Insight from the Outside In

Welcome to day two of behaviorism!  Now that you’ve mastered the terminology, we get to discuss what works, and why.  

I’ll get right to the point: Reinforcement works to change behavior.  Punishment does not.  When a behavior is reinforced, it means that the subject has to do the correct behavior in order to earn the reward.  It doesn’t matter if the reward is to earn something good or take away something bad.  The desired behavior still happens.  Punishment, on the other hand, does not work.  The subject still changes their behavior, but they do it to avoid punishment.  They may still do the same behavior, but they’ll get better at not getting caught.  Since last time little Billy hit his sister and left a mark, next time, he’ll pull her hair.  

So now that we know that we should to reinforce behaviors that we want, let’s talk about how we go about doing it.  First, it has to be something the subject wants.  It doesn’t matter if we’re talking about adult humans or puppies, this is how behaviorism works.  If we know that little Bella loves magic markers but couldn’t care less about stickers, then magic markers are going to be the reward.  If we made the reward stickers, she’d have no reason to try to earn them.  Some people call this finding their currency.  Then we establish with the subject how to earn the reward.  Bella has to wash dishes four nights this week.  Keep it simple.  It has to be observable and measurable.  Star charts, or some sort of visual tool, are important.  The subject will see their stars begin to accumulate.  This is a great way to combat frustration in the instances she doesn’t earn her star.  Stay focused on the positive.  “You didn’t earn your star today, but you did it two nights in a row before this!  You’re half way there!”  At the end of the week, we continue to focus on the positive, whether she’s earned the reward or not.  “You did the dishes three nights this week!  Great job!  Just do that plus one more next week so you can get your markers!”  Keep the focus on what she has done, not what she missed.  

Once she’s got that down pat, we raise the bar.  Now she has to set the table and wash the dishes four nights a week.  The parent can decide what the new system will be.  Does she have to do both to earn a star, or is it one star per task?  How many for the new reward?  Bella’s room is going to be overflowing with markers pretty soon.  Bigger tasks earn bigger rewards, but may also take longer to earn.  Also, keep it appropriate to age and capability.  A teenager may be required to mow the lawn and do his own laundry to earn a ride to the mall or the movies, for example.

Now let's talk about how often a reward is given. At first, it is every time.  Then over time, we space out the reward schedule.  But the most effective reward schedule is random.  The behavior is praised every time, but the reward may or may not be given.  It doesn't just work on dogs and children.  I bet you are drawn in by intermittent rewards. If you don't believe me, go plunk some quarters into a slot machine. You are not going to win every time.  In fact, you will lose more often than you win.  But every so often, you will get enough of a reward to keep you interested in playing. So you pull that lever again, and again, and then just one more time, really! Okay, one more...and three out of five match! You didn't even come close to the jackpot, but it's enough to make you think, "just one more."  It's the same thought process that gets people buying lottery tickets. Every time the jackpot gets high enough to be newsworthy, the next story will be about the lines out the door at the local convenience store.  The odds of any given ticket matching all six numbers in the Powerball game are one in 292 million.  We know this, yet just the opportunity for the intermittent reward is enough to keep us coming back every time. Intermittent reward also makes us believe unrelated events could be related.  According to research by Monica Wahdwa, Assistant Professor of Marketing at INSEAD, a person who matches five out of six numbers is more likely to play again than someone who only matches two out of six.  We attribute this to luck, when really, it's purely random.  The lottery officials know this. They know you are going to keep buying tickets. The casinos know this. They know you're going to keep pulling the lever. You're going to play just one more hand.  The house always wins.

Today I want to tell you about something that happened my first week in a new department when I was still working at a state hospital.  I was no longer working on the units because of my Cerebral Palsy, but had started working in a department with no direct patient contact.  At the time, I was using my walker, or even my wheelchair, as needed since I was recovering from a knee injury.  

Every month at the department-wide meeting, a different staff member was supposed to bring in something to promote diversity.  That’s a whole different blog entry, but back to this particular day…the staff meeting went fine, and then it was time for diversity.  The responsible staff member passed around copies of a photo of a man and a little girl, both amputees with new prosthetics (if I am using the wrong terminology, please let me know so I can fix it!). The caption read, “The only disability in life is a bad attitude. -Scott Hamilton”  The staff member beamed at me, and welcomed me to the team.  I half smiled and thanked him, but I was extremely uncomfortable.  I couldn’t put my contracted little bent finger on why though.  Since then, I have come across a term that describes that moment perfectly: INSPIRATION PORN.  Pornography, by the traditional definition, is media depicting erotic or lewd images to evoke sexual arousal by the consumer.  For the purpose of IOI, inspiration porn is depiction of people with disabilities doing things people without disabilities don’t think they should be able to, for the person viewing it to be inspired.  Often the caption will be something to the effect of, “What’s YOUR excuse?”

