is comforting and often it gives them something to do.  In the other camp are the many who like the convenience of appointments online; they are not happy to give this up.  The Bosses say both options will continue, but who can say.**

The drive to Mesa is a 30-40 minute commute. This allows time to listen to audiobooks and lectures and podcasts of longer duration.  That is a ‘plus”.  A ‘negative”:  this weekend I have to find my good trousers and again dress in ‘contemporary professional standards for dress’, as it were. I haven’t worn a bowtie in ages: I suppose that will be nice to do again. 

I think the hardest part about returning to office-based work will be being in an enclosed small room with other people, breathing and possibly unvaccinated.  After a year of anyone near me as contagion,  this will be difficult to let up.

As I ponder these matters, I wonder what  The Mesa staff think about me returning.  On the days I am there, their workload worsens what with patients are coming and going, checking in and out, and arguing at the glass about late fees etc. 

I suspect it will feel funny and be awkward at first but given a few weeks it will feel as if 2020 was merely a dream, dreamt while sitting at home in cargo shorts.

*I should also get a 2021 calendar (if available) and have a look-see into the office refrigerator to see if that egg sandwich I left there has endured.

**Phone appointments are right out, apparently. That’s too bad, as telephone appointments allowed me to surf the net or watch YouTube (volume off) while certain patients complain (for the umpteenth time) about things I’ve heard in every appointment. This opprobrious action cannot be done in when patients are there in the room in person. 

The Board of Directors Here at Spo-reflections have some peeves.* One of them is ‘repeats’. This morning The Muses (or somebody like them) delivered onto me an inchoate entry about security and uncertainty. TBDHSR quickly sent an email reminding me I already did this and recently  too. They suggested I write about conspiracy; they had checked and couldn’t find that. 

I would sooner eat rats at Tewkesbury than follow conspiracies. The only thing worthwhile about them is the psychology, the ’why’ people believe them rather than the heinous contents. 

Conspiracy theories have at their creepy centers an iota of truth. They have a point. This, combined with our desire for certainty (and our love to be ‘in the know’) makes them successful. They start with good questions which frankly I applaud:

How can I trust information I haven’t verified ? 

What if the sources are wrong ? 

What if the source is lying to me ? 

Where these questions lead often goes to delusional rubbish, but the questions themselves are worth asking. Since we cannot verify everything we read and hear, we have to have trust in the sources.  


I am supposedly an expert in my field (hey! I have several fancy diplomas on my wall to prove it!) I too have to rely on trust teachers and predecessors and researchers that they have been trustworthy; I am not going to test every new articles’ conclusion. This is a big deal. If knowledge is really all about trust, how do we know whom to trust?  Which ones are valid and which ones are bogus? 

I cannot speak to the specifics of certain conspiracy theories that are currently in the headlines. What I see before I run away looks too incredible for anyone in their right mind to believe. Alas, human psychology is wired we want to be in the ‘in crowd’ with secret and superior knowledge that no one else has and that others are trying to suppress. This is not a new phenomena; history is full of examples; only the contents change. Thanks to the internet they spread faster and to more people. Dame Rumor, not Google, controls the keys.

Sometimes when a patient tells me they know something they know is true (say, all you doctors know the cure for cancer but you are sworn to secrecy so you can make money from treating the sick)** I know through experience not to apply those three questions as this gets nowhere. I ask “Does your belief in this give you comfort?” which is sometimes just enough to shake them a bit into better self-reflection perhaps towards a more likely (albeit less glamorous) belief.  

After the patient leaves the office I take off my rubber face mask to reveal my lizard features and I call the AMA on the secret phone in my desk to assure them our secrets remains safe.  

TBDHSR doesn’t believe in conspiracies but they adore tinfoil hats.

*Their biggest peeves: warm mead, misuse of the word ‘mid’, and the Gauls. 

