The Altered Book: A Great Project for In Session Art Therapy

When I was in graduate school for art therapy, I had never heard of an altered book or seen one, and certainly it did not come up in my “Materials” class. We did not get assigned any kind of Altered Book in any class, whereas now I am hearing from grad students that in some class or other, one of their assignments involves an altered book, which is usually assigned to do outside of class.

I think my first experience of an altered book may have been at the Outsider Art Fair. I distinctly remember going to this Fair years ago when it was always in the lovely Puck Building, which is still there, located on Lafayette near Houston St. in Soho, downtown NYC. In fact years before that, I had some of my graduate art therapy classes in the Puck Building and we organized the student art show on one of the floors of this building. It is certainly a beautiful building. The last time I was there for an art event was the comic book graphic novel fair a few years ago when I met one of my favorite graphic novel authors/artists, Lynda Barry. It must have been back in 2008 when she had just published this beautiful book about her art making process, called “What It Is”. Anyway I think I saw an altered book years before that encounter in the same building. It was made by a female outsider artist and I remember the book being very thick and beautiful and having a lot of glue on all the pages. It was very inspiring and I wish I could remember the artist and find a photo of it.

I made my first “altered book” years before that without knowing it was an “altered book”. It was not quite what we tend to think of these days when thinking of Altered Books. I took all the pages out of this strange pretty bad dramatic novel I did not read and altered the cover completely to the point where it was not recognizable as having been a book. I put a lot of plaster of paris on it and then mod podged tissue paper collage. Then I somehow found part of a cardboard box and attached the book to it so the top opened up as the cover. I think I used the pages to rip up and glue inside the box. I will take a photo of it. Strangely it was a gift for a close friend, but she was a close enough friend that she told me she found the box to be too disturbing to use or look at, so I took it to my studio, where it has been more appreciated! It inspired one person to make something like it with me, and she ended up taking a dislike to the project and left it with me when she left town after we went through her art that she had done in art therapy with me. I still have that rejeccted box in my studio as well. (It inspires me to write a whole post about “ugly” and “rejected” art work and how it is therapeutic in art therapy!)

More recently, a few years ago I stumbled on an online class about altered books, and in fact I have now taken 3 online classes about it, each class covering different aspects of the art making process involved in altering books. I have been making them with patients for a while now, and by making, I really mean inviting patients to try it out and see if they like it. The first part of the process involves the explanation of what it involves, which is, basically, you choose a book and then you can start anywhere in the book or with the cover or back cover and start picking art materials to use on the book. The first steps also often involve ripping out pages from the book, either to use in the book or to throw out. It is usually good to do this at the beginning as a way to give yourself permission to “alter” the book. We all have pretty fixed notions about the sacredness of books, which I think still exists despite the internet, reading on tablets and other devices, or perhaps, the tablets have made books seem even more precious. Jumping in to starting an altered book project requires a certain amount of adventurousness, ability to tolerate anxiety about the unkonwn and anxiety about trespassing a boundary and destroying something in some way in order to create something completely new. It also involves changing ones mind in framing the idea of that book, from something to be read and kept intact, to an object just like any other “found object” to transform and make your own through your own creative expression.

There are many different aspects to altered books as part of the art therapy session that are quite fascinating, so this post will only touch on the first part, the beginning. Once invited the interested patient will next be introduced to the random assortment of books I have to choose from and pick something that speaks to them to alter. Usually Hardback books are more inviting as it is easier to treat the cover like a canvas, but lately I have seen a few people pick soft cover books, becasue I have a few that are an interesting size, kind of square and with a lot of photos, and a cover that is more sturdy than the usual paperback. So far, nobody has decided to go home and pick out one of their own books. Part of this I think is the therapeutic value of taking a book that’s in my studio already taking up space as a book waiting to be chosen, so the process of accepting this odd art project is made easier as you are not “ruining” one of your own books. And I really have a strange random assortment of everything from dictionaries/thesauruses to cookbooks to spiritual meditation type books. Included is a thick hard back Italian novel and some other random novels as well as several books with pictures about fashion or the styles of certain decades. I have a travel guide. I had a guide for artists about materials and how to use them.

