Mushrooms part 4: Making contact in exposure treatment

I started out by brushing my feet among them, stepping on some of them, and knocking some over. This made me anxious, but I was OK. I went inside for 10 minutes and then went back out there to step among them some more. This time I decided to pull one out of the ground and felt a little creeped-out by the slight resistance it gave. But I held it in both hands and turned it over, feeling the whole thing — which was mushy and gross – but I was OK. While washing my hands afterwards I started sobbing, but I think this was only partly from fear and mostly from relief. I went out there one more time so my husband could take pictures of this accomplishment… and I’m still OK.

I’m going to need to keep reinforcing this new learning experience to keep my life-long fear and avoidance of mushrooms from returning, but making this first contact today is a really big deal. (I realize this may not look like big deal to you, but take my word for it. It is.)

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This is the informative article by Joseph LeDoux on exposure therapy that inspired me to do this today: https://www.psychologytoday.com/blog/i-got-mind-tell-you/201508/psychotherapy-learning-expereince

Here are the links to read more about my mushroom phobia:

It’s the end of psychotherapy as we knew it (and I feel fine?)

For the last 30 years I’ve been in many types of therapy, and this has made me a witness to how dramatically the process of therapy has changed over these years. While many of the changes have been for the better, others not so much.

Years ago, therapy took much too long and there was no clear evidence of how (or if) it worked. Patients were encouraged to blindly trust that talking about whatever came to mind multiple days per week for years would eventually help them. And therapists were trained to resist jumping in to the conversation with information, direction, or even human responses. The lack of human response was itself distressing to many patients, and having to invest in a lengthy, unproven process wasn’t in the best interest of anyone. So clearly something had be done to relieve suffering faster, and to scientifically determine what can make therapy helpful or not.

Today, for those able to locate well-trained specialists, there are efficient therapies being developed and scientifically tested for nearly every type of psychological problem. Many of these specialized treatments represent tremendous strides, and the importance of this is not to be underestimated. But my own view is that these changes have been accompanied by a deterioration in services for the average patient seeking help from the average practitioner, and I’m concerned for the future of the profession.

Here are the general trends I’ve noticed:

1.The need to carefully listen to patients has been replaced with a readiness to jump in with handouts and unsolicited advice. I’m not advocating a return to the silent psychoanalyst, or the client-centered therapist who only repeats back what the patient just said. But if the therapist is talking at the patient much more than he/she is listening, something is out of whack.

While my experiences in individual psychotherapy have generally followed this trend, nowhere was it more pronounced than in the changes I witnessed in inpatient treatment. Twenty-five years ago, my stay on an inpatient psych unit centrally involved talking to people (doctors, therapists, interns, nurses, and other staff). Our group therapy sessions also involved a lot of talking and exchanges of ideas among the patients. By contrast, when I stayed on two inpatient units more recently, it was absolutely no one’s job to talk with me or listen to me. When in a moment of despair I asked someone on the staff if I could talk to her, she spent the whole “conversation” asking me what the point of it was, rolling her eyes and tapping her pencil on her pad. Even the required group sessions involved having the patients take turns reading out loud from pamphlets on topics that often had no particular relevance to anyone in the group. Being listened to was just missing from the entire experience.

2. Many therapists seem to have stopped considering it necessary to be careful about what they say or do in therapy, as if their actions no longer have the potential to be harmful or a waste of patients’ time and money. Whereas perhaps old-fashioned therapists were paralyzed by overthinking everything, and considering some aspects of the therapeutic process (such as transference) much more fragile than they really are, many of today’s therapists are just saying and doing things without appropriate thought to the potential meaning or consequences of their behaviors.  Gently recommending well-chosen books seems OK, and that’s not really what I’m talking about. But one therapist told me with a sense of authority that I really ought to quit the job that I had spent five years writing a grant just to get. Another therapist brought out a dead butterfly for me to touch — and when I asked her why she said she had no real reason, it was just a spontaneous idea and no big deal (at least not to her). Crap like this makes me almost miss the days when therapists exercised the self-restraint to say little but “uh-huh”.

