Showing posts with label therapy. Show all posts
Showing posts with label therapy. Show all posts

Interpersonal Social Rhythms Therapy: Good, Bad, and Ugly (Mostly Good)

Following #bipolar on Twitter for the last few years, I am often dismayed. So many people seem to spend so much time struggling with their medications and so little time focused on anything else that could help.

Don't get me wrong. Medication is an important tool for managing bipolar disorder. But it can't do the whole job. Education and life style changes are crucial for getting off the roller coaster of constant med adjustments to address the episode du jour.

I decided it was time to revisit my 2011 review of Ellen Frank's Treating Bipolar DisorderIt was a four-part review. The last three posts describe the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the educational foundation, describing the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory


How the Social Zeitgeber Theory Works, for Good or Ill - IPSRT

This -- this system is the gift I wish I could give to the people I meet on Twitter who struggle with their bipolar, who are in endless rounds of medication adjustments and medication failures and medication despair. Medication isn't the only thing you can do. I'm not saying quit your meds. I'm saying, add social rhythms therapy. Originally posted in 2011:

Ellen Frank - Treating Bipolar Disorder, Part 2

So you have bipolar. You know you have bipolar. You are way past the denial stage. You are into the pulling out your hair, screaming with frustration stage. Or maybe moved on to despair stage. Because:


  1. The medication sucks.
  2. You keep getting sick again anyway.

But contrary to what everybody has been telling you, medication is not the only thing that works. It may be essential to your recovery and continued functioning. But you can do better if you do more. From my last post:

IPSRT [Interpersonal Social Rhythms Therapy] is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder. The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

Do I have your attention? Today we continue with Ellen Frank's Treating Bipolar Disorderin which she describes this therapy of her invention.

What Happens In IPSRT

Circadian Rhythms and Fixing Bipolar's Wonky Clock

When nothing else worked, Social Rhythms Therapy got my bipolar under control. That's why Ellen Frank is my mental health hero. She invented it.

A few years ago, I spent four weeks summarizing Frank's book, Treating Bipolar Disorder: A Clinician's Guide to Interpersonal Social Rhythms Therapy. My goal was to create a patient's guide. Here is the link to Part Four. It includes links to the earlier posts.

Frank describes Interpersonal Social Rhythms Therapy like this: IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

Circadian rhythms are at the core of IPSRT. People with bipolar have difficulty maintaining the stability of our circadian rhythms, because our internal clocks, governing everything from sleep cycles to blood sugar levels to body temperature are, well, wonky.

Will This Trauma Never End?

I found this video while trying to survive the cluster f*ck of misdiagnosis, antidepressants, mixed episodes, and a psychiatrist and therapist who didn't know what they didn't know, so it must be me and maybe I had borderline personality disorder - the go to diagnosis for patients that the professionals are tired of.

OK Go - This Too Shall Pass. And in fact, it did. I survived to... today? I offer it to everybody who is trying to survive the current COVID cluster f*ck in the US.

Is It Time to Call a Therapist?

There is a difference between feeling depressed and having depression, which makes it hard to figure out what we need right now when - doesn't everybody feel like crap?

What you are feeling right now might be the entirely normal reaction to this currently abnormal world. Here is what's happening: everybody is experiencing trauma at the same time. Exhaustion, trouble concentrating, insomnia, hopelessness, these are common physical, emotional, and cognitive reactions to trauma. They are also symptoms of a depressive episode. And depression, the illness of depression can lead to serious complications, substance abuse, relationship problems, suicide. Not to mention that it simply sucks the joy out of living. Depression, the illness needs to be treated.
So do you need to see a doctor? It depends. A recent New York Times article can help you sort it out.

Misconceptions about Therapy

Continuing the press kit-inspired series...

No, therapists aren't like friends that you pay

Therapists make you work. The work you do depends on the kind of therapist you see. Interpersonal therapists get you to examine your relationship patterns. Are they working for you? Are you sure? Social rhythm therapists make you track your schedule. For people with bipolar, an off kilter schedule results in an off kilter brain. (The chart I use is here.) Cognitive behavioral therapists even give you work sheets! Mostly this homework involves learning to examine your thoughts. Just because your brain tells you something doesn't mean it's true.