This aspect of rejection of the project that began when I made my own rejected “too intense” book box and then an “ugly” book box with a patient is a part of the altered book project. I have had a few people pick out a book and start altering it and then by the next session ask to shelve the project until “I’m in the mood for it. It’s too daunting right now.” The Altered Book will either be seen as a great container that is continually inviting or sometimes it represents being overwhelmed and unable to make any decisions about what to do, resulting in the project getting “shelved”. One of my patients started a first session very excited about all the varied materials I had, wanting to jump right into art therapy and got going very creatively with some book that she even worked on for the first few sessions. At some point I think she started cutting pieces out of the book to create a kind of box within the book, maybe even using an exacto knife. Then in the next session she declared she no longer wanted to work on it, was not in that “headspace” anymore and went to other forms of art making. She made great use of art therapy but never went back to the book until we were terminating and she fondly remembered it as her introduction to me and our work and I think decided to take it with her. The book project just functioned as a jumping in point.

Why do some people get excited to do an altered book in the first one or two sessions of trying it out and then run away from it, shelve it, reject it? Maybe when this happens it is because I, the art therapist, am actually more excited about it than the patient and have high expectations for it being a great kind of project for long term therapy. Perhaps for some people, there is too much commitment too early and they are not really ready for it.

The other interesting thing about doing Altered Books is when people do get invested in them and go back to them every session. Lately that has been happening, probably because a few people in my supervision group randomly chose to work on altered books without my prompting them. Two people have left the group with unfinished books they have taken with them. One person brought her own book to the group to alter with materials from the studio. So that energy of the altered book I really believe was “percolating” for a while in the studio. I had another rejected altered book started about a year ago in one session and then put aside. For a while I was not really focusing on altered books in the studio, just taking these classes and thinking once in a while about it, and learning more ways to approach the Altered Book.

At this moment, my studio feels filled with Altered Books! Like anything that grows in a garden on its own, it feels like this altered book contagion has just sprung up naturally. Just this week I introduced the altered book as an option to 2 patients who got excited about it, chose their books and jumped right in using different media. Last week I had started my own altered book project in the supervision group I facilitate, thinking that now that I have so many patients working on them, I want to do one at the same time. So I chose a book that is a guide to artist’s materials for artists. It was very exciting to imagine taking this book that divides up all the materials and methods and painstakingly describes how to achieve certain effects, and how to “properly” use the different materials and media and rip up the pages and paint on it and collage ripped pieces on to the pages to start the process of making it into a book I hope will be hard to guess exactly what it was even called or to have a vague sense when looking through my book that there are a lot of pictures of how to make art and art materials terms but nothing much else kept from the original book. Synchronicity abounds in doing altered books. For me it came when I opened the book and realized it had belonged to the friend who rejected my first book box project and returned the gift to me. Of course I ripped her name out of the book first.

Anyway, at this moment there are at least 8 altered book projects that have been just begun or are in the mid stages of alteration. If I actually count how many patients have started altered books recently, excluding the person from last year who has not expressed interest in going back to the project, it would be 7, so my guess was not far from wrong, as I am the 8th and then there are one or two people in supervision doing them.

The next post would raise the question: What helps a person stay with an altered book project and continue working on it regularly? and What is it about Altered Books that some people become “blocked” or lose interest after jumping in excitedly.

The one thing true of everyone is that the beginning, that first session of being invited to make one, choosing the book and jumping into it or onto the cover and starting right away to alter it is universally exciting and stimulating. I have only seen people be intrigued and excited when they begin this process. Some express having a weird feeling about “destroying” a book but when encouraged get past that feeling. The fascinating part of the Altered Book is after the initial excitement and embarking on this without a doubt long-term project, there is a moment of remaining with it and committing to it further through getting inside the book and getting going with paint, collage, mixed media, ripping out pages and getting one’s hands dirty. It seems to require about 3-4 sessions at least to determine if one is going to get “turned off” of the project and too overwhelmed, or further jumping in and committing more and more to it. Those who find it to be a kind of safe container stay with it. Leaving it with me in the studio is a big part of that process. I will hold on to their book until they come back to it, so they don’t have to see it for a week. It is very different to work on a long term art project whether it is because the work is very large and will take a long time to finish no matter what or the project by its very nature requires time invested. It is hard to work on a lot of pages at once, especially if you are using any kind of paint or ink. Anyway, leaving the book with me allows the creator to take a break from it and not have to look at it in between sessions. This seems to help the project to become a safe container and holding environment. Even with my own altered book, I decided to try out at first just working on it during the supervision group and leaving it alone, so I also take a week off from it, in order to further get into the experience of my patients and supervisees doing this kind of project…

