"SINCE I STARTED THE ANTI-ANXIETY MEDICATION, MY DESK AT WORK IS A MESS"

"Doc, I'm in trouble," said Alex right from the beginning of our second session, with panic in his voice. "My anxiety is going away, that's fine, but I have no desire to work. I am falling behind. Thanks God I am a supervisor and nobody noticed yet. My desk is now messy. It has never been like that. I would always clean it up at the end of the day. Now it looks like... it looks like..."

"Mine?" I said, smiling guiltily, looking at my French Provincial desk piled up with many projects' papers, always having to work on more than one thing at the same time.

"Pardon me, but, yes. That wouldn't bother me one bit if I could ever get my work done."

"What do you mean, you can get your work done?" I asked, trying to understand what the problem really was.

"Well, I pick up a paper, I start reading it, then my mind wonders. Then the phone rings. I answer and when I am done, I start sending an e-mail. I never go back to the paper I was reading. By then usually someone comes into my office to ask me something. Then I am given another paper to look at. I look at it and I think, well, this can wait, this deadline is not yet here and I put it in the pile, on top of the first paper I didn't finish. By lunch time, I get so distracted, I can't even remember what either of them was about."

"I can see why you panicked. This has never happened before you started on Pristiq, the anti-anxiety medication?"

"No, never" he said emphatically. "I was so anxious all the time that if I wouldn't get something done, I would stay there until 8 or 9 pm and do it. Now I don't have that same energy. I am calm but I can't get my job done."

I started thinking at this point in the conversation that Alex may suffer from attention deficit. Many patients come to see me because they are anxious, but at a closer look, they are anxious because they can't concentrate and can't get their work done. I decided to ask him more questions in line with this diagnosis. He told me he can never stay still, that in the meeting he always squirms or has to tap his foot or has to leave briefly and come back. He admitted that his mind often wonders but when he was anxious he was so guilty and he was beating himself up so much that he would force himself to pay attention and work longer hours. Only he couldn't sustain it long term. He got through school by "being smart, begging your pardon," he shyly admitted. He never really studied. He would cram and read something only the day before the test. All of these information were major red flags for attention deficit disorder (ADD). I gave him a screening test for ADD. He scored in the medium range, meaning his attention deficit was not very severe. That could explain why he was able to, when pushed by anxiety, overcome it. But the price was very high: he was working 10-12 hours to do an 8 hour job; he felt miserably powerless and defeated; he had no time for himself and his only reward or pleasure was eating; the price for this form of entertainment was weight gain, high cholesterol and heart burns; he had to take Prilosec and Simvastatin as a consequence to that; his energy was very low and he could not do any exercise, not even walking. He had a monotonous existence, placing all his efforts into managing his job, having nothing left for himself.

"I still don't understand," he said puzzled, "how come I was able to manage when I was anxious and now that I am better, I can't?"

"That is because, in your desire to succeed at work, your anxiety was the engine pushing you to work extra hard to compensate for the ADD. You pushed yourself so hard it exhausted you. Yet, your anxiety, your fear of failing, of falling behind, kept pushing you even harder. You must have not had a moment peace for years before I gave you that medication. After taking the Pristiq and quieting down the fear, you disconnected the engine. Now, you can see that without it, you can't do your work, but with it, you are absolutely miserable and exhausted all the time."

"I am in a pickle, all right," he said pensively.

"Not really" I encouraged him. "After going to psychiatrists for years, now it may be your opportunity to finally address the very cause of your anxiety--ADD. We can treat your ADD symptoms and then we can re-evaluate the anxiety. Sometimes the anxiety goes away by doing just that. But if it persists, we can still continue the Pristiq."

"But Doc, I've been meaning to ask you a question for a while," he said, with the politeness of a man raised in the South. "A new medication, plus Pristiq, plus Prilosec, plus Simvastatin...wouldn't all these medications get me in trouble?"

"No, they can all go together," I answered. "But my hope is you will soon no longer need Pristiq. Taking a low dose of Dexedrine, a stimulant, you will get your work done in 8 hours and then you will have time to exercise. When anxiety subsides, you will be able to eat only when you are hungry, and not just comfort food, but healthier food. Loosing some weight, you will lower your cholesterol and it is likely you will not need the Simvastatin. Reducing anxiety and eating better, the acidity in your stomach will go down and you will no longer need the Prilosec. So, you see, everything is connected."

He seemed to think hard for a moment, then said: "I feel I will never be able to take control over all this. I want to exercise but I don't like gyms. They are too...artificial. I would like to go for a hike but...no offense, everything in Los Angeles is flat and arid. Before I came to live here, I lived in Montana. The beauty of that place stays with me even now, years later. I need something to do that helps me connect with the earth..."

I understood his predicament. I started thinking: what is here in LA that can help him connect with the nature? The ocean, I immediately thought.

"Think about it, every time you step on to the street you are, in fact, in the nature. It's harder to see it in the city but it is ever present. Live in the present. Pay attention to the living beings around you and try to connect with them. You can always take a long walk on the beach and be near the ocean and you can exercise, lose weight, quiet down the anxiety and connect with the earth at the same time. Or, have you ever thought of signing up for an ocean kayak class?"

"Funny you should say that," he said, with a bright expression on his face. "I have been thinking of that few months ago, but of course, I didn't do anything about it"

Here it is how Alex used the four layers of the Better Than Cured Program to construct his own, personailzed program based on the Better Than Cured Program's four basic priniciples:

1. He will educate himself about ADD and observe how ADD plus anxiety combination interfere with his daily life (the therapy portion of our intervention).


2. He was to structure his time better, scheduling time for shopping for healthy foods, walk 20 minutes everyday, investigate the kayak class without procrastination and develop strategies to be more efficient and live work on time (the life coaching portion).


3. He was to continue Pristiq but also use Dexedrine in order to control anxiety and ADD symptoms at the same time (the medication portion).


4. He was to learn how to ground himself emotionally, starting by re-connecting with nature (the Buddhist spiritual portion).

He worked diligently on these four points of his platform. Few months later, he felt no longer overwhelmed. He figured out how all these four portions of his plan worked together to help him in different ways, but focused on one single end point: helping him feeling in control of his life, making it pleasant, relaxing, productive and meaningful.