No, therapists don't give advice

The End of Miracles - A Review

What is it like to have depression with psychotic features?

What is a day like inside a psych ward?

What is the psychiatrist thinking?

Sometimes the best way to explore questions like these is in a story. So here is Prozac Monologues' first review of a novel.

Monica Starkman is a psychiatrist at the University of Michigan whose expertise includes psychosomatic disorders, stress, and women's issues around fertility, miscarriage, and obstetrics. In her debut novel, The End of Miracles, she turns her clinical experience to the story of one woman, Margo Kerber, a long-infertile woman who finally conceives, tragically miscarries, and then... unravels.

Giving Thanks for Ellen Frank

If you can manage one, just one self-care exercise for bipolar, make it a regular sleep schedule. This week I am thankful I found Ellen Frank and IPSRT, Interpersonal Social Rhythms Therapy.

IPSRT in a nutshell: people with bipolar have a wonky internal clock. The hormones that regulate everything from when we are alert to when we are hungry to when we are cold are governed by an internal clock. When that clock sproings a spring, so do we. Bipolar is like jet lag on a daily basis.

There are a number of events that set and reset the clock throughout the day. If you have a wonky clock, you can reduce the damage it does by making sure these events happen the same time every day. That is the Social Rhythms part. The Interpersonal part is plain old therapy, focussing on whatever issues prevent you from protecting your clock.

Keeping this clock set correctly is the single most effective strategy for maintaining good sleep patterns. And sleep patterns are almost the whole show. Disruptions cause cascading effects: increased inflammation, cognitive difficulties, irritability, emotional lability, depression, hypomania, mania, all three, weight gain... Somebody has probably written the book. I will write the testimonial, that when my sleep is in order, so am I. Ellen Frank focussed my attention on that #1 strategy. When the meds didn't work, she saved my butt.

Several years ago, I wrote the more detailed version of IPSRT in a review of Frank's Treating Bipolar Disorder, three posts to explain the theory and one summary review. So here it is reposted, with links to the earlier posts within it. 

Treating Bipolar Disorder Part IV -- Summing Up
May 4, 2011

Intending to review Ellen Frank's Treating Bipolar Disorder,  I spent most of April describing the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the foundation in work done on the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time.  (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory

Frank builds IPSRT on the theory that people with bipolar are more vulnerable than others to disruptions in our circadian rhythms.  When our interior clocks get screwed up, we do, too.  Daily events, like getting up at a certain time, seeing people, going to work, set our circadian rhythms.  The core of the therapy is to help keep our rhythms regular.

The best brilliant part of Treating Bipolar Disorder is this theory.

A good theory accounts for as much of the data as possible, and then provides a way to solve problems.

The old theory is bipolar is a chemical imbalance in the brain.  The advantages of the old theory is that it is simple, it suggests a way to solve the problem, and it is earning the pharmaceutical companies billions and billions of dollars.  The disadvantages are that decades after it was first offered, it has offered false hope and subsequent despair to millions of sufferers, focused blame on those who won't take the drugs that make them sick and/or don't work, and for a majority of people who receive the best pharmacotherapy possible, simply failed to fix the problem.  It also neglects a lot of data.

The chemical imbalance theory comes from the data of clinical experiments -- that symptoms go away when you change the chemical stew.  Or at least, they go away enough to get FDA approval for marketing claims.  It does explain a piece of the puzzle.

But another set of data has to do with what was going on before the symptoms developed.  Frank and company turn to circadian rhythms to account for how the chemical imbalance developed.  And here there is a wealth of data.  For example, study of circadian rhythms reveals that lack of sleep causes depression as often as it is caused by depression.  This suggests a whole other way to solve problems.

Treating Bipolar Disorder documents this evidence in support of the theory.  Most of the book then describes the therapy that derives from the theory.

People With Bipolar Who Are Doing Well

The Social Zeitgeber Theory accounts for the data of those with bipolar disorder who are managing their symptoms, working, thriving over the long haul.  There are almost no studies done from this angle -- what people are doing to stay well.  John McManamy reports on two of these studies at mcmanweb.com.  Healthy lifestyle is the top strategy for these people, particularly maintaining good sleep.  Most, 85% take medication, but do not make medication the center of their self-care.  None rely entirely on medication to stay healthy.