To be continued…

Here are some photos from my own altered book which I have worked on in different situations, first started it in the supervision group I facilitate, then worked on it alongside several patients who are doing altered books as well as in my studio the other day when I added a kind if nest into the book…

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Making Your Art Work Versus Showing It, A Common Struggle!

I just wrote this post and it vanished, so I’ll start again. This is another short post just to bring up some topics and questions, especially for artists and art therapists and those who identify as both.

Do you exhibit your work? If so, is it very sporadic or often? Where do you exhibit it? If you don’t, why not? Do you have gallery representation? Do you want to have your art out in the public eye? Do you sell your art work? Do you enjoy selling it? Are you attached to any of your art work, such that if you exhibited it, you would mark it as Not For Sale? Are you easily discouraged by the competition? Do you find yourself making lots of work as a way to procrastinate trying to show it? Do you every get blocks where it is hard to get yourself to make art? These questions are not easy to wrestle with for any artist, and often more frought with inner turmoil for us artists/art therapists…

For me, I’ve been an artist for way longer than an art therapist, even though I didn’t go to “art school” or major in Art. However, although my artist resume has a long list of exhibitions at various types of venues that I have shown my work, I find that in the last two years, I have not really exhibited it, beyond having it out for public view during the Tribeca studio tour: (http://www.toastartwalk.com/toastartwalk/Natasha_Shapiro.html)

I don’t have issues with getting attached to any of my art work, so that is not a road block for me. I admit that I get easily discouraged by rejection, and find it hard to hussle and market myself as an artist. I am currently working on these very issues, by writing about it here, and by actively trying to look for galleries and opportunities to show my work, that I normally don’t get out of my comfort zone to do… I have always been lucky in that I have no problem with blocks around making art. While I may have a block on a specific piece or idea, I always have two or three other things I’m working on, so I don’t notice getting blocked. However, I confess that I too find it very easy to procrastinate the marketing and selling end of things. For example, I got invited to be an artist on a great website called “Artiscle”, and it took me about a month to make a profile and get some work on it. I still need to post a lot more work on the site, as it is a great opportunity to not only sell work but rent it out.

I find myself making myself promises I do not keep. So it’s time to get on it, and work through all the things that get in the way of trying to succeed more as an artist! Share your struggles and triumphs in comments please!

My 9/11/12 post a day late…

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These photos did not show up in the order I intended, however they are a good representation of the way the day of 9/11 is punctuated by memories, memories of artwork I did that was very much a personal response, and the present day 11 years later with the ghost of the towers shining in the clear night sky. I also took some pictures of sunflowers at a deli on Chambers st. That I should have included…

So there was this desire to take many photos of the ghost lights making a large eleven and two white towers in the night sky; I took many photos of them on my walk home in the neighborhood. I also took sone self-portraits with them in back of my face. As well, there was a desire to take photos of the street signs and flowers in the deli, even the sidewalk, perhaps an expression of the weird feeling of, it’s as though it never happened when you look at the essential life of any NYC neighborhood: there are the street signs, different signs in a different color but the same street names, there is the concrete sidewalk and the corner brightly lit up deli open late…

The twin lines of light always inspire and move me; they function as a better expression of a “memorial” than any building or fountain or plaques could be, and there is something evocative about their annual reappearance and disappearance. Also, their simplicity and visual effect if having no words, accounts, stories, explanations, even objects from the day, etc., as no words capture the essence of such monumental events such as 9/11 and other more personal private losses people suffer with: because there are no words for the big gaping hole of a traumatic loss, any death of a loved one really… These twin white lights stretch high into the sky until they link together, no longer seen as separate, one white far away blurry line swallowed up by the night sky…

In my art work there is a continuity since 9/11/01 versus before it. I posted some images done soon after the event, the one with ink and green background and the double one with a filmstrip like composition of a face and traces of a building in pinkish colors.

