Mental Health

Mental Health

[Part 1 of this post is here.]

I made the mistake of Googling “How to recover from burnout.”

Seriously, don’t do it. No, really, I —
Well, okay. Don’t say I didn’t warn you.

Now that you’ve done what I did and maybe scrolled through some of the amazing tripe that’s out there as advice, lemme tell you: ignore 98% of it.

One of the reasons I no longer practice something called “Solution-focused Brief Therapy” (SFBT) in spite of it being a highly-touted, evidence-based therapeutic intervention, is because it is at best a bandage solution, meant to deal quickly and (IMO) superficially with potentially significant client issues… all for the purpose of returning them to the workforce as Productive Members of Society as fast as possible, thus minimizing impact to the EMPLOYERS and their INSURERS. I’m not going to call it a scam outright, because it does provide some real, albeit temporary, relief to those who seek it. But it’s not an approach I respect for the simple reason that it’s predominantly used to tape up psychic injuries and send internally-wounded folks often right back into the very teeth of the stressors that are grinding them down in the first place.

And you know what that leads to? Burnout. Bandaids ain’t gonna hold jack-shit when we’re talking about the psychological equivalent of disembowelment. (Why yes, I *DO* have Very Strong Opinions on this topic, why do you ask??)

Workplace burnout is fast becoming the primary reason why employees take stress leave, even though what is likely covered by their insurance (assuming they have the luxury of coverage in the first place) is far below what’s actually required for recovery. From an American Institute of Stress 2022 study:

Workplace stress is one of the largest hurdles you can experience on the job. Stress at work comes in all shapes and sizes, across all types of industries and careers. After extensive research, our data analysis team concluded:

  • 83% of US workers suffer from work-related stress, with 25% saying their job is the number one stressor in their lives.
  • About one million Americans miss work each day because of stress.
  • 76% of US workers report that workplace stress affects their personal relationships.
  • Depression-induced absenteeism costs US businesses $51 billion a year, as well as an additional $26 billion in treatment costs.
  • Middle-aged participants had a 27% increase in the belief that their financial status would be affected by stress in the 2010s compared to the 1990s.
  • More than 50% of workers are not engaged at work as a result of stress, leading to a loss of productivity.
  • Companies spend around 75% of a worker’s annual salary to cover lost productivity or to replace workers.
  • The main causes of workplace stress are workload (39% of workers), interpersonal issues (31%), juggling work and personal life (19%), and job security (6%).

That’s a pretty bleak picture, and I suspect the Canadian numbers correlate relatively closely. Under Canadian employment law, “if you are a full-time employee with a work week of 37.5 hours, you earn sick leave at the rate of 9.375 hours each month for which you receive 75 hours pay. Sick leave is prorated if you are a part-time employee.” Under the Ontario Employment Standards Act, “Most employees have the right to take up to three days of unpaid job-protected leave each calendar year due to a personal illness, injury or medical emergency. This is known as sick leave.” Good to see in print that even our federal and provincial governance can’t agree on how to effectively manage sick leave, which is what employees are requesting when they are asking for stress leave. THREE DAYS??? Oy.

Unsurprisingly, many people start with the same assumptions about a stress leave that they might take into a vacation break: it’s time away from work, I’ll feel so invigorated, I’ll get so many non-work projects accomplished, I’ll make such great use of my now-free time! I’ll find a new job! But even a couple of weeks into a leave, they find they often Just Can’t Even, and that’s when they often wind up in my office, or offices like mine. They’re wondering where their motivation went, and why can’t they seem to feel any better even with the time they’ve already taken off.

Burnout is a state that affects us on every level: physically, emotionally, mentally, and relationally. That means recovering from burnout needs targeted recovery processes (note the multiple there) aimed at each and every one of those aspects. And because burnout is often the product of long exposure to the stressORS that have ground us down to mush, it operates very much like a long-term illness. We’ve been “sick” for a very long time, even if we didn’t realize it until that sickness brought our functionality to a crashing, crushing halt. Ergo, we’re not going to “fix” it with a weekend of sleep, a two-week vacation, or even a two-month stress leave. We just can’t. THAT’S NOT HOW BURNOUT WORKS. (And yet, that’s what employers and insurers want us to believe because it benefits them, or they believe it does, to have their employees back in the trenches as fast as possible, recovered or not. They want the bandaids, because then they don’t have to fix their own destructive, systemic issues that create the stressors in the first place.)

So then, how DOES one recover from burnout, if at all??

The first step is recognizing the difference between the stressors, and the stress. Stress is what you experience as a result of a variety of factors (the stressors) having an ugly, corrosive impact on your quality of life.

“Stressors are what activate the stress response in your body. They can be anything you see, hear, smell, touch, taste, or imagine could do you harm. There are external stressors: work, money, family, time, cultural norms and expectations, experiences of discrimination, and so on. And there are less tangible, internal stressors: self-criticism, body image, identity, memories, and The Future. In different ways and to different degrees, all of these things may be interpreted by your body as potential threats.
Stress is the neurological and physiological shift that happens in your body when you encounter one of these threats. It’s an evolutionarily adaptive response that helps us cope with things […] [I]t activates a generic “stress response,” a cascade of neurological and hormonal activity that initiates physiological changes to help you survive[.] Your entire body and mind change in response to the perceived threat.” (Nagoski & Nagoski, “Burnout: The Secret to Unlocking the Stress Cycle,” Ballantine Books, 2019)

Burnout, therefore, is the result of living within the cascading effects of that threat-response pattern over the long term. And as a long-term issue, the recovery is also going to be a long-term process. How long? Well, that depends on too many factors to have a standard formula, but from my perspective, what I’m seeing is that the deeper the burnout, the longer the recovery will take.

I have come to liken what’s actually required for recovery as being akin to what happens when a serious athlete, like a marathon runner, breaks a leg.

At the point of the break, the marathoner does NOT think, “Hey! Now I can go and run all those OTHER races I’ve been meaning to get to for months/years!” No, the marathoner is going to be KEENLY aware of the damage and the pain… something burnout victims are notoriously bad at acknowledging (something, something, frogs in pots of slowly-heating water, something…). In a best-case scenario, the marathoner can get off the course and into help and safety immediately. Sometimes the break happens and the marathoner is going to have to continue on for a while before escape to treatment can happen, which means the pain will be inescapable once realized, and the damage might get worse before it has a chance to get better. Obviously, we want systems that support the former, but all too often we’re trapped in systems that enforce the latter.

Once the marathoner is off the course, then we’re into a healing process that looks a lot like this, and this model is what I’m now using with my burnout clients:

  1. First things first, the break needs a chance to actually heal: knitting bone and soft tissue back together, sometimes with professional intervention, but mostly just letting the brain and body do what they need to do to put broken pieces back together. THERE IS ABSOLUTELY ZERO LOAD-BEARING ACTIVITY AT THIS POINT. There can’t be; the broken bones won’t tolerate it. There’s a lot of rest. This stage usually takes several weeks for both bone breaks and for burnout.
  2. Then, once the bone has knit and the soft-tissue damage or inflammation has largely receded, THEN AND ONLY THEN will a doctor give the okay to start physiotherapy and rehabilitation. This is the stage in which the marathoner is trying to teach new tissue how to do basic things like move and flex, and integrate with the existing tissue. Agin, not a lot of load-bearing activity here. In burnout terms, this is the stage in which people start to do basic functions in their own lives, like tend to personal care or basic relational interactions. They might start THINKING about whether or not to update their resume, but they’re generally in no great energetic state to put their best selves forward in interviews. This stage can take literally MONTHS for both the marathoner and the burnout client.
  3. After that, and only once the medical and phsyio supports sign off, can the marathoner even THINK about starting to move like normal. They’re certainly not in a state to go back to running, but they might be able to take a walk to the end of the block and back. They’ll eventually work up to making it a sloppy shuffling runwalk, and be constantly monitoring the new tissue for pain or other signs of damage. THIS is also a stage that can take months to progress through, and this is the stage where both athletes and burnouts are likely to push too hard too fast, and experience inevitable setbacks when the recovery process proves unequal to the desire to just get on with things.
  4. When there’s a generally-consistent ABSENCE OF SYMPTOMS related the break/burnout for period of time approved by the support system (NOT the recovering individual), THEN AND ONLY THEN is the individual at the state where they can BEGIN to start retraining their body to work back up to a level of pre-break functional capacity. This is NOT the stage at which the marathoner goes and runs a 26-mile race. This is when they start actually running to see how far they can get, or they start for endurance but take it at a quarter-speed. This is when the burnout client MIGHT return to work one or two days a week on light duty.
  5. From there we collectively eyeball a “return to full-function” target but maintain a consistent and careful watch on how the recovering individual does with resumption of the load-bearing factors.