THE MAGICAL POWER OF PETS, PART II

Marie-Louise suffered from depression a long time. It has been generally mild and she could manage it for the most part. But when she had the accident and hurt her back and couldn't go to work, it became really hard to cope with her old enemy.

When she was diagnosed with type II diabetes, it was one thing too many. Her mood took a dive.

To make matters worse, she was living alone and felt very lonely.

"I don't know what is worse," she said at that time, "being in pain all the time or dealing with this overwhelming loneliness."

There were both equally worse. Especially when she had to go through the second surgery on her back. I was in close contact with her primary care doctor, who recommended her to me in the first place. We were both trying to keep her spirits up. But we couldn't be with her everyday. It was around that time when I decided to suggest a time tried remedy.

"Look," I said, "I can't be with you 24/7 and you need someone to watch after you. How about getting a dog? No matter how small, you will see that you will never feel alone if you do get one." We talked some more about this idea. She has never had pets before. She was not sure if she would like it. Her landlord had a "no pet" policy in her building. I gave her a letter saying that she needs a service dog for emotional reasons, letter that has always unlocked the "no pet" policy for my patients in the past. I told her to just think about it. Meanwhile, we decided to increase the daily dose of Cymbalta, an anti-depressant that could help indirectly with pain, in the hope that she would deal better with her situation.

Two weeks later, the puppy you see in the pictures stepped into my office, accompanying Marie-Louise. She followed, well equipped with dogie pads, treats, a toy and a small bowl for water. After she sat down, she told me the story of Good Boy.

Thinking about my suggestion and discussing it with her family in Seattle, she decided to adopt a puppy. Not knowing anything about it, she stumble upon a puppy mill--a person who breads dogs haphazardly, without carrying for their well-being or being concerned with the quality of the puppies bred. Just wanting to sell them for a lot of money. When she literally rescued Good Boy from that place, he had a nasty cough and he was so sick he couldn't eat. She had to practically live at the vet's office, trying to save his life. She met there carrying people who helped her nurse Good Boy back to health. At home, she was watching him every minute, giving him his medications or his favourite foods. By the time I have been introduced to him, he was healthy enough to be out of danger.

That first session with Marie-Louise and Good Boy was quite unorthodox. We sat on the floor, watching the puppy doing his cute puppy things and chatting about him, his care and the new tricks he has learned so quickly. She told me about the many people stopping her at the market or on the street, asking her about what kind of puppy he is. Strangers were talking with her about how cute, how funny, how intelligent his eyes look. She met tons of people this way. They would start talking about the dog and invariably ended up talking about themselves. She got this way more support from random strangers about her back pain and the puppy's near death illnesses that she has got from any other support group she has tried. She was happy despite the pain. She felt she had to rescue other puppies like Good Boy and she started a campaign against puppy mills by writing letters and getting in touch with various local rescue organizations, who embraced her and validated her outrage.

"I was trying to stay in bed all day, like I used to do," she was saying, "but now I have to get up and check on him." And she looked at the dog with a maternal smile, while he was tugging at her shoe .

She was now busy returning e-mails, connecting with all these new people she has met. She was also sending her vet daily e-mail reports about Good Boy's condition. She had to watch him and take care of him and she took these responsibilities very seriously. I showed her few more tricks about how to gently discipline him when he gets to rowdy and how to recognize early signs of illness or distress in him. She had no time to feel lonely.

We had a wonderful, relaxed, first session, the three of us. At the end, she gathered all Good Boy's things back in his bag, she put him in there too and, with the bag on her shoulder, she turned to leave. When she was just about to get out the door, she said: "Do you realize that in this one hour session I didn't say the word "depression" once? Isn't that something!" And she left, smiling broadly

Gradually, Marie-Louise and Good Boy got closer and closer. She started taking him to obedience classes. He is still not quite sure who is in charge, him or Marie-Louise, and he needs a trainer to teach him all the necessary things to know for a service dog, like being sociable, not barking, and so on. Every time other dogs in his class do something good and the trainer says "good boy" to them, Good Boy things it's about him and he is having a blast.

Meanwhile, Marie-Louise has a different look on her face: she is so much happier. Her pain went down. She exercises more. Her recovery from surgery is faster than expected. Her diabetes is now well controlled and she no longer needs insulin, just pills--much easier to deal with. Her depression got better and we decreased the Cymbalta dose. I hope we can discontinue it completely one day soon.

She's got so much motivation and love for her companion, that she quickly realized she had to take good care of herself if she wanted to give her pet the care that he needed.

Marie-Louise and Good Boy are both doing great now. And they thank you for your concern.

WHEN YOU NEED MORE HELP or DON'T BE AFRAID OF MEDICATION WHEN YOU NEED IT--PART I

Many people are afraid to take medication when they become very anxious or depressed. I sympathise with these feelings. Taking medication for emotional problems is a serious decision. It is not to be avoided at all costs, but it is to be understood and used properly. And, as far as I am concerned, I believe that medication needs to be used only when there is no better way. Much like driving a car in Los Angeles.

If you move to LA, you will soon find out that there is no good alternative to driving. But a car can be, at the same time, dangerous or it can take you places. Are you going to not go to work because you are afraid of getting in an accident? No, you will instead, like all car-dependent angelinos, try to learn how to be a good driver and have as safe a car as you can. When, for example, another car cuts you off, are you going to blame the car? No, logically, you will shout at the driver.

So it is the situation with psychiatric medication. It is, sometimes, a necessary risk. In good hands, it can do its job very well. In the wrong hands, it could make you feel worse than before. Is it the medication's fault?

From my experience, people who need to take medication and hated it, it was because either:

• the medication did not fit their biological profile, in which case it needed to be changed


• the medication did not give them side effects but it did not work either, in which case the dose had to be more carefully adjusted up or down, another medication needed to be added or they needed to change to another medicaiton


• there are uncomfortable side effects, in which case the medication needs to either be changed or reduced in dose

The real art is to find the right medication(s) and the right doses for each patient. That takes mutual trust between the doctor and the patient and it may take few weeks to figure out. From my work with patients, there is always a way to work around the side effects and find a medication or a combination of medications that is tailored exactly for each patients needs and works very well. But for that, I meet with my patients at least for a half an hour, sometimes weekly, until we find the right way to go. Fortunately, we have many medication options. I also educate my patients in detail about what to expect from their medication in terms of side effects, if any, and what to look for if the medication is working--the early signs of improvement.