Another photo posted here of two framed drawings is a diptych, entitled “Falling Towers” fine with pen and mostly bright pink ink, from around 2009.

Finally, tying it all together are 2 tiny pieces made yesterday evening in my studio. They were response art but seemed to be connected with the day, a long one which swung from everyday “normal” activities with my oblivious 5 year old keeping me in the present moment, and pockets of moments of replaying parts of the day 11 years ago, tiny emotional moments punctuating a beautiful September day with a clear sky…

Money and Therapy; A Very Confusing Topic

I just wrote a long draft for this post, and it disappeared, so I am very frustrated. I will try a shortened version of what I had in mind.

I started by describing a lot of potential scenarios (in private practice as opposed to clinics or training institutes or agencies) for therapists and patients to raise questions such as the following:
1. What is it about the exchange of money for therapy that directly affects the therapy?
2. With insurance companies often paying the bulk of your therapists fee, does your copay to your therapist hold any meaning for you or your therapist?
3. Is there such a thing as too low or too high a fee?
4. What does it mean for the therapy for a patient to be paying a very low fee over a long period if time due to real financial hardship?
5. Is the therapy compromised or changed when an outside party such as a parent or friend pays for all the therapy?
6. What is it like as a therapist to be mistakenly seen as very wealthy by your patients due to some misconceptions about therapists in private practice and their incomes?
7. What is it like for a therapist to have a patient who makes over twice the therapist’s income?
8. Is it wrong for a therapist to let a patient who has money problems and is paying a low fee get very far back in payments to the therapist and owe months of therapy? Who should bring up the topic?
9. Is there something strange about this scenario: therapist goes to a supervision group and pays a monthly fee 30$ more than the fee s/he charges her own supervises in the supervision group she runs.
10. What makes most therapists say no to bi-weekly (2 times per month) instead of weekly sessions and what makes a few therapists accept this scenario as well as a low fee due to the patients’ financial hardship?

In the world of many therapists the whole topic of the fee and sliding scale and how to handle the negotiations of it is hotly debated. Some say if you don’t pay attention to the fee and how it is paid you are avoiding a lot of important issues. Others have a philosophy of really using the sliding scale fee and accommodating people other therapists would never work with. I confess I fall in the category of those, the ones who lower their fee to accommodate patients with little money and at times I accept a patient coming only twice a month. In most cases it is a patient who has been coming weekly for a long time but not always. There are other reasons I have accepted this type of patient besides money issues though I agree with most therapists’ opinion that much more can be accomplished with the regularity and structure of weekly sessions. I also would never run a supervision group that did not meet weekly as I think the group process works with weekly meetings and consistency and keeps the group functioning for support as well as clinical issues.

Many years ago I read in the New York Times magazine a profile of a British therapist. I don’t remember his name or why the article was on him but I do remember him saying, ” I strongly believe that therapy should not cost more than (don’t remember the amount but it was equivalent to about $80 which these days might be around $120 as this was written around ten years ago)…” anyway I was really struck by his point. He actually thought there was a limit to a decent fair fee for his services despite his education, training and experience. Sort of like saying an ice cream cone from a truck shouldn’t cost more than 3$. This was and is very unusual in our profession to actually say that it’s indecent to charge more than a typical amount such as $100-$120 per session as your highest rate. Putting a limit on the value of therapy. Most therapist’s focus much more on the difficult issue of, can this particular patient afford to pay my highest fee and if not what can they afford. On the patient’s side, I have seen people say I don’t want to pay you less than such and such as I don’t want you to feel disrespected so this is what I could afford to pay you.

I admit I had a conversation with someone about couples therapy and how insurance companies often pay too little for it. Yes, some therapists charge more for couples than individuals. The reasoning is that couples therapy is much more difficult to do, which I think is definitely true. In addition, most couples don’t stay in therapy that long with some exceptions. While it is not unusual to have a patient in therapy for five years or more, the average couple dies not remain in therapy that long. I could diverge into a discussion of couples therapy but that is for another post. I will add that it’s not unusual for a couple to go to a couples therapist and end up with one partner continuing with the therapist individually and thus stopping their couples sessions. It is one way people kind of accidentally find a therapist they like for individual…

Back to money. The idea of going to someone’s office to share intimate details of your life and expose your self in various verbal and nonverbal ways is hard for some people to wrap their head around. Usually the boundaries of not knowing much about your therapist helps with this scenario and makes the whole money transaction make more sense to most patients. I am going to a doctor of the mental, emotional and spiritual body so of course I am paying as I would for a doctor of the “physical” body. This is how I would explain the process to a curious and puzzled Martian.