Throughout this, the burnout client, like the marathoner, is hopefully working on adaptive skills to better balance the stressors that created the state of collapse in the first place. This may involve being honest with themselves about what they can and can’t handle; this may involve needing to do different work on managing stressful relationships. This may require changing jobs, or dealing differently with health issues. Some of these factors CANNOT be addressed by quick-fix bandaid solutions, and the entire recovery process is NOT a short-term affair. Burnout can literally take YEARS to recover fully; that part is defined mostly by the client’s ability to adopt and sustain more effective capacity-management strategies, not just “coping” strategies.

Clients don’t like hearing that they could be recovering from burnout for a long time; most people don’t like the notion of being compromised, because it will mean having to change how they live, how they behave, and how they view their own capability, differently for the duration. Employers don’t want to hear that they may be paying full or partial salaries for absent employees for months on end, and insurers put out so many hoops and challenges to those applying for stress leave that it makes it hard to onside medical and mental health professionals who are required to provide corroborating evidence of the client’s mental state for the duration.

I get it. It’s hard. So is being laid up with a broken leg when you’d rather be out running the Boston Marathon or through-hiking the Appalachian Trail. But the point at which you’re willing to acknowledge that something is broken is NOT the point to simply switch gears/stressors and keep applying load to something that has been broken down by bearing too MUCH load for too long.

Heal first. Then start to retrain or add adaptive skills. THEN start to work back up to load-bearing functionality. THEN re-assess that capacity, and make whatever changes will be necessary to maintain yourself at non-breaking levels.

It’s a slow process, but so far, it’s the only one I have seen work, and I’ve been looking at the issues of burnout for a really, really long time.

Mental Health, Uncategorized

In 2019 (when I started the original draft of this post), the World Health Organization released an updated classification for burnout as an “occupational phenomenon”:

28 MAY 2019 – Burn-out is included in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon. It is not classified as a medical condition.

It is described in the chapter: ‘Factors influencing health status or contact with health services’ — which includes reasons for which people contact health services but that are not classed as illnesses or health conditions.

Burn-out is defined in ICD-11 as follows:

“Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:

  • feelings of energy depletion or exhaustion;
  • increased mental distance from one?s job, or feelings of negativism or cynicism related to one’s job; and
  • reduced professional efficacy.

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”

Burn-out was also included in ICD-10, in the same category as in ICD-11, but the definition is now more detailed.

The World Health Organization is about to embark on the development of evidence-based guidelines on mental well-being in the workplace.

This blog has looked at the issues of burnout many times before (here, here, here). On a personal as well as a professional level–across TWO career fields, no less–I am intimately familiar with what WHO somewhat blithely labels as “chronic workplace stress that has not been successfully managed”.

On one hand, I applaud WHO for putting their eyes on this issue as their attention can have repercussions on a global level. On the other hand, when North American culture seems hell-bent on stripping everyone but the richest of their rights, it means the workload of making things function as the entitled expect, continues to be the only kind of trickle-down effect to land on the common worker. And at the end of the day, people who fear for their jobs are increasingly UNLIKELY to raise concerns and issues about stressors in the workplace that affect their engagement and efficiency, as well as their overall mental health and safety.

This isn’t an issue I know how to solve. Especially since I left IT, this is a discussion I have had with a very great many of my clients who work in IT specifically. This runs the gamut from trench-level workers in support call centres to the content developers (programmers/testers/designers/writers) to system architects, team leads, managers and corporate braintrust-level employees, to HR agents and executives, to C-Suite bosses. Burnout is pervasive in the high-tech industry at levels I have never seen from any other field, with the possible exception of teachers. Stress-induced sick leaves are rampant in IT, judging by my own clientele in two practices, and what I know of the types of clients coming to see many of my colleagues.

Burnout, as “chronic workplace stress that has not been successfully managed” means that several issues are coming to a head in the workplace:

  • unrealistic performance expectations (individual or across the corporate board)
  • demands and pressures that exceed regular working hours and bleed across employees’ private lives
  • artificial pressure to advance and/or transfer around the company for a breadth of experience or “to avoid stagnation” (Google in particular is notoriously heinous for this practice) regardless of the individual’s preference or capacity
  • lacking or insufficient support for employee mental health and balance with life outside of work
  • HR solutions and EAPS that are constrained to get employees back to work as quickly as possible, which always ends up working in favour of the corporations, not the employees
  • corporate practices that reward employees for making sacrifices that then normalize the culture of sacrifice

Organizations like WHO can legitimize the workplace effects of unmanaged stress, but this does nothing in truth to change the sales and management styles of businesses intent of maximizing a profit line no matter how badly they chew through human resources to do so. Looking at resources online dedicated to offering suggestions on retaining talent, I see some common themes:

1. Start with recruiting “the right people” who will “stay the course” (read: “people who won’t complain about getting hired for a 40hr work week who are then regularly asked to work 80+hr weeks).

2. Pay them well, offer bonuses and a good benefits package (read: if you give them enough money, they’ll theoretically never notice they’re missing their children’s childhoods, or their own romantic partnerships, or even sleep).

3. Offer them opportunities for advancement (read: because nothing makes people work harder than giving them goals that they can burn themselves out trying to achieve for the reward of yet more work and stress and burnout…).

4. Flexible work schedules, and a great corporate culture (read: give them all the comforts of home so they don’t miss actually going home quite so much). — edit to add: we did see an enormous shift downward in stress levels for much of the workforce who adapted to working from home during the pandemic, many of whom are not reacting well to corporate pressures to return to the office even part-time as of mid-to-late-2022.

5. Offer praise and affirmation (read: pleasant words on the way to self-sacrifice as a reward for setting oneself on fire make EVERYTHING SO MUCH BETTER, YO).

Okay, so I admit the bias here is exceptionally cynical, but I come by it honestly. These were cultures in which *I* came of age, and these are corporate practices I now watch consume my friends and clients and loved ones on a daily basis. But can anyone else spot what’s missing from these kinds of lists? When we talk about retaining good employees, can you see the glaring hole where the best answers of all should be?

Where in the conversation regarding burnout and retention are the discussions about governance responsibilities? Where is “more effective project/product management” that avoids the common practice of overselling features that cannot effectively be designed, developed, tested, documented, packaged and deployed in a realistic timeframe? Where is the discussion about mitigating the profit craving so that we reduce the factors that produce burnout in the first place, and avoid paying stress leave in favour of making it easier for employees to stay happily at their jobs? Where is the improvement in management that better controls customer-driven scope-creep under project deadlines?

In FantasyLand, for the most part. That’s where. And more and more people are “coming down with” symptoms of stress, fatigue, anhedonia; comorbid diagnoses of depression and anxiety increase exponentially in my clientele every year, even before the pandemic sent those numbers spiralling out into chaos. People take insufficient downtime through the work weeks because they feel they can’t repent of their busy-ness, and when they do take time off as vacation or stress leave, they rarely do what’s needed to recover (more on that in Part 2). Part of recovering from burnout across the board is going to require the corporate culture that engenders the stress to begin with, to take a long, hard look at its own culpability, and step up to change expectations and management styles. That isn’t going to happen in my lifetime, I suspect; stress is built into the very nature of a build-and-deploy, feast-or-famine cycle of software development.

