THE ROLE OF THE STIGMA OF MENTAL ILLNESS AND CAREGIVER BURNOUT IN THE CONNECTICUT MASS KILLINGS

I have been viewing the horrific Newtown mass murder through my lens as a psychotherapist specializing in grief, loss, trauma and caregiver support. My professional lens was sharpened by my experiences providing critical incident stress debriefing and traumatic grief counseling in the wake of the mass shooting in Aurora.

Former Pennsylvania Governor Ed Rendell observed on MSNBC (12/16/12) that the issue is how to keeps guns out of the hands of the mentally ill. I would reframe the question as how to best treat and serve the mentally ill/developmentally delayed and their primary caregivers to prevent this type of tragedy. Despite some progress, there is still much shame and stigma connected to mental illness and to reaching out for support. The lack of ready and affordable care for the mentally ill and their loved ones compounds the problem. I can’t help but think that these obstacles to mental health care played a major role, preventing both the alleged shooter Adam Lanza and his mother slain at his hand from getting the care they desperately needed and deserved.

I was struck by the description of Nancy Lanza, Adam’s mother, presented in the front page Sunday New York Times article “A Mother, a Gun Enthusiast and the First Victim” (12/16/12) by Matt Flegenheimer and Ravi Somaiya. As we have all now learned, Ms. Lanza was divorced in 2008. Her son Adam lived with Ms. Lanza full-time. He was still living with his mother at age 20, at the time of the shooting. No one else lived at the home. Ms. Lanza was described by several people who knew her as “nervous” and “high strung.” In addition to living full-time with her troubled son, she home schooled him after she became dissatisfied with the education and care her son was receiving in the local schools.

The image that came to me as I read this description was of a woman at the end of her rope, burning out from the stress and despair of caregiving for her disturbed son. Based on statistical evidence, it is likely that the difficulties in caring for Adam contributed to the breakup of Ms. Lanza’s marriage.

When I try to put myself in their situation, I imagine an atmosphere of volatility and stress, helplessness and hopelessness. I can imagine that Adam knew he “should” be living on his own, with a full time job, or away at college. I can imagine his shame and rage at his situation. I can also imagine that he projected his rage onto his mother, not only because she was there as an easy target, but also because she was a constant reminder of Adam’s perceived failings as a young man. I can also imagine that Ms. Lanza was overwhelmed by the responsibilities of caregiving for her son, and trying to maintain some semblance of a nurturing relationship with him.

I also wonder what precipitated Ms. Lanza’s enthusiasm for guns and target shooting. Many have asked why the mother of a mentally ill son would have guns in the house. Clearly, this is a sign that all was not well in Ms. Lanza’s world, and the stress of caregiving may have clouded her judgment. Without yet knowing more about that, I can also imagine that she turned to the sport of guns and shooting as an outlet in the wake of her divorce in 2008 and being Adam’s sole primary caregiver. Did Ms. Lanza reach out for support, or was she too ashamed to do so, or did she just not know where to turn for the help she desperately needed?

As a therapist providing support to family caregivers, individually and in support groups, I am acutely aware of their needs. I hear about the sense of isolation, shame, helplessness, hopelessness and despair family caregivers experience. I also hear of the verbal and emotional abuse they sometimes have to endure. It is well documented that family caregivers suffer more physical illness, as well as depression, than others in their age group, and also suffer more divorces and schisms in relationships with other family members

We need to do more as a society to remove the stigma of mental illness, open more doors to support for family caregivers and make care for all touched by mental illness more available and affordable.

Experiencing Physical Pain

I have practiced working with chronic pain for many years, using my mindfulness meditation practice as an aid. However, nothing prepared me for the experience the acute pain I recently endured.

I tried to relax around the pain, experience the physical pain directly without adding thoughts about it that lead to suffering, etc. – all the things that I tell my therapy clients and mindfulness meditation students. However, while in the throes of the most intense and excruciating moments of the pain, it was almost impossible to remember to breathe and relax. The following tips are intended as a reminder for myself , and an offer to others, when experiencing acute physical pain:

• Breathe and visualize creating space around the pain. Imagine soothing water or an elixir bathing the area in love and light.
• Listen to soothing music. Music can be so healing. Allow yourself to enjoy its beauty.
• Have someone rub your back, hold your hand, simply be a caring presence. It is so easy to isolate ourselves when we are in pain of any kind. Remember to reach out for support.
• Take a bubble bath, get a massage. Be kind to yourself.
• Listen to the song of a single bird. Notice the beauty of a single flower. Focusing on one thing helps calm the swirling emotions that accompany pain.
• Banish negative self-talk. This pain is not your fault or bad karma!