People may notice they are sometimes treating their therapist like their mother (transference) but it helps to have the distance and strangeness of the personal information mostly flowing one way, from the patient to the therapist.

I admit or confess to sometimes wracking up a large bill with a patient who is on a low fee and having a very hard time confronting the patient about it. It certainly would be easier if the patient brought up the topic. Confronting someone who has a job they work hard at and are paid little for who has loyally stayed my patient when s/he could have found someone in network on their limited health plan and now owes me for quite a few months if therapy is not easy. I also have a patient who left therapy suddenly owing me about $300. She has paid off most of it but still owes enough that I need to chase after her every once in a while.

The majority of my patients not using their insurance pay me some fee lower than my regular fee and pay it on time.

The one insurance company I am in network with pays me a little more than half my regular fee. What does this mean? Probably that the insurance company undervalues my work in a much more insulting way than any patient is capable of doing. It says with your license, level of training and experience we agree to pay you almost half your fee. If course experience usually doesn’t mean much to the insurance companies nor do they raise your fee according to inflation and cost if living.

Raising your fee is another big topic which a lot of therapist’s struggle with.

Money and therapy: big topic to be continued in the next post!

Dreams and Their Meaning; Dreams and Creativity

I have always been interested in dreams and dreaming. I have taken various classes about dream interpretation, mostly focusing on Carl Jung’s teachings about dreams, now more than five years ago, but I remain open to all kinds of approaches to dreaming and meaning.

I don’t know what came to me or why, but at the beginning of this month, February, I decided to make a real concerted effort to write down my dreams. It started with just a dream here or there, and within a little more than a week, I was remembering at least 2 dreams a night. I thought this would keep up, but it’s an up and down process, where sometimes I have a day or two where I don’t wake up to write down a dream, and then another day I have one or two detailed dreams. I’m hoping with the passage of time, I will be regularly, nightly, remembering at least one dream, and that my dreams will become longer, more detailed, more complicated, or from another standpoint, it could be that I’m training my mind to remember them more often and in more detail.

It is a necessity to have a notebook by the bed and a pen that I like, because I am often writing at 2 or 5 am in a haze. At first I found it hard to read my handwriting, but I started having the intention to write more clearly. Then while reading a book about dreams that I randomly found in the library a while ago, “The Secret History of Dreaming”, by Robert Moss, I was reminded of the concept of the really “rich” dream, the dream filled with symbols, and last week I voiced to myself my desire to dream about animals. I think I was hoping for dragons (it is the year of the dragon) and other mythological creatures. Anyway, I haven’t gotten dragons yet. However, the night of the day I wished for animals, I had a dream with a lot of pink pigs in it that took place in a hotel. (I actually have  had a few dreams in hotels and I remember last time I did this exercise years ago, I had some hotel dreams.) To me, the hotel symbolizes a transient place, and if the setting of the dream is where my psyche is at, having a hotel dream means to me that I am going through transitions, and a lot of temporary things as well as many changes, comings and goings, which seems to be true. A lot of new things are coming into my life, especially my professional life as a therapist. At the same time both the supervision group that I run and the one I participate in are going through terminations and new members and transitions simultaneously. Synchronicity!