So if we cannot remove or significantly redesign the stressORS, how then do we begin to reframe our understanding of healing from the stress itself? For that, we go to Part 2 of this discussion. Please stand by! 🙂

Current Events, Life Transitions, Mental Health

So there we were, six months into a pandemic, trying to pretend the world was getting back to “normal” in spite of COVID numbers slowly creeping back up in the wrong direction, a race war brewing, backlash against militarized and violent policing growing, an American election fiasco in the making, questionable political decisions on our own side of the border…

No, wait. Not “were”. ARE. Here we *ARE*.

Today in Ontario, many schools reopened their doors to returning students without a clear plan on how to manage classrooms under pandemic conditions. Parents, teachers, and school staff alike have been dreading this moment since things closed down in March; next to actual lockdown adjustment crises, that’s been the second or third most common issues walking into my (virtual) office for the last month or so. Even for those of us without kids but with an excellent understanding of science basics, there’s a sense of a timer ticking, and this year it’s not just about the surge of the usual colds and health issues that come from children playing together as children do. It’s all the OTHER infection vectors that are now in play.

And yes, we’re concerned. We’re concerned about how best to continue to support our clients and our communities while keeping ourselves, our colleagues and office staff, our offices, and yes, our clients and everyone to whom YOU are connected, as safe as we can. We’re still being advised by our governing colleges to avoid returning to in-person sessions for the foreseeable future, so virtual meetings continue. Six months into things, we’re still not back to normal operations, nor will we be any time soon.

Our clients continue to be graciously understanding for the most part, but they’re as frustrated as we are. We’re still helping folkx navigate a world where jobs are still disappearing as businesses falter, where pandemic/lockdown fatigue and social distancing remain considerable barriers to mental health, where “Zoom fatigue” and the normalization of working from home creates a whole new set of challenges to work/life balance routines. We’re trying to figure out how best to help our seasonally-affected clients prepare for the autumn and winter in the absence of most of their normal social options. And we’re trying our best to make sure we as therapists don’t succumb to this tidal bore ourselves.

All of which to say, six months on, we’re still here, still working, still doing our best to support where we can, validate and commiserate where we can, change what we can, offer what hope and perspective we can… And we know that some days, many days even, will be harder than others. We can’t make any of this go any faster, we can’t predict what life will look like in The After, and we don’t always know what will make it easier to get from Here to There either. But we’re in the mud with everyone else, and we get it.

Stay strong, stay safe. As the clich? says, especially at this point, “The only way out is THROUGH.”

Current Events, Mental Health, Practice News

So, here’s another truth about being a therapist at this particular moment in human history (last week’s behind the curtain view was a humorous one; this one’s a little more serious). Most therapists work from what’s called a “trauma-informed” perspective, meaning we are “treating a whole person, taking into account past trauma and the resulting coping mechanisms when attempting to understand [current] behaviors and treat the patient.” We also take into account the differences between trauma as a disruptive event, and complex trauma, which is “a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape.”. In other words, we’re good at coming in when the client is ready to do the work of unpacking or changing the way past events have, or continue to disrupt their current life.

…AFTER THE FACT.

We sometimes get lucky enough to be available as someone is processing an event in progress, like working to escape an abusive relationship or dealing with a loved one as they are dying. But even in those circumstances, we’re on the outside of the experience looking inward, a stable neutral presence that can help anchor and support clients in distress.

Hard truth time: ain’t none of us trained to deal with global epidemics and crises on this scale AS THEY ARE HAPPENING and AS THEY ARE ALSO HUGELY IMPACTING *US*.

We sometimes get called in very soon or immediately after a crisis event happens, but we’re not usually enmeshed in it ourselves. Right now, however, we’re supporting our clients and colleagues (many of whom are themselves in identical unfamiliar circumstances) in working through virtual channels, working from home, dealing with children and partners underfoot all the time in quarantine… while dealing with exactly those same issues ourselves. As I wrote last week, we’re all in this together, but like medical health professionals, having been determined by the government to be “essential services” therapists are ALSO working long hours to make sure we keep our own shit under wraps enough to be an effective support for our clients right now.

I don’t tell you this to make us seem like superheroes, because I can assure, we’re still pretty human (see last week’s post for proof of that). I tell you this because there’s a need to understand that while we’re doing the best that we can, we’re really not trained for this, either. Many of us are cobbling together what we know of trauma care with what we know of working with high anxiety and (where appropriate) basic CBT tactics to hold the intrusive, fear-laden thoughts at bay. The problem is, when we’re living through an honest-to-god global pandemic, the actual worst-case fears and risks are both absolutely legitimate, and pretty terrible… and the clients aren’t the only ones seeing that. The therapists are living and breathing those concerns and fears right alongside you.

The definition of complex PTSD keeps coming back to me as I watch people adjust to the new normal, including a persistently-high state of stress/worry/concern/anxiety/fear about the what-ifs. When you’re living in a dangerous time, there isn’t any form of escape other than to just “live through it”, no matter how long it takes. And being in that persistent state over the longterm always exacts a toll; it’s not going to be the same for everyone, nor will it manifest in the same timeframe for everyone. But it’s there. And we have to take that into account when we’re dealing with ourselves and our clients, not just in the future and after the fact, but right now. Today. In this moment.

The best tool I’ve got right now is working with people to normalize and validate everything in their maelstrom of feelings; to shorten down their personal event horizons and look specifically, and exclusively, at what is in their power to do TODAY? What will make them feel better TODAY? It’s not that I don’t want to sustain a sense of hope for the future, but we have to keep hope in the context of daily-fluctuating uncertainty. We need to frame it in an understanding that our current heightened state of curve-flattening mitigation tactics will take WEEKS yet, if not MONTHS, to drop the infection rate back to near-zero (because as long as there IS a new-case reporting rate, we ALL remain at risk; that’s just how viral pandemics work). I’m watching friends and clients intellectualize that timetable, but the truth of what their lives will look like is barely just starting to take hold on an emotional level, especially knowing that the pandemic is only the trigger for an economic crisis of equally epic proportions to come. This kind of uncertainty really eats away at a person’s sense of grounding and control.

It eats away at ours, too. Trust me on that.

We’re in a high-stress, high-uncertainty scenario not of our own making and even less under our control. The odds of this crisis *creating* complex trauma responses for a large number of individuals is likely high, because it’s a longterm situation and it’s inescapable. The challenge for us as therapists is that we can’t wait for this scenario to be over before we’re needing to put boots on the ground and be effective. We can’t wait until we get ourselves clear of this scenario before we wade in to offer support to others. When I say, “we’re all in this together”, I mean it quite literally. As therapists, for once we are not apart from your crisis; we may have our own responses to what’s going on, but we are also up to our eyeballs in it. We’re as uncertain, as stressed, as anxious, as terrified, as exhausted as you may be.

And we’re still here. If you need us, we’re keeping the lights on for you as long as we can, and hopefully all the way through.

(Both my home office and Bliss Counselling are still open and seeing clients, BTW. We’re only doing virtual sessions via Zoom or phone for the duration, but WE ARE OPEN!)

Current Events, Mental Health, Practice News, Self-care

People keep asking why I’m continuing to see clients in person both uptown and at the home office. It’s simple, really: the therapist’s office is the only safe space some people have. Many who might have used work to escape volatile, toxic, abusive, or outright dangerous home situations are now being told to stay home and not come to work — meaning they are trapped in the very situations that threaten them the most.

It’s unclear what protocols local shelters are enacting in a time of pandemic, but the anxiety levels around exposure and uncertain shelter occupancy arrangements will also serve to keep the vulnerable from getting clear of a dangerous home environment.

