The Stress Doc Newsletter
Notes from the
JAN 2006, Sec. II
This email came in yesterday. You might want to check out this neat site;
samples of soothing and inspiring music.
Hey Dr. Mark---
This is just a note to let you know that we included the link to your article
"Top Twelve Tips for Beating (Mostly) Moderate Chronic Clinical Depression" in
the next issue of our online newsletter, REACH HIGHER, The Good Newsletter.
[Article is pasted below.]
If you would like, I'd be glad to forward you that issue. We should be sending
it out to our readers this weekend.
Thanks again for a great article. I read it twice!
Top Twelve Tips for Beating (Mostly) Moderate Chronic Clinical Depression
1. Recognize the Reality of Depression. Your depressed phase has lasted
too long, with too many disruptive or intense symptoms - erratic sleep and
eating patterns, frequently on the verge of tears, chronic procrastination and
difficulty completing projects. You "just want to disappear" (as a client
recently expressed), and there's a generalized loss of interest, pessimism,
distrust and disorganization. The problem is likely more than just extended
grieving or having "a sad personality," as one therapist told her client. The
client had asked for a second opinion when, despite nine months of therapy, good
insight and vigorous daily exercise she still felt on the verge of exhaustion.
This woman still had to strain continuously to just keep up.
2. Begin to Let Go. Normal ways of coping won't work in this existentially
and biochemically troubling period. You're not just grappling with depressive
symptomatology, but also likely struggling with denial and shame; one must admit
that will power is not sufficient. This can be particularly confusing with
moderate chronic depression. In the past you were able to get yourself out of
your depressive box or cave. Alas, as we age, ongoing stress can impair the
effectiveness of our biochemical and hormonal systems. In fact, just using will
power, thrashing about to break the depressive bonds will probably exhaust you
further. You feel trapped in that black hole or have a heightened sense of
3. Acknowledge Shame and Ignorance. Too many people associate depression
with cocooning under covers for hours on end or covering up through various
addictive tendencies -- compulsive eating, drinking and sexing, TV watching,
video game playing, out of control shopping, etc. And, in fact, these may be
accurate warning signs. However, many Type A achievers also struggle with
depression. (Don't let resume size blind you to the possibility of
depression.) For such hard-driving folks, shame and inaccurate information
often impede getting the needed psychological and medical help. Especially if
there's family history of mental illness or mood disorders, acknowledging that
one hasn't fully escaped a genetic legacy can be a difficult step. And if you
were or are the family standard bearer, the one who exemplifies "improvement in
the generations," then giving in to depression becomes a sign of failure, of
letting others down.
4. Beware Drug Reaction. Despite the widespread use of SSRIs, many are
still resistant to exploring the use of antidepressant medication. These
include individuals who: a) erroneously see medication as a crutch or as a
means of simply numbing or masking emotions, b) had a troubling trial with the
older generation of antidepressant meds - tricyclics or MAO Inhibitors, c) had
an unsuccessful brief trial with an SSRI, including troubling side effects and
don't understand that a meds trial is as much art as science; for some Zoloft
works better than Prozac or Wellbutrin may interact differently than Serazone
with other prescription drugs and d) have psychological if not medical scars
from previous drug or alcohol history; folks with family members who've
struggled with substance abuse also may be guarded.
Warning: When taking antidepressant medication, using alcohol in anything but
very strict moderation is inviting trouble. In fact, alcohol is
contraindicated. And remember, alcohol is a depressant drug.
5. Admit Dread of Losing Your Edge. For individuals with an agitated
depression as well as cyclothymic (a cycle of mood swinging) or bipolar
tendencies with pronounced highs and lows, especially where the agitation-mania
fuels productive efforts or creative outbursts, there may be understandable
resistance to a meds trial. There is a natural fear that ones existential and
emotional range, post-Prozac, will extend from the mediocre to the tapioca, that
is the blandly normal. While there is an adjustment period, with the proper
medication and dosage, over time my bias supports the likelihood of more energy
being freed for creative endeavor. Performance may take on a somewhat different
hue, but will still have your distinctive quality. (Email email@example.com for
a provocative, counter-intuitive essay on "Van Gogh, Prozac and Creativity.")