So I am hoping I can train myself to have richer more symbolic dreams simply by having the intention of remembering my dreams. I have not done this in a long time, but I remember the last time was for a dream class, and it is very true that if you keep a notebook and pen nearby and are very focused on the topic of dreams, in any way, it becomes easier to remember dreams, and one’s dreams become longer and more complicated. Even the possibility of a kind of chain of dreams where one leads to another, can actually happen. And when you become really involved in the process, you can sometimes engage in lucid dreaming, which did happen to me once a long time ago…

When I took the Jungian classes, the method of interpreting or “translating” dreams was taught in a very specific way. The idea was that dreams contain messages that we need to decode that tell us important things about our waking life and our “attitudes”. Nightmares were seen to be dreams that shout at us that we must change something very big in our lives and “wake up” to some reality we are not facing or the results will be scary and dire. The setting of the dream is seen as the setting of one’s psyche. Having dreams with groups of unidentified men or women is seen as having a very undifferentiated unevolved animus/anima. Having a dream about an older man for a woman could mean that her animus is highly developed and wise. Having a dream of a young woman could tell a man that his feminine side is undeveloped and needs work and integration. The same is true of the Shadow in the dream. Sex dreams can be about connection and integration. There were some other very specific ideas I don’t remember any more. I still remember one teacher saying that dreaming about one’s patient(s) tells us something in the therapy is very wrong and needs to be looked at. I never liked that idea, as I think dreaming about a patient could mean multiple things, including the opposite of what he said, that is, that one is very connected to the patient or that there is something special and positive happening in the therapy. Or it could be about boundaries and fantasies.

However, I like to approach dreams from all kinds of angles, and I don’t believe there is any one way best to understand their meaning, if you believe they have a meaning. I also believe that, if you believe in dreams, if you really believe they are not random and have messages in them, then they do. I have even seen people, actually close family members, who think dreams mean nothing and are just the brains way of tossing around bits of the day or some other biological function, well, I have sometimes seen those same people marvel at a dream they had in a way that shows they have come under the spell of the dreaming mind — the mystery and wonder of it, rather than it being bits and pieces of random leftover brain matter. However this is not a common occurrence. It is we people who love dreams and looking at them, who even find a magic in them, we are the ones who will pay the most attention to them. For us, the dreaming process is a very personal and very important journey of one’s soul and consciousness.

I am also interested in doing this experiment on myself, that is, recording my dreams on a daily basis for an extended period of time, to see if this exercise has an effect on my creativity and on my work with my patients. To see if indeed, Jung’s idea is true that in dreams we can learn about how to approach important aspects of our real lives.

“A Mesopotamian term for an obscure or mysterious dream is ‘a closed archive basket of the gods.'”

“The early Iroquois regarded someone who was not in touch with his or her dreams as the victim of serious soul-loss. A specialist might be called on to bring the lost dreams — and the missing vital enregey — to the sufferer.”

Some quotes from Moss’s book that I like. I do have this feeling that I want to find something by dreaming and catching my dreams, and to feel that I am living my life more fully, more awake when I’m awake, and more awake to my dreams when I sleep…

This post will be continued in a few weeks as I learn more about this mysterious and wondrous process called dreaming.

Next week’s post will be called “Silence and its Meaning”. I find if I allude to the next post in the current post, it helps remind me that I want to address this new topic…

Medication and Therapy

In my last post, I touched on the topic of medications and mental illness. This post will attempt to address some of the issues connected with this vast topic…

Psychotropic medications have always been a controversial topic in many different societies. I have had much experience working with people on all kinds of medications, as well as working with people in the midst of going off their medications, starting to take medications for the first time, and many who tried out medications and then stopped them without finding a medication that was helpful. In addition, I have encountered people suffering from various emotional and mental difficulties and disorders who were vehemently opposed to taking any form of medications but were willing to try alternative forms of healing instead of medications.

I try as a therapist and person to be open to all points of view about this topic. What one chooses to put in one’s body is a very often private and vulnerable personal topic. While psychiatrists that I have talked to about this admit that we know very little about what makes a medication work and why and how, we also know a lot more now than ever before, and there are a lot more choices of meds than ever before…

As I mentioned in my last post, I have found that people struggling with and suffering from such issues/disorders as schizophrenia, schizoaffective disorder and bipolar disorder (both 1 and 2 as they appear in the DSM), really benefit from regular medication for an extended length of time. Often the reason for a re hospitalization or “relapse” with one of these serious disorders is caused directly by the person stopping taking their medications, usually because the person feels a lot better and thus thinks, “Oh, now I can stop taking these medications,” which makes some sense, as very often when our suffering is relieved by medication, it makes sense to stop taking it. But these disorders are more like diabetes. You don’t stop taking your insulin because you feel better. When I worked at a Continuing Day Treatment Center for adults and also at a residence for emotionally disturbed children, I saw how the medications really helped people with these serious types of disorders. Almost all the adults at the CDT were taking some kind of psychotropic medication, and a lot of but not all of the children I worked with at the residence were also on medication. The topic of medication and diagnosis and children is a complicated topic better addressed in a separate post. Suffice it to say that I saw children also helped by medications, especially those with ADHD and other behavioral disorders.