It’s the darker side of quarantine, isolation, and the desperately-needed social distancing practices: yes, we’re trying to flatten a curve and spare hospitals and treatment centres from overloading, but we’re also trapping some of the most vulnerable people in their own worst nightmares, caging them with their abusers for an indefinite period of time.

So yes, if my office is the one safe space that remains open to them, then I will take every precaution I can to protect us all for as long as I can. I will disinfect everything I can and keep to a reasonable distance across the room, but come hell or high water, for those that need us — we’ll keep the lights on for you as long as we safely can.

Emotional Intelligence, Mental Health, Self-care

The problem with not sitting down to write anything since some time in the last half of November is that, of course, I haven’t actually cracked open the tablet I use for such things since some time in the last half of November. Ergo, first thing this morning it was both (a) utterly out of go juice, and (b) way behind in installing operating system updates. Have you ever watched a device simultaneously try to recharge and update itself? Trust me when I say, it’s not pretty. In fact, from an impatient end-user perspective, it’s really fabulously frustrating.

So as I’m sitting in my favourite coffee shop, masticating my toasted bagel and ruminating into whatever coffee Tori poured for me this morning, forcing myself off the precipice of my own impatience, it occurs to me that this simple piece of electronica is reflecting back at me a valuable learning opportunity. Never mind that I hate being schooled by inanimate objects at the best of times, truthfully over the years I’ve learned to be open to “lessons from the universe” whenever, however, and from whomever (or whatever) they originate.

I’ve been sunk in a massive depression for a while, unveiled finally in late November by a series of confluent precipitating events (aka, “a bunch of shit crashed together and crushed me”). Since then, struggling to retain any degree of functionality has meant circling the wagons ’round, pulling in my boundaries, shutting down every gate and ingress to all comers, and just kind of hiding out, entirely to conserve near-depleted energy. In short, my internal batteries are entirely out of go juice.

Since early December, I’ve been trying to update the operating system: getting back to my own therapist at least biweekly, starting the game of Russian Roulette with antidepressants, making sure I spent the entirety of the holiday season sleeping as much as I could (which might even have been within spitting distance of as much sleep as I need), reintroducing massage therapy as a more frequent thing (the convenience of having the massage college with an excellent student clinic close by), and as of last week, getting back to my nightly meditation practice. I have a nebulous idea about attending to what and how I eat as the next step, and then at some point, trying to finagle an increase in movement back into my schedule.

It all sounds good, doesn’t it?

Now, imagine what it’s like trying to think about/plan, to implement, and then to SUSTAIN, all of this when, on top of normal day-to-day functionality, there is ZERO POWER in the batteries.

Like the tablet this morning: start an update, power cycle into a shutdown, leave the user wondering if the OS is going to boot up this time or if it needs a kick. Some days, you need to lean a little on the Power button; some days the power cycle reboots on its own, gets a little further into the next update process… and shuts down again. Lather, rinse, swear a lot, repeat.

This is, unfortunately, a really exquisite description of my life for the last several months, but particularly since the November crash. On the upside, I have been finding that it gives me a whole new metaphor for talking with clients about their own experiences of depression (especially those who have some experience with the cyclical frustrations of Reboot Hell). For some, a depressive cycle starts with a crash; things may have been going wrong in the OS for a whole, but as long as it wasn’t BADLY impacting functionality, we could ignore the slow downgrade until it crashed out completely–I don’t know for sure what the depression equivalent of the feared “Blue Screen of Death” is, but I’m betting there is one. For others, the slow cascade of fail is something they see yet cannot stop, even as they throw mitigating efforts at it along the way. The lucky ones are those who have some way of actually rebooting in mid-decline AND HAVE IT STICK. I aspire to be one of those people, even though I have zero idea what that actually entails.

The biggest challenge for deploying this kind of metaphor with high-functioners in particular is getting clients to realize that depression recovery isn’t just about the updates and reboot process, it’s about recognizing the dead battery aspect. Even many depressives who otherwise have no trouble recognizing their own lack of energy as a critical feature of depression, will struggle against the imposed limitations. The desire to push to be “happy” means that, like my poor tablet, any process of updating and rebooting is automatically hampered out of the starting gate because there just isn’t enough energy to do both the regular startup AND the additional implementation of updates. The hardline lesson of learning to live with depression, and I see this reiterated all of the place now, is learning to live WITH it like a recurring but perpetual illness. That means learning to accept that it comes with limitations and discomfort, much like anything from recurring cold sores to arthritis flares or MS relapses, will. It will come with the frustrations of watching your core operating system get stuck in a process you can’t clearly see into, and can’t do much about once the process kicks off. You can only sit by in frustration, waiting impatiently for the cycle to finish. Or you can learn to relax into it, do what you can around it, find other ways of doing what little you CAN find energy to manage. (I’ll give you two guesses which category I fall into, and the first guess doesn’t count.)

The stigma around depression prevents many of us from “being okay” with simply being depressed. Most of us work in situations that leave us feeling like we can’t afford to be physically sick, never mind mentally compromised or incapacitated. The pressure to just grit our teeth and get through depression is enormous… and depletive. Culturally we don’t have any good answers for how best to treat depression beyond recognizing it as a legitimate illness encroaching on epidemic proportions, even as mental health professionals grapple with the notions that depression’s causes are almost as numerous and varied as its manifestations and its impacts. (For example, even as we note that depression can run in families, we still have no surefire way of determining whether it’s a nature or nurture effect, genetic predisposition or learned coping strategy; how is it that I remained high-functioning for 18 months and still continued to work through and after a hardline crash, while my mother was rendered bedridden by her depression for long periods of time? Genetics? Situational necessity? Combinations of the two? Who knows?)

My only good answer remains, as frustrating to many as I’m sure it is: slow down. Realize you’re compromised, and will be for a while. If you can’t accept the limitations depression imposes, for whatever reasons, at least be realistic in your workarounds (see previous note, re: compromised functionality). Consider the fact that you may reach the point where you can EITHER recharge your batteries OR upgrade the operating system somewhow, but attempting both simultaneously may make things more complicated and frustrating than you mean them to be.

Sometimes all we can do is wait something out. Eventually one of the interminable reboots will hopefully get us back to the point where we can do something more like what we expect of ourselves. Be patient. It’s been my unfortunate lesson to learn that sometimes there’s nothing else for it but to hang on and ride the ride until it’s over and you can exit the damn thing safely.

Yeehaw… or something.

Mental Health, Uncategorized

Pride Month (Pride Week in Kitchener-Waterloo just wrapped) often gets me thinking about intersectionality:

Intersectionality is a concept often used in critical theories to describe the ways in which oppressive institutions (racism, sexism, homophobia, transphobia, ableism, xenophobia, classism, etc.) are interconnected and cannot be examined separately from one another.

Intersectionality is a concept that has developed from feminist theory (specifically exploring the lived experiences of women of colour), but now provides a lens through which to look at the power dynamics inherent to, but often invisible within, ANY kind of relational system. “The personal becomes the political” when we amalgamate those individual lived experiences into a narrative that can then influence–hopefully for the better, though the road is long–both cultural thought on the broad spectrum, and political agendas that often interfere with movement towards balance and equality.

Intersectionality also gives us a framework for exploring all of the many factors exerting influence on our day-to-day relationships with ourselves, partners, family, coworkers. It’s the language of systems theory, shifted a little to consider the oppressive nature of some, often many, of these factors. Family Systems looks at the function of the family actors and values on the individual; intersectionality gives us a broader perspective in which to observe and change the oppressive impacts of racism, ableism, patriarchy, classism, etc. on the individual within those relationships. In short, the personal became the political… became the personal again, providing us with better tools to re-examine the relational from clearer perspectives.

