Let's Review Marijuana

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Nearly every day another state or country makes the news as it considers legalizing marijuana. Here in New York City you can smell it just about everywhere around the clock in the most unexpected places. It's so common, so easy to find, many do not consider it a "drug." Consensus is that it's not bad for you.

Furthermore, there are scientific and medical studies that say marijuana, even when used regularly, is essentially harmless without long-term consequences. Celebrities readily share, endorse, promote and celebrate marijuana. 

But is it really a problem? 

Clients say they enjoy smoking marijuana in the following ways: 

• Lowered anxiety, a feeling of calm and peace
• Makes their troubles and worries go away temporarily
• Helps them sleep
• It enlivens the senses: movies are funnier, music sounds better, sex feels more intense, food tastes more delicious
• Life feels less dull 
• They become more imaginative, more creative
• Helps them connect to a higher level of consciousness
• One young client even told me that it cures cancer; it doesn't 

However, regular smokers of marijuana also admit there are problems. Biggest complaint is that it lowers their cognitive/mental functioning; they can't think clearly immediately after and even hours and days after smoking. 

These are common problems clients experience with regular use: 

• Memory problems, mostly short-term
• Low mood: feeling irritable, anxious, more on edge
• Tiredness, feeling groggy and cloudy 
• Decreased motivation and increased procrastination
• Feelings of numbness, less inclined to feel happy
• Coughing and chest congestion

These are what we professionals call withdrawal symptoms. 

And there are more serious problems linked to marijuana. I've met people for whom it triggered a psychotic breakdown even after trying it just once. It's a rare occurrence, but it does happen.

For others, they say marijuana makes them anxious, paranoid, and self-conscious. So they stay away from it. 

In my experience, I've learned that for people who already struggle with anxiety and depression regular marijuana use produces unwanted, unpleasant feelings, as it exacerbates pre-existing sensitivities. 

Clients seek help to cut back or even stop using marijuana because they can’t do it on their own. They recognize that negative effects outweigh the positive and want to feel and function better.

Obviously a discussion on abuse, dependence and addiction needs to happen, and I will continue to explore this subject.

If you feel you have a problem with marijuana, first step is to to ask yourself what you are getting from it and what it’s taking away, in other words, look at the pros and cons. 

Drinking in America

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When a client comes to me because they are drinking too much, the first thing we do is we evaluate how much and how often they drink. Part of this exploration is to educate the client on health effects of alcohol and to understand the difference between healthy drinking and high-risk or problem drinking. And after the initial screening/evaluation, we then go on to look at other parts of their lives, to see what is contributing to excessive drinking and what the consequences are. This isn't an easy process, but a necessary one.

Often, clients are shocked when they learn that their drinking habit falls into the "problem or high-risk drinking" and, that they often binge drink. What may seem like a typical night out turns out to be a binge drinking session! (For women, binge drinking is drinking 5 or more units of alcohol in one session, and for men it's 7 or more.) For most people, I think, binge drinking is associated with college drinking. But this is not so.

Unfortunately, most Americans don't know what problem drinking looks like and dismiss their own heavy drinking until something bad happens. The fact is chronic heavy drinking shortens life and lowers the quality of life.

Here are some facts culled from recent findings about drinking in America.

• New England, Pacific coast, West and Midwest are the regions with the highest rates of alcohol consumption and the largest number of problem drinkers. 
• Young women on college campuses binge drink more than male students. Between 2005 and 2012 binge drinking rate for women increased by 17.5%. For men it increased by 4.9%. 
• Americans are drinking more, but it's not that more people are drinking. Alarmingly, people who drink are drinking more: 56% (some polls say 64%) of Americans report drinking regularly. Between 2005 and 2012 binge drinkers increased from 9% to 18.3%. 
• Regular churchgoers (47%) drink compared to 69% of those who don't. 
• 30 to 49 year olds drink the most. (So much for the stereotype.) 
• More whites (non-Hispanic) (69%) drink than nonwhites (52%). 
• More men (69%) drink than women (59%). 
• Wealthier and better educated Americans drink more. "8 in 10 upper-income, college grads drink, compared to about half of lower-income Americans." 
• Wealthy people drink more regularly but binge less often than their poorer counterparts.