I find these memes and such problematic for a number of reasons.  The first is that it reduces the person with the disability down to a one-dimensional figure; a caricature.  This is something the media often does to people with disabilities.  We are either the comic relief, the misunderstood villain, or the tragic figure.  All three are shown to overcome their disability by the end of the story.  The person with a disability frequently has little to no backstory unrelated to their disability.  I know this has gotten better in recent years, but it still predominantly the way people with disabilities, both mental and physical will see themselves depicted.  

Second, it implies that because one person can do something it’s perceived they shouldn’t be able to do, anyone can do anything.  It creates unrealistic expectations.  If somebody sets their mind to do something and achieves that goal, then yes, they should be celebrated.  Shout it from the rooftops!  Goals are extremely important, as they keep us moving forward.  They can motivate us and help us focus.  But goals need to be individualized.  I have zero interest in running unless I am being chased by something hairy with big teeth, a spider, or some stranger telling me I inspire them.  So please don’t hold up a picture of someone with leg braces on running to show me what I’m capable of doing.  For certain disabilities, trying to run could seriously injure them.  

Third, it teaches people to see people with disabilities as inspirational.  People I don’t even know have come up to me on the street when I’m using my walker to tell me what a good job I’m doing.  I want to pat them on the head and say, “you are too!  Keep trying!”  Telling me I’m doing a “good job” just getting through my day-to-day life is incredibly condescending.  It reduces me to what they see in front of them: a disabled person using a walker.  It takes nothing else into account.  I default, in that person’s mind, I am the tragic figure they are so used to seeing on TV and in the movies.  No backstory.  I used to have a different coworker who, ever time she’d see me in the hall, would tell me I inspire her.  It had no meaning to me though.  I didn’t inspire her, her idea of me did.  My character did.  

I also have friends and family who tell me I inspire them.  This feels different.  They know me.  They know my strengths and my challenges.  I am a three dimensional being.  They’ve seen me at my best and my worst.  We’ve gone through things together.  We encourage each other, and can laugh our butts off at one another when we fall down, before offering a hand to pull each other back up.  

So instead of “you inspire me,” why not try “Hey! How’s it going?”  Get to know someone.  Pre judging someone for what you perceive to be a positive reason is still pre judging.

My favorite people in my life are the ones who see my disability for what it really is.  It’s a part of me that affects how I live my day to day life.  One of my favorites was when I told a coworker I was going to steal his coffee.  His response was, “Go for it, Gimp.  I can outrun you!”  It may sound awful, but it made my day.  We joked about coffee all the time, being the two most caffeine addicted staff on our ward.  For him to just pull my disability in as just another part of who I am made me feel completely accepted.  

I want to write about something fun today.  The nuts and bolts posts are important, and I hope you are getting useful information from them.   Today I want to get creative.  More importantly, I want you to get creative!  If you are dealing with a mental health diagnosis, this can be a really important way to work with and work through symptoms as they arrive.  But even if you don’t have a diagnosis, this is something I guess I can share with you too.  You’re welcome.

As for me, I really enjoy writing, I always have.  As early as middle school, I wanted to be a writer “when I grow up!” I still want to be a writer when I grow up!  I also love to draw.  Whenever I share my art with someone, 95% of the time the response is the same: “I can’t draw!”  My response is, “when was the last time you tried?”  It’s not about being good at it, it’s about doing what makes you feel good.  I have never sat down with my sketch book, worked in it, and walked away feeling worse.  Drawing and writing are ways that I process.  For me, this means getting me past whatever thought is stuck on repeat in my head.  

Doing something creative allows us to access parts of ourselves we don’t encounter in our day to day lives.  Marc Chagall said that “Art picks up where nature ends.”  I’d like to take this a step further and say that art picks up where words end.  Art is its own language.  Even when we engage in writing as an art form, we are tapping into creativity.  When we access creativity in one aspect of our lives, we start extrapolating it into other areas.  I problem solve while I draw.  I problem solve by drawing.  In the past year, I starting doing art about Cerebral Palsy.  Doing so gave me a sense of control over my disability I’d never experienced.  I decided how it would be depicted on the page.  A monster? A torturer? Something comedic?  It was all up to me.  This made me feel less powerless when I had to do things like take a muscle relaxant.  I figured I’d gotten my digs in, we (the CP and I) could both use a break.