Many psychotherapists, and certainly anyone operating from a feminist-informed perspective, has likely already been working from some degree of intersectional understanding. This is a perspective that goes beyond the therapist speak of having “an eclectic practice”, which usually means we draw from any number of intervention strategies or therapeutic modalities to help alleviate client issues. This gets into the heart of truly seeing the vast array of impacting factors on any one individual trying to function in a relationship… and doubling or trebling that with every other relational partner we add in the room.

Depending on the kind of practice we work in, we’re somewhat hampered by a variety of cultural blindspots:

  • Access to psychotherapy is often a privilege tied to income, making it a very classist resource; agencies that can offer sliding-scale fees are often hamstrung by funding to limited, severely-short-termed services. Private practitioners who can offer scaled fees, especially geared to those on low- or welfare-based income levels, are few and far between.
  • The overwhelming majority of our clients are white, even in a plausibly-multicultural urban environment, introducing a (sometimes only subtle) degree of implicit racial bias, whether we are aware of, or admit to it, or not.

    • “Middle-class black women and men were about 30% and 60% less likely, respectively, than their white middle-class counterparts to hear back from a therapist agreeing to see them. Working-class individuals fared even worse: Women and men, regardless of race, were about 70% and 80% less likely, respectively, to get an appointment, compared with white middle-class individuals.
    “Psychotherapists are not immune to the same stereotypes that we all have, and I think they could become even more relevant for psychotherapists than for other professions [both medical and nonmedical], because they are embarking on this intimate, potentially long-term relationship with these [clients],” said Heather Kugelmass, a doctoral student in sociology at Princeton University. Kugelmass is the author of the study (PDF), which was published Wednesday in the Journal of Health and Social Behavior.” — “Therapists often discriminate against black and poor patients, study finds”, Carina Storr for CNN

  • Not every office space is handicap accessible for a variety of reasons–creating a very ableist environment even when we don’t mean to. (Point of disclosure: both my home office space and the Bliss office space uptown can only be accessed by means of stairs, and for a variety of reasons, not all of us can/will offer video sessions as a means of alternate access.)

Part of the ethical training to become a therapist deals with uncovering what we can about our own internal biases, but often we can only see where those biases reside by looking at what we’re NOT doing, those areas of the population we can see we’re NOT adequately addressing. Gender bias and transphobia, xenophobia and racism–some aspects of a therapist’s personal aversion may become clear during their training. It becomes the work of the training institute and supervisors to ensure that potential therapists explore those aversions and biases, pushing comfort boundaries where they can, but at the very least working to assure the therapist will Do No Harm to clientele out in the field.

The dark side of working to identify our own blind spots is the unfortunate side effect of being equally blind to how these factors potentially impact our clients, not just in terms of the therapeutic relationship (though this can become a strong tool in session; more on this in a minute) but in the broader systemic perspective. Becoming aware of therapeutic blind spot can then lead to some interesting conversations with the client about their experience of these biases on the micro and the macro levels; if the therapeutic relationship is deemed “safe enough” by the client for the conversation to happen, it opens up a level of insight to the therapist and client alike about how classism, racism, ableism, etc., impacts their ability to function in their relational contexts, their narratives about themselves, their values, their perception of their roles, their expectations for themselves and others.

Most white therapists I’ve known over the past decade don’t willingly bring these questions into the therapeutic conversation unless the client introduces the topics first. I don’t know how often I’ve heard a white therapist trot out the phrase, “I don’t see colour,” when speaking with or about clients of colour, but if racism is a system factor impacting the clients in question, then the therapist may be at fault for not being open to that discussion as it potentially affects the client. I still encounter therapists who refuse to work with queer or trans clients, or the well-meaning ones who claim that orientation or gender are no issue for THEM, and don’t know what to do with clients for whom orientation or gender identity clearly *IS* an issue.

Trans clients are often my best example of complex intersectionality; it’s never going to be “just a simple case” of depression or anxiety. The endemic issues of workplace or school bullying transfolk experience, for example, speaks to the trans/xenophobic and sexist issues that have enormous impact on self-esteem and self-image; they may not feel they can safely access support networks and services, even when those service are financially accessible to them. The entire transitional experience can be hugely impactful on a client’s social, familial, relational structures; it can threaten their employability, introducing the classism issues:

“The 2011 National Transgender Discrimination Survey found that trans people are four times more likely than the general population to have an annual income of less than $10,000.” — Lara Rutherford-Morrison, “8 Statistics That Prove Why Transgender Day Of Visibility Is So Crucial”, citing National Transgender Discrimination Survey: Full Report, SEPTEMBER 11, 2012

Women, especially women of colour, experience many similar intersectional issues; many struggle against gender roles projected by a male-dominated cultural narrative. They battle in the workplace against glass ceilings imposed by traditional male-biased evaluation systems (up to and including being outright penalized for things like mat leaves), limiting their upward mobility and earning potential. Working in the bromance-laden High Tech industry, for example, introduces some significant challenges for women. Single women, and single mothers in particular, face strongly-biased class/financial and racial stigmas, even in the 21st century.

These are NOT ISOLATED FACTORS that bear zero impact on the clients and the issues they bring into therapy. It’s therefore a huge disservice for therapists to be blind, however inadvertently, to the unknown impact of these systemic influences. Practicing intersectionality doesn’t mean we turn therapy into discussions ABOUT those issues, but it does mean we really need to learn to be fearless in asking about the client’s own experiences in these areas as potentially affecting the challenges they ARE bringing into the counselling room. Our job as therapists is to check our own biases, including our own well-intended willful attempts at non-bias, at the door.

Mental Health

Recently a friend — actually an ex-colleague from the software company I worked for prior to a slow-rage-quit that got me back to grad school as part of the career change process* — asked if I had written anything about the impact of workload stress on relationships. The short answer before today was no, not specifically, but today’s your lucky day! (Thank you, Don, for being the inspiration for this weeks post, BTW; I’ll cut you in on a half-percent share of the book royalties when this essay eventually goes to the Big Time 😉

My online bio pages both at my own site and at the Bliss site make it very clear that I wasn’t always a therapist. For twenty-five years I worked primarily in IT as a tech writer, deep in the bowels of software development teams and processes. I still keep a toe in the IT waters; I have an interest, uncharacteristic for non-tech psychotherapists, in data security, even when it makes me sound a lot like Cassandra preaching catastrophe to those who prefer to not know the doom rolling in toward them.

In the year-plus I’ve now been at Bliss in particular, I note how often people are requesting to book with me specifically on the basis of that IT background. It tells them, right off the bat, that not only do I speak a common language — it’s amazing how well project management lingo adapts to relational change processes — but I also absolutely “get it” when it comes to understanding the impact working in High Tech has on… well, everything, frankly.

My IT career started officially in 1993. I sent my first email in 1985, however, and haven’t really been offline since. I grew up in the world of math and computer science students and the all-nighter crams to finish assignments and projects under deadline. I came of age in the industry before and during what we now only dimly remember as the Great Dot Com Boom & Bust, and I’ve survived I don’t even know how many accelerating waves of technological progress ever since. Eventually, I came to hate so much of certain aspects of the industry that I unfortunately unconsciously sabotaged my way out of my last job, rather than speak up in self-advocacy to save my own arse. (I really need at some point to take my ex-manager out for a beer by way of an apology for that; he went out on a limb for me, and I did not repay him well.) It worked out extremely well for me, ultimately, in that now I have finally completed the transition to full-time therapist, work that I feel is soul-fulfilling, meaningful, deliciously challenging, (sometimes heart-rendingly exhausting), always engaging. And I like to think I’m modestly good at it. I’m ALSO a Very Good Writer, most of the time, and I’m very good at navigating and managing the process of figuring out and explaining processes, which is a key trait for technical writers specializing in end-user documentation. My LinkedIn bio starts with the brazen declaration that “I explain complex processes to people, and complex people to each other.”

What all of this means to my clients in 2018, at the end of the day, is simple: I GET IT.