6. Find a Psychiatrist. A common medical mistake, if not a professional
abuse, is the numbers of GPs, internists, gynecologists, etc. who prescribe
antidepressant medication for patients without psychotherapeutic follow-up and
sufficient monitoring of side effects. The professionals best trained in the
realm of mood medicine are medical doctors with degrees in psychiatry and
psychopharmacology. Alas, even consulting with the latter specialists does not
guarantee proper meds dosage or regular supervision. The medical field is still
in the learning curve stages of understanding the bio-psycho-social dynamics for
overcoming mood and mental disturbance. As mentioned, finding the right
medication is as much art as science and must take into account individual
7. Integrate Psychotherapy. Upon completion of a proper diagnostic and
medication evaluation and the start of a supervised meds trial, if you can't
afford to see a psychiatrist on an ongoing basis, search for a mental health
professional experienced in the depression field. For chronic depression,
interview a therapist who is open to exploring the best biochemical and
psychotherapeutic intervention mix as opposed to a clinician whose bias pits one
approach against the other. The problem isn't just hair-trigger prescriptions.
Too many therapists still misdiagnose clinical depression as "deep sadness"
which can be overcome by "intensive working through."
8. Assess Initial Symptomatology. Conventional medical wisdom says it
often takes from two to six weeks for the therapeutic effects of antidepressant
medication to kick in. If you are so predisposed, that is, you react
sensitively to medication, be prepared to notice a mind-body difference in
two-six hours. This is an "N of 1" experiment and you are the star subject.
Early side effects may include sleep disturbance -- restlessness or a slothful
lying in bed, vivid dreams, having more energy, including aggressive energy and
phases of hypomania (a rash of impulse shopping, for example) and diminished sex
drive. Your mind-body system is adjusting to a biochemical sea change. As you
adapt to the meds and your depressed mood begins to lift, these symptoms may
diminish or your tolerance for them may increase. (Hey, with Prozac I had some
unprecedented and not totally undesirable side effects: I started grooving on
chocolate and my mildly diminished libido -- slowed ejaculation time yet without
impeding erectile functioning -- certainly drew no complaints from the ladies.
Sometimes side effects may be double-edged, e.g., some restlessness during sleep
opened wider the window to my dreams. Or even the drowsy morning haze (once
meds dosage was properly adjusted) became more a maze for mentally meandering
through dawning levels of consciousness.
Clearly, if the symptoms feel troublesome or confusing, do not suffer in
silence; you don't have to tough it out. Call your therapist and psychiatrist
for a medication consultation.
9. Assemble the Cumulative Evidence. In two-three months, with effective
medication and psychotherapy there should be noticeable improvement: more
energy, better eating and sleeping patterns, sharper mental focus, crawling out
from the barrel bottom, the return of laughter and a less generalized sense of
emptiness and teariness. In fact, the lack of reflexive crying, despite feeling
empathy at a traditional tear-jerker movie scene at the three month meds trial
mark opened my mind to the correlation between biochemistry, overt emotionality
and my inherent "sensitive nature." I could now be moved without necessarily
Much past and present jarring life experiences and behavior patterns are open to
reexamination and reinterpretation. From chronic procrastination and profound
shyness to impulsive or addictive tendencies ("recreational" drug use as
self-medication, for example), all may be influenced by a mood disorder or be
depressive adaptations. Your existence and essence was and is not simply a
byproduct of an intrinsically or intractably deficient moral character and
10. Use Self-Accepting Analogies and Self-Energizing Rituals. An important
part of integrating the depressive experience and being able to share it with
others is having accessible and vivid analogies and illustrative examples at
your command. For example, the feeling that one has been running with an
invisible 30-pound weight tied to ones ankle. Another way of framing the
problem: imagine yourself as a car that's slowly leaking oil and power steering
fluid. You're a quart low on oil. Can you still get around? Sure, but
increasingly, as the miles mount, there will be wear and tear on the engine,
transmission, steering, etc. If you don't plug the leak, major damage lies
Also, integrate new rituals to aid your depression recovery-meds adjustment
process. If you're a slow starter, try some morning exercise. Personally,
thirty minutes of answering email after rolling (or crawling) out of bed is like
a warm-up for the creative writing looming ahead. If self-employed, for
example, find a coffeehouse that gets you out of the computer cave and that
allows for work and some socializing. Learn to take a rejuvenating post-lunch
or dinner, 10-20 minute nap. (And now you realize the effects of depression,
not just "low blood sugar," may make this a necessity, not just a luxury.)
11. Confront Approach-Avoidance Conflict and Impatience. While mood uplift
and enhanced role performance is likely to seem remarkable, the challenge now is
not to shortchange longer-term growth for newfound chemical balance. In other
words, there's a lifetime of depressive ways of perceiving, interpreting,
relating, reacting and defending that need to be acknowledged. Old assumptions
will be put to the test. Much unfreezing and new learning must occur for
ongoing mind-body and interpersonal maturation. At the same time, all childhood
emotional or perceptual sensitivities and sensibilities need not be thrown out
with the darkened depressive waters. This process may be scary, though.
