I received a letter from a woman I'll call Jane who was an avid sky diver prior to a disabling illness. She said she sometimes cannot stand how much she misses it.

Jane,

I think part of the reason people engage in sports like skydiving, skiing or speed racing is because all of the exhilaration combined with the risk forces your mind to only experience what it is experiencing moment by moment. I doubt that when you were flying through the air you were thinking about what you were going to wear tomorrow or regrets about past lovers! These activities stimulate all those parts of the brain that not only give us excitement and pleasure, but gives us the ability to experience our lives fully. The prefrontal cortex where all of that thinking takes place is probably pretty quiet.

So what can we learn from that experience? There are vast parts of our brain that call for us to simply experience our lives without categorizing them as good or bad or frightening or hopeful. So here is this writer understandably grieving is the past and thinking about the future that may look sad or worrisome. At the same time there is a part of your brain/mind saying "can't we forget about all this worrying stuff and just go sky diving?"

Well, you can't stop grieving and even if you could, that would be unhealthy. And you can't stop worrying, that's not realistic. So if your brain wants to experience your life fully, let's respect your brain. So that when you feel grief, feel it fully. Try not to let that thinking brain come in and start telling you that you should have done something different or that you shouldn't be in this position. Because that thinking brain takes you away from experiencing your life. So feel your sadness, your loss and your helplessness. And when you feel scared about your future, let yourself feel that also. And eventually you will know that if you can fully experience these emotions, they pass pretty quickly. That is, when you are paying attention. So when you grieve, taste your sadness, feel your grasp for what it is no longer there and cry as long as you need to. Grief doesn't need to be cured. Grief is part of the cure.

And when you feel anxiety about the future, let yourself feel that anxiety. And when you feel curious and even creative about your future, let yourself feel that also. My guess is you will feel all of those things several times every day. And by the way, you will probably feel lots of other things in between.

I am treating a couple, and the husband had an emergency and arrived after the session was half over. So in that time we were together, the wife and I had a very powerful meeting as she and I learned things about her that had been unknown. Our time together was quite meaningful for both of us. And then the doorbell rang. When her husband came in, I could see that his mind was racing so we just took a couple of minutes to be quiet so that he could find his way into the room. It was then that I realized that my whole life had changed the minute he walked into the room. And it changed again the minute they left

I was struck by her raw honesty about her life and lives of many caregivers:

Dear Dr. Dan,

 I feel like I’m always in the fight mode.  My husband’s injury has changed me.  I used to be reserved, non-confrontational, rather subdued, but I am totally different now.  I can’t begin to tell you all the medical mistakes, insurance mistakes, and various other screw-ups I have encountered over the last 7 years.  My attitude now is that everyone is going to mess up unless they prove otherwise.  I guess in some regards that has suited us well because I have fought hard for things that were denied to my husband and my persistence has ultimately paid off.

The problem is that I have lived in this fight mode for so long that sometimes I can’t seem to turn it off.  Tonight we ordered pizza.  My husband did it online and redeemed some online coupon for $2.  The pizza guy shows up at the door and wants a copy of the coupon otherwise he is going to charge us an extra $2.  I get furious as we ordered pizza there 50 times and this hasn't happened. I rummage around the house and finally find the coupon. He satisfied, but I slammed the door in his face. By now I'm completely worked out and I start looking in the phone book so that I can call the manager and scream at him.  Luckily I snapped out of it.   OK, this time I have come to my senses and let the pizza thing go, but what about the next time?  I have this mentality that everyone is on the brink of screwing us, and I’m going to do anything to keep that from happening.  How can I be kinder and gentler when the world feels dangerous?

Dear Trish,

anger? Anybody reading your letter probably felt anger. When something or someone threatens someone we love, anger turns into rage. Some people talk about positive emotions and negative emotions. Personally, I don't believe in that stuff. All emotions have positive and negative parts. When I had my accident, my family used their rage to move mountains. Insurance companies were pestered, lawyers were mobilized, hospitals made exceptions with rigid policies and none of that might have happened without anger on the other side. But our bodies crisis mechanisms are designed to work in short bursts. That's because when we were all on all fours, crises happened in short bursts. The mountain lion came and one way or the other the crisis was over quickly. Your mountain lion seems to have taken up residence in your life.

I usually talk about people's hearts, I'd like to talk about your brain. I'm sure you know by now that your husband was not the only one traumatized seven years ago, but what you may not know is that trauma also affects the brain. Add to that all of the stress hormones coursing through your veins, and you have a cortex that needs care.

Once a brain and nervous system gets agitated repeatedly, it takes less to agitate them and more time to calm them down. And pretty soon your brain becomes like an overtired child and it can no longer distinguish a mountain lion from a pizza guy!

So how do we take care of your brain? First of all, you have to agree that you and your brain health is as important as anything else. So you must find time to get rest, eat well, and find something that gives you pleasure every day if only just for a few minutes.

I'd also like to see you make a distinction between what is happening on the and how you are reacting. Research shows that if you can put a few seconds between a stressor and your response, you have many options. If you could be more aware of when you are chest tightens and you feel out of control, then you could know that you need care in that moment. Whatever is happening outside is not a mountain lion and it can wait. What is happening inside needs care right away. So close your eyes, take a few breaths, notice how distressed you are in and focus on Trish just for a few seconds.