Medication, Medication, Medication

My chief reservation about the book has to do with its assumptions about medication.

Let me put it this way.  It is a bold move to list the uses of specific medications in a hard copy printed published book.  Chances are that such a book will report positively on a medication for which the manufacturer then settles a class action suit in the same year as publication.  Zyprexa/olazapine is just one example of how quickly the chapter's information became debatable and/or dated.

Frank assumes that IPSRT is an add-on to pharmacotherapy.  She notes that lithium, the miracle drug that was supposed to have solved the problem of bipolar has turned out not to have done so in near as many cases as people think.  She acknowledges that there are problems with side effects and efficacy for anything that is currently in use.  But just barely.

Unfortunately, it is only a minority of patients with bipolar disorder who can comfortably take the medications that seem to control the symptoms of the illness and who are willing to submit to this control.  Especially early in the course of the illness, before it has wrought complete havoc in the patient's life, there is denial that there is anything permanently wrong and a longing for the highs that the medications take away.

Yup.  There it is.  Ellen Frank, too.  They miss their highs.  I won't go there right now.  It's just too tiresome.  But stay tuned...

Frank continues the clinicians' tradition of oversell.  She considers whether a clinician should refuse to work with a person who has bipolar I and does not take medication.  Her recommendation is that the work might proceed anyway, with the goal of revisiting the issue at every opportunity until the patient finally does take meds,and holding open the possibility that treatment may be terminated if the clinician concludes that he/she cannot accept responsibility for somebody who is not on meds.

Okay, on a positive note, Frank pays more attention to side effects than other clinicians, repeatedly urging that the therapist and prescribing clinician work in partnership, and that medication problems be addressed.

On a very positive note, Frank spends a lot of ink on the issue that people with bipolar I or II spend way more time depressed than manic and hypomanic.  And our depressions are far and away the part of the illness that disables us.

Can We Ever Crack This Medication Nut?

This medication debate never seems to get anywhere.  Like abortion or the Palestinian issue in US politics, nuance is not allowed.  You're either pro-med or anti-psychiatry.  And I can feel myself drawn into the blogosphere's quicksand.  So let me do the down and dirty on Frank's position and get out of here.

Frank's assumption that everybody who has bipolar I and not on meds is a trainwreck waiting to happen -- maybe that is a necessary evil to maintain her professional credibility; maybe more of the usual professional wishful thinking: I call it disappointing.


Frank's repetition of the old they miss their highs thing: I call it tiresome.



Frank's concern to take side effects seriously and her criticism of the standard practice of medicating people with bipolar into a permanent state of mild depression, treating anything approaching a normal feel-good state as a danger sign of impending mania: I call that refreshing. 

Clinical Language Alert

I have spent the last several years reading books and articles written not for me, but about me.  It is a perilous business.  Prozac Monologue readers occasionally are on the receiving end of my efforts to manage the consequences of this endeavor.  It is getting less perilous, as I learn some skills, the first of which is simply to acknowledge the intended audience.  So...

Treating Bipolar Disorder is written for clinicians and about people with bipolar.  I am not a clinician; I am a person with bipolar.  Therefore, Treating Bipolar Disorder is not for me; it is about me.

If you are like me, you need to take this into account when reading this book.

Having said that, this book is less perilous than others.

Yes, there are a couple bumps in the road: the bipolar temperament, the attitude of entitlement and they miss their highs.  For the record, Frank never uses those exact words.  Her exact words are above.

On the other hand, this book is exceptional in its tone of respect and genuine partnership between clinician and patient.  Absolutely exceptional.  Props to Ellen Frank.

The Future Of IPSRT

Like I said, this book was written for clinicians, who are addressed directly.  It was not written for people who have bipolar disorder, nor for a general audience.  There is no book, no pamphlet, no article, no website, no youtube that describes IPSRT for a general audience.  Prozac Monologues is as close as you get.  Not enough for a do-it-yourself-er.  But a start.