The bottom line is that alcohol causes far greater harm than drugs. By CDC's estimation, between 2006-2010, 88,000 people died annually from complications from alcohol, while 38,329 died from drug overdoses in 2010.

Individually, persistent or chronic problem drinking is associated with depression and anxiety, decline in social and professional functioning (missing work or school, decreased productivity, social isolation, frequent arguing and fighting). Nationally this becomes a $249 billion problem each year in lost productivity and costs to cover treatment and crimes resulting from alcohol. Ultimately we all have to pay.

Child Adverse Experices (ACE) and Adult Health

Federal law defines child abuse as the following:

• "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation"; or
  
• "An act or failure to act which presents an imminent risk of serious harm."

Number of reported cases of child abuse is about 3 million annually. Every ten seconds another case of child abuse is reported to child protective services. 

I can't help wonder the actual number of children affected by child abuse and neglect. In my private practice and my work at a community mental health clinic, vast majority of clients experienced some form of abuse and neglect as children, but most of these cases did not get reported.

So, why do my clients come to therapy? Main complaints are: depression, anxiety, problems with drug and alcohol, addiction to food or sex, relational problems, sleep issues, low self confidence, general dissatisfaction in life. 

The relationship between childhood trauma and its effect on adult physical and mental health has been measured and documented in a study with over 17,000 people: ACE Study (Adverse Child Experiences). You can measure your score here. 

I will definitely revisit this subject in future posts.

How to Beat the Holiday Blues

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Thanksgiving is the first of the triple threat (Christmas and New Year's complete the trifecta) that can make you sing the holiday blues... If you are like me making "happy happy" during this time can actually be a real downer. If there are family conflicts (who doesn't?) the obligatory joy and gladness can seem like one big fat cruel joke. In addition, if you are struggling with relationships, work, money or going through a significant life-changing event (breakup, divorce, death of a loved one) you feel you want to skip the festivities. However, non-participation may not be an option. And for others the possibility of spending any of these holiday without family and friends can them into a dark and lonely place.

Here are some tips for avoiding emotional fallout this holiday season. 

1. Recognize physical symptoms of depression and anxiety. Emotional distress begins in the body. If you feel exhausted and tired look inward to see if it's psychological or physical. Anxiety can manifest as stomach upset, insomnia, irritability or jumpiness. Again, take an inventory. Identifying and understanding physical symptoms is the first step in addressing them. Whether the source is emotional or physical, you can do something about them.

2. Ask yourself what the symptoms mean. If they are physical, slow down, rest, change your diet etc... If they are psychological in origin ask yourself what are these feelings and what do they mean? Are you trying to suppress or ignore feelings of guilt, obligation, resentment and anger, or any other negative emotion?

3. Be kind to yourself and others. If you don't feel well and cranky maybe going to a holiday party isn't the best idea as it may make you feel worse. Sitting out a party or a gathering can be the kinder thing for yourself and for others; you are sparing negative energy from people you love and like. Listen to your inner voice even if it's saying something out of the ordinary.

4. Talk it out with your therapist, friends and family (not at the party or the dinner). Engage, reach out and share your feelings. If other people aren't available, talk to yourself by writing it out in a journal.

5. Go easy with food and drink. Alcohol will certainly amplify whatever you are feeling and overindulging will actually worsen symptoms of anxiety and depression and decrease the quality of sleep. As for food, gaining extra weight is much easier and more fun than losing it, so practice moderation.

6. Get your sleep and exercise. Enough said.

7. Be proactive. If you know you are going to be alone research and plan ahead activities. Do you have books, movies and activities to keep you occupied? Reach out to others who may be also be in the same boat.

8. Lower your expectations, or at least make realistic your expectations of the holiday season. Norman Rockwell's version of American holiday experience is aspirational at best. 

9. Create your own rituals even if it's just for this year. Maybe Santa Claus will no longer be welcomed in your home. Rather than receiving maybe Christmas is just about giving nonmaterial things. Go ahead and create your own activities based on YOUR values.

10. Be mindful. Holidays come around once a year and for some it is a season of fun and celebration. Acknowledge their right as your own. Also, be mindful that, thank god, they come around just once a year and this too shall pass. 

Swedish Therapy Cabs: Therapy on the Go

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Sweden has the highest number of one-person households in the EU — 47% of Swedish households are comprised of persons living alone. Living alone can increase loneliness and other symptoms of depression especially during long Swedish winters where there is very little daylight.