This whole issue about medication in psychiatry can be handled beautifully if there is a good relationship between the patient and his doctor and if the doctor puts in the needed time and attention. I strongly believe that if you happen to find or to have a psychiatrist who you feel does not give you the time or attention you need or you feel is not listening or you are not even comfortable telling him about the problems you have with the medications, you definitely need to know this much: it is your responsibility to look for another psychiatrist.

Most of the time, however, psychiatrists will honestly try to do a good job. Or so I like to believe.

Less than 50% of psychiatrists in the US today do more than just medication management. So if you need to see a therapist and a psychiatrist, you are not in a minority. The key for you to get good care is to have a therapist you feel is helping you, a psychiatrist you feel is doing a good job and the two talk to each other. Often. It is very important for all three of you to be on the same page with every detail of your medical care. I meet with the therapists I share patients with once a month, or at least we touch base on the phone about our patients once a month or more, if there are changes in the patients' condition.

When I started writing this blog, I wanted to share with the world the amazing success I have with my patients working in the Better Than Cured Program. But gradually, I realized that, through this blog, I could not only let the readers know about my program, but also help them design their own Better Than Cured Program, utilizing the resources available to them in their own communities, on line or in the literature.

Through success stories, case examples and explanations of the key issues in dealing with anxiety of all kinds, depression, bipolar and attention deficit disorders, I hope that every one of my readers, even those without an emotional problem and simply dealing with life's happenings, will learn how to make his/her life more emotionally balanced and happier.

THERE IS NO REAL "NO" FOR AN ANSWER

"When did this latest depression episode started?" I asked my patient, Ray.
"In March, when I was turned down."

Ray has built his company from an idea into a multimillion dollar enterprise with national and international sales. He is a driven, creative person, deeply invested in his business. He also has a history of bipolar II, a milder form or bipolar disorder, but nevertheless, responsible for a a lot of problems for him. The story of "being turned down" is about one of his new business development ideas that was not bought by a group of influential investors. His disappointment was huge. It simply flattened him out. It was unacceptable to him that he, who usually has this enormously successful ideas, will be rejected flat out.

He since lost any motivation to do anything, even to wake up in the morning. Although he was, even before this happened, on the verge of depression, after that meeting, his mood really plunged. His medications were not working. He continued to see his psychiatrist in Chicago for few more months but it did not help. Then, two months ago, he came to Los Angeles to visit a friend who became alarmed by Ray's condition and referred him to me for a second opinion medication evaluation.

At our first meeting, I was impressed by the contrast between the successful business man smiling confidently from every page of his company's website and many business magazines, and the broken, almost suicidal man I had in front of me.

We started by talking about his medications, a mambo-jumbo combination of high dose anti-depressant without any mood stabilizer. He was using too many tranquilizers to slow down his racing thoughts, which in turn were making him more depressed and dazed. We decided to change the medication regimen completely. It was a bold and aggressive decission but it was either that or hospitalization. I kept him on Pristiq but I started him on Abilify and we discussed a detalied plan to get off, over few months, of the tranquilizers. He agreed to that and made an appointment in one month, which we had to do over the phone from Hong Kong, where he was in a business trip. We kept fine tuning his medications. He was keeping up with all the instructions religiously, despite travel and not taking any time off from work. This was my only recommendation he did not agree to follow, taking time off, so we decided to do our best while he continued to work his 12 or 14 hours a day plus travel.

Today was our second meeting face to face. He was much more relaxed. No longer suicidal. The depression was almost gone. No side effects, the result of fine tuning in the medications' doses. His intrepid spirit has returned, so has his proverbial energy. And he was not manic either. His mood was nicely balanced and he felt comfortable in my office, chatting about all the hip people he has met lately and how much he had enjoyd that.

This was the moment when I decided to revisit the trigger of his most recent depression, in the hope we could find a way for him to better manage rejection. So we discussed about what happened. He says he revisited that idea lately but he decided to try it at a smaller scale. He also changed the team that will implement it. He plans to go back and propose it again, but in a slightly different form and scale. He felt good about his new plan and confident that he will get it through this time.

"Don't you know?" I said, applauding his plan, "There is never a real "NO" for an answer."

He looked at me completely puzzled, which was funny, giving his high confidence level, and was waiting for me to explain.

"If something doesn't work or you hit a road block, or someone says "no" to you, that really only means that you may have not A--presented in a way he can understand it, B--it's not well developed yet or C--you need more experience or more money to be convincing. It doesn't mean you can't do it. And if you have everything lined up proper and he still says "no," you go to someone else and discuss it. There will always be people interested in a good idea or a good product, right?"

He nodded. I knew that this was his business philosophy anyway, one that has made him very resilient and very successful over the years.

"Then," I continued, "you can see now that there is no such think as "no" for an answer. If you get a rejection, go back to your drawing board or to you list of contacts."

The discussion was longer. We each came up with arguments and counterarguments to my statement. Although not infallible, it a positive way of looking at rejections that can be constructive and can take away the painful bite of pain normally associated with the "R" word. Especially for ambitious and highly driven people.

FINDING YOUR TRIBE--LIVING WELL AMONG LIKE MINDED PEOPLE

"I am not spiritual. I don't believe in life after death and things like that. All I want is to have a good job and to be able to take care of my family, " said Ella, my patient, with a defiant look on her face as if she was waiting for me to disagree with her statement.

This was our second session and I didn't know her very well. In her early thirties, slender and pretty, with an intelligent look on her face, she had something daring about herself, as if she was used to be "different" and rebellious but not yet comfortable with this identity. Keeping in observance with my golden "do not judge" rule, I didn't say anything, waiting for her to continue.