At this point, getting access to this therapy would be a trick.  If you use one of those Find a Therapist websites and actually do find one in your area whose interests include bipolar, you are still likely to get the response I got, The way to treat bipolar is with medication.

Frank and company keep track of those they have trained.  She says maybe she should develop a website.  A lot of people think maybe they should develop a website.  Most of them have many other things to do.  I wouldn't hold my breath.  I would write her directly and ask.  And then come up with a do-it-yourself strategy.  I have one outlined below.

Frank has the support of NIMH's STEP-BD study giving IPSRT the magic label of evidence-based.  So she has a therapy, a book, a training.  And 5,700,000 people who could benefit from this treatment.  She needs to develop the market for her training the same way pharmaceutical companies develop their markets -- go directly to us 5,700,000 people with bipolar.

There's a whole world of people out here who get our mental health care from Facebook friends and [Name Your Diagnosis and/or Treatment] for Dummies.  We need an IPSRT for Dummies.  We need a workbook.  Once we get started, we'll ask for help, and our care providers might get interested.

Here is my story: The meds don't work.  I have been stalled in Cognitive Therapy for some co-morbid trauma issues.  I don't have the capacity to interview a bunch of therapists who might deal with my bipolar, even if I could find them.  I lose my voice when I talk with therapists -- back to those trauma issues.  So I went back to my CBT therapist.  We are renegotiating to do more interpersonal work and I am experimenting on my own SRT/Mood Chart.  I will do the SRT part on my own.  My therapist and I can talk about my grief for the formerly healthy self.

You have to really have it together to do therapy this way.  I am not starting from a position of crisis.  I have good insurance and a lot of resources.  My wife tells me, if I have lost half of my cognitive functioning, that still makes me smarter than 80% of the people in the room.

So this might work for me and maybe another 100,000 high functioners out there.  5,600,000 more to go.

On July 14, 1990 Ellen Frank knew with absolute certainty that [she] needed to dedicate the next decade of [her] life to doing better by these patients and family members.  It was a decade well spent.  And then another.  I hope she keeps going into the third.

Last Words

If you are a person living with bipolar disorder, cut the author a break for the inevitable mental health provider mentality.  The medication issue is a minor, minor piece of an otherwise helpful, hopeful book.

Treating Bipolar Disorder offers hope.  Read it.  Talk to your therapist about it.  Get yourself a schedule that includes enough sleep at a regular time each day.  Talk with your therapist about whatever keeps you from doing that.

If you are a therapist, read this book.  Give its techniques a try.  If they help somebody, don't you need some CEU's?

If you are a doctor, read this book.  Stop promising more from meds than meds can deliver.  There is more help out there for your patients.  Help us find it.

If you are Ellen Frank, get this stuff out to those of us who can't find or afford a therapist whom you have trained.  And God bless you.

photo of clockworks by HNH and used under the Creative CommonsAttribution-Share Alike 3.0 Unported license
flair from facebook
caution sign by RTCNCA and used under the GNU Free Documentation License,

Farmer Wisdom - For While Waiting

Summer seems like a good time for farmer wisdom, filling in while I am filling out forms for my new psychiatrist appointment.  It's a repeat from a year and a half ago.   It has been getting a few hits lately, bringing it to my attention, and reminding me of two good therapists from my past.  Michael and Liz may or may not be on vacation right now, as they were when I first posted.  In any case, their offices are 2000 miles away, so they may as well be.  I am grateful for my time with the both of them.  I could still use double teaming.

from February 8, 2012:

For When Your Therapist Goes on Vacation

Untangling Redemption

Kelly Flanagan is a psychotherapist who blogs.  I think that is brave of him.  Most mental health professionals keeps a decidedly low profile online.  Boundaries, you know.

Flanagan not only blogs -- he puts it right out there.

[I have been sick as a dog this week, and will share him with you, instead of churning out my own stuff.  Thanks, Kelly, for doing the heavy lifting.]

Flanagan's blog is called Untangled, and his theme is redemption: Tell a redemptive story with your life.  Now.

