LIVING WITH A PARTNER WITH DEPRESSION OR BIPOLAR DISORDER

 

The recent suicide of Robin Williams awakened many of us to the toll depression or bipolar disorder takes not only on the afflicted person, but also on those of us who love and live with the person with a mood disorder. As the tragedy of Robin Williams illustrates, there is no such thing as being “just” depressed. Depression and other mood disorders are serious illnesses, and mental illness should be treated as seriously as physical illness. Partners of mentally ill loved ones are often thrust into the role of caregiver, and self-care is paramount.

Here are some tips for caring of yourself while caring for someone with depression, bipolar disorder or other mood disorders.

1. Set healthy boundaries. It is tempting to forget your own needs when living with someone with a mood disorder. Remember that you need to take care of yourself. If you do not, you will become resentful and may suffer burn out and your own depression.

2. Do not isolate yourself. A person with a mood disorder is likely to isolate him or herself. This is a primary symptom of the disorder. It is also often a result of the shame or guilt the depressed person feels. Make sure to maintain your friendships, work life and the activities that give you satisfaction.

3. Learn about the disorder. This will help you understand your partner and give you tools for caring about yourself while caring for your loved one. If he or she suffers from bipolar disorder, learn not to say “he is bipolar.” He or she is not their illness, but someone with an illness. Learning about the disorder will also help you to….

4. Don’t take it personally. A symptom of many mood disorders is irritability and uncontrolled anger. Do not take it personally, as hard as that may seem when your loved one is lashing out and directing his or her anger toward you. Do not argue or defend yourself at those times – it is like trying to be rational with a baby having a temper tantrum. Arguing and expressing your anger at these times will only escalate the situation. If the anger is overly hurtful, disengage, and walk away, as unemotionally as you can, while not suppressing your own feelings. You can say “I know you are hurting right now, but you are also hurting me. We’ll talk after you feel a little better.”

5. Determine if the anger is abusive, and weigh honestly whether to stay or leave. Only you know if the personal attacks are overly abusive and if they outweigh the love and good in the relationship. If you are in danger physically or emotionally, it will likely be best for you to leave the relationship. Abuse is never acceptable. Determine if the angry outbursts and behaviors are simply that or if they cross the line into abuse. If it is only occasional emotional attacks, that may be acceptable, but only you can judge how much it is affecting you and your life.

6. Take care of your own feelings and health. It is important to preserve your own health, both physical and mental, when you are living with a person with mental illness. You need to express your feelings, or you will become depressed yourself. Allow yourself a good cry, take a walk, hit a pillow or stamp your feet to get the feelings out. It is best not to do this in front of your loved one, as this may result in further guilt, shame and depression for him or her. Talk to a trusted friend. Get professional counseling for yourself. Get a massage. Exercise. Stay connected to your spiritual community.

7. Do not try to “cure” or “fix” your loved one. He or she may hope, whether consciously or unconsciously, that you will be a savior/rescuer and cure the illness. Remember that this is not your role or job. Remind your loved one of this gently and firmly, and suggest professional help. This is a big piece in setting a healthy boundary. Do not nag about that, as tempting as that may be.  Make suggestions once, avoiding the word” should.” He or she will hear you, and may just not be ready to take the necessary steps toward healing. Remember that only your loved one can choose to get the help he or she needs, and forcing him or her into therapy or into taking other steps will backfire if he or she is not ready to commit to the process.

8. Do not feel guilty about your loved one’s depression or other mood disorder. Remember that you are not responsible for it. Offer support, understanding and love, and again, don’t take it personally.

9. Do not make excuses for your loved one. Unfortunately, the negative symptoms of a mood disorder, such as undue anger, irritability and self-isolation, often spill over into other areas of your loved one’s and can affect your relationships with others. Let your loved one know that you will not make dishonest excuses, while assuring him or her that you will not divulge confidential information. If we all start saying “We would love to see you, but my partner is dealing with depression and is unable to go out tonight” we will begin to take away the stigma associated with mental illness. We have no problem excusing ourselves when we have a cold – why should it be any different with symptoms of a mental illness?

10. Be willing to engage in activities without your loved one. This goes hand in hand with not isolating yourself. If your loved one’s illness prevents him or her from keeping a social commitment, go yourself, especially if it is a commitment with a friend or community that nurtures you.

11. Have compassion for yourself, and acknowledge the good you are doing. Living with someone with a mental illness is a difficult challenge. Know that staying with your loved one and acting in the best interest of both yourself and your partner are acts of courage and compassion. Remember that you cannot have compassion for another unless you have compassion first and foremost for yourself.

 

 

 

 

Psychotherapy and the Middle Way

When I hear the clients in my psychotherapy and grief counseling practice talk in black and white terms, or view their options in terms of extremes, I am reminded of the Buddhist concept of the Middle Way. When the Buddha was asked how one should meditate, he responded “not too tight, not too loose.” He analogized this to a string instrument, like a lute: If the strings of the lute are too tight, they will break, and if the strings of the lute are too loose, they won’t play.