In an attempt to introduce therapy to riders who may be experiencing depression and/or other issues, Taxi Stockholm, a private taxi service, has hired three therapists to provide counseling in the back seat of its taxis to passengers. The idea is to normalize therapy and even help passenger/client with a pressing issue. No matter how short the ride, bringing therapy to the rider can expose and normalize the idea of therapy so they are more likely to seek it out themselves after they leave the taxi.

What a great idea! I am all for it — especially in large cities where personal connections are difficult to make and maintain and time is short. This could be one very clever idea to destigmatize therapy for the general public.

Anxiety in Choosing

Whether you are looking to purchase your first home, choosing an outfit for that first date or job interview, or deciding to marry or move-in together with your boyfriend or girlfriend, making decisions can be a harrowing process.

If the decision involves a lot of money it will raise all sorts of associated worries. Do I have enough money? Will I have to cut back on something else to cover the investment? If something goes wrong what will happen to my future? Will I become homeless or need to work two jobs?

If you need to decide the fate of a romantic relationship, anxieties in the form of ambivalence may rise. You can love and feel affection for someone while secretly harboring concerns about them: Will they become financially and emotionally dependent on me? Will their quirks become full-blown craziness down the road? What sort of parents are they going to become? Will they become their parents?

Ambivalence is the experience of feeling two opposing emotions simultaneously. The ambivalent partner may feel weighed down by guilt and confusion: If I really loved this person I shouldn't be feeling this way... so the thought goes. But is there anything in life that is wholly black and white?

The fact is we are constantly choosing. We make decisions each and every moment. We don't notice because for the most part these decisions are miniscule and inconsequential: a poorly thought-out outfit probably isn't going to affect your future too much. Also, when we make the same decision repeatedly (mindlessly, without thinking) we forget we are choosing.

One aspect of being a mature human being is that inevitably we have to make a big decision that will affect the rest of our lives. The option to not choose is really not an option (remember Bartleby the Scrivener?).  The other option is to live off the grid and live independently, freed from social conventions and modern amenities.

Here is a very good piece of marketing — profound and entertaining at the same time!



More on decisions and decision-making process later.

P.S. I condone moderate drinking, as does Jim Beam and Willem Dafoe, I am sure.

David Foster Wallace on Meaning of Life or How to Think

Waking up on this beautiful spring morning I wanted to share this with my readers (and my clients). Listen for his emphasis on "the default settings" of the self, which "make us automatically think that we are the center of the world." Becoming aware, or tending to our awareness is the escape key from this default setting. Sounds like mindfulness practice to me.

I also love how he defines true freedom: ". . . attention, and awareness, and discipline and being able truly to care about other people and sacrifice for them over and over, in myriad, heady little unsexy ways. That is real freedom."

This is just one part of the talk, for the other half please follow the link.


Here is a meaty quote to ponder from the commencement speech delivered at Kenyon college in 2005.

"If you worship money and things — if they are where you tap real meaning in life — then you will never have enough. Never feel you have enough. It’s the truth. Worship your own body and beauty and sexual allure and you will always feel ugly, and when time and age start showing, you will die a million deaths before they finally plant you. On one level, we all know this stuff already — it’s been codified as myths, proverbs, clichés, bromides, epigrams, parables: the skeleton of every great story. The trick is keeping the truth up-front in daily consciousness. Worship power — you will feel weak and afraid, and you will need ever more power over others to keep the fear at bay. Worship your intellect, being seen as smart — you will end up feeling stupid, a fraud, always on the verge of being found out. And so on."

I can't close a piece on DFW without mentioning his suicide. I don't have much to say at present other than again raise the connection between creative people and mental illness. BTW, one piece of fact I do know is that he hung himself as he was trying to wean off psychiatric medications he had been taking for many years for depression.

What Not to Say to Someone Who Is Depressed

Depression is the common cold of mental illnesses. Statistics of Americans with diagnosable symptoms of major depression is staggering. Nearly 20% of Americans experience major depression during their lifetime. As someone who have struggled with it myself I know personally how it feels like to live with it.

During our lowest point, our inclination is to reach out to people close to us, to remind ourselves that we are not alone. Sadly, many people, even those who love us who haven't experienced the darkness of depression misunderstand the illness of depression and believe it is a personal choice the depressed person makes.