In the town where I grew up and went to college, there was a local folk singer I liked to go see when she performed.  One of her songs was just about having a bad day.  Here’s the first verse, reprinted with permission:

Well it’s a bad damn day

I got another ticket today

And it’s my third one this week

Leave me alone

And if you see me on the street

Don’t talk to me

Unless you really have to

Unless it’s an emergency

Like you caught your leg on fire

And can’t put it out yourself

Yeah, only if you really need my help

Cause if you call my name

And you ain’t in pain

I’m gonna be even more pissed off than I am right now.

Who can’t relate to this feeling?  Leave me alone!  My day sucked!  But what this woman chose to do with it was to use the creative method that works for her: writing and making music.  

So maybe it’s writing songs.  Maybe it’s drawing pictures.  It could be slapping some paint down because the colors look like how you feel.  You don’t need a fancy camera to take pictures, use your phone, or a little point and shoot pocket thingie (technical term!).  Writing this blog helps me organize whatever’s bouncing around my cranium that day, and reminds me of things I need to do for my own self care.

Earlier this week I wrote about what to expect when you’re put on an involuntary hold.  Today I want to write more about long-term help.  I hope that none of you ever get to the place where an emergency hold is necessary.  But if you do, taking the mystery out of the process may make it a little easier.  At least that was my goal.

So now let’s get into the subject of seeking more long-term help.  I wrote yesterday about my psychiatrist and my therapist.  Both of these professionals have been invaluable to my mental health and well being.  Finding the right professional for yourself can be a daunting process.  I strongly suggest to start this process when things are going well.  it makes dealing with any frustrations or setbacks that much easier.  Also, if you are already seeing a professional when things start to go wrong, you already have an established relationship.  When I am not doing well, it’s so much harder to describe my background, and what got me to where I am.  If you already have a therapist and/or psychiatrist, the foundation is there.

So, to go about finding one of these helpers, here are some starting points.  Your milage may vary:

If you are working, see if your employer has an Employee Assistance Program (EAP).  My former employer’s EAP pays 100 percent for three sessions with a therapist.  These three sessions are great for you and the therapist to get to know each other.  It gives you time to start digging into why you are there, and how they can help.  It also gives you some time to find out if that person takes your insurance, and how much they charge.

Your insurance carrier will be able to tell you therapists in your network.  This can be done over the phone, or on the carrier’s website.  This is great if you know you’re going to need for insurance to cover some of the cost.  Understand that some therapists have limits for how many people they will take with certain insurance plans.  Insurance companies also may not have up to date information.  Please try not to get discouraged.  Take a deep breath, and call the next one.

Your primary care doctor may be able to refer you to a therapist.  If they do and you like the person, make sure to let your primary care provider know.  Also let them know if it’s a bad match, if the therapist isn’t taking new patients, or if any other issues arise.  

There are several different websites to help you find a therapist.  If you have unique circumstances, like needing a therapist who speaks a different language, many of these websites will allow you to search by that criteria.  The websites often list specialties of the particular therapist.  These may be things like anxiety, trauma, or substance abuse.

Word of mouth can also be a great way to find a professional.  If you call a professional who is currently treating someone you know, they cannot disclose anything about you to the person who referred you, and vice versa.  In fact, don’t be surprised if they don’t seem to know who you’re talking about if you tell them who referred you.  If whomever referred you tells you how much they are paying, remember that every situation is different.  Some therapists who take insurance will allow you to pay the whole fee out of pocket.  Others have sliding scales.  It is not uncommon for a therapist’s fee to go up over time, but for them to allow existing patients to continue paying the same rate.   If you find a professional through other means, let me know so I can add it to the list.  This can be a challenging process, but it’s so important to mental health.  Please don’t give up, and remember to stay safe in the mean time.

A few days ago I shared that every 3 months I get shots for my Cerebral Palsy.  They make me feel pretty awful for the first 72 hours.  Recovering from the shots this time got me thinking about medication in general.  

Before I go any further, I am going to assert that I am pro-psychopharmacology.  I believe strongly in treating mental health issues with psych meds.  I know that there is a wide range of points of view on this topic.  That’s a good thing.  It means we’re talking about it, and engaging in an ongoing dialogue.  This is how we learn and keep growing.  Getting back to my own point of view, since it is my blog, I believe that meds play an important role in the treatment of mental illness.  

I began treatment with a psychiatrist after having had my psych meds prescribed by my general practice doctor for years. (I’d tried off and on for a few years to find a psychiatrist, but that’s another entry.) After about 6 months of seeing this new doctor, it was clear that a medication I was taking had become problematic. I was really scared to talk to my psychiatrist about it. I really like this doctor, and was afraid of being judged. Instead, I was heard and understood. Being heard and understood is a human need. Shame is one of the most stifling emotions we can have, and the problem I had with the medication made me feel awful about myself. A great weight lifted from my shoulders when my doctor replied to my tearful explanation with, “Clearly this is the wrong med for you. There’s nothing wrong with that!”