"And I think we need to increase my medication because I am not happy," she said. It's curious, I thought, how often people who could greatly benefit from taking an anti-anxiety or an anti-depressant medication say they don't want it, and people who are already on medication have the tendency to expect it to do everything for them, including making them happy, successful, thin and fit. I ask you, how could a pill do all that?

I asked her to give me some examples of the things that make her unhappy.

"I feel bad because I don't enjoy shopping all day, like my friends do. And I don't like bar hopping. Actually, I don't like bars at all. I don't understand for the life of me why people think of bars as fun entertaining. They are loud and smell badly of cigarettes. And it's impossible to carry on any kind of conversation there. Then I don't like gossiping, I think it's a waist of time and eventually, someone always gets upset."

Ella works as a free lance writer for some of the magazines in town. I have read her articles. They were really good. She also has a low grade anxiety and she often pushes herself too hard, being too critical of herself. This has been a real problem few months ago, when she first came to see me. She was having obsessive thoughts which kept her from sleeping. She was very nervous and edgy then. We discussed at that time about her taking a small dose, 75 milligrams, of Zoloft, an anti-anxiety medication from the same family with Prozac, and she agreed to try it. The medication was soon effective: our target symptoms (obsessional thinking, insomnia, irritability) went away. But happiness is a different matter all together. It will take more than Zoloft, I was beginning to see why.

"When was the last time you felt happy?" I asked.

"Last week-end when my girlfriend and I went for a hike in Santa Monica mountains. It was a gorgeous day!"

I was relieved. If she had the capacity to enjoy a day in the nature just recently, chances were she was not depressed. something else must be going on. Continuing our discussion about things she likes and doesn't, I learned more about her. I learned that she was donating her time writing articles for a nonprofit organization working on increasing awareness about global warming. She was member of a book club and she liked to go to concerts and dance performances instead of shopping and bar hopping.

The problem was that, comparing herself with most of her current friends, she was "unusual" borderline "wired," but by other standards, she was smart and broad minded. Whose standards is she going to follow?

"You know," I begun, after I made up my own mind about this, "you say you are not spiritual but you like nature and even volunteer as part of the environmental movement. Has it ever occur to you that this is a form of spirituality?"

"No, never!" she replied.

"Well, it is. When we believe and deeply care in causes greater than ourselves, that reflects our spirituality, our core believes, and defines who we are and our place in the world. You may say you are not spiritual, and there will be people who would agree with that, but others, with broader views, may think that you are. It is a matter of whom you are talking to. If you associate with people who are judging you harshly and deny who you are and try to put you down because you are not like them, you will feel exactly like that: different, isolated, confused and unhappy."

"But if you associate with people who think more or less the way you do, on the other hand, like minded people, you will feel completely accepted and admired for all the things you do and you believe in. That inevitably will make you stronger, empowered and much more confident. And, of course, happy. I believe this is where the problem, and the solution, is. What do you think?"

Then Ella discovered exactly what I was hoping that she would, proving how smart and intuitive she was: "Then, I need to make new friends if I want to be happy?"

"Precisely," I said, glad that she was beginning to figure out this new way of thinking. "Yes, making new friends who think the way you do will make you much happier. Finding your tribe! Sometimes, as we evolve in our thinking and life experiences, the friends that accompanied us this far may no longer understand us. Not that it's something wrong with them or with us. We just move on, transitioning to a different stage in our life. It seems to me you are at that point. It may sound too simplistic, but yes, if you want to be happy, you need to be around like minded people. "

"Oh, so there is nothing wrong with me then?" she asked hopefully.

"I don't think so. You just need to reorganize your life in a new way, one more suitable for who you are today."

Ella left my office with a spring in in her step and a pensive smile on her face. I knew she got it and she will soon start making the necessary changes in the new direction.

For the next few times I have seen her, she told me that she increased her hours for the non-profit and met new people there. Few more months later, we discontinued the medication. She continues to do very well.

FINDING A "MIDDLE PATH" IN LIFE

"I owe them a depth of gratitude," said Maria, talking about her family, who has given her a lot of support for her to become a successful electronic engineer. "How can I not be devoted to them? Without them I would be nothing." Then, after thinking for a moment, she continued: "But I feel suffocated by their neediness, by their fear that if I have a life of my own, I will no longer take care of them." So what did she do? She continued to live with her parents all her life. Never married. She almost never goes out with friends. She can't even remember last time she went on a date. Unhappy as she is with her life lived in complete devotion to her parents and her sister, she feels terribly guilty to make time for herself. The only time when she allows herself to relax is when walking with Riki, the poodle, in the park twice a day. Her family is not jealous of Riki so they don't give her a hard time about it. But it is the only thing she does outside of the house that they don't make her guilty about.

For months I have been trying to point out to her the toxic, co-dependent nature of her relationship with her family. Every time we talk about this, she starts swinging widely between her devotion to her family and her guilt of wanting to have more of a life of her own. Our visits are so predictable. I sit and watch how she agonizes between the two extremes. The medication, Effexor, helps her only marginally, by stooping her panic attacks and improving her sleep somewhat. But it can't stop the storm raging in her mind and can't make her happy.

At our latest appointment last week, I decided to try something different. I started talking to her about the Buddhist understanding of the "middle path," the path that helps us avoiding extremes, a path that our minds can define and comprehend, a balance between guilt and duty.
I told her stories about how difficult it was even for Buddha to find the middle path. Coming from a life in luxury and excess at his father's court, he thought at first that the path to enlightenment asks of him to become an ascetic. He nearly starved himself to death while praying. Then he realized that enlightenment can be achieved even without going to extremes, that the real path to enlightenment was through understanding of a balance between conflicting thoughts.

In line with this thinking, Maria could try to find this path herself. She could figure out what kind of life style could she have, in between her guild and devotion. How would that life style look like? Spending some time with her mother and sister and some other time with her friends. Going to a movie she really wants to see by herself or with her own friends and going to church on Sundays with her family. Going out with them one week-end, going with her friends the other.

I told her that I would like her to be more mindful of her feelings to think before she reacts either with guilt or with devotion to things her mother or her sister say, ask or demand of her. To use her logical mind as a referee that is in charge with being objective and keeping the balance firmly in the middle.