While Bipolar Disorder is a serious and sometimes even deadly illness, it is amazing how much medication taken regularly can really transform someone and their ability to function, such that people who continue to take their medications on a regular basis can function and thrive. Sometimes one or sometimes a combination of medications, and there are now many different mood stabilizers whereas a while ago it was mostly lithium, anyway these meds can really help balance the fluctuation of moods from manic to depressive. Most people have to learn the hard way that they need to accept their biology and that they suffer from Bipolar Disorder, by going off their medications, having a relapse or even two or three, and then accepting it and staying on the medications that work for them. Luckily there are now a variety of mood stabilizers, and these medications don’t all take away a person’s creativity and liveliness; they just help an individual to manage their mood disorder.

Schizophrenia and schizoaffective disorder are much more debilitating than bipolar disorder. However, I witnessed many of my patients healing with a combination of therapy, day treatment which provides structure and socialization, and medication. This combination of approaches really help people with severe symptoms, such that the voices they are plagued by can disappear, or at least subside to the extent that the individual can function on some level and receive some relief. It is very unusual for an individual suffering from these illnesses to be able to not take any medications. There are many good medications out there that work; unfortunately many of these  st cause weight gain, and I saw my patients suffer with the side effects of weight gain as well as worse side effects. Some people manage to be careful with their diet and are able to take these very potent medications without experiencing weight gain. However, I saw many of my patients at the program who were on Medicaid and had poor dietary habits; still for many to be able to socialize with others, even to be able to leave their house or residence and attend the program was a big step towards healing. The medications were only one part of this; therapy, groups, meeting others with similar issues, having a structure to their day — all of this was necessary for some or partial recovery.

Depression, including both major depressive disorders and other less serious depressions, is much trickier in terms of medication management. I have certainly seen people with bipolar disorder take medication for depression along with a mood stabilizer and be helped by the extra medication. I have also seen people get out of a terrible depressive period with the help of anti-depressants. Some of these people were helped by taking some  kind of anti-depressant for several months to a year and then were able to stop their medications and use other means for their daily self care to avoid slipping back into a depression. I have also seen people with depression who continue to take their medication even when they are not depressed, and these people find it helps them to combat the return of depression. Any person taking anti-depressants temporarily or permanently is greatly helped by having  some form of therapy, as well as a support group or yoga or regular exercise or any other number of  “non medications” that help with healing. In fact, sometimes the medication helps the person to be able to be motivated to do these other things that they were too depressed to do for themselves before taking medications.

On the other hand, I have seen some people struggle with taking anti-depressants, even to the point that they are willing to try a few different ones, looking for one that works, only to be defeated. These people sometimes can find no medication that works for them ,and they often make a valiant effort to find one. However, the good news is that there are other ways to shift depressive brain chemistry. Art therapy is especially effective in that the act of making art and being creative in the moment does have a positive effect on the brain. With the support of the art therapist or the group therapy, a person with depression can begin to shift his/her mood towards feeling better. Regular exercise has been proven to help with depression as does yoga. With good support from friends, family, a therapist, a support group or therapy group, some people are able to combat their depression without the help of any psychotropic medication.

Of the people who refuse to try any of this kind of medication for their depression, many do self medicate and even are aware they are doing so. Some use drugs or alcohol, which of course actually physiologically contribute to depression, but the slight lift or high at the beginning of injesting substances can outweigh the crash for many people caught in a cycle of addiction or dependence. Even limiting food intake to an extreme is known to produce a high, so restricting food intake can be another form of self medicating. The challenge for this group of people is to become aware that they are self medicating in an unhealthy way and after that to change these behaviors.