If I’d kept my pain and anguish to myself and just tried to power through how the med was making me feel, I could have been in some very real trouble. All it took was speaking up.

All medications have side effects. Some are so mild, the patient doesn’t even notice them. Others are easily managed, and some are tolerated for the benefit of the drug. When a medication is causing side effects that feel as bad, or worse, than the symptom it’s supposed to be treating, PLEASE say something!  

Now, here’s the thing about psych meds: they work by treating chemical imbalances in the brain.  For example, a person with Depression has a lower amount of certain neurotransmitters, like Serotonin.  Medication works to fix this.  For a person with Depression to see the best results, however, medication should be part of more comprehensive treatment.  

In addition to my psychiatrist, I also have a therapist.  My therapist and I work together to see patterns in my life that contribute to Depression, and patterns in Depression that affect my life.  We have worked together to help me identify when I am having a depressive episode before it becomes so severe it takes over my ability to function.  When I’m able to identify an episode early on, I can take steps to keep it from getting worse.  From there, my therapist and I look at what I need to do during a depressive episode to start feeling better.  If I don’t do anything at this stage, the symptoms will progress and make it much more difficult for me to reach out and access the help I need.  One of the first things I do is call my psychiatrist, and tell her that I’m having symptoms.  She can then work with me to see what can be done, medication wise, to help me work on feeling better.  My therapist and I work on breaking things down into manageable tasks so that life doesn’t feel so overwhelming.  My Depression tries hard to tell me terrible things about myself, but talking them out with someone keeps me from getting sucked into believing them, or worse, acting on them.

Medication alone will not fix a mental health issue.  Behavior alone will not fix a mental health issue.  Friends and family alone will not fix a mental health issue.  Therapy alone will not fix a mental health issue.  Here’s the big one though: You alone will not fix a mental health issue.  No matter how many times I go through it, I am always pleasantly surprised at how much easier it is once I get my support people involved.  This doesn’t mean it’s easy.  But every time I get through it, I prove that nagging voice in the back of my mind wrong.  

Please don’t be afraid of the meds.  You can’t drive a car without gas, but you still have to do other things to make the car move.  Mental health issues can be made manageable if you can take care of the different components so that they all work together.  One of my first feelings when I start experiencing symptoms is fear.  I am learning that this fear is just my Depression trying to take over before I can send it back from whence it came.  It takes work, but it’s worth it.  You matter.  

It's time for the panic attack to start panicking, because we're going to talk about how to get rid of it!

Last time on IOI, I gave a biology lesson and a history lesson, AND managed to put all 4 of my readers to sleep at the same time!  It was a proud day for me.  I started writing about panic attacks and what causes them.  Solving a problem works better if you know what's causing it.  I don't want a bandaid on my broken arm, I want a cast that's going to help the bone heal.  So now that I know what's happening to my brain and my body during a panic attack, I can use my parasympathetic nervous system to make choices to counter the effects. No dozing off over there...I'll try not to do that again.  Probably.

So, there's WAY too much adrenaline in the body thanks to this panic attack and if the body doesn't do anything with it, it's going to feel bad physically.  When it's your body this is happening to, move.  Do whatever you can to move.  If you're in a physically confined environment, like your seatbelt is buckled, your seat is upright, and your tray table is in the locked position, You can still wiggle your toes and fingers.  Roll your ankles, wrists, and neck.  Wiggling toes also works in situations like meetings where you really have to be stealthy.  If you are some place with more options, move more.  Stomp your feet, or at least tap them if stomping isn't safe for you, physically.  Stretch.  Stand up.  Walk around.  Run in place.  Run out of place...you get the idea.

Moving makes your blood circulate faster, so the adrenaline gets moved around, and eventually used up.  But it gets used up in smaller amounts so you're not being flooded anymore.  Also, by focusing your attention on your body, you're no longer solely focused on what was causing you to panic in the first place.  This means your brain can move on from what it had previously thought was a threat, and get back to the business of regulating itself and feeling better.  So now that you've dealt with the physical effects of the panic attack, you can start working on taking some control over your mind.  There are a lot of different ways to do this.  I am going to describe a technique that works really well for me.  If you already have one that you like, by all means, use it!  There are plenty out there, so find what works for you.  My preference is to be able to do this out loud.  But if that's not possible given the situation, it works fine to just think it:

Start with naming 5 things that you see, each prefaced with, "I see..."  Right here at my desk, I see a lamp, I see my computer, I see a glass, I see pencils, I see a notebook.