**Yes, people believe this. I hear this one from time to time.

I recently heard the joke ‘what was Jesus’ greatest miracle?’ Answer: he had twelve close friends in his 30s. The humor rests on the sad commentary men are not good at making and keeping friends and this only worsens with age. Older men who lack friends are at great risk for loneliness, depression, shortened life-spans, and suicide.

The predicament is worse for straight men but gay dudes have it tough as well. In history the love of a man for his comrade was something held in high esteem; it was considered more noble than the love for his wife or to his family. In modern times, if there is any sign of love between men they and those around them become uncomfortable – does it mean they are gay? Even the gay guys are guilty of this. Modern folks who read how two men in history loved each other as brothers conclude they couple were closet cases. Sometimes gay guys struggle making male friends from the awkwardness of boundaries: are we just friends or friends with benefits or what? Whatever team they bat for, it’s tough for men to be friends.

Women don’t usually have this problem; on the whole they are much better at making friends. My late Mother could go into a crowd of female strangers, start talking, and within twenty minutes she had formed a budding relationship “Oh, do join us for bridge/church/gym class” etc. She once conveyed she was bewildered why Father needed a lot of work to form a bond what she could accomplish without much effort. I told her to imagine trying to form a friendship when you are not allowed to talk about your feelings, your home, your sex life, or personal problems. I remember coming home to a neighborhood party to discover all the ladies where in the kitchen, gabbing, and the men-folk all went to the living room. The women were talking about themselves and making plans; the men were discussing baseball.

The situation is a bit better now that men (and women) are beginning to realize the importance of middle-aged and older men having buddies, but there is little success yet towards achieving this goal. Many of my male patients (gay or straight) tell me they would like friends but they don’t know how. This problem is made worse by the covid19 situation; we aren’t supposed to go out and socialize.

Traditionally men form a sort of friendship through a goal or a project. They join a sports team or a chess club. This gives men something to do and cooperate with and through this they may form a lasting relationship after the activity is completed.* Gay men have bars and some apps to try, but these are usually useless for forming pal-ships.**

My twenty year old nephew tells me he has about a dozen friends, which he fatally figures will drop off after graduating from college, but he hopes by the time he is in his forties one or two will have endured. “Cause you can’t make friends later”. I don’t have any easy answers for him or for my lonely friends/patients what to do about this. I only know it is something they need to work on. Like Ursula K. LeGuin’s concept of “Those who walk away from Omelas” I cannot describe it and it is possible that it does not exist. But it is worth walking to find it.

Spo-fans of the male persuasion: do you have chums? Do you have someone besides your spouse you actually talk with?

Spo-fans of the female type: do you have gal-pals? The menfolk in your life: do they have friends?

*Not often though. What usually happens is these relationships are compartmentalized. ‘Chuck’ is the pal with whom I play chess and ‘Bob’ is the fellow who plays second base on our softball team. For a man to call Chuck or Bob and ask him to go out and do something else out of context would probably bewilder both parties so it isn’t done.

**Nowadays going to bars to meet others is a dead enterprise. Everyone is engrossed in their phones. I am not aware of any apps for straight mean looking for chums. I cannot imagine one working.

Hey, Spo-fans! I am up to my oxters in hosting family and haven’t had time to write a proper post. Here is one I was working on for later. Spo

It’s been a year now since I started working from home. I know this so by the “Roster” file. At the end of each work day I send to the billing department the daily roster of my day.  I see the first one is dated 3 April, 2020. * What a funny anniversary to commemorate.  

I was fortunate with covid19 my job readily translated to zoom/phone appointments; I can easily shrink heads at home while sitting in my jammies.**  The majority of patients liked the zoom arrangement. Some of my patients have to travel long distances for their 15 minute check up and others felt limited to only be seen in the Mesa office, which had less opportune hours. On zoom, both matters ceased to be an impediment.  Patients could check in from where ever they were. Curious! A year ago at-home/zoom type appointments were not allowed nor covered by insurance programs and it was almost heretical to suggest trying such. Now they are the norm.