During this discussion I could see that I have finally made her think, rather than automatically swinging from one powerful emotion to another. It's always fascinating to me when I find the thought or the story or the metaphor that makes someone stopping in his tracks, forgetting for a moment to keep going down the same path of thinking leading to anxiety and stress, and consider for a moment the possibility of a new path, one that leads to comfort and happiness, one that, although in front of them all the time, they never thought to take.

Elements of Buddhist wisdom come to the rescue in unexpected ways in my work, helping me and my patient along, illuminating new paths, giving us both the strength to consider new ways of healing, new solutions out of emotional pain. Sometimes is nothing we can (or even should) do when suffering. What counts is gaining the understanding that we need to find another kind of way out if we want to gain peace of mind. This other way, or path, may not be the one we imagined, nevertheless, it could be the path leading us out of our torment. The beautiful attribute of it is that it's always there. The difficult part, is to open our mind's eyes to see it.

"I AM ANXIOUS, SO I EAT!"--COPING WITH ANXIETY THROUGH EATING

"Could you give me some kind of medication to make me lose weight?" said Margaret taking heavily a seat on the armchair facing me.

It turns out that she can't lose weight because, even though she may be eating "healthy and little" all day, in the evening, when she starts worrying about the next day at work, she feels the need to eat "everything in sight." Mostly bad, fatty, comfort foods.

I was debating whether I should prescribe an anti-anxiety medication in addition to the mood stabilizer she was already taking. She used to deal with mood swings for years before she came to see me. Tegretol, a mood stabilizer, has been effective to control them, but obviously, unable to control the anxiety symptoms she still experiences. I confess I was strongly considering prescribing another medication. The appointment time was almost over. My next patient was already waiting in the waiting room for his appointment...

But I decided to try another way.

"Margaret," I said, "here is what I would like you to do..."

And I wrote on a piece of paper a list of things she is to try first, before we go to the medication route:

When the anxiety level rises like an unstoppable high tide, she was to take one of these actions:

• make a phone call to a comforting friend

• watch a comedy on TV, or her favorite show, the one she TIVO-ed for weeks but couldn't find time to watch
• she can put on her running shoes and go for a walk
• she can learn how to properly breath by taking yoga classes and learn how to take deep, relaxing, abdominal breaths, rather then the shallow, unsatisfying thoracic breaths of anxiety
  
• she could say a prayer (she happened to be a devout Catholic)
  
• she could take herself to a quiet place and think: what would my mother think about this? (She had a very loving relationship with her mother, who passed away few years ago. She often talked about her mother as a funny, practical person.)

Reading the last point of her plan of action, she started laughing: "I should better think 'What would Dr. Forest say about this?' It would better remind me to do my best to put my mind over mood, like you always say."

After discussing this list point by point, she agreed to trying this plan before we do any changes in her medication. The measure of our success will be her to losing at least 4 lbs in the next coming month.

The race is on.

There will be no more eating because of anxiety. Only because of being hungry.

VISITING KYOTO AND DISCOVERING THE ART OF JAPANESE BRUSH PAINTING

Do you know Unknown Mami? She's awesome and she's started a fun Sunday theme inviting you to get out and take pictures of your city to share with the rest of us. Click here for details and her logo and click here to see Unknown Mami's City today. She has initiated this series of posts based on personal travel impressions, a very informal and personal travel log from people all over the world.
My friend Joanna, author of a wonderful blog, "The Fifty Factor" that you can check out at this address, put me on this path and I am grateful that she did.

Here is my contribution of "Sunday in the City" travel blog. I hope you will find it interesting.

DISCOVERING JAPANESE BRUSH PAINTING IN KYOTO


Many of the visitors to my blog asked me if the art work I use here is mine. It is, and here is the story of how I became a curious at first, and then a passionate student of brush painting.

This is the story of my travels to Kyoto, an amazing historical and cultural center of Japan, and the unexpected discoveries I have made there.

You know how it is when travel: we go and allow ourselves to experience the journey, not knowing what effect on our mind and soul what we see will some day have.

The site that really captured my heart is the enigmatic and the very romantic Nijo Castle, Nijo-jo, as people there call it.
It was build in 1603 by the first Tokugawa shogun, Ieyasu, the one that started a very important cultural revolution in Japan, the Edo Period, marked by some of the most graceful pieces of ceramic, painting, screen. All arts flourished during this period. Tokugawa Ieyasu is the impressive historical character in the popular book SHOGUN, by James Clavell.

Nijo-jo is built almost entirely of Japanese cypress, with delicate would carvings and screens painted by the Kano school. Taking pictures was not allowed inside the castle. But, just to give you an idea about how beautiful these screens are, here are two of the famous screens painted by the founder of the Kano school, Kano Eitoku (1543-1590) who revolutionized the Japanese brush painting and screen painting.

His unmistakable style is characterized by bold broad strokes, flowing freely, rather than painstakingly stylized as the artists before him did. He was considered one of the most prominent artists of his time and was under the protection of Toyotomi Hideyoshi, the daimyo who united Japan. He was a protector of arts and culture and started the Momoyama Period. Toward the end of his career, he started painting in more and more bold strokes creating a special feeling and state of mind in the viewer. His work served as inspiration, centuries later, for the French Impressionists.

While I was in Kyoto, there was a large visiting exhibit at the Museum of Art with original screens painted by Kano Eitoku. It was fantastically beautiful. These two screens in the pictures, I have seen in original. Looking at them, changes the way you think, they are so powerful in the emotion they transmit over the centuries, that it feels as if they are painted before your eyes and your soul vibrates with those of the artist's, in complete unison.




At the Nijo Castle, there were many screens similar with the ones above, from the same school of painting but few hundreds years later. One of the larger chambers of the castle is "The Hall of Chrysanthemums." It has few larger than life six feet tool panels, dressed in gold leaf and painted over with white, immense, voluptuous chrysanthemums. They were so large and so luminous that had an almost hypnotic effect. They were perfect in every way, except for an occasional small petal, often at the top of the flower, that was folded in a funny, unexpected direction, bravely defying the perfect symmetry of its sister petals. It was as if, after doing a masterful work, the artist wanted to remind the amazed viewer that even in the most formal, perfect painting, there is room to lighten up and have fun. These panels were executed in Japanese brush painting style, an old art form learned by the Japanese artists from their Chinese counterparts who invented it many centuries ago.