Almost every client who seeks me out for the IT background is coming in for issues relating to stress:
stress at work, about work
stress at home (partner, kids, extended family, all of the above), because of work
depression and anxiety, because of and impacting work (and also impacting partner, kids, extended family, all of the above)
health issues related to stress

Overall job satisfaction is at an all-time low. “Company loyalty” in either direction is in a shambles, as the Tech Sector tries to appease its workforce with enforced team-building activities like axe-throwing (really, who thought arming the QA team with throwable weaponry was a Good Idea??), beanbag chairs or slides in the workplace, nap rooms, on-premises childcare/yoga classes/laundry/drycleaning services, gourmet cafeteria service… all while stagnating salaries in may places, outsourcing hiring reqs to offshore sources, and cutting benefits or paid time off options.

“Job engagement, according to Gallup, is low. Distrust in management, according to the Edelman trust index, is high. Job satisfaction, according to the Conference Board, is low and has been in continual decline. The gig economy is growing, economic insecurity is growing, and wage growth overall has stagnated. Fewer people are covered by employer-sponsored health insurance than in the past, according to Kaiser Foundation surveys. And a strikingly high percentage of people, even those covered by insurance, say they forgo treatment and medications because of cost issues.

I look out at the workplace and I see stress, layoffs, longer hours, work-family conflict, enormous amounts of economic insecurity. I see a workplace that has become shockingly inhumane.” — Dylan Walsh, for Stamford Business, March 15, 2018

It’s not all doom and gloom, but the industry has tried to placate its employee base with beads and baubles, all while demanding increasing worktime commitments with decreasing management support. Performance reviews are a time of huge strife for many, especially if stock vests, bonuses, or salary increases are tied to performance evaluations; right now, a lot of my Google clients, for example, are getting clear of the twice-yearly PERF processes. They bring their anxiety into the counselling offices as they struggle with their fears around not delivering on expectations, or worry about what working on high-performance/high-stress teams for the bonus money is doing to their homelife. They bring in their depression and general “life malaise” as they struggle to reconcile the 60-80 hour workweeks with the growing distance between them and their partners or children. “I need to find a better work/life balance,” they almost all say at some point or another in our conversations. They look to me for answers, not just because I’m the therapist in the room, but because (as at least two different clients have said to me now) I somehow managed to beat the system.

(The problem, of course, is that I *didn’t* beat the system; I became a classic victim of the system, first in 2007 then again in 2016. I only “beat” the system by doing a Captain Kirk-like Kobayashi Maru maneuver: I changed the rules. I created my own door marked “Exit”, and left the game. Very few people are equally willing to make that same sacrifice, it turns out.)

One of my greatest potential gifts to these clients who are struggling to cope with the sense of entrapment in this brutal system, is that, having been in it as long as I have been, I can normalize the situation in a way that carries the gravitas of experience. Unfortunately, the gift only goes so far with High Tech clients in particular; in general psychotherapy, normalizing helps the client recognize they are not alone in their struggle, that others have surely gone through very similar circumstances and for similar reasons, with similar outcomes, and we draw strength from knowing we are not alone in the suffering. Yes, the Buddhists really ARE onto something with their tonglen practices. The sad part in High Tech is that EVERYONE ALREADY KNOWS JUST HOW MUCH EVERYONE ON THEIR TEAM IS STRUGGLING. They may not know how much of that stress everyone else is also taking home, but odds are good they implicitly know that a lot of workplace stress follows all of the team mates outside of the work environment, regardless of how many games of foosball we play in between code compiles or meetings, regardless of how many extra hours we work (or take home to finish there) to try to stay on top of the deadlines.

When asked about the psychological obstacles to moving on to greener pastures even within the industry, Jeffrey Pfeffer, author of “Dying for a Paycheck” (which I just ordered for myself), said,

There are many issues. One simple one that we should never overlook is sheer exhaustion. Finding a job is itself a job. If you are physically or psychologically drained by workplace stress, then you?re not going to have the capacity to go out and look for another job.

Companies also play to our egos. They say, ?What?s wrong with you? Aren?t you good enough? We?re a special organization. We?re changing the world and only certain people are going to be up for the task.? Who wants to admit they?re not good enough?

And we are influenced by what we see our peers doing. I?ve had people say to me: ?I look around and all my colleagues are working themselves to death. What makes me think I?m so special that I don?t have to?? We have come to normalize the unacceptable. It?s hideous.

This, then, is the backdrop to the relationships High Tech employees tend to have. Unreasonable demands on time, tied to unreasonable demands on loyalty for that time at the expense of anything Not-Company (regardless of increasing lip-service paid by HR to work/life balance, management and sales demands apply not-so-subtle counter-pressure to jettison that balance on the crunchy end of every project cycle) threaten a person’s ability to effectively prioritize non-work relationships. When I ask clients what their core values are organized around, they almost always list their top three-four in this order:

  1. kids (if they have any)
  2. partner(s) (if they have any)
  3. family
  4. work

But when we look at how they distribute the finite resource of their time (often the indicator of truer “real-life” prioritization, it looks more like this:

  1. work
  2. work
  3. work
  4. everything else

The exhaustion factor that Pfeffer describes above, that follows our clients home from the work environment every day. Unfortunately for many of them, the work ALSO follows them home. So, exhausted as they are, they engage minimally and exhaustedly with their partners and families, then fight to find “just a few more hours” to do more work, all before getting up the next morning to do it all over again.

Pfeffer: You know what might change this? I gave a talk on this to Stanford alumni and afterward a lawyer came up to me and said there are going to be lawsuits.

Interviewer: On what grounds?
Pfeffer: In a way parallel to the lawsuits that were filed against tobacco companies. Some companies are killing their workers. People have been harmed. If I had to bet on how this will change, some company is going to get sued, some lawyer will win an enormous award, and that will open the floodgates.

Interviewer:If you meet with executives, can you make a competitive strategy argument to not treat employees this way?
Pfeffer: Of course.

Interviewer:Is that effective?
Pfeffer: Depends on whether they have any sense. […] There?s data on this ? there shouldn?t need to be, but there is ? that suggests that when people come to work sick, they?re not as productive. Companies have problems with presenteeism ? people physically on the job but not really paying attention to what they are doing ? with lost workdays from psychological stress and illness, with high health care costs. Seven percent of people in one survey were hospitalized ? hospitalized! ? because of workplace stress; 50% had missed time at work because of stress. People are quitting their jobs because of stress. The business costs are enormous.

I support dozens of stress-leave clients a year. MOST of them are High Tech. All of them report some variety of the anxiety/depression cocktail, almost all of them report feeling lost or disconnected in their relationships, unable to muster energy for connection, further disrupted in their recovery as frustrated partners trying to address their own needs and wants ALSO add to the pressure. And the general consensus is, this is never going to change. Since 1993, it has rarely changed in favour of the employees; more perks and colourful baubles are added to the corporate environments, but at the same time, High Tech’s love affair with the “collaborative open office” is taking away employee beliefs on an increasing array of levels that we’re at all entitled to ANY boundaries in the workplace, including the perfectly-reasonable ones.

Unsurprisingly, lack of boundaries and lack of willingness to speak up about the conditions becomes a common theme in the personal relational issues with which my High Tech clients are also struggling. The personal mirrors the professional, or vice versa.

In the short term, there are no good answers. I hate admitting this. I can work on helping clients differentiate the personal processes from the professional ones, trying to create some new boundaries that separate and protect the private connections so that they can be repaired as much as possible within the context of the larger, pressing priority of the workplace. But in truth, the primary culprits in this scenario remain the corporate mentalities driving workplace policies, setting the standards AND the stage for the 21st century work ethic that demands unreasonable things from a workforce that cannot sustain delivery on those demands. They remain the HR policy pundits who see the numbers and fail to influence effective changes in corporate expectations. And to a lesser extent, they remain the employees themselves who yield their own agency in exchange for a paycheque, who don’t mass together and stand up to the unreasonable demands, who repeatedly burn themselves out in the process of instead capitulating to corporate priority over their own personal ones. Who sacrifice their lovers and spouses and children to “the demands of the job”.