Long-term survival (albeit, self-defeating) coping patterns must be gradually
dismantled. Untreated depression is like being stuck with a 486 computer when
the world keeps changing at a dizzying pace. You cant or, more likely, are
afraid of or feel overwhelmed by upgrading.
The other concern, of course, is impatience, when your mood state and energy
levels aren't improving fast enough. Again, proper supervision for medication
and commitment to ongoing therapy strongly increase the chances of building over
time a solid foundation for recovery. Medication is not a crutch. Neither are
depression support groups, men's or women's groups, 12-step groups, etc. The
latter are normative resting, retreating and refueling stations on the
challenging journey of life.
12. Is It Forever Prozac? How long do you stay on Prozac or its
chemical cousins? I'm not sure there is a definitive answer. Each meds trial
is as distinct as the patient's genetic and life cycle history, along with
current resources, sense of affiliations and accomplishments, strength of
self-identity and future possibilities. Carefully supervised experimentation is
the password. Biochemical and emotional stability along with positive
functioning over time, yet still accompanied by some moderately disconcerting
side effects, may signal a window for trying a new antidepressant medication or
for reducing your current dosage. Regarding the latter, with strengthened
attitude and activity levels, less medication (thereby further attenuating side
effects) without diminishing therapeutic benefits is possible.
Some may choose to be meds free. I recall a woman artist in her 40's, after a
successful meds trial, announcing in a bar: "Prozac for the house." Yet she
decided to stop taking Prozac upon basically overcoming her dark period. She
didn't mind feeling "a little blue on Sundays." Though I've encountered more
people who regretted or had second thoughts about stopping their meds trial.
The combination of biochemical intervention and psychosocial maturation seems to
make some lasting repairs in neurotransmitter functioning. While long-term
research results for the SSRI meds family and its offspring are still in
transit, until there's contrary scientific evidence, I'm taking that "serotonin
supplement" (10mgs/day). This regimen is part of my natural path, one still
filled with passion and pain. And it's a path for recovery, resiliency and
rejuvenation. Amen and women!
[This article was written for MANAGEMENT WORKSHOP-- DAYSPA Magazine, January
Sea of Tranquility
Keep a star hire from sending your spa staff into orbit.
YOU RECENTLY HIRED MARY, A SEASONED ESTHETICIAN who's highly accomplished. The
problem is, some of the other therapists on staff find her arrogant and have
complained that she talks down to them. If Mary is more capable and
knowledgeable than her peers, is this just a matter of some fleeting jealousy
that will eventually settle down? And if it doesn't, how can a new employee
adjust when others begin to exclude and ignore her? As a supervisor or manager
it's up to you to improve teamwork and the overall interpersonal climate. But
First, you need to assess the nature of the problem. Do you have a
knowledgeable, confident and assertive woman inadvertently setting off others'
insecurity "hot buttons"? Or, do you have a "stress carrier," someone who
spreads stress much like the common cold, by the nature of his or her
dysfunctional interaction with others? The answer may very well be a bit of
Think of your recent hire as the brilliant basketball star who's also
emotionally immature and behaviorally dysfunctional. You know that too many
second chances for this star could take a toll on everyone. If your spa's
shooting star is consistently antagonizing others with off-putting behavior or
words, she could seriously injure team morale before burning herself out. In
addition, the resulting stress on staff members could disrupt your spa's
carefully cultivated atmosphere of tranquility.
If you haven't already done so, informally document any specific behaviors of
concern that others bring to your attention and any disruptive behaviors you
observe. How does Mary speak to and interact with others? Also note any clear
patterns of ostracism or isolation from the staff. If the entire team goes out
to lunch, is Mary invited? Do other therapists gossip about her in the spa?
If you observe two worrisome incidents within a relatively short time, the new
esthetician deserves your closer scrutiny. To use a natural disaster analogy,
two problematic events are equivalent to a tornado watch -- that is, conditions
are ripe for the formation of a serious weather system (or for disruptive
behavior or interactions). To help prevent the onset of a storm, begin with an
informal discussion. Ask Mary how things are going. Emphasize that any questions
she may have about her new workplace are welcome.
Now, three problematic events equal a tornado warning -- that is, you know there
will be touchdown, you just don't know the precise location and the extent of
the damage. If you observe truly problematic behavior, don't simply take cover.
Take more definitive steps to solve the problem.