• Know that everyone experiences pain, and use this opportunity to develop compassion for yourself and others.
Of course, follow your doctor’s advice. When you are experiencing unusual pain, it is important to speak with your health care providers. Emotional and spiritual care are complements to physical care. As I have learned, pain is global – physical, emotional, social and spiritual. It is therefore important to support ourselves in all of these domains when experiencing physical pain.

NAVIGATING A LOVED ONE’S ANGER

It has been a long, hard day. You rush home to make dinner for yourself and your partner. He/she comes home grumpy after a frustrating day at work, throwing his/her briefcase down with a thump, sighing and ordering you to make a drink. You quickly oblige, knowing that his/her anger could quickly escalate. You rush back into the kitchen to get dinner ready and on the table. Your partner sits down with yet another sigh. You try to make small talk, which is ignored. Immediately, the dinner is criticized as too cold, and you are criticized as a lousy cook. You defend your cooking and yourself, and your partner’s anger escalates. Soon you are both engaging in a screaming match.

Sound familiar? How can you navigate your partner’s anger in a more productive way? Here are some tips:

• As soon as you notice that your partner is unhappy or frustrated, center yourself. Slow down and breathe.

• Remind yourself not to take his/her anger personally.

• Practice “tonglen on the spot.” Tonglen is a Tibetan Buddhist compassion practice in which you breathe in pain and suffering and breathe out peace, love and compassion. First do some tonglen for yourself: Breathe in your hurt feelings and the suffering you feel, focusing on where you feel it in your body. Then, breathe out peace and light into that hurt. You can then practice tonglen for your partner – breathe in his/her pain and suffering and breathe out love and compassion for him/her. This can take a very short time, and is very effective in slowing down the force of anger and increasing compassion for yourself and all others.

Our first reaction when we are hurt is to react and defend ourselves. This is a habitual pattern that may take some time and mindfulness to break. When I asked my Buddhist teacher the best way to deal with this unproductive habit, his one word response was “Disengage.” The tips described above can be very helpful in learning to disengage from another’s anger and not react.

I am also reminded of the 70s saying “What you resist persists.” One way to experience this notion is to push one of your hands push against the other one. Notice how this increases the force of energy in both hands. Now, instead of pushing against the moving hand, go with the direction of that hand. Notice how the force dissipates when there is nothing pushing against it. Another analogy I find helpful is navigating a skid: Going in the direction of the skid is what works. If you go against it, you’ll be in trouble.

Similarly, like in the scenario presented at the beginning of this article, if you defend against anger by pushing against it, the force of that anger will increase. Find a way to let your partner’s anger be rather than resisting it. Breathing and knowing that it’s not about you will help. Saying “I’m sorry you had a hard day” may be one way to do it. If that doesn’t work and your partner can’t control his/her anger, you may have to leave the room until he/she settles down. Continue to remember that your loved one is hurting and doesn’t know how to handle it at that moment. When things quiet down, the two of you can work together to come to an agreement as to how to handle anger in your relationship in the future.

Using Mindfulness Meditation to Tame Intrusive Thoughts

Intrusive thoughts — those pesky thoughts that can spiral from a simple thought into a full-blown novel — can interfere with our work life, as well as our life in all other areas, interrupting our sleep, intruding in our relationships and in enjoying our lives in the moment. We give so much power to our thoughts. Learning to let them go and not attach importance to them can be tremendously liberating. This is especially so with thoughts that are self-critical.

The first step in dealing with those intrusive thoughts is to be aware of them. Mindfulness meditation can be extremely helpful in dealing with our thoughts. Here are some basic instructions:

• Sit comfortably in a chair or on a cushion, making sure your back is straight yet relaxed, so that your breath can flow freely. If you are sitting in a chair, uncross your legs, feeling both feet on the floor. Unclench your jaw muscles, by resting the tip of your tongue directly in back of your teeth. Have your hands rest comfortably on each thigh, palms down.

• Breathe — notice your in-breath: the rise of your abdomen and chest, the feel of the cool air coming in through your nostrils. Then notice your out-breath — warm air coming out your nostrils, letting go of stress, the fall of your abdomen and chest. Notice the pause before the next in-breath.

• Continue breathing in this fashion. As thoughts arise, simply label them “thinking” and come back to the breath. If you find yourself caught in a story or discursive thinking, simply notice that, without judgment, let it go and come back to the breath.

Practice this for a few minutes each day, slowly increasing the time of each session. The key is to do this every day.  It may be helpful to have an experienced meditation instructor guide you through this practice.