The patients and my bosses are beginning to wonder when the offices will return to old-fashioned face-to-face appointments.  Many are also asking if they can continue using zoom anyway. My answer is: who can say. The cynical answer of course is ‘that will depend if your insurance company is still willing to pay of zoom’.  It will be difficult in my opinion putting the genie back in the bottle. Too many folks want zoom-type appointments.  I will be curious to see what happens: will zoom remain an option and in what circumstances?

I wouldn’t mind having a day ‘working at home’ when all I do is zoom appointments, to cut down on driving and help me mind my aging dog and not have to put on pants.**. We shall see.

*This is supported by zoom appointments being done at the Mesa office; patients doing their appointmens from there remark the calendar in my office is at April, 2020.

**The APA secret police: back off this. These are figurative not literal comments.

Medical schools recently discovered a gimmick named “The white coat ritual”. In it, first year medical students don short white coats that have been bought/sponsored for them by alumni. The students like the ceremony; the alumni feel good for doing so; the schools get some cash in the process. Over the years I’ve sponsored a few students; most have had the good manners to write an email thanking me for doing so. When I get one of these correspondences I write back with an introduction of myself and an offer to keep in touch if they need advice. Only one as done this, a young woman named Bo*.

In the past four years, MS (medical student) Bo has sent emails from time to time, telling me about her studies and how things are going. In return I’ve given her sage advice on how to keep sane and not be swindled by the BS-itude of medical school, of which their is plenty. Bo comes across as a bright and excited person, which is good for someone going into Medicine. She’s had the challenge of being trained during covid19 – can you imagine? 

Last week was “Match day” was last week when students discover where they are going for post-school training. She is excited to have matched to some swanky-sounding medical center in Cleveland Ohio- which was her first choice. She will be near her relations.  It is a joy to hear her happiness about all of this.  She asked for some guidance about residency; I wrote my thoughts on how to prepare for the challenges ahead of her.**

I wish there had been someone to have helped me through the trials and shenanigans of my medical training.  I’ve read med students and residents now have more humane work hours and mental health resources to get them through the grueling process that is residency. I hope so. I struggled alone with my depression and anxiety and loneliness which was 1988-1989*** and when I reached out for help it was held against me.  I would not wish my residency experience on anybody.  I hope hers will be more supportive.

Despite the misery and fears that was internship and residency I survived. Bo will survived too. I daresay she will find it hard in her own way. I don’t know for sure but I think she is African-American which means she will be dealing with that challenge too. I hope most she comes out a good doctor and with a good network of colleagues – something I did not yet nor have to this day. I will be curious to see what happens to Bo and I hope to be there to guide her on her Journey.

*Not her real name.

**It is hell.

***I used to joke I was one year younger than I was as “I do not wish to count as part of my life the year lost in internship”.

Philosophy and Psychology have in common the notion of Self-growth as the goal of living. “Man, know thyself” was written over the door at the Oracle at Delphi for folks to see as they came to learn about their fate. Psychotherapy is mostly about looking at what is getting in the way of the patient’s progress in life.  Both have the assumption – perhaps naïf- people actually want to grow.  In my job I’ve learned not everyone wants to grow. In fact this may be the majority; nowadays people want certainty which is detrimental to growth and learning.  Many people are trying merely to survive. Their lives aren’t so much ‘how do I become a better person” but “how the hell to I get through this day?” and repeat again tomorrow.*

I see a specific sort of clientele, so my data is skewed towards the folks not looking for insight or Self-growth but for medication to appease their anxiety or lift their melancholy so they have more strength and stamina to get through the direful situations they are living in/contending with. I try to insert some education about escaping that awful job/relationship/situation; I also try to get them to see growth and survival as not a choice or one or the other. Often this goes over like a lead balloon. I’ve learned lots of my patients aren’t going to grow and to drag them kicking and screaming down The Journey is foolish. They get their meds, they vent/complain about their lot, and back again in three months.