1. Formal One-On-One
Schedule a private meeting with Mary. Share the feedback you're hearing from
other therapists. At this point, maintain their confidentiality. Ask Mary for
her perception of the situation. She may well respond that others are jealous of
her skills and abilities. Empathize if she's feeling excluded or ostracized; ask
for specific instances. While you might solicit suggestions for improving the
atmosphere, don't push hard for solutions at this point. Let her know of your
intention to address these matters by speaking individually with the other spa
2. Individual Meetings
Meet with other spa staff members and give them a chance to express their
grievances individually. Ask each if she's aware of attempts to exclude Mary.
Assessing the degree of denial and defensiveness or insight and openness among
Mary's fellow therapists is vital for subsequent successful intervention. The
latter group of individuals can become your overt or unspoken ally in trying to
change a possibly antagonistic spa work culture.
3. Selective Recruiting
Approach a few of the staff members who seemed open in individual meetings.
Enlist two or three who will agree to represent spa therapists in a
problem-solving meeting with you and the new esthetician.
Select colleagues who can be objective enough to acknowledge that both the spa
team members and Mary have reason to be frustrated, and set a time to get the
two sides together.
If you discover that a spa staff member truly has entrenched hostility toward
Mary, you'll likely need to speak to this person privately and perhaps even
mediate a joint meeting between the antagonists, if Mary feels similarly.
Clearly, this angry individual shouldn't be one of your spa's group
4. Mediation Meeting
Meet with Mary and the recruited spa staff to air issues and propose action
steps. These should include ways to help Mary fit into the spa work atmosphere
and to improve team communication and cooperation. The goal is to reduce the new
esthetician's provocative actions while validating her strengths.
In addition, explore whether any spa therapists are uncomfortable with Mary's
strengths or are feeling undue pressure to improve their performance.
Assure Mary that your goal isn't to quash her individuality, but to design a
better working fit with the team, which will now meet as a whole.
5. Team Meeting
Your spa team as a whole now has a chance to respond briefly to the initial
concerns; this should not become a bash session. The problem-solving steps
proposed should be the primary focus. The goals are:
· Ventilation among everyone regarding both the issues of condescension and
· Acknowledgment of the stress that can be caused by any change -- be it good or
bad -- in your spa.
· Further refinement (if needed) of the proposed action steps.
· Group acceptance of those steps.
When staff members see that anger can be expressed appropriately and safely --
that is, when no one, feels emotionally attacked or belittled and no one
experiences retaliation -- a greater sense of group trust can begin to emerge
among spa staff members. Your follow-ups with spa staff members will indicate if
this is happening.
6. Follow-Up Meetings and Training
Follow up with Mary within a couple of days to see how she weathered the
team meeting. Plan to meet with spa staff weekly for the next month to monitor
the social atmosphere and progress in improved communication and cooperation
along with effective integration. You might also consider communication and
conflict-resolution training as part of ongoing team building.
If any of these steps sounds daunting or if the process breaks down (for
example, if the new esthetician -- or any staff member -- refuses to participate
in this intervention), meet again with the recalcitrant individual. Firmly state
your intention to formally document unprofessional behavior that negatively
impacts either work productivity or productive team relationships. This step
also should apply to any spa staff member engaging in exclusionary behavior.
You may also want to avail yourself of a coach (if so, engage this person in
these steps from the beginning). If your organization has the resources, call in
an Employee Assistance Program counselor to help guide the process. If
necessary, consider hiring an outside conflict mediator,
Respectful working relationships are vital to building a cooperative, productive
spa team. If you want to help an employee like Mary enjoy cordial work
interactions as part of a task-focused, inclusive spa team, steps like these can
become an investment in your staffs morale and cohesiveness, as well as in
retaining a potentially valuable therapist.
Mark Gorkin LICSW, "The Stress Doc," is a psychotherapist and author of
Practice Safe Stress: Healing and Laughing in the Face of Stress, Burnout &
Depression. He can be reached at 301/496-0865 or through www.stressdoc.com.
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Practicing Safe Stress: Healing and Laughing in the Face of Stress, Burnout, &
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Published: 2004; Pages: 372
Price: $20 + $4.95 priority shipping in US; $4.05 in Metro, DC area; $27 in
Mexico and Canada; other international destinations to be determined
E-book Price: $15
Practice Safe Stress tackles the "Toxic-Traumatic Trio" -- stress, burnout, and
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for transforming these toxins into life-affirming energy, creative focus, and
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§ Reducing conflict as a healing or motivational "psychohumorist" ™
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Ř Identify self-defeating styles of anger and violence-prone personalities
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Ř Bust the guilt not burst a gut
Ř Prevent emails from becoming e-missiles
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Published: 2004; Pages: 116 [Book size: 9"x12"]
Paperback: $20 + $4.95 priority shipping in US; $4.05 in Metro, DC area; $27 in
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