So here is a helpful guide to what not to say when someone reaches out to you (those of you who haven't experienced the psychic pain of depression). And for those of you who are struggling with depression, I hope that it can help you educate/inform those around you to become more sensitive.

What Not to Say to Someone Who Is Depressed:

1. “Get busy, and distract yourself.”
2. “Do you want to get better?”
3. “Change your attitude.”
4. “Stop focusing on the bad stuff, and just start living.”
5. “You have everything you need to get better.” 
6. “You can snap out of it. Everyone feels this way sometimes.”
7. “Just pray about it.” 
8. “Why can’t you work?”
9. “You have the same illness as my ______.”

These are bullet points from a longer piece by Margarita Tartakovsky, M.S.

Again, I am reposting this illuminating talk by Andrew Solomon on depression. 

Running as Therapy

One of the first things I explore with my new clients is how they spend their day. The intended goal is to see what sort of structure or routine their days rest on.

Difficult and inevitable life changes (break-ups, unemployment, loss) activate situational or reactive depression or grief. It could be pass as sadness or become a full-on depressive episode. See Andrew Solomon's talk on depression.

For clients struggling with substance abuse instituting a new routine can help manage habitual mindless patterns of behaviors or rituals (after work drinks, weekend brunch drinks) that led to out-of-control use and consequent abuse and dependence.

I stress the importance of structure to one's day, and I stress exercise, journaling, and some sort of a mindfulness practice (yoga included).

Regular physical exercise should be a part of every one's life. Physical exercise a win/win proposition, just as smoking is a lose/lose.



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This post is about running, and it is my primary form of exercise. Like so many things in life, it has its own set of challenges and pleasures: It's time consuming and commitment; you sweat more and that means breakouts; it hurts; it's hard to run when it's cold, windy, hot, rainy, or when you don't feel like it; and laundry that require immediate attention.

However, after a few miles when you get your bearings (doesn't happen all the time), your breathing and legs sync up, and you realize you are mere physical matter cutting through space. You get in that headspace one strives for in meditation. Your thoughts recede behind a veil that alternate between euphoria and pain. You are just your body. For this reason, running is referred as meditation in motion.

After running a substantial distance, after the chocolate milk and mandatory stretching and shower, you feel clear headed, calm, energized. Your sleep improves, you easily fall into a deep, satisfying sleep. In addition, as your body grows stronger, leaner and gains stamina, so does your sense of confidence in knowing that you can endure temporary pain and meet goals which at one point in time unimaginable.

Just don't take my word for it. The Times runs many pieces on benefits of running (and many tedious pieces about it too). And there was this: a personal essay on long distance running and how it helped the writer deal with life's harshest emotional challenges. 

And she mentions Haruki Murakami's book What I Talk About When I Talk About Running, which helped me transition from a fitness runner to a more "serious" runner.

I will end this rather long-winded blog with my favorite quote from the book (as does the author of the Times piece):

“Pain is inevitable. Suffering is optional.” ― Haruki Murakami, What I Talk About When I Talk About Running

Depression Is a Flaw in Love

I can't say enough about this clip of Andrew Solomon speaking about depression from a TED Talks from December 2013. 

It requires amazing courage to write about one's experience with severe depression, or in his words "an illness of how you feel." 

Nevertheless, it is an illness; he reminds us that it is the leading disability world wide, and people die of it every day.

Here are some extraordinary bits of wisdom I will always want to remember.

• Opposite of depression isn't happiness. Vitality is its opposite. 

• Depression is a flaw in love.
• Quote from another sufferer: Depression is "a slower way of being dead."
• True clinical depression is characterized by delusional perceptions.
• For the depressed, truth lies. An example: We will all die eventually, but it's not necessary that we dwell on it because it keeps us from living.
• Our needs are our biggest assets. I hope to experience this some time soon.
• What are our treatment options for depression? Chemical cure or psychological cure?
  Neither are very effective and inaccessible to the poor, who are more likely to suffer from depression as a result of poverty-created environmental stressors.
• Treatment for depression (talk therapy) is expensive.
• Side effects from antidepressant medications keep people away from its imperfect solution, even though many people do benefit from pharmacotherapy.
• Sadness, grief and depression are often confused. Grief is a reactive response to loss, which resolve over time. Time heals.
• Sadness is sadness. But depression is much too much sadness.
• Depression can be triggered by catastrophic loss.
  
  http://andrewsolomon.com/

Who Are These Alcoholics?