Immediately, he is asking for trouble in this bizarre world where meanness has become the measure of ones Christianity, and all those Christian words are distorted to stand for the opposite of what they intend.

In this Orwellian world, (where entitlement means something to which you are not entitled) Redemption means that you have paid whatever price somebody else has decided you ought to pay in mental gymnastics and conformity to their way of life.

Stages of Recovery - AKA Hope

It gets better.  It really does.

People who get tired of the Chemistry Experiment go off their meds.  Why?  Because the meds don't work.  Or they make us sick.  And the doctor doesn't hear us, because the doctor has one tool in his/her toolbox.  [Hint: It's not an ear.]  And he/she thinks that the solution to our problem is compliance, because there isn't time for listening and problem solving.

When you walk into a hammer store, they will try to sell you a hammer.  Fair enough.  If you are trying to rebuild the life that your illness took from you, chances are you will need a hammer.  Chances are you will need some other tools, as well.

The doctor doesn't have those other tools.  But they are out there.  And so is the map.

You are angry that the meds promised what they could not deliver.  Get over it.  Pull out the map.  Or the toolbox.  Mixed metaphor.  Whatever.  Get over it.  Get to work on your recovery.

The Recovery Map

Apology?

So Robert Spitzer's Apology struck a nerve: apologies made or received, or not.  More like, Robert Spitzer's apology stuck a fork into a 220 volt socket, the nerve labeled Apology in the Clinical Setting, Or Not.

I have long been curious about this issue.  Fork in the 220 volt socket kind of curious.  I watched with wonderment as a therapist handled my complaint, which was, to me, about a life-threatening experience, steering the conversation away, time and again, from what I thought was the simplest, most natural direction, I'm sorry.

Now, I trusted this person.  Her avoidance of those words, her downright circumlocutions confused me.  My brain has long practice in making sense of the nonsensical behavior of people I trust.  So I decided there must be a rule, a therapy rule, that says a therapist shouldn't apologize, because it diverts attention from the real issue, which is about the client's mother, and not about the therapist at all.  Or something like that.

For When Your Therapist Goes on Vacation

I have two therapists and they were both on vacation the week I got home from my mother's funeral and all those issues and all the family and all those issues.  And still on vacation the week after that!  My brother-in-law subbed - thank you, Darryl - with the following email.  I offer it as a resource for when your therapist picks a lousy time to go on vacation.

For extra entertainment value (my entertainment, anyway), I have identified which one I hear Michael telling me with >>, and which ones I hear Liz telling me with **.  One of them regularly irritates me.  I'll let you guess which one.  I have to keep both, because the double-teaming seems to help.

Wisdom Learned From the Seat of a Tractor


Your fences need to be horse-high, pig tight, and bull-strong.

Treating Bipolar Disorder Part IV -- Summing Up

Intending to review Ellen Frank's Treating Bipolar Disorder, I spent most of April describing the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the foundation in work done on the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory

Treating Bipolar Disorder Part III -- The Interpersonal Therapy Part

Lately I have been reviewing Treating Bipolar Disorder by Ellen Frank -- the recommendation of a friend who is researching hypomania. Part I described the basis of Interpersonal Social Rhythms Therapy (IPSRT) in circadian rhythms that control the many physiological symptoms of mood disorders. Part II outlined the Social Zeitgeber Theory and described the early stages of the therapy process, history taking and stabilizing social rhythms. Today I pick up with the later stages, interpersonal therapy and maintenance.

Interpersonal Social Rhythms Therapy came to Ellen Frank in an epiphany on her birthday, July 14, 1990. Personally, I like that. I especially like that it was the day that she participated in a conference for people with bipolar, and listened to them.

Frank and her colleagues were already using interpersonal therapy for people with recurrent unipolar depression. Their theory was that certain life events, particularly losses could result in lost social zeitgebers, (timekeepers), with subsequent disruption of circadian rhythms, leading to eventual relapse into another episode of depression.

IPSRT took up from there as an adaptation specifically for people with bipolar disorder, integrating the work on issues (as in, you've got issues) with greater focus on behavioral changes to achieve and maintain daily rhythms, time of rising, time of first human contact, work, main meal, etc. The purpose of IPSRT is to help people achieve stability and then to avoid relapses into either depression or mania/hypomania. 

