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The Stress Doc Newsletter
Notes from the Online Psychohumorist™

JAN 2006, Sec. II

Shrink Rap:

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!
Ronnie Kimball

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 whirlpooling madness.

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 stressdoc@aol.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 difference.

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 being flooded.

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 demotivated nature.

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 ahead!

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!

Main Essay:

[This article was written for MANAGEMENT WORKSHOP-- DAYSPA Magazine, January 2006.]

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 how?

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 both.

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 team members.

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 representatives.

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 exclusion.

· 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.


1. Consultation-Counseling-Coaching Service from the Stress Doc ™

Expansion of Service:  In-Office, Phone or Online

The Doc's areas of expertise as a consultant, counselor and speaker include:

+ Stress and Burnout and Rebuilding the Fire
+ Anger Management and Managing Difficult People
+ Growing from Loss, Grief and Depression
+ Couple Counseling and Family Issues
+ Career/Life/Relationship Transition
+ Conflict Resolution and Team Building
+ Executive and Management Coaching
+ Organizational Downsizing and Change
+ Time Management and Personal Organization
+ Motivation and High Performance/Anxiety Issues

Flexibility in length and availability for coaching-consultation sessions; day and evening times.  Fee to be determined during the first contact/consultation.  The first phone or online contact/consultation (up to 15 minutes) is free.

For more information, call 301-946-0865 or email stressdoc@aol.com.

Organizational Clients have included:

Corporations: Dupont Corporation, SAP--Human Capital Forum/ASUGS, Celebrity Cruise Lines, America Online, Kelley School of Business/Indiana University, Day and Zimmerman, Tellabs, Computer Sciences Corporation, SkyLink: The Airline Ticket Center, Biography Magazine, US Pharmacopeia, Skadden Arps (Intl law Firm), Patton Boggs (Intl Law Firm), LTS, Blackbaud, Georgetown University, Shrader Funeral Home

Associations/Conferences: CONEXPO-CON/AGG--2005, Intl. Personnel Management Assn. (IPMA)--2005, Human Resources Association--Natl. Capital Area, Society of Human Resource Management, National Society of Professional Engineers, Business Owners and Managers Assn Intl, Airplane Owners and Pilots Association, Association of Legal Administrators, National Association of Insurance & Financial Advisors, American College of Physicians, National Wildlife Federation, Defense Research Institute, American Industrial Hygiene Association

Government Agencies:  Australian Embassy, Centers for Disease Control, Health & Human Services--Div. of Acquisition Management, DOD/Population Health and Health Promotion, Department of Justice, National Institutes of Health, National Oceanographic and Atmospheric Administration (including National Weather Service), Army Corps of Engineers, Naval Reserch Lab, Naval Sea Systems Command, Department of Commerce, US Postal Service, Fairfax County Govt., Suffolk, VA

2.  Stress Doc Books:

Make check to:  Mark Gorkin
Send to:

9629 Elrod Road
Kensington, MD  20895

a) Really Hot:  The Paperback Version of Practice Safe Stress:

Practicing Safe Stress:  Healing and Laughing in the Face of Stress, Burnout, & Depression; Stress Doc Enterprises

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 depression.  Learn practical and playful, inspiring and insightful strategies for transforming these toxins into life-affirming energy, creative focus, and goal-achievement.  Bringing a personal, professional, and organizational perspective, the book is alive with imaginative language and memorable "how to" ideas for:

§ Understanding the "Four Stages of Burnout," the "Erosive Spiral"
§ Rebuilding your fire and developing "Natural SPEED"
§ Achieving liberation through "Emancipation Procrastination"
§ Reducing conflict as a healing or motivational "psychohumorist" ™

There are satirical essays on "lean-and-MEAN" managers and on mismanaged downsizings.  Learn to "laugh in the face of layoffs" and ponder the possibility of "Van Gogh, Prozac, and Creativity."  The Stress Doc also shares his his own trials, errors, and triumphs in battling the "Toxic Trio."

Safe Stress provides many discrete "Top Ten" lists and "strategic tips" essays useful as educational/informational handouts.  To quote the Internet Newsroom:  Your Guide to the World of Electronic Factgathering:  "The most outstanding feature…is his 'psychohumor' essays.  Always witty, thought-provoking, and helpful."  With this easy-to-follow, fast-paced, and fun health and wellness guide, you'll return often to Practice Safe Stress.

b) The Four Faces of Anger:  Model and Method
Transforming Anger, Rage and Conflict Into Inspiring Attitude and Behavior

The "Four Faces of Anger" presents an elegantly simple yet intellectually powerful model that will challenge your beliefs about anger -- both regarding its range of emotion and its potential for positive communication.  The book is a dynamic blend of popular psychohumor articles, essays, case examples and short vignettes, as well as Stress Doc Q & As and even "Shrink Rap" ™ lyrics.  You will gain ideas and tools, skills and techniques for personal control, playful intervention and conflict mastery.  Learn to:

Ř Identify self-defeating styles of anger and violence-prone personalities
Ř Transform hostility and rage into assertion and passion
Ř Confront directly or disarm outrageously critics and (passive) aggressors
Ř Bust the guilt not burst a gut
Ř Prevent emails from becoming e-missiles

And finally, his years as a multimedia psychotherapist and as a Stress and Violence Prevention Consultant for the US Postal Service yield a survival and spiritual mantra at the heart of the "Four Faces of Anger":

Seek the higher power of Stress Doc humor…May the Farce Be With You!

Published:  2004; Pages:  116  [Book size:  9"x12"]

Paperback:  $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:  $15