So it is as we live our lives and navigate its changes. Ideally, we strive to find a middle way where the “strings” of our life can resonate. However, due to anxiety, we may get wound up to the breaking point, where there is no give and take, no spaciousness to allow things to be. On the other hand, we may be so downtrodden with depression that our “strings” are too loose — we just don’t have the emotional energy to tighten them enough to play.

The Middle Way can be likened to living in the space of ambiguity — which is truly the condition of life. Because of our emotional histories, living in ambiguity can be fraught with difficulties. In our anxiety, we frantically fill the spaces in our lives with doing, rather than being. Yet, possibilities for growth and renewal can only arise if we are able to rest in that unknown space. If we can take a breath and rest in that space, called “the gap” in Buddhism, we see that it truly is spacious, vibrant, alive and full of possibility.

Similarly, our emotional wounds sometimes prevent us from seeing the complex nature of the people in our lives, including ourselves. At its extreme, we see them as all good or all bad, known as “splitting.” In fact, sometimes the same person is seen as all good one minute, all bad the next. A goal for people in therapy with this type of issue is to be able to see the shades of gray — people, including the client, are neither all good nor all bad. Many people with this tendency are perfectionists, with resultant depression, eating disorders, self-injury and other issues. For these clients, having a safe experience that it is OK not to be perfect (and that perfection is in fact impossible for human beings) leads to self-compassion, and compassion for others. Their emotional “strings” can then be loosened enough to let themselves — and others — be, allowing for the possibility of joy, satisfaction and intimacy in their lives.

The Middle Way approach is also helpful in my work as a grief counselor. People who are struggling with their grief sometimes ask me “when will I feel better, and when will I ‘get over it’”? Some go the “too loose” extreme, numbing the pain of grief with drugs or alcohol, or jumping into a new relationship. Others go to the “too tight” extreme, idealizing and idolizing their deceased loved ones, or holding on tightly to their pain for fear that letting go will mean forgetting their loved ones. Finding that Middle Way, where the bereaved can safely feel and express their pain and go through their own personal journey of grief, without having a map, but the compass of the grief counselor, is a key component to growing and healing in grief.

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.

Mind the Gap: Living in the Space Between Loss and Healing

One of the most difficult phases in any life transition is the space of the unknown between a loss or change, and healing or new beginning.  All life changes, even positive ones, entail a sense of loss or grief.  For example, there is a sense of loss in giving up addictive behaviors like cigarette smoking, despite the fact that the change is a positive one.  Even the change of getting a better job or promotion entails loss — you might be giving up security, relationships and the comfort of the known in making such a change.  The most difficult changes involve the death of a loved one or death of a relationship.

Our lives are always in transition.  Every breath we take involves a transition, from inhaling to exhaling, to the gap or space before the next inhalation.     After the end of a phase in our lives, we have a tendency to jump into something (or someone) new, because that space of the unknown can be so uncomfortable.  William Bridges (1980) calls this space the “neutral zone.” As Bridges explains (p. 112), “one of the difficulties of being in transition in the modern world is that we have lost our appreciation for this gap in the continuity of existence.  For us, emptiness represents only the absence of something.  So, when the something is as important as relatedness and purpose and reality, we try to find ways of replacing those missing elements as quickly as possible.”

Resting in the space of the neutral zone — feeling the pain of our loss, exploring our options, getting to know ourselves on a deeper level — is the key to transformation and growth.   How can we sit in that space of the unknown that feels anything but neutral, without giving in to the impulse to do something?  The first step is to be rather than do, which sounds much easier than it is, until we develop some friendliness toward ourselves and our anxiety.  Notice the impulse, and instead of acting on it, explore it with curiosity:  Where do you feel it in your body?  What is it telling you?  Breathe into it and let it be without having to change it in any way.

Mindfulness meditation, especially mindful breathing, is very helpful in learning how to be in the gap or neutral zone:  Feel the cool air entering your nostrils on the in-breath.  Pause and then feel the warm air leaving your nostrils on the out-breath.  Notice in particular how the out-breath dissolves and experience the space before your next in-breath.

Journaling can also be helpful in navigating the neutral zone.  Journaling helps us get those swirling emotions out of our bodies and head in a way that is workable and spacious.  We can gain some perspective on the stages of our journey — a major function of the neutral zone, and get to appreciate that time as a time for renewal.

Finding a regular time and place to be alone is also helpful in the neutral zone.  The period after a loss is a natural time to turn inward. This time of year, the barren stillness of winter, is also a natural time to turn inward.  Experience the loss of summer’s richness and the loss of the autumn leaves.  Know the gap before spring comes again as a time for renewal.  Without death, there can be no rebirth.