Next, 5 things that you hear, again, each prefaced with "I hear..." I hear birds, I hear the fan, I hear typing, I hear myself breathing, I hear birds.  Yes, I said birds twice.  It's fine to repeat.  Don't get caught up in what you're saying or how you're saying it.  

Third is 5 things you feel.  This means using your sense of touch, not your feelings.  I feel my glasses on my nose, I feel my back against the chair, I feel my feet on the floor, I feel my fingertips on the keyboard, I feel myself breathing.

Next, say 4 things you see, hear, and feel, using the same method.  Then 3, then 2, then 1.  

What I like about this technique is it gets me present. This way my brain stops paying attention to the threat that was probably never actually going to kill me anyway.  Not only that, but my focus changes to my immediate surroundings and my body.  As I go through each cycle of I See, I Hear, I feel, I become more aware of my body calming down, and going back to its usual functioning.  

Feel free to use this and share it.  I also like to use it at night when I can't shut my brain off and get to sleep.  When I use it for sleep, I almost never make it all the way through the third round.  

I'm so relaxed now, I need a nap.

Who’s driving the bus?

I had a professor in graduate school who used to use this analogy for when mental illness was taking charge of a person’s life.  It’s a good analogy.  The healthy self may still be on the bus and see what’s going on, but not able to get to the wheel, much less take control.

I want to expand on the metaphor in this blog entry.  I believe that each person is a sum of all of their experiences.  The 5-year-old you that got your first spanking with a belt?  She lives inside you.  The 12-year-old  who got teased in school because he was dyslexic and had trouble reading aloud in class?  Right there.  So is the valedictorian, and the man who will never forget how beautiful his wife looked walking down the aisle.  They’re all in there.  Every you that has ever been is on the bus.  Don’t worry, you get to use the carpool lane. Here’s the thing about the bus: Only one gets to drive at a time.

Most of the time, it’s our present day self.  He, she, or your pronoun of choice drives around through your life.  Sometimes other passengers may give input like, “It’s you from last year.  That restaurant gave us food poisoning.  Keep driving!” Or a much younger passenger may get really excited about getting to have the kind of ice cream that was our favorite when we were 7 years old.  For the most part though, we stay in the driver’s seat.  

But then something different happens.  We find ourselves in a neighborhood that looks and feels familiar, but not for a good reason.  We realize we’ve been here before.  This neighborhood smells the same as the aftershave our attacker was wearing.  The light is the same as it was the day of the car accident.  For whatever reason, I don’t like it here, and I certainly don’t like driving through this part of town.  What may happen then is that whichever passenger was driving here before will start trying to take the wheel.  The 4-year-old runs away and hides.  The 19-year-old reacts by getting into a physical fight.  The 30-year-old turns to alcohol.  It’s not an issue of character or strength.  We’re doing what we know how to do.  The thing is, we can boot those past selves out of the driver’s seat just as quickly as they grabbed the wheel from us.  There’s more to it than that though.  This can quickly escalate into a tug-of-war.  When the rope is replaced with a steering wheel, it’s pretty easy for this big, cumbersome vehicle to get into trouble fast.  We need to figure something else out.  I have to keep driving, but 4-year-old me can still watch what’s going on.  What’s really cool is that 4-year-old me can be helped by watching.  He or she can see that just because it feels the same doesn’t mean we’re going to be harmed.  

It doesn’t mean the other passengers never get to drive.  The 21-year-old who felt SO grown up and sophisticated having her first glass of champagne can also feel just as enthralled signing papers for her first mortgage.  Sometimes when we get together with friends and laugh until we cry, it feeds the 10-year-old who loves nothing more that a good case of the giggles at a slumber part after lights out.  The important part though is that our present day self can step right back in whenever he or she needs to.  Keeping our past selves safe is how we heal them.  Uncle may have hurt your 7 year old self, and it hurts and it’s scary to be around him now, even decades later.  But 7 year old self, I will never let him hurt you again.  I will protect you the way no one did when you needed it.  Now you can get on with the business of being 7.  

It’s past present day me’s bedtime, so I’m going to park the bus for the night.  Drive safe, everyone.

Today seems like a good day to write about anxiety.  It must be because I got 8 shots yesterday.  Talk about anxiety producing!  If you’ve never had an anxiety attack, or panic attack, I am truly happy for you.  They’re awful.  They’re terrifying.  

I have had panic attacks for as long as I can remember.  One thing I am truly grateful for in my professional training, however, is how much I have learned about them, and how to treat them.