3. Therapists no longer feel committed to continuously working on their own issues. Seeking their own therapy and extra supervision used to be considered a necessary part of a therapist’s training and later professional growth. In today’s culture, by contrast, being a therapist no longer requires getting any therapy of one’s own, and two or more years of training is often considered sufficient expertise, period. Obviously there have always been bad therapists, and there always will be bad therapists — but what I think is new is that the professional expectations for therapists no longer emphasize modest and careful attention to the personal flaws that can influence their work.

So why not just use apps instead?  Ultimately, by not listening to patients’ individual needs in the moment, many of today’s therapists are making themselves entirely replaceable by smartphone apps. Clearly, smartphone apps could be a valuable adjunct to a caring therapist. But with so many therapists interacting with patients in ways that range from robotic to sloppy to just plain insensitive, I don’t see much motivation for the average patient to bother with a human therapist at all. I guess the larger question is whether the rejection of therapists in favor of smartphone apps would be a detriment or benefit for patient care over the next decade or two, and we’ll have to wait to find out. Smartphone apps, at least, are not expected to have self-awareness or the ability to listen and respond with compassion.

Mushrooms part 3: Exposure treatment

To try to make progress on overcoming my mushroom phobia, I’ve been working on exposure goals this summer. The most common and effective treatment for phobias, exposure involves doing the things that you’ve been avoiding out of fear, so that you learn that you can in fact handle them. Exposure is usually done gradually so you can feel a sense of mastery over each aspect of it and feel that the whole process is under your control. Before starting the exposures, I worked with my therapist to create a list of the types of things I was afraid to do (involving mushrooms) and we ranked them in order of difficulty.

Starting with the low-difficulty exercises, I first looked at pictures of mushrooms. I also practiced saying and writing the word mushroom (for a few decades I had avoided doing even this).

Then it was time to start dealing with some actual mushrooms, but easy ones (not the living, growing ones that I’m most afraid of). To be honest, I found these exercises a little more strange than scary. I bought a jar of (small) whole mushrooms, took some out, and poked at them with a stick. I was even able to touch one, but I think this was because rubbery, slimy, and soaking in a jar, it didn’t have the frightening properties I associate with mushrooms that suddenly appear in the wild. My therapist made some mushroom spore prints and brought them to one of our sessions. Assuming that you don’t have a mushroom phobia, these are actually kind of cool (see link to instructions below). The print is made of mushroom spores but it looks like an incredibly detailed charcoal drawing of the underside of a mushroom. You can preserve these images with fixative, but my therapist left them natural so I could touch the spores. I smeared the spores all over my fingertips, but it felt just like smearing charcoal. Again this was not really frightening as much as it was surreal.

Wild, growing mushrooms are what really frighten me, so I’ve started trying some exposure exercises with those too. I transplanted some tomato plants that had very small mushrooms growing around them. Though I didn’t touch any of those mushrooms, I did have to dig (with a spade and gloves) in soil where I knew mushrooms would be, and pull the plant out with many little mushrooms dangling from the root ball. That did make me quite anxious, but it was manageable. The other thing I did was visit my friend the mycologist for a guided tour of the mushrooms in the woods surrounding his house. We saw a wide variety of mushrooms and he would pick them up and show me their special features. His enthusiasm for the mushrooms was very amusing (he kept referring to them as “cute,” “perfect,” and occasionally “delicious”). He also said I would make a good mycologist because having a phobia for mushrooms makes me extraordinarily good at spotting them. The visit was informative and only a bit frightening, since I was just watching and not touching anything. (I also asked my husband not to touch anything because I didn’t want come away from this visit with an image in my mind of him holding a mushroom.) The hardest part was being careful about where I was stepping, since I’m very nervous about brushing up against a mushroom with my foot, even while wearing boots.

Clearly, trying to walk where mushrooms are growing has to be my next goal. And maybe eventually touching a mushroom with my shoe, or walking in grass without being completely focused on looking for mushrooms to avoid. I truly don’t know if I’m ready to do this now — with classes starting in just a few weeks I am reluctant to take on challenges that could potentially compromise my emotional stability. But we’ll see. Maybe.

