Depression, ADD and Boundaries: A personal interlude...

Well, since I've told readers in a previous post about my health issues, I guess I should update all that...

The UC has settled down quite nicely, and though I have occasionally had mild flareups, they haven't been serious or long lasting, so officially I'm in remission.  Now the depression symptoms are another matter:

I originally talked to my doctor about my troubles late in 2009.  He suggested a course of a mild ssri antidepressant called cipralex.  Since I was in the process of weaning off prednisone at the time, I was in rather desperate need of something to mediate mood swings (and anyone who's known me for a while knows I'm not exactly a passive person...  When I go nuts, I go really nuts...).  So to keep from continually frightening my girlfriend, I agreed.  It actually worked quite well to level me out, and even if I was still quite lethargic and apathetic, at least I wasn't overreacting to minor anxieties...

I can't remember exactly when, but I think it was February of 2010 (By then I was completely off prednisone and moved on to a full dosage of azathioprine.), that I returned to my doctor to see if we could find a way to get my energy level back up.  We both agreed that adrenal insufficiency was a likely culprit, exacerbating the native side effects of both the azathioprine and the cipralex.  I started a course of wellbutrin in an attempt to give my a bit of an energy boost and get my productivity on the road back to pre-turning-40 levels.

Clinical depression is something that is still a bit of a taboo subject of conversation between friends and family etc.  There's a cultural tendency to try and hide any signs of mental illness.  After all, who wants to be pitied or thought of as crazy?  It really wasn't until I read a Scientific American Mind article about the differences between the symptoms experienced by men and women that I truly started to go along with the diagnosis. Apparently anger and restless agitation are primary symptoms for men. And I have to admit, I've been avoiding dealing with those signs since my late teens.

Martial arts training has been a great help, but I've had periods when I haven't trained, and the anger always comes back.  Something that's frustrated me about understanding where it comes from is that I don't have any real abuse in my background.  I was bullied somewhat, but that's normal in school.  Smart un-athletic kids get picked on (Though once I started judo, they only did it from a distance for some reason!).  I think it's a rule somewhere.  And we always have the last laugh, as we go on to bigger and better things after high school and our bullies languish in white trash hell (mwaaah haaa haaa!).  So increasing anger as I age doesn't make sense.  It should have declined rapidly after graduating, but didn't (I'm recalling a particular instance when, after finishing a kitchen shift, I was having a drink or two with friends and became so animated in the conversation I was having that my co-workers nervously approached to tell me to stop pounding on the table as customers were leaving in fright.  I had no idea what they were talking about!).

Becoming a massage therapist has also helped.  The act of treatment has a tremendously calming effect.  It's hard to stay angry and agitated while helping someone else relax.  And the process of becoming a therapist had it's own lessons in self-observation.  I don't think I know anyone who's managed to complete their massage training without facing some unpleasant truths about themselves.  "Fixing" that unpleasantness is another path however, and even after I've moved forward with this one, I know I'll be dealing with another.

Not long after starting the wellbutrin, I decided it was time to talk to someone and see if I might benefit from talk therapy.  I researched some of the options in the building I practice from, and booked an appointment with Dr. Angela Corradini.  We had a great session, and her recommendation was that I seemed to be on the right track, and that I didn't really seem to need extensive therapy, though I could come in once a month if I chose (Reduced productivity has made that difficult, but it's on my list as I get my affairs caught up).

One of the difficulties of pharmacological treatment for depression is that it's mostly trial and error.  Try.  Wait.  Assess.  Adjust.  So it takes time and patience.  By the end of 2010, I was frustrated with my lack of progress and returned to my doctor.  We discussed increasing the dosage of wellbutrin, but didn't act on it.  It wasn't until the spring that we finally did increase.

The limits of exploratory treatment had been reached however, and over the summer, I became even more lethargic and apathetic.  My extremely patient and understanding girlfriend was reaching her limit.  I started to think that perhaps the depression is a symptom rather than a cause.

My mother tells the story of my toddler years as somewhat trying.  We lived in a two story duplex in Montreal.  The landlords and neighbours were an older German couple who routinely complained about the amount of noise I would make charging about the apartment.  In their opinion, I should be tied down and drugged until I grew out of this unpleasant stage (It sounds like a joke, but no.  They were quite serious).  My parents (thankfully) refused, and while they certainly didn't encourage my energetic behavior, they recognised that trying to "beat it out of me" wasn't likely to help.