Hmmm I wonder if pizza could ever be slid under a front door in order to prevent serious injury to pizza guys.

Please take care of yourself. Please

Dan

When Trish agreed to join me on our Web chat Tuesday, she sent the following:

I hope that like today, the kind, gentle, compassionate Dr. Dan shows up on Tuesday.  You know we caregivers are tough as nails on the outside because we have to be.  But deep down we are tired, frustrated, edgy, guilty, and feel very alone because not many can comprehend the circumstances we face daily.  

I went to see a new cardiologist the other day as I have been having ongoing blood-pressure difficulties that have been difficult, well, impossible to diagnose. After a brief wait, a nice-looking 50-year-old man walked in with his young intern trailing behind. They both took their respective chairs (hers near the corner) and he began the interview. The first thing that thing that struck me about this man was that he actually listened. He paused after my answers just for a second or two before he asked another question. The second thing I noticed was how exhausted this poor intern looked, and how hard she was trying to hold on to all the information that was coming her way. As the doctor moved closer to me in order to listen to my heart and take my blood pressure, he asked me another question about my symptoms. My answer seemed to take him by surprise as I don't think it fit in his diagnostic formulation. He sat quietly for several long seconds with his eyes closed and then continued our discussion. Towards the end, he made some recommendations and an interim plan and said goodbye. On his way out the door, I said to the intern that what she witnessed was an example of doctoring at its best. I told her how this man sat next to me with his eyes closed not afraid of not knowing what was happening. Not afraid to be confused, and caring enough to do all of that in my presence.

There wasn't time to tell her everything I wanted to tell her about caring in medicine and eye contact and the power of touch. I couldn't tell her how alone people feel in that examining room and whenever they see a cardiologist that it is about matters of the metaphorical heart also. I wanted to tell her that it takes courage, strength and self confidence for a doctor to be open to their own ignorance.

But I did have time to tell her that if she practiced medicine the way she just witnessed she would be more than a very good doctor. She would be a healer.

The following letter illustrates how depression affects every generation in the family. In our Web chat on Tuesday we will talk about the difference between depression and sadness and how to deal with both. And we will also talk about what family members can do.

Dear Dr. Dan

My brother is in his 40s and has been divorced for 8 years.  His heart was broken unbearably by his divorce as he was still in love and wasn't expecting this.  He is always just staving off the profound loneliness by throwing himself into his work (he is a teacher/administrator), marathon running and similar intense activities.  Over these past 8 years, I have been an ear for him to share his feelings with and he is very stoic but also forthright about his profound loneliness.  He cried deep, anguishing tears to me last night.  There are times to try and offer solutions but also, those times it is equally important to just listen and affirm the struggle and pain.  I sensed last night, all I could do was affirm his pain.  I hesitantly suggested that it is often darkest before the dawn and he reminded me I've been saying that for the last year.

I was afraid, frankly, that he was suicidal and I asked him if he would be alright tonight.  He said he was and reassured me that as distraught as he is, he wasn't considering doing anything harmful to himself and I believe him.

Can you offer me any advice to pass on to him, Dr. Dan?  It is so difficult to see him suffer

worried sister

After eight years of suffering, the problem goes beyond the very human experience of grief and loneliness and becomes a clinical issue of depression. Now, I don't want to oversimplify this and suggest that if he simply gets treatment for depression (generally psychotherapy and medication are pretty effective), that his problems will go away. On the other hand, if there is a clinical depression, it means his brain, the very organ he needs to work his way through this is impaired by an imbalance of neurotransmitters like serotonin.

I want to respect how he experiences his anguish as profound loneliness. I think loneliness is one of the great human fears. And most humans I know do what your brother does, work hard stay busy ruminate frequently and stay away from our demons. Almost everyone has experienced the difference between being alone and loneliness. One hurts and one doesn't. Loneliness causes anguish when we ache for something different than what we have right now. Loneliness is the pain of grasping for something that isn't there. We tell ourselves we can't survive without companionship. Or that we all are alone because we are defective or unlovable. Or is that this loneliness we feel now will last forever. But it is this ongoing mental activity that is stimulated by that grasping that causes the anguish.

Sometimes loneliness is universal, and sometimes it is a symptom of depression. When I suffered clinical depression years ago, loneliness and shame were with me constantly. Ideally, your brother can learn through psychotherapy that went his mind is racing, it's simply a racing mind rather than the voice of truth. And when he aches for something different, it's just an ache that feels sad and painful.

So that ideally he can become less afraid of his own mind. But even good psychotherapy cannot cure one's sense of loneliness and isolation. This must be done by expanding one's lens and caring for more than one's own pain. Your brother has many talents that could benefit others who suffer. What a great gift to the world if he could get involved with big Brothers or the Boys and Girls Clubs or any other charitable organization in which he could help others. I have found in my professional experience that reaching out to others not only helps diminish the pain of isolation, it can diminish the impact of depression also.

And your letter also brings up a very difficult issue of what can we say to a loved one who is depressed? Certainly becoming a cheerleader or motivator only creates more distance. Understanding and empathy are certainly the first steps, but you don't want to reinforce your brothers self-pity either.

When someone is feeling sad distressed, they typically feel out of control so the last thing you want to do is try to "take over". So I would simply ask him questions about the big picture: "what would you like with your life and how can I help?" Or would you like your life to be different and do you have any ideas about how to make that happen?

we will talk much more about these issues on Tuesday.