First, let’s talk about what a panic attack actually is: an over-engagement of the sympathetic nervous system.  Yep!  Simple as that!  But to break it down further…a very long time ago when we lived in caves, drew on walls with rocks, and were trying to figure out the whole fire thing, life was pretty dangerous.  We got eaten by big animals a lot more frequently than we do now, despite what Shark Week may lead you to believe.  Were it not for fight or flight, we'd have been snack food for lots of different bigger animals, and that would be it for the species.  Human beings are also animals though, and our animal brains do wonderful things to protect us.  This includes our fight or flight mechanism.  We have 5 senses that are constantly taking in information.  The information goes to our brain, and the brain decides what to do with it.  Then the brain sends us into action.  Some of these messages get delegated to the parasympathetic nervous system, which I can override.  My leg itches? My brain tells my arm to move my hand, my hand to curl my fingers, and my fingers to scratch the itch.  If I don’t stop the process, the itch will get scratched.  I can, however, tell that part of my brain, “not now,”  If I happen to be in a situation where I can’t reach down and scratch. I can choose not to do it.  Then there are the things my brain tells my body to do that I don’t get to override.  Remember the sympathetic nervous system from earlier?  That’s where these end up.  Some of these are great!!  They tell my body to do things like breathe, and keep my heart beating.  But when the message is I’M BEING THREATENED AND AM ABOUT TO DIE, everything goes into overdrive.  My ability to feel pain goes down, my heart rate goes up, and I start breathing faster.  All of these are to enable my body to fight off the threat, or to run really really fast to get away from that saber-toothed cat.  What makes all of this possible is adrenaline.  My brain floods my body with the stuff to make everything happen.  So, there’s the mechanics.  Senses take in information, brain decides it’s bad, sends adrenalin to make my body do what it needs to in order to survive.  Somewhere is the last bajillion years, give or take, we stopped having to run away from big cats nearly as often in order to survive.  Our brains, however, have not gotten the message.  So information comes in, brain sends adrenaline, but there’s no need to run, nor fight to the death.  Enter panic attack!  The feeling of my heart racing, my thoughts going to fast, and panting for breath are all brought to me courtesy of my sympathetic nervous system.  My brain has sent enough adrenalin to carry me through the threat.  The thing is though, I don’t need to fight or fly so the adrenaline is all dressed up with nowhere to go, so it starts settling in.  This doesn’t feel good, and it’s why our bodies feel the way they do when we’re having a panic attack, and for a little while after.  

TL;DR: Panic attacks, and what happens during one, kept humans alive long enough for you to be here.

So why the anatomy lecture on a mental health blog?  Because now that we know what’s causing the way we feel, we can be more effective at doing something about it.  I’m going to pause here and break this up into two entries.  Stay tuned for our next episode when our hero (that’s YOU!) will send the panic attack into oblivion and reign victorious once again!  

As I mentioned in my first post, in addition to Major Depression, i also have Cerebral Palsy. I am mostly mobile, but feel much safer using a walker.  Today seems like a good day to talk about when medical and psychological diagnoses decide to stake claims on the same person.  

Every three months, give or take, I get Botox injections for the CP. It works by fully relaxing the muscle, then mildly paralyzing it.  It starts to wear off after a few weeks, and then i get about a month or two of "normal" usage before it starts tightening up again, and it's time for more shots.  To give you an idea of the difference between cosmetic and therapeutic botox, my in-depth research, aka Google, tells me that for crow's feet, one injection averages 10 units of Botulinium Toxin Type A.  (I sound so smart!) For my CP, I get 300 units, divided among 8 injections, give or take.  The side effects are pretty brutal for the first three days or so.  I got my shots this morning, so if you're going to throw things my way, throw soft things.  Thank you.

It is certainly not uncommon for a person with a physical disability to also mental health diagnosis.  It makes sense, actually.  We experience the world differently, and are exposed to a lot of things our non-disabled counterparts are not.  There's also an alarmingly high prevalence of abuse that happens to people with any sort of disability, but that's a whole different post.  

So this particular post deals with managing a mental health diagnosis and a physical diagnosis at the same time.  The challenges are the same as for a person dealing with one or the other, with more thrown in. To keep life interesting.  For example: I know that something that really helps me when my Depression is bad is to draw.  The Cerebral Palsy, however, may have other plans.  I may not be able to hold a pencil, may not feel like sitting up at my desk, or may be too tired from not having slept the two nights before because the CP felt like being nocturnal. This is why it's so important to have as many things at your disposal as possible that can help with how i feel.  Maybe the pencil idea isn't going to happen, but I can take out my tablet, and use a drawing app in whatever position feels most comfortable.  Maybe i can use my equipment to get myself outside.  My shower is accessible for me, and taking a shower is one of my favorite ways to help myself when I am having symptoms of Depression.  