I believe to this day that it was the astounding beauty of these panels and the playful, brave little stray petals, moved me so deeply that as soon as I arrived back in LA, the first think I did was to find a Chinese brush painting teacher. That was a year and a half ago. I am still a beginner. I am still learning the simple but sophisticated technique of loading the brush. But I continue to be fascinated by the grace and beauty of this art form and I keep learning and practicing.

Chinese brush painting is done on rice paper. Once you made a stroke, it can never be erased. If it's not right, you can not correct it. The Chinese brush painting teachers often say that if you made a mistake, it is a happy accident, it is the way it was meant to be, and it organically becomes part of the painting. You need to accept it and leave it alone. If you try to correct it, you will only emphasise the mistake but will fail to fix it. In the end, you will bear the full fault for ruining a perfectly good painting.

Here are other images of Kyoto, a fascinating, old cultural center, where traditional architecture and temples blend in with modern skyscrapers and European sidewalk cafes.

This is a picture from the Heian Shrine--Shinen Garden, landscaped in Meiji Era style. It is famous for its changing maple leaves in the fall and its weeping cherry trees in the spring.

This is the emperor's private garden at the Kyoto Imperial Palace, in the rain, in November. Even though raining, the tours were not canceled. Everyone, including the guide, was braving through the rain drops to see only the outside of the Palace. Tourists can not go inside unless they have a very special permit, seldom granted.

The imperial family dwelt in this palace from 1331 until 1868 when they moved to Tokyo. It was destroyed by fire several times but rebuilt identically with the original, every time. The style is in keeping with the Heian Period--peaceful but somewhat stark and somber.

One of the most famous rock garden in Japan is the one at the Ryoanji's temple, a Zen temple of the Rinzai tradition. It was created first between 1488-1499. It has 15 stones, but the garden is designed in such a way that not all 15 are visible from the same angle. Hence, it is very difficult to photograph the entire garden. It may seem, at the first sight, there isn't much to see, just rocks and gravel combed in a certain way. But when you sit down by it, and quiet down your thoughts, allowing only the peace of these rocks to keep you company, the effect is almost hypnotic.

I couldn't take my eyes off this garden. My eyes were scanning it from left to right and from right to left, each time discovering new ways in which the light falls on the rocks, new patterns on their faces, new dimensions of its space. The time seemed to have halted to a stop. We were in a timeless place, looking at an work of art, in awe, as the first viewer of this garden must have done centuries ago. For more info and viewing angle, you can use this link: http://learn.bowdoin.edu/japanesegardens/gardens/ryoan/ryoan-ji.html.



View of Ryoanji's rock garden. Photo Marcus Trimble.

Many Japanese now believe that the "Old Japan" is gone, being replaced by the modern life, architecture, anime, and fashion. As tourists, we discovered that it takes some searching if you want to see the historical Japan, the world that mystified the Europeans in the 1800s by its strict rules, art, beauty and romantic mysteries. But all these are still there. You just need to be patient and scratch the surface. Nothing is really lost. It just changes.

BETTER QUESTIONS TO ASK YOURSELF WHEN YOU FEEL DOWN: CHANGING THE POINT OF VIEW CHANGES HOW WE FEEL

"...and I keep trying to understand why we broke up. I just can't understand why we couldn't work it out in the end," Carol, my patient, was saying, while trying to cope with the breaking up of her five years relationship with a boy friend whom she hoped to marry one day.

Listening to her agonizing over "why this didn't work" and "why couldn't he understand" and "why didn't we figure out," I started thinking that "why" was really the wrong question to ask herself in this case. Just like we go to a job interview, we feel it went great and in the end, nobody calls us about that job. We just need to understand and accept we didn't get it. But nobody ever bothers to tells us why. We may never know the reason, we just need to figure out rather quickly that it didn't work out, regroup and look for the next job.

"You know," I said, "just asking yourself why this didn't work it's not going to help you much."

She lifted her head as if awoken from a dream. "Dr. Forest, all the therapy I have been through, thought me I need to understand why things are the way they are so I can fix them."

I told her that there are some things we can't and will never understand. Especially when other people are concerned. I explained to her how useless it is for her to keep asking "why," being unable to find any satisfactory or real answer, and sink deeper and deeper into the victim role.

"I think a better question to ask yourself is HOW rather than WHY."

"What do you mean?"

"Well," I said, "assuming that this relationship is over, and he told you in no uncertain terms that it is, I believe a better question would be: How can I come to terms with this break up and cope with moving forward?"

"I don't know," she sobbed, "I am not ready for that yet. I will see a counselor on Monday, see how that goes."

"You may see a counselor," I said, "but I tell you right now that if you do not learn to ask the 'how to move forward' question and will spend the therapy time in anger and resentment about the past, you will block your own ability to move past this incident. You will not allow yourself to see that, rather than staying a bad relationship, you have a chance to start anew, make better choices and be, eventually, much happier."

It will remain to be seen if Carol will have the strength to move forward or will be stuck regreting the past. It is, ultimately, her choice. But she left me thinking about how easy it is to put the breaks and kill our own future by asking ourselves the wrong questions. For example, rather than asking ourselves "why is this happening to me?" we can say "what is the meaning of this? What do I need to do to make this situation better?" Rather than saying "Where is my happiness?" we should rather say "How can I get to it?" The truth is, I have yet to see a problem without a solution.

My own life experience, and especially my patent's, has thought me that there is no problem without a solution. Sometimes we may just not see it. Blinded by grief, disappointment and fear, the solution we seek is hiding in plain sight and we can't acknowledge it. Sometimes we don't see it because it's not the solution we want. Sometimes it opens a too difficult road ahead and we are too scared to follow. Sometimes the solution is just accepting and making peace with what happened. Sometimes the right solution is doing nothing at all, while our anxiety drives us to action, any action, just to calm the anxiety, taking us further away from solving anything. But if we have the strength to see and follow the right solution, overcoming the storm of our own emotions, eventually we will reach a good conclusion and a good outcome.