When I started school, teachers were frustrated with my apparent inattentiveness, but had difficulty punishing me for it as I was more often than not still able to answer their question about the current lesson.  I don't know the exact circumstances, but I was labelled "superactive" (I can't find anything about the term, but suspect it was on the Connors Scale rating back in the 1970's.  This diagnostic tool seems to be really well protected and I can't find out much about it's previous versions other than that it has been revised over time.  Please let me know if you know anything!).  As far as I can tell, we now refer to the same symptoms as ADD (attention deficit disorder, as opposed to ADHD, attention deficit hyperactive disorder).  The recommendation was that my parents put me on ritalin.  They refused (Quite wisely, I think.  I can't help but hypothesise that mediated chemical changes to a developing brain would cause more harm than good.  In an adult brain, at least the basic developmental structure is there, so treatment with pharmaceuticals that alter brain chemistry might have less permanent effect.  This is very lateral thinking, but I've noticed that tribal societies don't let their young men use psychotropic plants until they're considered to have reached adulthood.  Perhaps they knew that these plants might damage a person whose brain that was still partially undeveloped.  It might also help explain how some young men failed their manhood ritual:  If their brain developed slower than their peers, they might suffer sever neurological injury from the chemicals in the plants.  Don't quote me on this though!  It really is just interesting conjecture.), and eventually I developed my own coping skills.  Unfortunately I was a little too smart for my own good and while I finished high school with good grades, I never really developed  proper study habits.

While in the Biological Sciences program at the University of Guelph, my over-active brain became a liability.  I think I only survived the first two years by tutoring people in the more difficult classes, as I rarely did any work of my own.  I gather that things have changed a fair bit, but twenty plus years ago, one could only go so far by just being smart.  At some point, students were expected to learn on their own and if they didn't, they failed.  And I hit that wall in my third year.  I was disbarred at the same time as I officially dropped out.  I was frustrated, angry, disillusioned and (I can admit this now...) scared.  Certainly, I was extremely depressed.  And being the stubborn young man  I was, I dealt with it by ignoring the problem entirely.  I've surfed the ups and downs of mood and behaviour in a similar way ever since.

The concept of adult ADD is relatively new, and poorly understood (In my estimation anyway.), though that's gradually changing.  I was reading the linked criteria on Wikipedia, and decided that it was time to change tracks.  My doctor agreed, and as I write this, I've just begun my  first week on a full dosage of concerta.  It seems to be helping, though it's too soon to tell if that's just a psychosomatic expectation, or actual pharmacological effect.  I've mentioned The Brain That Changes Itself and the study of neuroplasticity in a previous post.  My eventual plan is to take advantage of that plastic growth potential and engage in cognitive therapy to train my brain to do some of the things it doesn't want to do (I.e.  Anything I don't take pleasure in.).  It will have to wait until my affairs are in order, but that's why I'm taking medication instead of just going right to it.

That brings us up to date!  I'll certainly be blogging about this path as it continues.

A thought that keeps nagging me as I've been writing has been whether sharing this kind of personal health history is a good idea for a health professional (This post has already gotten quite a bit more in depth than I'd intended, so why not just go all the way!).  I'm in two minds.  One is that it's a blurring of the professional boundaries any health professional works hard to maintain, and the other is that hearing my own troubles helps patients open up about theirs.

Clear boundaries are necessary for any health professional in order to protect the safety of both patient and practitioner.  When boundaries blur, we can fall into the trap of transference and counter-transferance.  For professionals engaging in psychological treatment (psychiatrists, psychotherapists, and psychologists), this is an essential tool for aiding in the growth of the patient, but for the rest of us (Massage therapists are particularly prone to its dangers due to the intimacy of our treatment process.  We also lack the depth of training in psychology to use it as a tool.  I know many RMT's won't agree with me, but I'm not a supporter of somatoemotional release as a treatment modality.  In general, I feel we just don't have the training.  When I feel there is a likelihood of a deep emotional release, I try to suggest to the patient that I am there to witness and be there for them, but that they should find someone to talk to with the appropriate training.), it's something to watch for and stay clear of.  From this perspective, talking about my own problems, even if the patient has asked about them, can be seen as a breach of those boundaries.

The alternate argument comes from the experience of having patients leave off important sections of their health history.  Due to the social stigma around mental illness (I'm including mood disorders and learning disabilities in the rather broad category), many patients are ashamed to disclose psychological diagnoses.  When they learn that I've been struggling with depression, anger management and ADD, patients will often open up about their own struggles, and find that they can more fully relax in my treatment environment.  I've also found that they are more likely to be honest about their reasons for last minute cancellations if they aren't afraid to admit to having a bad day and are feeling too fragile to leave their homes.  Sometimes they'll keep an appointment because they can tell me that they're feeling bad. The challenge with this tactic is to gauge whether there is any need to expand the therapeutic relationship in this way.  For lack of any external guideline, I've been going on intuition.