Another technique that I often use with my clients is called “the container”:

• Visualize a container or box with a lid or other top, something you can evoke simply.

• When thoughts arise that are getting in your way, consciously say to yourself, “I do not need these thoughts right now”, and put them in your container, and close the lid or top.

Something else you can do is to visualize your energy going from your head — where all those intrusive thoughts are buzzing around — to your feet. Put both feet firmly on the ground, feeling the floor or ground beneath you, and bring your energy to your feet. This is very grounding as well as a good way to release those pesky thoughts.

It is amazing how much time we spend in our heads, and are not present with whatever it is we are doing or feeling. This is a “curse” of being a thinking human being. With our fast paced world, we are often multi-tasking, on our iPhone, iPad and MacBook all at the same time!. Take a break from your devices.

Another very effective way to slow down those intrusive thoughts is what I call “driving meditation”. The goal of this exercise is to drive when you are driving. Here are the steps:

• When you get in your car, turn off your cellphone and all other devices, including the radio.

• Have the intention to be present with your driving.

• Notice how it feels to put the key in the ignition, then listen to the sound and feel the vibrations as you turn on the car.

• Feel the tires on the road as you drive. When your mind wanders, notice that without judgment, and come back to being present driving, feeling the tires, seeing the road and the flow of the traffic, listening to your car engine and the other cars around you.

• When you get to a stop sign, actually STOP and take a breath, noticing where you are, both inside and out, and then proceed. As my Buddhist teacher says, “Don’t do a California Roll through the stop sign!”

We all have an inner-critic — that voice inside our heads that judges and criticizes ourselves. These mindfulness techniques are so helpful in freeing ourselves from these self-negative thoughts. After meditating for a while, I actually gave that critic a name that was different from my real name, as well as a different voice than my actual voice. After a year or so of meditating, a friend asked me how it helped me. After pondering her question, I answered, “Wow! I no longer mentally beat myself up, and that’s a miracle!”

USING MINDFULNESS-BASED PSYCHOTHERAPY AND MINDFULNESS MEDITATION TO OVERCOME TRAUMA

As a psychotherapist specializing in trauma and grief, the tenth anniversary of 9/11 gave me the opportunity to contemplate anew working with trauma — including my own. I was an eyewitness in New York City to the horrors of the terrorist attacks on the World Trade Center that beautiful September day. All of the media attention about the 9/11 anniversary could have reactivated serious traumatic reactions if I were not mindful of my thoughts and body sensations. I was aware that seeing footage of the collapse of the towers and revisiting other events of that day made my heart race and my hands tingle. I was also aware that my thoughts were careening back to the events of that tragic day and my feelings of helplessness and hopelessness. Staying mindful of the present moment helped me work with my thoughts and feelings. Focusing on my breath rather than my thoughts, I was able to breathe into my body sensations and emotions of fear and anxiety, and breathe out calm, healing and compassion for myself and all others experiencing those feelings.

Unresolved trauma — whether from abuse, witnessing or being a victim of violence, grieving a sudden or painful death, being in a car accident, or a myriad of other difficult events — can affect every aspect of a person’s life: physically, socially, emotionally, cognitively and spiritually. For example, intrusive thoughts and images can impact a person’s sleep, eating and overall health. The body’s flight, fight or freeze response to unresolved trauma can impact a person’s social and emotional life. Trauma is usually accompanied by negative beliefs such as “I am not safe”, I do not deserve love”, “The world is a terrifying place”, “God cannot help me”, “I deserved to be hurt.,” which affect the traumatized person’s sense of self, world view and spirituality.

Mindfulness meditation and mindfulness-based psychotherapy can be powerful tools in healing trauma. Mindfulness meditation helps free people from the seeming power and “truth” of their thoughts, helping them stay in the present, rather than dwelling on the past or worrying about the future. In addition, many people dealing with depression, anxiety or trauma are not connected to their bodies. They literally live in their heads. This is a coping mechanism to escape the pain of their feelings — it may have served them in the past, but is no longer serving them. Mindfulness meditation helps a person focus on the present moment and notice where thoughts and emotions are felt in the body. This experience can help the traumatized person feel grounded. The simple act of feeling one’s feet on the floor, feeling the support of the floor and Mother Earth, is especially effective in letting go of racing thoughts about the past and future and being grounded in the present. This grounding helps clients feel safe in the present,

Mindfulness practices keep us in contact with things as they really are, helping us let go of the seeming power and solidity of our thoughts. Dealing with the past in the present moment creates spaciousness and workability around swirling and claustrophobic thoughts and feelings. Thus, mindfulness based psychotherapy allows traumatized clients to re-experience the traumas of the past while being in touch with their present thoughts, feelings and body sensations. The experience of the present moment actually provides a sense of safety and distance from past horrors. We are able to experience as a witness the thoughts, feelings and emotions associated with the past without being stuck in them, simply letting the experiences come and go. This witnessing ability is extremely powerful, allowing us to see that we are not our thoughts or our past experiences.

