Listen to Your Heart: a meditative practice

When discussing mindfulness, meditating is one of the first things clients and therapists alike bring up. Some of the most common advice is to focus on your breath. I often struggle with this, because breath is something you have control over. The moment I start thinking about my breath it changes. It's no longer natural, but performed. Many clients I've spoken to have reported the same, citing this as definitive proof that meditation doesn't work for them. However, meditation comes in many forms; breath is not the only point of focus your meditative practice can have.

A second style of meditation focuses on a safe or calm place or activity. This can be somewhere you've been (on vacation or at home), a favorite hobby (riding a bike, painting), or something completely imaginary. Of all the safe places friends and clients have brought up, a relatively common one is curled up with a partner, listening to their heartbeat. Many clinicians prefer clients choose a meditative place with nobody around, so that the scene still feels safe if stressors come up with that person. But it can be hard to deny the soothing nature of listening to a loved one's heartbeat, and harder still for those who are quarantined separately from their loved ones. While you may not be able to curl up with your partner, you can still listen to your heartbeat.

As I often do, I turned to good friends and trusted colleagues for their thoughts on this practice. Some liked having something steady to focus on. Others, however, found it easy to incorporate into deeper work they'd been doing. Those struggling with loneliness found it centering, and those doing inner child work found it soothing. It sounded like something worth trying. So one morning I sat down, set a timer, and closed my eyes. It took a moment or two to find my pulse, but once I did, I leaned into it. Soon, it was like my whole body was beating.

And it was kind of magical.

There is something vulnerable about noticing your own heartbeat, and this vulnerability can make the importance of tending to your own needs much clearer. I've since started using this practice as such, focusing on my heartbeat whenever I check in with myself. Noticing your heartbeat in a calm state can help you familiarize yourself with it more, and this can particularly be helpful for those who experience panic attacks and anxiety. If you know your resting heart rate well, you may get better at noticing when your heart rate starts to increase, which is often one of the earliest signs of panic. 

The feeling of focusing on your heartbeat is a prime example of what it means to just be with yourself. It makes it easier to tend to your needs, know yourself better, and help loneliness melt away. Your heartbeat is something you carry with you everywhere, making it a perfect tool for mindfulness and grounding. And with all the chaos going on in the world, we could all use a little serenity.

Sad, Mad, and Bad: What depression looks like in children

There are a limited number of mental health problems that are thought to affect kids. ADHD and Autism Spectrum Disorders are commonly diagnosed in childhood, while mood disorders are most common in teenagers and adults. However, this doesn't mean that children don't get depressed. Children experience depression differently from adults, and thus their symptoms can look very different. This can result in depression being underdiagnosed in kids, or not diagnosed until they are much older, despite early symptoms.

The most commonly known symptom of depression is depressed mood. In children, this can look more like irritability. They may have more outbursts, break down crying more often, or not get along as well with friends and family as they used to. The next most common symptom is anhedonia, which means less interest in pleasure. Kids may be less interested in seeing their friends or participating in favorite hobbies and activities. They might even come up with excuses or feign sickness so that they can stay home from a friend's birthday party or miss an outing. Adults often experience significant weight loss or gain, though this can be difficult to track in kids; instead, we need to look at where they are compared to their expected growth and weight gain. Kids are also more likely to have bodily symptoms, such as headaches and stomach aches, and may go to the nurse's office a lot with such concerns.

Of course, this is not to say that kids never experience adult depressive symptoms. Sleep problems are common with depression in adults and kids, as are feelings of guilt and trouble concentrating. However, kids are more likely to have trouble expressing these symptoms. They might not understand depression at all, or have the words to say what's going on for them. Even if they do, they might be afraid to express it. Depressed kids often withdraw from their families. If your kid avoids telling you about their day at school, they may be avoiding telling you about their difficult feelings, too.

Suicidality in depressed kids can be a tricky subject. Just because they're kids doesn't mean they don't get suicidal ideation, but not all talk of death indicates suicidality. This is especially true in elementary age kids, who may be just processing the idea of death or suicide, and who may be repeating things they've seen in the media or heard from friends. When kids talk about death, it's important to ask about the meaning of what they say and get a clear picture of what's going on for them before jumping to conclusions. The national suicide hotline (1-800-273-8255) has a youth division, and their website has many resources specific to many common causes of suicide in kids and teens, like bullying, gender/sexuality, abusive relationships, and more.