Hopefully some of you reading this will have some input, as this is a challenging topic.  I don't feel it's a simple as "No.  This is not in our standards of practice."  Principle II of our Code of Ethics is "Providing sensitive, compassionate and empathetic quality massage therapy.".  As I'm attempting to increase empathy with the patient, my disclosures seem to fit.  Please feel free to comment!  Hopefully we can expand this discussion in future posts.

Footnote:
Many of you will note my reliance on links to Wikipedia in my posts, and particularly this entry.  It's my intention to provide links to expanded information with cluttering my writing unnecessarily.  I've heard some criticism of Wikipedia as a reliable research/information source, but I find that unless the topic is controversial or un-researched, it seems to be as accurate as possible for a general reference source.   Even the post on its reliability is well referenced.  I did try to find a better review of research.  Anything I found is both referenced in their article, and too technical for most people to appreciate.  If any of these posts are sought after for more professional publication, I'll make a more critical approach to my references.  Until then, I'll keep using Wikipedia as a convenient and approachable reference resource.

Blog the fifth: Massage and Martial Arts

New and prospective patients often ask me what style of massage I do. I find this a particularly difficult question to answer. I have training in swedish massage as is required in Ontario's massage schools. Deep tissue massage was also taught in school. Since then I've completed advanced training in craniosacral therapy with Robert Harris of the Cranial Centre (http://www.cranialtherapy.ca/) here in Toronto. Prior to ever becoming a therapist, however, I studied martial arts.

In eastern cultures, martial arts and healing arts are often taught in parallel. For example, I can remember reading on a korean hapkido web page that orginally, advanced dan rankings in Hapkido (which I currently study) require certification in both massage and acupuncture (I'm afraid I can't find the link as I write this... I'll keep looking!). As far as I can tell, the healing and martial aspects divided somewhere in the middle of the last century as eastern martial arts spread west and began the process of commercialization that's culminated in martial arts "brands" in the last couple of decades.

As part of a personal path, I felt that a massage therapy career would enhance and be enhanced by my martial arts training. Being self employed would also give me the freedom to train even more intensely (It hasn't quite worked out that way... The realities of small business keep me occupied more often that I'd expected!).

I've always thought of myself as a bit of a jack of all trades. Miyomoto Musashi in his Book of Five Rings said: "Be knowledgeable in a variety of occupations, and learn the thinking of people who work in them." (http://www.bookoffiverings.com/) Aside from having had a few career paths myself, having a massage practice is also about relationships... Getting to know people and developing an understanding of how and why they're on the table. A massage career is certainly great for a martial artist for that alone.

Martial arts at its foundation is about movement and rhythm. This is an aid to me in a number of ways. In solo practice, I learn about my own bio mechanics, my personal ability to move. In joint practice, I learn about how others move. It's particularly useful to see different body types in motion when they also come from different vocations and athletic backgrounds. After years of this kind of observation, I can often tell what a person does for a living (within some broad categories. ie. working on the phone or computer, physical labour, driving), and what they do for fun in their spare time. It's also helped me develop an profound sense of efficient posture and bio mechanics (the move efficient someone is able to move and the more integrated the rhythm of their movement, the better their posture and bio mechanics tend to be).

Even greater tools available to me through martial arts training, are an understanding of leverage, and a functional knowledge of anatomy. Leverage is learned through grappling practice (both standing and on the ground), and helps me as a therapist to apply force efficiently when necessary while remaining sensitive to the tissue response, and safety of the patient. With so many years training with different people, with different body types I found that when we studied anatomy in massage school, I was able to put labels to structures I already had a feel for and thereby increase my palpation effectiveness in both martial arts and massage. Combining those two sets of ideas gives me an intuitive sense of how to work on a patients body that goes well beyond anything that can be learned in a textbook. It's also made my style of treatment somewhat unique. I've been told it reminds people of either shiatsu, or osteopathic styles of treatment, even without distinct training in those disciplines.

I can't imagine doing one without the other. I feel I could study bodywork style after bodywork style, and collect tremendous knowledge, but without the parallel martial arts path, I'd have difficulty integrating them into a coherent personal style of treatment.