There are people who do not self medicate with unhealthy behaviors who believe alternative medecine is the way to go. These people really work hard to combat their depression with positive self caring behaviors such as regular yoga, massage, reiki, some kind of creative endeavor or creative arts therapy, as well as writing and using some of the cognitive behavioral therapy techniches as well as creative visualization, acupuncture, and even being careful with their diet, as it is true that certain foods contribute to depression.  Often it can become a vicious cycle where depression leads to eating unhealthy foods or bingeing on unhealthy foods, then becoming more depressed and continuing to take bad care of oneself. So changing one’s diet can really help with depression.

Separation Anxiety

Separation anxiety is normal in extremely young children up to around 14 months old. As the child gets older s/he can tolerate periods of separation from caregivers. Obvious signals that your child is too anxious about separation includes crying and inability to be soothed after separation, nightmares about separation, excessive obsessive “checking” that parent is there and clinging, constant temper tantrums at separation and reuniting, even bed wetting.

Often a child will pick up on an adult’s anxiety, and sometimes changes in the caregiver’s behaviors can go a long way towards easing the anxiety of the child.

What happens when these issues don’t get addressed? What behaviors linger on into adulthood?

“I notice that I get very anxious when I know the time I’m spending with a friend or on a date is running out and we are about to say goodbye. I know it’s an overreaction but I still feel this anticipatory anxiety and after we part ways I feel immediately a lot of sadness, loneliness and fears of being alone.” At other times this person is fine with being alone.

Another interesting scenario: “I seem to keep getting into long distance romantic relationships. Reuniting is always so dramatic and intense but then when one of us has to leave, it feels almost as bad as if we’re breaking up, and the depression lingers for a few days. During that time I’m excessively calling, texting, chatting online with him/her. Then for a while I feel fine and then it’s time for another visit and the whole pattern starts all over again”

“I hate the beginning of the therapy session. I always feel really uncomfortable. And at the end of the session it’s hard to leave. The worst is when you announce a vacation…”

Some people express their anxiety through needing to control the session, wanting to be the one who alerts their therapist that the session is over every time.

Of course as therapists we constantly see different styles of attachment. Aloof and avoidant: this may be the patient who can only tolerate bi-weekly sessions and/or “misses” sessions often through forgetfulness. It can be very challenging to work with a patient with this attachment style as they have a hard time staying in therapy. They may need to control things so much that they become the patient who suddenly leaves therapy when the therapist is noticing that s/he is finally starting to open up and trust. Next minute the patient leaves with no warning or notice. S/he may be able to send an abrupt text or email saying s/he needs a break from therapy, but in some cases this is the elusive patient who just stops coming to sessions and avoids any contact with the therapist. In these cases I have found it is still a good idea to contact the patient and leave a message voicing concern about this behavior, demonstrating to your patient that you have noticed their disappearance and are concerned about it. Often the “parentified adult”, used to the role of caretaker of absent, unstable or anxious even alcoholic parent is very accustomed to their role and has a hard time being in therapy and admitting they need care and attention.

The “ambivalent” attachment style can be expressed quite differently. This may be the patient who opens up very quickly in therapy, demonstrates many shifts in and dramatic affect states, even starts a fight with the therapist. This person needs a lot of contact but feels conflicted about needing it and how to express that need. The consistency and firm boundaries of the therapist with this type of person can be very effective.

The very neglected child can be very consistent as a patient and respond well to individual psychotherapy. S/he is often punctual and gets a lot out of the consistency and holding support of the therapeutic relationship. While this person may take a long time to trust the therapist, I have found patients like these to be very self aware even if their awareness includes a lack of connection to their feeling states and a lot of intellectualization. The goals of therapy are as clear as the patient is eager to work on his/her self…

Many people oscillate between different attachment styles and feeling states about separation depending on the stressors in their lives.

Personally I have oscillated a lot in my life between feeling overly needy and clingy to feeling overly detached, uninterested in connection with others and when under too much emotional stress, reacting very differently as a teenager versus young adult versus older adult. Most of us have a variety of experiences with separation.

I also find it interesting that having a pet dog or cat can help a person heal from whatever childhood separation anxiety they may have experienced. The unconditional consistency of a dog cannot be matched by a human. While this leads probably to a big topic for another post, I find it fascinating how our relationships with our pets can help repair early anxiety and trauma. Of course there is the other side to this, when people get overly attached to their pets and it affects their relationships with people…