Many kids don't feel comfortable talking to the adults in their life. In some cases, it can be as simple as making sure they know you are a safe person to talk to. Talking about your feelings can help them feel more okay being open about theirs (even something as simple as "I'm frustrated that the waiter hasn't taken our order yet" or "I'm so tired from work"). Being more explicit about the okayness of difficult feelings might be necessary for some kids to safe talking about their difficult feelings. Just make sure you don't pressure your kids into talking to you. It's like one of those finger traps: pulling hard doesn't get them to open up as well as gentle nudges do.

If your kid won't talk to you, or you aren't sure you can help them on your own, therapy can be hugely beneficial. Not only can a therapist teach your kid about their emotions and how to deal with them, but they can also help you and your child open up to each other more. Cognitive Behavioral Therapy can teach a kid how their thoughts aren't always reliable (i.e. jumping to conclusions, minimizing strengths and maximizing problems, etc). Narrative Therapy can help kids explore who they are in relation to the world around them -- which can be important for kids nearing puberty. Gestalt Therapy can help kids process any bottled up feelings. Therapy can also help kids gain the communication skills necessary to talk through problems and difficult feelings with others. Many kids don't feel comfortable talking to the adults in their life, but are willing to talk to a therapist; often times the therapist is the only person in the kid's life who doesn't have expectations for them, and this makes them safe to talk to. A therapist isn't going to have a kid wash dishes or take a math test, and most kids understand that therapists are there to listen and help.

While childhood depression sometimes goes away, it can be hard to distinguish from lifelong depression in the moment. Untreated depression can make it hard for kids to learn, make friends, and thrive in their daily lives, and can thus affect their long term development. Symptoms of depression also often overlap with symptoms of other illnesses, mental and otherwise, so it is important to bring up any symptoms your child shows with their doctor. If handled effectively, childhood depression can often recede and leave no traces in adulthood.

Distraction techniques: active, passive, and regulatory

When life gets difficult, it can often become tempting to distract yourself from your own thoughts and feelings. Loved ones may scold us for this, telling us that we should confront our feelings, because distracting ourselves doesn't accomplish anything. However, distraction is an important part of distress tolerance. Imagine Jill, a young woman who, in typical romantic comedy fashion, gets fired and dumped on the same day. Sure, distracting herself isn't going to help her find a new job, but binge-watching her favorite TV series would give Jill time to let her emotions around the problem cool down before she decides to start working on it.

Of course, different kinds of people may require different kinds of distraction. For Jill, a more passive distraction like watching TV is perfect; she may not have the energy to do much else. However, her now-ex Bob is worried about how awkward their break-up is going to make things with their mutual friend group. If he sat down to watch TV, he would still be worrying about it. Bob needs a distraction that he can throw himself into, something that takes so much effort and focus that he can't spend any time worrying. So instead, he decides to pick up his guitar and practice a new song he's been trying to learn. Bob opts for a more active distraction.

The examples above not only show the difference between passive and active distraction, but also how to match what kind of distraction you need to your mood. For a lot of people, depression makes it hard to do things, so a more passive distraction may be preferred. Jill would not have had the energy to practice an instrument while depressed. On the other side, anxiety often manifests as a sort of nervous energy, which can easily be redirected. Of course, this isn't the case for everyone. Some people find anxiety paralyzing, so they may prefer a passive distraction despite being anxious. The important thing here is that the activeness and passivity of your distraction match your energy level.

What some people find to work as a distraction, others might find works better as emotional regulation. Maybe the real reason Jill didn't want to play music is that it wouldn't distract her at all, and would instead remind her of Bob even more! A few days after the break-up, Jill may still be feeling sad and missing him, so she sits down at her piano and plays the saddest song she knows. Here she is not using music to distract her from her feelings. On the contrary, she is leaning into her emotions, and letting them out. The song she plays could be the same exact song that Bob was trying to learn on his guitar; the important thing here is the approach. Jill is choosing an activity that matches her mood. If she was angry about the breakup, she might play an angry song, or go to a kickboxing class. If she was sad, but didn't want to play music, she might write a long letter to Bob, then shred it.

Not only is distraction anecdotally helpful, but research has been done to track symptoms in those who do and don't use the technique. A Swedish study showed that patients admitted to the hospital after a car accident were less likely to develop PTSD if they played Tetris within a few hours of admission. Some of the core symptoms of PTSD involve recurring thoughts, intrusive memories, and flashbacks, and it is thought that distracting a person from ruminating over the event blocks this pattern from forming. Those who distracted in this study had fewer intrusive memories in the week following, and these intrusive memories diminished faster. An earlier Oxford study showed that in a case of simulated trauma, playing Tetris was the best of three options, with taking an online trivia quiz as worse than doing nothing. This indicates that choosing the wrong distraction technique (in this case, a passive one rather than an active one) can actually be hurtful. In this case, it makes sense that a failed distraction could actually train the brain to ruminate even while occupied. A distraction must be sufficiently distracting without being overwhelming.