Google “alcoholic pictures” and you will find that an alcoholic tends to be an unhappy adult white male who sits in the dark with his head in his hands. He is alone and depressed with only a bottle for company.




An alcoholic, defined clinically, is someone physically dependent on (addicted to) alcohol and unable to control how much they drink; alcoholic also has cravings and increased tolerance, and goes through withdrawal symptoms when alcohol leaves their system. Comparatively, a problem drinker, or an alcohol abuser, is someone psychologically dependent on alcohol but without the physical dependence (although a hang over is a collection of moderate withdrawal symptoms). For the problem drinker, the issue isn’t alcohol (because they can go without) but the reasons why they drink and what happens after they drink.

National Institute of Health and National Institute of Alcohol and Alcohol Abuse classified U.S. alcoholics into five subtypes. These results are from a 2007 national survey, and it is estimated 14 million Americans qualify as alcoholics.

Young Adult subtype: largest group in the U.S. with 31.5 percent of alcoholics. Low rate of mental illness, drug abuse and history alcoholism in their families. Least likely to seek out help.

Young Antisocial subtype: In their mind-twenties, 21 percent of U.S. alcoholics. Early onset of alcohol use and problems related to alcohol abuse. More than half from families with alcoholics. About half are diagnosed with Antisocial Personality Disorder. Many suffer from the trinity of mental illness (depression, bipolar disorder and anxiety problems). More than 75 percent smoke cigarettes and marijuana, and many have problems with cocaine and opiates. More than a third seek help.

Functional subtype: 19.5 percent of alcoholics. They are mostly middle-aged, well-educated, with stable jobs and families. Third have alcoholism in their family histories, a quarter had major depression at some point in their lives, and nearly half were smokers of tobacco.

Intermediate Familial subtype: 19 percent of American alcoholics, they are middle-aged and half withs familial history of alcoholism. Most smoked, half of them had clinical depression, and 20% have had bipolar disorder. Nearly 20% had problems with cocaine and marijuana. In this group only a quarter get treated.

Chronic subtype: 9 percent of U.S. alcoholics. Middle-aged; began drinking heavily at an early age. High rates of Antisocial Personality Disorder and criminality. Highest rate of mental illness (depression, bipolar disorder, anxiety disorder). High rates of smoking, marijuana, cocaine, and opioid dependence. 2/3 of the group get help (many of them to mandated to treatment making them the most prevalent type found in treatment.


Information, which I summarized here, comes from:

http://www.news-medical.net/news/2007/06/29/27074.aspx?page=2

http://www.alcoholic.org/research/alcoholism-statistics-and-information/

Are you an alcoholic? Find out here. 

In my practice I work to help problem drinkers with their emotional health, in addition to learning how to become a more mindful, moderate drinker.

Minding the Mind: What Is Mindfulness

By now everyone has read and heard about this thing called mindfulness. If you believe the hype it can help you eat less, become nicer, smarter, more relaxed and less stressed. Sounds good, doesn’t it? So, what is it and what’s the catch?

It's difficult to write about it because how do you describe a state of consciousness without sounding hokey? But I hope that the following will pique your interest enough to look into it for yourself. 

First, let’s look at what it is. 
1. Mindfulness is a state of mind we aspire to. It is a meditative state through which we can experience passage of time fully awake and conscious. It is being aware of your senses as you go about life in the here and now. The intention is to center your attention through your physical self and less from your inner, thinking self. Brain is part of the body and so whatever feelings and thoughts that arise throughout the day, they can be experienced for what it is in the present. You can be mindful and enjoy food, feel close to your friends, have a deep a conversation and feel and emotionally connected — meaning, any activity can be experienced mindfully.

2. Regular practice of meditation will make it easier to connect to the mindful state. It’s like running, the more you run, easier running becomes. 

3. It’s paying attention to the “thing” which you are doing, whether you are engaged in deep, meditative breathing, walking your dog around the park, washing dishes, reading, listening to music, or having sex.