Why Do People Relapse?

Treating Bipolar Disorder Part II -- The Social Zeitgeber Theory in Action

So you have bipolar.  You know you have bipolar.  You are way past the denial stage.  You are into the pulling out your hair, screaming with frustration stage.  Or maybe moved on to despair stage.  Because:
  1. The medication sucks.
  2. You keep getting sick again anyway.
But contrary to what everybody has been telling you, medication is not the only thing that works.  It may be essential to your recovery and continued functioning.  But you can do better if you do more.  From my last post:

IPSRT [Interpersonal Social Rhythms Therapy] is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder.  The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

Do I have your attention?  Today we continue with Ellen Frank's Treating Bipolar Disorder, in which she describes this therapy of her invention.

What Happens In IPSRT

Treating Bipolar Disorder Part I -- Interpersonal Social Rhythms Therapy

Medication And Mental Illness

Medication for mental illness is just like medication for anything else.  It works better when you don't ask it to do all the work itself.

In the case of bipolar, once lithium and the chemical imbalance theory came along, the thinking was that medication was the only thing that worked.  Therapy by itself certainly didn't.  I wonder if therapists, worn out by their bipolar patients, were simply relieved to believe that medication was the only thing that worked.  I wonder if therapists today, worn out by their recurrent depression patients, are secretly relieved to terminate when the diagnosis changes to bipolar, because medication is the only thing that works.

Frankly, there is a lot of wishful thinking out there in pharmacotherapy land.  If only our brains were a chemical stew and the illnesses of the brain could be treated by adjusting the recipe.  If only.

But people with mental illness, especially people with bipolar, can't afford the wishful thinking behind the better living through chemistry fantasy.  Sometimes the medications do work.  But not as well nor as often as your doctor would like to think.

I have a friend who is a psychiatrist.  He challenges his colleagues who keep trying to solve this noncompliance issue, to get their patients to comply.  He reminds them, if the medication (antidepressants, in this example) worked for 40% of those who took it in the trial, and the placebo worked for 30%, that means only three out of ten people benefit from the medication itself.  So what's the big deal about seven who quit?

He says they just look at him funny.

Treating Bipolar Disorder by Ellen Frank

This same friend, God bless him, loaned me a book about a psychotherapy designed specifically for bipolar disorder titled, appropriately enough, Treating Bipolar Disorder.  The author Ellen Frank, professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at Western Psychiatric Institute and Clinic, and her colleagues invented Interpersonal Social Rhythms Therapy (IPSRT), a kind of mash-up between talk therapy and regulating circadian rhythms.  It gets my next few posts.

In A Nutshell... 

IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

Depression and the Shackles of Shame


There is no blood test for depression, no x-ray nor sonagram.  Depression is the label that is given to a constellation of symptoms.  There are theories about the cause of the symptoms.  But the diagnosis is more like tea leaves. 


Depression Diagnostic Criteria 

· Lasting sad, anxious, or empty mood
· Loss of interest or pleasure in activities once enjoyed, including sex

· Feelings of hopelessness or pessimism
· Feelings of guilt, worthlessness, or helplessness
· Decreased energy, a feeling of fatigue or of being “slowed down”
· Difficulty concentrating, remembering, making decisions
· Restlessness or irritability
· Sleeping too much, or can’t sleep
· Change in appetite and/or unintended weight loss or gain
· Chronic pain or other persistent bodily symptoms without physical cause
· Thoughts of death or suicide, or suicide attempts
.


If you have five of the above, including one of the first two, for more than two weeks, and without appropriate reason (like, your mother died) then that's depression. You've got the Grim at the bottom of your teacup. 

Guilt

I have done enough intake interviews that I recognize the differential diagnostic tree when it's coming at me. I used to get nervous when they asked about guilt. No, I don't actually feel guilt, except appropriate guilt for recent misbehavior, not the horrible self-judgment for imagined offenses. I don't feel guilty for my depression. I am not the offender but the offended.

Shame

No, what I feel about my depression, and events that are related, is shame.  And what I really feel shame about is feeling shame.

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