Because these are issues that hit us rather-more-literally-than-we-care-to-admit where we live, there is no quick fix for this. This is a systemic clusterfuck of bordering-on-epidemic levels. We do what we can to examine the priorities and adjust for MORE congruence, but as long as we stay tied to the High Tech industry for the sake of those glorious, sometimes-outrageous IT salaries and benefits, we remain imprisoned by these unrealistic, unsustainable, destructive demands. And it will continue to cost us all, in terms of struggling to find healthy balance, in terms of corporate costs to benefits packages, or covering increasing numbers and duration of stress leaves, and in terms of overall morale in the industry.

Here endeth the rant sermon, at least for today. I strongly expect this will be a recurring topic for years to come. Next week I’ll try to take a more directed look at how we work with the relationship-specific aspects of this epidemic.

*–In and of itself, a very long and convoluted story that isn’t entirely unrelated to this week’s post, but I’ll leave it for another day.

Emotional Intelligence, Mental Health, Self-care, Uncategorized

[This week’s post is by request. Yes, we take requests! Honestly, anything that gives me some direction more than fifteen seconds before I sit down at the keyboards with the first coffee of the creative day is welcome. Assuming it’s something I actually know something about, of course.]

When I talk about making starting the career change from Hired Pen in IT to Personal Improvement Sherpa, I often use the term, “I hit the wall” as part of the formal narrative explaining what happened. For me, there was probably a large chunk of undiagnosed and probably-not-even-recognized depression already in play, but the biggest factor behind the need to change course lay in a persistent and burgeoning case of burnout. The friend who requested some exploration of this topic is also grappling with something that feels like burnout but with the more pervasive sense that most would more likely associate with depression, in a “absolutely anti-motivated to do anything that is not absolutely mandatory” kind of way; they describe themselves as feeling neither sadness nor despair, nor are they unable to get out of bed. But they do feel “frozen”. There is still a sense of connection to joy and lightness in other aspects of life, but there is no energy to connect with the actions most commonly associated with creating joy and mirth.

Working with as many clients, and still having an exceptionally large number of friends working in IT, I can verify that there is a LOT of comorbidity between the symptoms of depression, burnout, and fatigue. It’s one of the major reasons why, when clients come in with a self-diagnosis of depression, I want to explore more of a general context for what’s happening in their lives to see if there are any systemic factors that might suggest more clearly the predominance of any one of these states.

“Depression is one of the most common mental illnesses, and it can be mild, moderate or serious. There are several different types of depression that can be recognised by different signs. Which symptoms of depression occur and how strong and frequent they are vary from person to person. People in any social or age group can be affected, both women and men. If someone has had at least two of the following symptoms for longer than two weeks, it might mean that they are depressed: deep sadness; listlessness; loss of interest in the things they usually care about.” – US National Library of Medicine

“Exhaustion is a normal reaction to stress, and not a sign of disease. So does burnout describe a set of symptoms that is more than a “normal” reaction to stress? And how is it different from other mental health problems?

Experts have not yet agreed on how to define burnout. And strictly speaking, there is no such diagnosis as ?burnout.? This is unlike having ?depression? diagnosed, for example, which is a widely accepted and well-studied condition. That is not the case with burnout. Some experts think that other conditions are behind being ?burned out? ? such as depression or an anxiety disorder. Physical illnesses may also cause burnout-like symptoms. Being diagnosed with ?burnout? too soon might then mean that the real problems aren’t identified and treated appropriately.” — US National Library of Medicine

Fatigue as a general symptom runs through a lot of these kinds of conditions, running the gamut from “I’m a little tired today but I can push through it” to “it’s a Blanket Forts Against the World kind of day”. Fatigue’s commonality is also one of the factors that makes it more difficult to differentiate between situational burnout and deeper depression, because fatigue is a profound thief. So when we’re talking in session about what’s going on, we explore the presence and perceived impacts of fatigue: how long has it been going on, how often does it impact functionality, what else is occurring in the subject’s life that contributes to exorbitant and draining stress? What aspects of their lives DON’T currently feel like a drain on their personal energy resources? What restores them?

From there we look for burnout symptoms: what are the high-demand attention drains currently (or recently) impacting the subject’s life and energy levels? Where is the balance with self-care and/or external support? How much of their day is being dedicated to these high-demand pursuits, and over what length of time? What other aspects of their lives still provoke joy, delight, mirth, wonder, passion, even if at lowered levels than constitute their normal baselines? The likelihood of burnout being the dominant effect rather than depression is often tied to these discernible draining factors over an undefined-but-probably-extensive-or-ongoing period of time. Without such key indicators as work stress, family stress, personal health stress, etc., we consider the scales tipping more in favour of depression. We also look at bigger systemic factors including family histories around mental health issues/Family of Origin relational modeling/parental alcohol or drug abuse, etc. when looking for indicators of depression.

And finally, we ask the question, “As difficult as it might be to imagine right now, if we took away the fatigue, what kinds of feelings would be left?” Self-reporting clients have, at least in my experience, been clear to indicate whether they expect themselves to “bounce back” and be right as rain again, or whether the nihilistic disengagement from the world would still be a part of the picture. (Self-reporting measures are generally problematic at best, but lacking a verifiable clinical diagnosis for depression, as counsellors and psychotherapists, we operate largely at the mercy of what our clients tell us.) The clients’ own hopefulness about their potential future state provides at least some degree of useful information, and can often gives us a platform (however small) on which to start building that sense of hope into some sustainable, hopefully realistic faith in change and progress. Clients stuck in depression often cannot connect with hope; hopelessness is one of the most common lies depression tells us. But burnout, while it may not allow for significant enthusiasm about the future, doesn’t completeley dismiss it so much as waves a hand at anything hopeful and begs, “Come back later, please”.

Typically, burnout is the result of specific and identifiable stressors like occupational burnout, persistent relationships stresses, or ongoing/long-term care practices for ailing or high-demand family members, for example. When facing burnout we look at rebalancing self-care practices in the short term, sometimes involving very deep conversations about the willing (often repetitive) sacrifice of self-care in pursuit of project deadlines or the drive to care-take others. We discuss the values keeping clients potentially stuck in these kinds of patterns, a conversation that comes up a LOT with driven professionals. Often we have to normalize the fact that corporate mindsets and project management pay a degree of lip service to the nebulous “work/life balance”, then expect the superhuman in terms of commitment to near-impossible project deliverable dates. And in the case of those who persist in “taking on too much” and deliberately, repeatedly pushing themselves into burnout states, we have some conversations around what’s their return on investment that makes doing this to themselves over and over, worth the costs of the pattern?

With depression, the work is more complicated, and may often necessitate conversations about clinical diagnostics (that psychotherapists are, unfortunately, not trained to do) and/or medications to help level out the worst of the symptoms. Because the depression may not be cognitive, it’s harder to shape a therapeutic conversation around motivations, and we may have to work more fundamentally with the bodily experience of depression, up to and including normalizing it as a chronic persistent or recurrent medical condition like diabetes, arthritis, MS, and others. We change how we consciously relate to the presence and impact of the illness when we can’t shift the illness itself in significant ways.

We can do the same with burnout, but burnout needn’t be a persistent issue for people so it’s sometimes less effective to treat it as a persisting condition (though it can be argued that project cycles increase the likelihood of it being recurrent). When burnout becomes a cyclical factor in someone’s life especially, we could really use some increased self-observation to watch for markers of this state sliding into depression. A pervasive sense of inescapability can shift a mindset from the hopeful, “light at the end of the tunnel” coping mechanism to a fatalistic sense that “it will never be any different or any better than this, so why bother?” Losing hope is fundamentally damaging to our mental health:

?Life is never made unbearable by circumstances, but only by lack of meaning and purpose.? ? Viktor E. Frankl

Burnout can leave us with purpose but no energy to engage without a period of recovery and restoration; depression leaves us feeling devoid of meaning or purpose. And fatigue is the river that runs through both states. How we treat any of this depends on our abilities to differentiate between these conditions, and how willingly our subjects can still feel any connection, however tenuous, to hope.