The Christian mystics call this gap and time of turning inward the “dark night of the soul.” It is a time to allow ourselves to feel the pain and despair that is a universal part of the human condition in the face of loss and change.  We may feel bereft and spiritually arid, and it is necessary to feel those feelings in order to transform them.  Despair can be seen as the manure from which spiritual growth and personal transformation arise.  As Michael Washburn so beautifully says in the aptly titled article The Paradox of Finding One’s Way by Losing It (1996), “It is only in the depths of despair that genuine spiritual life is found.  It is a paradox that we sometimes have to lose our way in order to find our true self.  We sometimes have to die to the world and to our worldly self before we can discover that our deepest and truest self was within us all the time.”

REFERENCES

Bridges, W. (1980). Transitions:  Making Sense of Life’s Changes. Cambridge, MA:  Perseus Books.

Washburn, M. (1996).  The Paradox of Finding One’s Way by Losing It:  The Dark Night of the Soul and the Emergence of Faith.  In Sacred Sorrows, Nelson, J.E and Nelson, A., eds. New York:  G. Putnam’s Sons.

Children and Grief: A Story of Trauma, Abuse and Healing

In my therapy work with grieving children and adolescents, it is important for me to keep in mind that the child’s age and stage of development at the time of the loved one’s death will strongly influence the ways in which the child reacts and adapts to the loss. An understanding of the child’s emotional and cognitive development will enable me to determine how best to communicate about death with the particular child, to understand and empathize with the child’s experience and guide the child through the grieving and healing process with appropriate interventions.

For example, I successfully worked with a grieving twelve-year old girl, who I will call “Abby.” I worked with Abby both individually and in a small group with other grieving pre-teens at a hospice-based children’s grief support group. Abby’s maternal grandfather died suddenly and violently two years ago while cleaning his gun.  There is some uncertainty as to whether the death was accidental or a suicide.    Abby is an only child, who lives with her mother.   Although Abby did not speak with me about it, her mother has reported that Abby’s father physically abused Abby when she was four or five years old and he has been court ordered to not have contact with her. Abby has not seen her father (who is divorced from her mother) since she was six years old.  She had a very close relationship with her grandfather, and spent every Saturday with him, doing special things together.  Abby reports that since her grandfather’s death, she spends her Saturdays alone, mostly sleeping.

The Interdependence of Grief and Development

Childhood grief and development are interdependent:  The early death of a parent or other loved one affects a child’s development, and the child’s development affects how he or she will grieve and reconstruct his or her relationship with the deceased.  Furthermore, children re-experience their grief as they reach each milestone in their development.  .

Capacity to Grieve and Understand Death’s Finality

A child’s ability to understand the meaning and finality of death corresponds to his or her cognitive development.  For example, a three to five year old believes that the deceased person has gone away and will return at some point.  Thus, it is common for a child of this age to constantly ask questions such as “Where’s Daddy?”  and “When is Mommy coming home?” A child of five to approximately nine years of age  believes that death can be avoided.  Furthermore, a child in this egocentric phase also believes that his or her parent died because either the parent was bad or the child was bad, and that if the child is good, the parent can return.  This is thus seen as one of the most vulnerable and difficult developmental stages for adjusting to a parent’s death

In working with Abby’s grief over her grandfather’s death, I always kept in mind that she was dealing with her loss both from her current cognitive developmental stage, and from the earlier stages she was in when her father abused and then left her.  Thus, she was likely relating to her grandfather’s death emotionally from that earlier stage, and may believe that she is somehow be responsible for his death. The child at this stage needs someone who can clarify what the child is thinking and feeling, and can reassure and build self-esteem by praising the child’s accomplishments.   This is something that I tried to do each time I met with Abby.

Although Abby is able to grasp and verbalize abstract concepts about death, her grief process was still informed by early developmental issues of safety and trust, as well as the magical thinking of the child in latency.  Abby’s grandfather’s sudden and violent death, coupled with her father’s abuse and abandonment, seems to have made it unsafe for Abby to trust and truly connect with her peers at a life stage when peers and feeling accepted are so important to social and emotional development.

Developmentally, even in more “normal” circumstances, 12-year olds yearn to belong, but may feel different and isolated, as the brain and body go through a dramatic growth spurt instigated by a surge of hormones. Physically, a 12 year old girl is starting to become a woman, and may experience self-consciousness and awkwardness that may lead to withdrawal.  Emotionally, she may experience a strange and seemingly uncontrollable roller coaster of highs and lows exacerbated by pubertal hormonal changes, as well as grief over the impending loss of her childhood.  Cognitively, in moving from concrete to abstract thought, an introspective and intelligent 12-year old like Abby is increasingly aware that others may not share her feelings, thoughts and values.  A grieving pre-teen, like Abby, may also feel different because so few of her peers have experienced the loss of a loved one.  This recognition can lead to the first taste of existential alienation, causing further withdrawal.  Those who are more firmly in the formal operational stage of abstract reasoning can have a more panoramic view about these differences, and develop true compassion and empathy for others.  The child not quite out of concrete operational thought, especially one dealing with profound grief like Abby, may have a difficult time getting to that stage, and may regress to more egocentric behaviors, like those I have witnessed in Abby’s case.