Eventually, with courage to face the painful reality, we can walk on a clear path that leads to peace of mind and success.

MARCHING FOR MENTAL HEALTH--SANTA MONICA, CALIFORNIA

Do you know Unknown Mami? She's awesome and she's started a fun Sunday theme inviting you to get out and take pictures of your city to share with the rest of us. Click here for details and her logo and click here to see Unknown Mami's City today. She has initiated this series of posts based on personal travel impressions, a very informal and personal travel from people all over the world.<a href="http://unknownmami.blogspot.com/search?q=Sundays+In+My+City" target="_blank"><img border="0" alt="Unknown Mami" src="http://i610.photobucket.com/albums/tt184/UnknownMami/SundaysinmyCity.jpg" /><
My friend Joanna, author of "The Fifty Factor" at this address put me on this path and I am grateful that she did.

MARCHING FOR MENTAL HEALTH

ONE IN FOUR AMERICANS SUFFER FROM A MENTAL ILLNESS

NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI),

FIGHTS TO REDUCE STIGMA AND INCREASE AWARENESS ABOUT MENTAL HEALTH

NAMI WALK
SANTA MONICA, CALIFORNIA
OCTOBER 3, 2009

The march was about HOPE, the hope that, in the near future, no one suffering from a mental illness will be discriminated against and no one will be left out from getting the treatment that will restore his health and happiness.
In the near future. But until then...

It was a beautiful day in Southern California yesterday. The atmosphere was elated. Everyone was enthusiastic about our cause. It was music, guests, signs--a lot of good will and good energy. It feels so good to be in the presence of like minded people. There were over 2,000 people gathered.

For those unfamiliar with mental health, National Alliance on Mental Illness (NAMI) is an extremely active and well organized national organization fighting for reducing stigma about mental illness and educating the public about mental health and mental illness. It's activities are made possible by volunteers, thousand of people nationwide dedicated to it's cause.

One in four Americans suffer from mental illness, or about 60 million people in US. Only 6% of all people with mental illness suffer from severe mental illness--severe schizophrenia, bipolar I or depression--seriously disabling illnesses. The remaining 94% of people suffering from a mental illness, suffer from mild or moderate forms of mental illness, perfectly treatable and, according to the newest research, perfectly preventable.


Unfortunately, only about 30% of all people suffering from a mental illness receive medical care. Why? Because of stigma and shame associated with mental illnesses, because the public is not informed well enough about their successful treatment, because it's not enough funding and medical insurance coverage for mental illness--to name only a few of the reasons.

• We were marching yesterday to say:
  
• It is wrong to treat mental health differently than any other medical conditions

• It is wrong to discriminate against people suffering from mental illness in your neighborhood, in your company at work, in your school. With one in four Americans suffering from mental illness, everyone knows someone suffering from mental illness, even though that person may have never been diagnosed or treated and is suffering in silence, allowing it to take over her or his life, living in fear and shame of this burden.

• We were marching because nobody should be a victim of mental illness. Nobody should suffer in silence. We live in a modern society, we must open up our minds and stop stigmatizing people. The science has evolved far enough to discover effective treatments for these illnesses. People recovering from a mental illness can become happy and successful. At the march, there were many people who recovered from severe schizophrenia and bipolar disorder, testifying to this new reality.
• We were marching because discriminating against mentally ill should end. Mental illness is "a disorder" and not a character flaw. No patient with diabetes or heart condition is blamed for his illness, right? Mental illness is no different. Mental illness is a biological disorder, very commonly genetically inherited. Mentally ill patients did not have a choice in getting it or not. But they do have a choice of getting healthy and happy.
  

Emboldened by our ideals, the walk was, in fact, a lot of fun. There was music and short speeches. The event started in Santa Monica on the 3rd Street Promenade, a beautiful street with shops and restaurants, were people stroll everyday.

One of the guest speakers was Nathaniel Ayers, the real person with mental illness that was the inspiration for the book and the movie "The Soloist." He was in his second year at Juilliard School in New York, one of the very few black students there at the time, as a double bassist, when he had his first episode of schizophrenia. He droped out and, with the death of his mother, he became homeless. Until he was discovered by Steve Lopez, Los Angeles Times reporter, he was living in the streets, ill, playing half broken musical instruments at the corner street for change.


At the march, I've met colleagues and friends from the Psychiatry Department at Cedars Sinai Medical Center, dedicated people working everyday to help mentally ill patients in crisis, coming at the hospital for the help of last resort.

We all felt we were in the right place at the right time at NAMI Walk, fighting for a good cause and for the well being of our patients. We had fun and there was a lot of joy.

My husband and I wear the white T-shirts of NAMI. My friends wear orange T-shirts, the official sponsoring color of Cedars Sinai.









At the start of the march. A lot of music and enthusiasm.
Their signs say:
"There is no health without mental health."
and "I love someone with mental illness."







Marching along the Santa Monica Pacific Coast.
It was a beautiful day. Warm but with a fresh ocean breeze. The enthusiasm was contagious. People from all over Los Angeles came. It was only a 5K walk, an easy walk, but it was a lot of fun doing it together.

Passers by and people from the balconies of their buildings, were throwing flowers and giving us the thumbs up. One young man was siting on the porch of his house with his guitar. His friend says: "Write a song about NAMI!" He started playing with the chords and began to sing a ballad: "For the rights of people suffering..."

At the end of the walk, we were all dusty and tired. But we were happy to show our support for all our fellow human beings' right to overcome mental illness and stand a chance to be healthy and happy.

We returned to the 3rd Street Promenade and then we went to have lunch at a Deli near by. Strangers though we were, we felt we knew all the people sitting at the tables and wearing the T-shirts of the NAMI Walk. We felt part of a collective consciousness, united into the same thought, nationwide, for one Saturday morning in early October.

BETTER THAN CURED PROGRAM--COGNITIVE BEHAVIOR THERAPY, POSITIVE PSYCHOLOGY AND SPIRITUALITY

The Better Than Cured Program is the end product of years of experience working with mentally ill patients. It is the sum of many lessons I have learned from my patients. It is the best collection of techniques that I could come up with, in my effort to help my patients in the best possible way and give them the support, the strength and the knowledge they needed to heal and pursue their own happiness.