4. It’s noticing the chatter that fills your head. When you become more mindful, you will notice many thoughts, memories and feelings come to your awareness; mindfulness is not letting your attention fall on them and letting them take you into the past or the future. Think of it this way: You are walking down the street with a destination in mind, and you run into people you know. You say hello and greet them pleasantly, but do not stop and get into conversations, because you are headed somewhere else.

5. Mindfulness is understanding that the chatter — inner voices, negative self talk, flashbacks, cravings, obsessions — is the source of our anxiety and depression. I don’t mean to say anxiety and depression will cease to happen or that it shouldn’t happen, but that we can quiet the chatter which is responsible for unnecessary anxiety and depression.

And, what it isn’t:

1. Mindfulness isn’t being distracted. Everyone experiences the discomfort of doing something or being with someone without being fully present. Your inner self is elsewhere, thinking or feeling something not in the present. It feels as if you are holding two conversations or doing two things simultaneously, which is exhausting. Focusing on what you are doing will actually enrich your experience.

2. Ignoring physical states: if you are hungry, eat something; if you are tired, take a break or nap; if you are angry, talk or write about it; if you are lonely, reach out for a connection, whatever that may look like; if you are in pain, physical or emotional, do something to lessen or stop the pain. The idea is that we can’t tune in with the here now if these primary needs go unmet. It’s like trying to operate a car that has no gas or has a major mechanical problem. In order for you to function optimally, you need to take care of your self. 

3. Giving up because you can’t “get mindfulness right.” Perfection, or in this case being completely attuned to the present, is something we aspire to; it motivates and gives direction but perfect mindfulness is not possible. Go easy when you find yourself distracted, gently redirect your attention back to the here and now and the task before you.

Here is a link to a guided meditation which is a very good introduction to meditation, and it will actually help you relax!

Addiction, Depression and Antidepressants

I read with great interest this piece on The Fix called The Dumbest Article You'll See About Addiction, and that's about right. The writer, Maia Szalavitz, is responding to a criticism of her original piece, in which she shares how Zoloft had saved her from a deep depression after kicking a serious heroin and cocaine habit she picked up during college. Twenty years later, while still prescribed Zoloft, she describes how it dramatically improved her mood and the way she responded to the world (depressed people, she says, tend to misread other people's facial expressions), that she has had a successful writing career and a very satisfying life. 

The second writer, critiquing on Slate, says that Szalvitz merely replaced one addiction with another, and asks the astoundingly naive question why we are easier on pill poppers than alcoholics. It's difficult to believe that her editor or anyone else on staff, let slide her ignorance and insensitivity to issues of mental health. While it’s true Big Pharma has integrity issues, the fact is anti-depressant medications and other psychopharmaceuticals dramatically improve, if not save, the lives of many, many people.

Be sure to read the many comments on both pages. It's a serious subject matter that affects many people.

Pain Killing

More women are dying from overdoses of narcotic pain medication than cervical cancer or homicide. They tend to be poor, older white women living in rural areas who are also taking medications for depression and anxiety.

Some of the reasons for this trend are as follows: Pain medications are readily available; women are prescribed pain medication at higher doses; women are diagnosed with depression and treated with medications at a higher rate. Women who are single mothers struggling financially are more likely to experience symptoms of depression and anxiety (duh!).

It’s somehow rational that an unhappy or depressed person would succumb to the quick, narcotic relief delivered in a pill. Why not take a respite from pain when it simply means swallowing a pill, even though taking this short cut can mean dealing with serious consequences such as full-blown addiction and even overdose. One symptom of depression is a shortened sense of time or the inability to consider the future at all; so the depressed person is not likely to consider the risks involved when self-medicating with an opiate.

This phenomenon illustrates the fact that substanceabuse and mental illness are two sides of the same coin. It also shows that personal choices and lack of proper planning can cause stresses later on. At the same time, government policies also create hardship that contribute to poor mental health. And, pharmaceutical industry is guilty of profiting from products that are often abused as a quick fix to escape the hardships.

It also shows us that managing symptoms with medication alone is inadequate because it only cushions our ability to handle anguish. A pill cannot change the facts of a life and its context. Experience of pain can be temporarily delayed but it cannot be erased. Soon or later one must begin the tough work to locate the source or the cause of emotional pain. And, if the source of pain is outside ourselves then we must adapt to it or work on changing the environment.