It may not be the CP holding me back from managing the Depression.  They two seem to have a mutual understanding, and take turns.  Gee, how considerate. /sarcasm font.  So when the Depression is making it hard for me to do what I need for the CP, the activities may be different, but the strategy is not: do what I can.  Focus on what makes me feel better, not worse.  I may feel better physically after a walk outside, but the Depression zaps both my energy, and my drive.  The thought of putting on shoes, finding my keys, and going feels like I might as well try to scale the Empire State Building.  But I can still get myself to open the windows, and drink a big glass of water.  Is that going to solve everything? Of course not! I have Depression and CP! But it helps turn down the volume on that nagging voice inside me that tells me I can't. Can't fight, can't succeed, can't do just about anything.  

Keep It Simple, Stupid.  But this time, I'm not the stupid one.  My Depression especially loves to complicate things for me until I feel paralyzed.  Well maybe that's not the right word for a blogger with Cerebral Palsy, but you know what I mean right? So let's make the acronym for ourselves Keep It Simple, Sane.  Sane and simple.  Find what makes sense for you without overcomplicating it.  Find what you can do, and focus on it.  Make lists.  Keep them handy.  I'll write entries in the future about these, but for now, let's keep it simple and sane.  Remember that small successes are just as important as big successes, maybe even more so.  The small ones remind us that we're capable.  We're creative.  We're resourceful.  Take that, Depression.  Okay, time for crackers and ginger ale.  

As someone who has worked in mental health, I have had patients describe this to me.   As a woman, a person with a disability, and a person with a mental illness, I have experienced it.  As a human being, I see it over and over.  It’s when person A tells person B what person B’s experience is.  This gets called different things: mansplaining, whitesplaining, straightsplaining…you get the idea.  What I have observed that I find particularly alarming is that the person doing the ‘splaining is the person who belongs to the majority group.  History is written by the winners, but so is the present in this case.  When I first got my diagnosis of Major Depression, I had people whom I know love and care about me, explain what I need to do next.  Apparently their cousin’s girlfriend’s nephew’s bestie has depression, and she started running 5 miles a day and eating more pineapple, and now she’s great!  Or ZOMG, Psych meds are poison!  You can’t take those!  You may feel better mentally, but there’s a .00000001% chance your liver WILL explode.  I like to believe this comes from a well-meaning place.  I think there’s also another motivating factor: No one wants to be powerless.  When we see someone suffering, especially a loved one, it’s awful.  We mean it when we say we’d trade places with them if we could.  So if there’s anything at all that a loved one believes can help, they’re going to cling to it.  When we reject it, they may take it personally.  That’s on them though, not you.  You’re not required to make someone feel better about your illness.  There are a number of ways you can respond to sanesplainers: “Oh! I hadn’t thought of that.  Thanks,” and then get on with your life.  “My doctor/therapist/treatment team/guru and I are making those decisions, but thank you for wanting to help.” Lather, rinse, repeat as needed.  “I had no idea you’d gotten your MD!  If I’d known I would have sent a gift!”  Okay, this one’s getting snarky.  It happens.  How ever you choose to respond, there may be some pushback.  Just remember that you are responsible for yourself, and do what you can to be safe.  After having someone push a Multi-Level Marketing juice as the miracle cure for my CP several times, I’d had it and told him, “you have to stop.  Now.  My friends support me in doing what needs to happen to be well, but they don’t make the decisions.”  We’re not friends anymore, and I am totally fine with that.  

So far, I’ve been focusing on things you can do for yourself and your own mental health.  But before I go any further, I want to start addressing the subject of getting help.  First and foremost, let’s talk about emergencies.  

*If you are experiencing a psychiatric emergency, Call your local emergency number, or proceed immediately to the nearest emergency room, provided you are able to do so safely.  Psychiatric emergencies include wanting to kill or harm yourself, wanting to kill or harm someone else, or having already taken steps to do any of the above.  

*When you make contact with someone, don’t worry about what you’re going to say, or how you’ll say it.  Do your best, and let them do their jobs.  The professional will know what to ask, and how to help you be safe. When I was hospitalized, it was because I sought out help.  I went to the local county’s emergency mental health center, and told the intake worker I was having a strong desire to hurt myself, and that I had a way to do it, and everything I needed to get the job done (Professionals call it “means and a plan”).  