Tasks of Children’s Mourning

Worden (1996) has identified four tasks of mourning:  (1) accepting the reality of the loss, (2) experiencing the pain and emotional aspects of the loss, (3) adjusting to an environment without the deceased, and (4) relocating the dead person in one’s life.  The satisfactory completion of these tasks depends on both the child’s stage of development at the time of the death and his or her adaptability and ability to attend to any unfinished tasks at later stages of development.

Accepting the Reality of the Loss

A child can accept the reality of losing a loved one when he or she understands, through the achievement of formal operational thinking, “the nature of abstractions such as finality and irreversibility” (Worden, 1996, p 13, citing Piaget, 1954).  Some grasp of such abstractions is possible during the concrete operational stage of cognitive development, and is only fully understood at the formal operational stage.  Thus, if a loved one dies before formal operational cognition has been achieved, the child will experience a deeper level of grief when he or she attains that cognitive stage and fully and deeply comprehends the finality and irreversibility of the loss.

This was clearly the case for Abby.  Abby has an understanding of the abstraction of death’s finality.  She has been grappling in our sessions with giving spiritual meaning to the finality of death.  My job was to empower Abby’s cognitive work by normalizing and validating her process and the private thoughts she has chosen to share with me, while at the same time providing a safe space for her emotional process.  Furthermore, as Abby was then a pre-teen on the cusp of profound developmental challenges, I needed to stay aware that as she comes to terms with the meaning of her grandfather’s death, her new cognitive abilities also opens her to a new level of understanding – and pain – about the loss of her father.

Experiencing the Pain and Emotional Aspects of the Loss

The pain and emotions of grief can be frightening for a child to experience. Awareness of the child’s capacity based on his or her stage of emotional development to cope with strong emotions is important. It is also important to assess the child’s coping and defense mechanisms, and their effect on how the child experiences the pain of the loss.

In Abby’s case, the abuse and abandonment by her father early in her life has left deep developmental holes and she has split off from her emotions, which has complicated her grieving process over the death of her grandfather.  Journaling in a group setting proved to be an effective means for Abby and the other group members to deal with their feelings, as well as allowing them to connect with the others and feel less isolated, empowered by the realization that they have all experienced a loss, and they are not so different, after all.

Adjusting to an Environment without the Deceased

This task is an ongoing process through progressive stages of development as well as important transitions throughout one’s lifetime.  The child– as well as the adult he or she will become –  re-experiences his or her grief at each stage of development as a result of his or her growing cognitive abilities, and also as he or she comprehends the vacuum left by the dead loved one, who is not there to nurture and support the child’s growth and achievements. An intervention I used with Abby was the creation of a memory box for her grandfather, in which she has placed pictorial depictions of their relationship.  We also did an art therapy project together when Abby returned from summer vacation.  This was primarily a non-verbal exercise in which Abby was able to “tell” her grandfather through the medium of collage about her summer activities and experience her emotions of loss and sadness on a somatic level.  My job in this process was to simply sit beside her and be an empathetic witness.  In joining with Abby in this way, we established a good degree of contact and trust.

Relocating the Deceased in One’s Life

As the child grows and changes, his or her relationship with the deceased parent or other loved one also changes (Christ, 2000).  Thus, according to Worden (1996), another ongoing task is to find new ways to memorialize the deceased loved one with the attainment of each developmental milestone:  Children need to “find a new and appropriate place for the dead in their emotional lives – one that enables them to go on living effectively in the world.”  The above-described art therapy projects have been helpful with Abby in this regard.  The narrative therapy intervention of letter writing was also helpful at this stage, having Abby write a letter to her grandfather.  This process helped Abby clarify her feelings and create a safe container for them, allowing her to relocate her grandfather and live an effective life.

Today’s Top Ten on Healing Grief

Grief and loss are stressful — physically, emotionally and spiritually. Remember to take care of yourself.  Here are my top ten ways to transform loss into healing and growth:

1.  Eat nourishing foods.

2. Get plenty of rest.

3. Exercise — especially walking.

4.  Allow yourself to cry — and drink lots of water (crying is dehydrating).

5.  Surround yourself with loving people.

6. Journal — don’t worry about grammar or spelling!

7. Meditate.

8. Take a warm bath.

9.  Appreciate nature.

10. If your feelings are overwhelming, see a trained grief counselor or psychotherapist.