Physiologically speaking, working with the present body sensations, emotions and feelings associated with the past actually releases traumatic material that is literally stuck in the amygdala, or “reptile brain.” This stuckness affects our adrenal system and other body systems as well as our brains, resulting in the automatic flight, fight or freeze response Mindfulness practices facilitate the release of traumatic images from the brain, making them less intrusive. In turn, the individual can choose more healthy responses than fight, flight or freeze, let go of negative thoughts about him or herself, and actually replace those thoughts with positive thoughts.

As one client grieving the traumatic death of her husband noted, “I still miss him, and still have images of him being in the ICU on life support, but those images no longer intrusive and disturbing. They are now just memories, and the negative beliefs about myself and the world are gone. I know that my husband’s death was not my fault and I am OK.”

Using Anger Mindfully

Many of us, especially those on the spiritual path, tend to look at anger as an entirely negative emotion.  However, anger used mindfully can be extremely positive, powerful and ultimately healing.  Anger is simply energy, and we always have a choice as to what to do with it. Dzogchen Ponlop, in his recent book Rebel Buddha (2010) aptly states:

We usually think of anger … as negative.  Ordinarily, our impulse would be either to cut through it and get rid of it or to transform its intense energy into good qualities like clarity and patience….[T]he  direct experience of our unprocessed, raw emotions can generate a direct experience of wakefulness. These emotions are powerful agents in bringing about our freedom, if we can work with them properly (p. 144).

So, what do we do that that energy?  We are often afraid to feel its raw power, and fear that expressing it will make us seem less than the kind compassionate people we are.  However, using anger mindfully will actually awaken our compassion, starting with compassionate lovingkindness toward ourselves.

In fact, many people who are compassionate toward others do not treat themselves with the same degree of compassion, and are self-critical and often depressed.  It has been said that depression is “anger turned inward.”  One of the major goals in treating depression in psychotherapy and in grief counseling is to help clients feel safe to express their anger, and turn the energy of anger outward.  “Ex-pressing” anger literally means pushing it out, so that it becomes workable and is not a toxic agent against oneself.

Anger in its pure form, without the “additives” of concept and labeling it as a bad thing, is simply energy.  The key is to harness that energy through the use of mindfulness.  Mindfulness enables us to recognize the anger without simply reacting — either spitting it out against another or turning it against ourselves.  By looking at it without reacting, we have the ability to choose to use our anger productively.

The following are some suggestions for using anger mindfully:

  • Notice how anger manifests in your body — is it a burning sensation in your heart?  A cold tight clenching in the pit of your stomach?  A flush of heat in your face or hands?  Become as familiar as you can with your own unique physical “early warning signs” of anger so you can catch its energy without reacting.
  • As soon as you notice the physical sensation of anger, stop and breathe.  Allow the energy of anger to wake you up to what is actually happening at that moment.
  • Give yourself permission to feel hurt, abandoned, scared, frustrated or sad with a sense of compassion for yourself.  Breathe in light, peace and compassion, and breathe out the dark, heavy sensations of anger without judgment, accepting it just as it is.
  • If you notice the anger turning inward against yourself, continue to breathe it out more forcefully.  Use your body to keep the energy of the anger outward — shake it off your hands into the air, stomp it into the ground with your feet  — whatever it takes not to turn that energy against yourself.
  • Be curious.  Ask yourself:  “What is this feeling?  What is it telling me?”
  • Trust your body to tell you the appropriate course of action.  Is there something you need to say to someone who has hurt you, in a way that will forward your own healing and contribute to the growth of the other person and your relationship with him or her?  Is it something you can simply let be, making sure not to turn the anger inward?

As Stephen Levine (1987) eloquently says, “the investigation of anger…leads us directly to the love beneath, to our underlying nature. When we bring anger into the area where we can respond to it, where we can investigate it, where we can embrace it, it emerges into the light of our wholeness….Then anger is no longer a hindrance, but a profound teacher.”

References

Dzogchen Ponlop (2010).   Rebel Buddha: On the Road to Freedom.  Boston:     Shambhala Publications, Inc.

Stephen Levine (1987).  Healing into Life and Death.  New York:  Doubleday, a division of Bantam Doubleday Dell Publishing Group, Inc.

© 2011.  Beth S. Patterson, MA, LPC.  All rights reserved.