The results are amazing. The emotional transformation that my patients undergo in this program is almost magical. I am in awe at how my patients utilize these knowledge to heal and better themselves in so many aspects of their lives. I am blown away by their creativity and the new ideas they come up with, often never knowing they were capable of them before. It is like watching a beautiful monarch butterfly emerging from its chrysalis, unfolding its wings and flying into the sunrise.

During my post-graduate training, I was exposed to all forms of psychotherapies, old and new. Our Cognitive Behavior Therapy (CBT) teacher, Dr. Spring, was a gifted psychiatrist with a true passion for CBT. I was immediately attracted by this model. It made sense: changing the way we think will change our behavior thus we will stop giving in to the spontaneous, unwanted negative emotions. We can learn how to put the logical mind in control. Mind over mood. There are practice exercises to learn how to do that. There is evidence based research showing CBT to be the most effective form of psychotherapy, especially for anxiety and depression. The intervention was very practical, intense, short term. The relationship with the patients--highly interactive and rewarding.

But in time, I realized that in order for my patients to follow the CBT program and work through all the exercises, they had to want to do it,they had to have a real motivation to be able to accomplish it. Another teacher and mentor, Dr. Kingsbury, a brilliant psychiatry professor, has come my way to give me confidence and guidance in my explorations, while allowing me the freedom of thinking I needed to move forward. I observed that many patients, although they could see the logic in the CBT method, felt it was too much for them. Felt that they didn't have the willingness to to even start CBT. Felt beat and discouraged. They were giving up on their treatment even before they started. These patients need to activate the motivation to get well within themselves. How could I help them do that? Logically, by enhancing their strongest qualities and teach them how to use them as leverage against the symptoms of anxiety and depression.

I started approaching every new patient with this thought: "What does this patient have good and strong in his mind and soul, what are the parts of his brain and thought process that are still untouched by the illness?" The patient and I started working our way toward healing from the healthy place in them, instead of overemphasizing the ill and damaged parts of themselves. Intuitively, I was practicing positive psychology. Later on, perhaps years later, I came in contact with Dr. Martin Seligman's work and it made perfect sense to me. I believe I stumbled by myself, to some extend, upon these ideas only because it was a logical thing to do and because we all have, inherently, a deep seated need for positive development, for truth and light, and for happiness.

At this point, I realized that my patients and I were beginning to interpret health and illness in a very different way. I was beginning to relate to my patients not just as patients but as fellow human beings who were suffering and to whom, if I could, I would bring my expertise and offer healing ways and choices. In hypnotherapy, for example, this deep part of ourselves it's called "subconscious mind" and it's regarded as "the seat of emotions", the emotional source of energy that directs, in fact, the acts of the conscious mind. Freud felt that the subconscious mind was filled with a jumble of negative energies, guilt and shameful instincts. Hypnotherapy instead, advocates the subconscious as an essentially positive, luminous core being, covered up by layers and layers of guilt, shame and negative experiences. But when we are able to cut through all these layers, with the help of hypnotherapy, when facing a crucial situation, when we have "a moment of clarity" or even a healthy "gut feeling," it is believed that we can address ourselves directly to our core being. Once we access it, we can reprogram it, so that it directs its will toward helping us stay on the path to good health and happiness.

I am not a scholar of Buddhism. I am only a humble student who can not stop marvel at its depth and wisdom. In the Buddhist philosophy, especially in the view of American Buddhists like Dr. Mark Epstein for one, it is deeply acknowledged the sentient being's existence of a core being, one that could transform, learn and develop in ways that overcome suffering, by changing the way we relate to it. Buddhism, in its ancient wisdom, firmly and without reservations offers hope for emotional and spiritual growth. In my work, I make sure that I offer every patient a glimmer of hope, no matter how remote it may seem to them. Sometimes they are, at first, so hurt and so disillusioned that they are no longer able to see the hope, the "light at the end of the tunnel." I then remind them that the hope is there even if they can't see it yet, that they can overcome the obstacles in their lives and that they will get better and see without a doubt, that they are headed toward wellness. Anxiety and depression, as most common forms of mental illness, are just that: obstacles. The symptoms of a mental illness do not define a person. They are just obstacles that can be, with knowledge and practice, surpassed.

How can these obstacles be surpassed? By learning and implementing CBT. By using, if needed, medications that will make these symptoms easier to manage. By building strategies and setting realistic goals, choosing life styles, life partners, friends and careers that are more congenial with one's personality and dreams and vision of the future--learning and utilizing the pragmatic tools of life coaching.

The many layers of Better Than Cured are not artificially separated. They naturally flow and blend, coming full circle to embrace and support the personality, way of thinking, neuro-biological profile and the unique nature of the core being of each person I work with. Approaching healing and pursuit of happiness in this way, my patients not only heal from the mental illness--cured. They also become emotionally stronger, happier, able to enjoy life, unafraid to learn from their own experiences, living in harmony with their world and at peace with themselves. A state of being my patients and I decided to call better than cured.

STOP THE DENIAL AND FACE THE FACTS

"If you are afraid, just close your eyes and nobody can see you," said a little kitten to his brother, two Disney characters, while lost out in the field at night. This to me represents one of the best definitions of denial: if you are afraid of something, turn your back to it, pretend it doesn't exist, hope in your heart of hearts it will just go away without you having to do anything. But most of the time, that is not what hapens. Not only that turning your back to an upsetting matter makes you vulnerable to the dangers posed by it, but that matter, whatever it may be, tends to grow in size and danger with every minute you are ignoring it. It grows there in silence, becoming a bigger and more menacing shadow while you are shutting your eyes tighter and tighter to stop yourself from looking at it. But one day, no matter how tight you try to close your eyes, you will be forced to acknowledge it's existence. And that is a frightening sight. And one day, you will need to do something about it. Forced by the circumstances, with your back against the wall, shivering in fear, you wonder how was this possible, how you didn't see it coming. Now, you have to come up with some kind of an emergency intervention which will either cost a lot or will have dreadful consequences.

If you recognize yourself in this scenario, do yourself a favor: never close your eyes when you are scared.