Once in a while (alas not frequent) someone comes in who doesn’t have ‘clinical depression’ but has ‘spiritual depression”.  In psychoanalysis, depression is not a medical condition to suppress like hypertension but a warning sign one’s life is not right. It’s like an engine light coming on in you car.  When this happens one doesn’t ask the mechanic to turn it off, but to lift the bonnet and see what’s wrong inside with the engine. Dynamic depression feels lousy but thems who experience it have been given a prod to do some something about it viz. mend their lives and find what out needs to be done.  My job is to point this out and try to get them going on their path, despite the fears, the uncertainty, and for some the perceived lateness. 

Few recognize this sort of depression and what it is calling them to do, and fewer still are willing to go on the difficult unforeseen Journey.  Psyche has a curios way to ‘encourage one” to do so when you don’t go willingly by creating road blocks in the form of nervous breakdowns or unconscious acting out to lose your status quo. “Finally!” is seems to say when you’ve lost the jobs/spouse/health “It took a lot but perhaps now we can start the real work!”  

Anyone who has ever read a fairy tale or seen an adventure movie knows The Hero does not go alone on their Journey but goes with sidekicks and meets people to help them. My job often serves the role of Friend or Sidekick.  I am honored to be part of anyone’s Journey.  I hope to give assistance even when I cannot show them the Way. 

 

*I would like to figure out in a Venn diagram two circles, one titled “Those who are just trying to survive” and another titled: “Those not interested in growing” to see if there is much overlap. I used to think thems not interested led to thems just trying to survive, but I know now this is not cause and effect per se.

I routinely ask my patients what’s happening since we last met and if there is anything exciting or ominous in the immediate future. Thanks to covid19, the usual response I receive now is ‘nothing’ and ‘nothing’. This is often said with a grin and the add-on ‘I’m boring!”. I usually reply I like boring; it’s a sign no bad matters are happening.

Most emotions point us to pay attention to something, but boredom tells us what we are doing isn’t worth our while. With the instant availability of cellphone shenanigans, boredom is now rarer than at any other time in history – and more awful when experienced.  We would rather eat rats at Tewkesbury than experience boredom.  I recently heard about a study on boredom involving college kids asked to do nothing but sit and think in a room that had in it a device that would give a small but unpleasant electric shock if touched.  It turns out a sizeable amount of participants preferred shocking themselves – sometimes often – to that of being bored with their thoughts. 

Our monkey brains are wired to learn and grow and do things that have meaning and when this isn’t happening, we become sorely vexed. An element of why folks to do drugs, drink, smoke, eat junk food, etc. is they feel bored and cannot think of anything else to do.  Most job dissatisfaction is based on boredom and the underlying sense what they do has no meaning.  

Urs Truly is seldom if ever bored, simply because I always have something that interests me. I feel fortunate this way. There is nearly always something to do and what I have to do is worthwhile. Like Mary Poppins’ spoonful of sugar, I make meaning out of the mundane.  However, the dark side of this is I don’t allow myself times to be bored. This would be a good thing I reckon. Many authors and inventors relate their ideas came to them during quiet times of boredom when they were not distracted by things.

Covid has many folks feeling bored for the first time in a long while.  Rather than try to escape from it, let’s try to learn something from it. The quote “Be still, and know that I am God” holds truth that when things are quiet we are open to inspiration and insight.   

I never go online to read what is written there about me.  I suspect there is some (a lot?) of negative reviews. In general, people go online to rate doctors when they are unhappy, which makes Yelp reviews etc. biased towards the complainers.  I cannot rebuke and clarify* matters as it breaks confidentiality. Lately I haven’t gone online to see the news either. Only recently I heard about the bad weather in Texas and Mr. Cruz in Mexico.**  Thanks to my avoidance of social media I wasn’t aware Mr. Limbaugh had died. *** 

As I write this, the sun is shining and it is 18C (mid-60s F).  When I don’t’ go onto the internet, life is quiet and pleasant – my life anyway.  The question arises: am I being sensible not going online looking for things or am I deluding myself?  Am I better off knowing what might be said of my online?  If there is a lot of negative reviews online, I see no evidence my business suffers for it.  New patients have to wait weeks, sometimes months, for an appointment with me. 