*Know that once professionals are involved at the crisis or emergency level, your choices will be limited.  This is not to punish you.  This is what they’re there for.  It’s to keep you safe.  The night I was hospitalized for the first time, I was terrified.  I knew that my life was unraveling from the inside out, and that I couldn’t put it back together myself.  I remember clearly the worker coming back into the room after interviewing me.  He very calmly told me that I was being placed on a 72-hour hold.  He explained that this meant that I would not be allowed to leave, and that I would be transported to a 24-hour facility for assessment and treatment.  My initial reaction was relief.  It was some of the most intense gratitude I’d ever felt.  I was going to be cared for.  I was safe.  It was out of my hands.  I went back and forth between relief and fear many times while we waited for transportation.  

*The upside to emergencies is that they don’t last long.  Dealing with the emergency and its aftermath may last much longer, but the worst of it is over.  I experienced a flood of emotions over the days and weeks following that first night.  But not a single one of them felt worse than when I was trying to deal with it on my own.  It’s okay to be scared.  You’ve earned it!  An important realization for me that first night once I finally got to go to bed was that as scared as I was, nothing was happening to me that was even 1/10th as bad as what my own brain had been putting me through.  

Having a self care plan will be an ongoing topic here at Inside Outside In.  For my own mental health, I have two.  The first, I use when things are starting to go wrong.  Some examples of when I’ve used it are to deal with a panic attack, when my Cerebral Palsy is making me feel bad physically, or when I know I haven’t had enough sleep.  My plan reminds me of safe things I can do to change the way I’m feeling.  I can go sit outside where I live, and I know that this is something that helps me.  Sometimes I feel better if I draw something.  At the very top of my plan are the words “WATER FOOD MEDS.”  This is to remind me that there may be a physiological reason for the way I feel.  It is a cue for me to think about how much water I’ve had that day, what and how much I’ve eaten, and whether I’ve taken all of my meds.  My plan also has a list of safe people I can call or text.  Depression thrives in isolation, and shrinks in company.  My safe people know about my diagnosis, and I can be honest with them about my symptoms.  Right now, there are about 12 things on my plan.  It’s important to make the plan when you are doing well.  It’s also good to revisit it from time to time, and make sure the things you have listed still apply.  If you have a friend listed as a support person and then the two of you have a falling out, when you’re feeling bad is probably not the best time to be reminded of it!

Here’s where it gets a little trickier, but just as important

Next up is the crisis plan.  This is what I use when things have really broken down, and I know I need more help than what I can do for myself.  My spouse knows where it is.  It clearly outlines how they will know that I need outside help.  Some of the these are, “I state that I’m suicidal.”  “I refuse more than 1 meal per day.”  “I skip two classes in a row.”  These are observable things with no ambiguity.  I either eat 2 meals per day, or I don’t.  I state that I’m suicidal, or I don’t  (I always say that I am, when I am.  If you don’t, then it’s not appropriate for your plan!).  Next up is what I want my spouse to do, and how to do it.  I have phone numbers listed, and what to tell that person.  Examples of useful numbers may be your physician, therapist, or psychiatrist.  Maybe you’re really close to your step-mom, and want her to know immediately if something is wrong.  It’s totally up to you.  Just as important are the people you don’t want called.  It doesn’t necessarily mean they can’t help in the future, it just means this is not a call to be made during the crisis.  The next item on my plan is where it’s okay to take me.  There is a hospital in my area I will not go to.  There are a couple of other facilities where I feel comfortable, and would want to be taken.  This is all spelled out in my plan.  I have a list of what I need to bring with me (sweat pants, t-shirts, underwear, my box of medications, my favorite book, etc).  Now, here’s a biggie: at the top of my crisis plan, I have written: “IF (my name) REFUSES TO FOLLOW THE CRISIS PLAN, I GIVE PERMISSION FOR EMERGENCY INTERVENTION.”  I’ve signed it at the bottom.  So, there it is.  It’s out of my hands, and my spouse's.  It’s spelled out very clearly what to do when.  Yes, this is a modified version of published material.  I’m writing about what I’ve found helpful.  

I will be telling you more about myself as I get further into this blog.  I have a Master’s of Social Work degree, and worked for 8 years in inpatient forensic mental health.  I left because I was diagnosed with Major Depressive Disorder.  I was also born with Cerebral Palsy.  My diagnosis with MDD was the result of being placed on an involuntary psychiatric hold, having become suicidal during a depressive episode.  Being hospitalized was one of the best things that could have happened to me.  I was finally getting the help, not to mention the diagnosis, I needed.  I will write more of my story bit by bit, but that’s where I’m starting, and what I believe qualifies me to write about this topic.

Insight Outside In will touch on many different topics.  I am a social worker at heart, and a social justice advocate.  I am sure my political views will come through.  I will talk about my struggles and how I get through them.  I’ll talk about what works for me, and what doesn’t.  I encourage you, always, to take what I write, and think about what you can apply to your own life.