This is not to say that distraction is always the best technique to use in a given situation. Distraction works best as distress tolerance, and is not a replacement for emotional regulation. As discussed above, the two work differently. Distracting yourself instead of using emotional regulation can lead to unprocessed or buried thoughts and feelings. In the moment, it can be hard to tell whether distracting yourself is helping or not. Different people have different tells (losing track of time, forgetting to do something important like eat lunch, etc) but generally, distraction should make you feel better, not worse. If you feel worse after a period of distraction, it may not be the right technique to be using. So next time you are feeling overwhelmed and need to veg out, go ahead! Just take the time to think about the kind of distraction you need first. 

The 5 Stages of Grief, and Why They May Not Be Accurate

In Western culture, we often talk about grief coming in phases. When we first hear about death of a loved one, we may not believe it. Then, once we come to terms with it, we may need to mourn for a very long time before we are able to move on. Many cultures around the world have ceremonies and traditions that deal with mourning, but in the US, people most often talk about the 5 Stages of Grief. This model, also known as the Kubler-Ross Model, goes as follows:

1. Denial (this can't be happening)
2. Anger (why me)
3. Bargaining (maybe if...)
4. Depression 
5. Acceptance

This model, though it does focus on grief, was developed specifically in relation to those who are dying. Rather than being developed about someone grieving a dead friend or family member, it was meant to teach loved ones of a dying person what they go through emotionally upon finding out that they are dying. So, for example, the bargaining phase is not meant to show that a person may think there is a way to get their dead friend back. Instead, it shows that, at a certain point, a dying person may be convinced that there is a way to cure them of whatever is killing them, or hope that their illness may mysteriously disappear.

So what does the process of grief actually look like?

In the 80s, John Schneider developed what he calls the Transformational Stages of Grief. This model looks not only at emotional responses, but cognitive, behavioral, spiritual, and physical responses as well, and thus is designed to nurture growth. Rather than just covering loss of a loved one, it also covers other losses like break ups and divorce, as well as more internal losses like a change in beliefs or a loss of faith. Schneider's model is:

1. Initial awareness of loss (shock, confusion, disbelief)
2. Attempts at limiting awareness by holding on (bargaining, guilt, ruminating, and trying to use coping behaviors that have worked in the past, all in attempt to put off instability. often associated with insomnia, muscle tension, and yearning.)
3. Attempts at limiting awareness by letting go (depression, anxiety, shame, pessimism, forgetting, and hedonism, sometimes involves giving up on formerly held ideals and beliefs)
4. Awareness of the extent of the loss (mourning, deprivation, grief, defenselessness, flooded thoughts, noticing what you are now missing)
5. Gaining perspective on the loss (healing, peace, acceptance, noticing growth and change, awareness of the extent of your and others' responsibility, realizing any positives)
6. Resolving the loss (self-forgiveness, finishing unfinished business, accepting responsibility, saying goodbye)
7. Reformulating the loss in a context of growth (discovering potential, problems as challenges, regaining curiosity, think of a divorced person who has decided to start dating again)
8. Transforming loss into new levels of attachment (awareness of interrelationships, wholeness, empathy, end of searching, reflection)

As a counterpoint to traditional models, there is also what's called The Dutro Model, which doesn't focus on stages at all. This model claims that traditional "stages of grief" models are not supported, and placing time limits on grief is inappropriate. It also holds that pathologizing the suppression of sadness as a response to grief is also incorrect. Instead, the model sees grief as being complex, multidimensional, and individualized, based on a number of variables that are different for each person's individual experience. 

Often times, a grieving person can expect a flood of support when people first hear about the loss, though the support may wind down when the news is no longer as new. It is important to keep in mind that grief can go on for a long time. Sometimes, particularly when grief involves trauma, people can experience post-traumatic stress along with their grief. Think of the couple going through a particularly contentious divorce, or someone who witnessed a friend being killed. This can result in a complicated grief reaction, which can take much longer to process than grief on its own. 

Ultimately, each person's experience of grief is going to be different, depending on the type of grief they are going through and the circumstances around the loss. Stage models are useful for those in the middle of the grieving process, as well as friends and loved ones of the grieving person. The grieving person may find comfort in knowing what may happen next and understanding that this too shall pass, while their friends and family may feel that knowing what's going on and what to expect can better help them be supportive. Complicated emotions around grief can be sudden and painful, or they can sneak up on you when you don't expect it. Understanding what you are going through and knowing that you are not alone in your experiences can often be one of the most helpful things in getting through that dark tunnel and out the other side.