I always ask new patient ‘how did you find me or this place?”. Many say their GPs sent them (code: their doctors are happy with me to send me more patients) or they read something ‘good online about me’.  Word of mouth seems good enough to keep me gainfully employed, surpassing what may be written in the doctors reviews.

I will leave you with this charming vignette. I once asked the usual question and I got this response: The patient explained he had gone online to get the address where I work only to be taken right to a doctor review site. He states he read a review saying I was

‘Distant, pompous, arrogant, and godlike”

He explained: since he’s heard from his loved ones he is all that, I must be the right doc for him.  I was deeply touched by this complimentary thunderbolt. However, I stopped wearing to work the helmet and the eye patch.

 

*‘He did not listen to me’ is often code for someone wanted controlled substances and I would not give them.

**I like to go online and give Mr. Cruz a negative review. Stirge. 

***Can we say this is God’s will, and it was his own damn fault for his lifestyle choices? 

A common complaint from my patients they procrastinate.  It is always the same: they ‘know what needs to be done” but do not do it. They are unhappy about it; they do not like this. They usually attribute their procrastination to their mental illness (depression, anxiety, OCD etc.) or ‘that they are lazy’. Another ubiquitous belief is if their low motivation were remedied this would solve the problem.

Happily, most of these erroneous beliefs and assumptions can be changed.

Putting off something is a universal human endeavor: they are not a sign of mental illness per se. Procrastination has at its heart is the desire to avoid experiencing negative emotions.  Making that phone call, starting those taxes, cleaning out the garage etc. all make us face unhappy feelings: fear, anxiety, pain, embarrassment etc.  We are wired to feel good and to avoid bad things. Thus we go towards sitting on the couch eating nasty chips rather than getting up and starting the new year’s resolutions to do a daily walk, as the later puts us face to face with the sad feeling how out of shape we really are.

Whenever I find myself procrastinating, I immediately pounce on what negative emotions I am trying to avoid. I remind myself while these emotions are no fun they are not devastating. Often, I do a 180 and immediately do something about the task I am trying to avoid.

I teach my patients to first stop to acknowledge their feelings behind procrastination; this is the first step. The second step is rearranging the equation. Motivation is not the first step towards action. Rather, it is the motivation is the reward for taking action.

Let’s say the goal is to ‘clean out the office’. By seeing it as one big task this evokes feeling overwhelmed and coming to painful feelings of the long tedious task ahead. Rather than doing it that way do the following:  set your alarm for the same time of day (we are more likely to do something in a structured time) to do the ‘five minutes’ rule.  For five minutes and five only – regardless of your motivation – go to the office and do something, anything. Start with something small like a drawer or putting papers into piles. After five minutes you feel you cannot go on, stop. Most people keep going though, after they get over the speed bump of starting. Always give yourself credit for having done something! Glorify in it!  Do this every day at the same time for five minutes. Over time you develop a sense of accomplishment, and by focusing on ‘the trees not the forest’, eventually the task is done.  Sometimes the patients complain they didn’t develop ‘motivation’ but they admit it feels good to have done it.

I try to lead by example. Rather than having the vague and mammoth goal to “Learn Spanish”  I have the goal to do the five-minutes rule on Duolingo. Every night at 830PM my phone goes off as if to say “whatever you are doing, cut it out. Time for Spanish lessons – five minutes only – and I don’t care how you feel about it.  I’ve done this over 600 days in a row now. Usually around 8PM I start thinking of it, and when I do, I usually start it then.  I’m slowly slogging my way to proficiency.

I’m considering setting my phone for 9PM now, to tackle a closet. But I’ve been putting it off.  hohoho

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