Mental Health, self-perception

Something I’ve been thinking about lately:

About a week ago, I was speaking with a client about depression, exploring “the lies that depression tells us”. It’s a standard externalizing narrative framework clinicians use to help clients put a little emotional distance between themselves and whatever’s afflicting them; it’s an approach that works for a lot of different things. But I made a mental note in the back of my head that in my own mind, something had started to ring a little hollowly around that particular narrative construct (not for the client; the client ran with the externalization like it was tailored for them). It’s taken me most of the week to figure out what the mischord is. When we talk about depression and “the lies it tells us’, the implication is there’s something inside us that whispers or talks to us and fills us with narratives that are neither helpful nor healthy. This implies that depression functions as a cognitive process, operating in the part of the brain where language and thought processing occurs. When clients respond well to the idea that “depression lies” or tells us things about ourselves, we’re operating in the cognitive realm. We define the cognitive realm this way:

This domain includes content knowledge and the development of intellectual skills. This includes the recall or recognition of specific facts and concepts that serve developing intellectual abilities and skills. There are six major categories, starting from the simplest behavior (recalling facts) to the most complex (Evaluation)
http://serc.carleton.edu/introgeo/assessment/domains.html

I absolutely believe that this definition of depression as a cognitive dysfunction (with all its standard attendant physical byproducts and related chemical imbalance) rings true for a very great many sufferers.

It is most decidedly not, however, true for me. My depression doesn’t talk to me, and I’m increasingly certain it never has. And the more I work with other depression sufferers, the more convinced I am that there’s an entire constituency for whom there is no (or no signficant) cognitive aspect to the their depression at all. For example, my depression says nothing to me about my worth or value. It says nothing to me about my happiness or misery, nothing about the value of doing anything I would normally do, energy I would normally expend. I increasingly suspect that part of the reason why I failed to recognize depression in myself for what it is for as long as I have is precisely BECAUSE the entire internal “demon narrative” has been conspicuously absent. This suggests some forms of depression might operate predominantly, perhaps exclusively, in an affective state, manifesting physically and exclusively without the cognitive narrations::

The Affective domain includes feelings, values, appreciation, enthusiasms, motivations, and attitudes.
http://serc.carleton.edu/introgeo/assessment/domains.html

What I get is something like a gravity well; a thing I fall into in which the weight on my mind and body just increases until I have no tolerance, no strength to move past it. Emotionally I still feel happiness and joy, though muted; I still feel engagement. I’m still reasonably high-functioning, though compromised in scope and sustainability. It’s like something sits on my chest and weighs me down. It can be hard to breathe sometimes, it’s definitely nigh-unto-impossible to move. It’s easier to just stay still, or better yet, just sleep. There’s no judgment, no scripted storyline about what it means; I don’t know if it was always like that. I know I beat myself up fairly heavily the first spring I failed to get back to walking like I had been the previous fall, but that failure and self-recrimination narrative was as much disappointment over lost momentum and gear investment costs as it was anything else. All things considered, it was easy to let go of that cognitive process once I figured out what was going on.

My depression doesn’t talk to me, and I don’t talk to it. At the deepest points of the gravity well, it doesn’t whisper to me to kill myself, that the world would be better without me or that no-one would notice. I actually like my life; I have a mostly-healthy connection with my world and the place I have made for myself within it ? not without challenges, but hey, I’m still human. At the deepest points, where people start to have urgent conversations about suicidal ideation, the sensation has been more what I imagine drowning swimmers eventually reach when they are too tired to keep struggling up past the weight of the water to the air, too tired to keep pushing their own waterlogged bodies to draw in breath, and they just… succumb. There’s the instinctive urge to breathe and stay alive, but eventually we can’t keep fighting against the weight and resistance of the surrounding elements. It seems to me that there’s not a lot of internal narrative in those moments, beyond “so tired” and “just let go”. I’m reasonably certain the only thing that pulled me through those times was the utterly unconscious, instinctive urge to keep breathing. In those moments it’s not so much that one consciously care much about living or dying; we can’t battle the weight any more, but autonomous bodily functions keep going. It occurs to me, this is likely where a big part of the mantra that has been a core operating principle for the last five years is rooted: “One day at a time, one breath at a time; one foot in front of the other.” Think no further ahead than the next breath; there isn’t enough energy to invest in speculating any further ahead than that.

A clinician friend in Boston this morning pointed me to the works of Edwin Shneidman, an American psychologist and author who wrote extensively on his work with the suicidal mind. Specifically, she was correlating my thoughts on depression as a predominantly non-cognitive, felt experience rather than a mental, narrative one, with Shneidman’s description of suicidality as a “psychache”, language that I suspect may resonate strongly with affective depression sufferers (even those nowhere near the point of suicidal ideation):

“As I near the end of my career in suicidology, I think I can now say what has been on my mind in as few as five words: Suicide is caused by psychache (sik-ak; two syllables). Psychache refers to the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind. It is intrinsically psychological ? the pain of excessively felt shame, or guilt, or humiliation, or whatever. When it occurs, its reality is introspectively undeniable. Suicide occurs when the psychache is deemed by that person to be unbearable. This means that suicide also has to do with different individual thresholds for enduring psychological pain.”
(Shneidman, 1985, 1992a).

Looked at through this lens, we have the option now of language that supports exploring depression as a form of psychache, one with a scope of tolerance for enduring the affective or physiological experience, and how the client is able to function within the threshold of that experience. For clients who get frustrated by trying to use cognitive, narrative process to relate to their depressive experience, we can instead use bodywork language from the likes of Eugene Gendlin or Bessel van der Kolk (whose groundbreaking work on bodily retention of traumatic experiences is a go-to resource for many clinicians). This affective approach also opens up the options of a dialogue with clients around other physiological variables that can impact the physical and affective states. Western psychology sometimes skirts the edge of this holistic understanding when we press clients to consider their sleep/diet/exercise (any energy expenditure) habits in light of their depression, but often stops short of giving legitimacy to depression as potentially being a *wholly* affective state for some people. (The more I recognize this in myself, the easier it becomes to see this as an option for other depressive clients).

So now we can observe when the default cognitive “depression narrative” approach seems to sit badly with clients and others, and offer them this as an alternative to consider. Humans are narrators and interpreters and story-tellers by design, but I think sometimes the words actively get in the way of simply being *IN* an experience, especially if the experience itself is frightening in some way. If we can describe an experience–if we can safely box it up in words and interpreted meanings–then we feel we understand it. We feel we have a handle on it… we feel we have, in that handle, some measure of control, however slim. And therein we find comfort. We’ll invent entire mythologies simply because we experience fear when we don’t know why the sky flashes and rumbles at us.

Sometimes a cognitive, narrative *isn’t* the right approach. Sometimes it *doesn’t* encapsulate the experience. Sometimes it actually distances us from it. Recognizing the physical experience of my depression this week was a massive shift for me. There is no internal discussion or discourse, no whispered threats or seductive emanations. There is simply a force of gravity that is very localized; some days I function at Standard Earth Gravity, and sometimes I am flattened by Jovian Pressure so forceful it feels like it would be easier to stop breathing completely than expand my lungs against my crushing ribs one more time.

Even those words don’t capture the experience. Those are words and narrative elements that only fill in the blanks after the fact, for the most part, when I’m having to describe the experience to someone outside my own head. Most times, it never gets past the sensation of just stopping, letting my eyes close where I sit or lie, and letting sleep take me the rest of the way down into the pressurized deeps of that gravity well.

Now at least I have language to explore that with others as well. See? Even clinicians can learn new (and hopefully useful!) things.