References

Here is how to make a mushroom spore print:   http://www.wikihow.com/Make-a-Mushroom-Spore-Print

Here are the links to read more about my mushroom phobia:

Mushrooms part 2: Understanding and re-thinking a lifelong irrational fear

After years of thinking about it, the best explanation I could come up with for my fear of mushrooms is a metaphor: You think you have a lovely flower bed, but underneath lies a web of fungus that feeds off of death and decay, showing itself in ugly alien forms that appear seemingly out of nowhere, overnight. In other words, I think mushrooms are a symbol for my difficulty trusting people — because of what goes on beneath the surfaces people present and what awful things they may be suddenly capable of.

Though the untrustworthy friends and romantic partners that I had when I was young didn’t help change my greatly pessimistic view of humanity, this view clearly originates in my relationship with my father. Growing up, nearly everyone characterized my father as a well-intentioned and charming person, though he did get a bit more irrational and upset than other people when disappointed. Since I hold the dubious honor of being the person who has probably disappointed him most, to me he has often become terrifying and (verbally/emotionally) cruel without warning.

My therapist speculates that some scary incident probably occurred to classically condition me to have a phobic reaction to mushrooms. Though I lived in the city for nearly all my life, between the ages of 2 and 4 I did live in the suburbs, and it is plausible that I would have seen mushrooms there. Perhaps one day I expressed curiosity about them, and my father reacted by screaming at me that they were poisonous and going to kill me and that I was stupid for going near them and so on. Or maybe my father went on some random tirade at me in his typically terrifying way over something else entirely, but since mushrooms were nearby I came to associate them with the terror I felt. Of course we’ll never really know, and it hardly matters. Somehow this strong association developed, and here we are.

To start thinking about mushrooms differently, I talked with a mycologist to learn more about them and what he appreciates about them. So instead of thinking of mushrooms as a manifestation of death and ugliness, I try to remind myself that they are part of a process that makes life possible, and a process that contributes to things I like (e.g., cheese, wine, and beer). Also, when I see a mushroom, I try to focus on the interesting scientific aspects of it rather than aspects that frighten or disgust me. Finally, my therapist suggested that when I do start to feel fear in the presence of a mushroom, I should remind myself that my father’s unwarranted rage and cruelty are the cause of my fear, not the sort of silly-looking thing in front of me.

It has become easier for me to think of mushrooms in non-frightening terms when I am not around them, though it is still hard to maintain this perspective while walking across the lawn. But I’m working on that too.

Mushrooms part 1: A story of lifelong, irrational fear

As a small child I used to eat mushrooms, sliced and cooked into amorphous brown pieces, when my mother served them. But the first time I remember seeing one growing out of a crack in the sidewalk, I was very frightened yet just couldn’t look away. Somewhat later, my mother asked me to help her clean some fresh whole mushrooms before cooking them, and seeing her holding one of those things made me cry and run out of the room. Walking in the grass became terrifying, and when my family bought a vacation house in the woods, I started having nightmares about having to walk from the car to the house. My fears persisted and I made many choices (such as which college to attend, and where to live) based on the availability of paved places to walk (but ever vigilant for mushrooms growing out of cracks or pieces of wood). When I found myself unexpectedly or inescapably near where mushrooms were growing I had panic attacks and crying fits. During my childhood, my father told me he would cure me of my fear by putting a mushroom under my pillow while I slept, so that I would wake up with it and realize it hadn’t hurt me. He never actually did it, but I was terribly afraid that he might.

People have always asked me why the heck I’d have this fear. Did I think poisonous mushrooms could somehow hurt me just by sitting there? Or that they’d run after me and attack me? Did my fear develop from hearing about ominous “mushroom clouds” when I was growing up in the early 70s? Was it because mushrooms can sort of resemble penises and (never mind the rest of this question)? I felt sure that the answer was no to all of these things. I also knew it was irrational to fear mushrooms and that they could not hurt me, yet I remained completely terrified of being near them.

I have many other life-long fears that are similarly unusual and irrational. But the mushroom fear is the one that I’ve been working on recently, because accepting my job as a college professor required moving from a city to a place full of woods and fields where I often can’t gracefully avoid mushrooms. In my next few blog posts I will describe my attempts to understand my fear of mushrooms and to learn to think about mushrooms differently; I’ll also describe some of the exposure exercises I’ve been doing this summer, and those I have yet to take on. In essence, I’ve come to realize that fungus is everywhere, whether I can see it in the lawn or not — so I have no choice but to accept and learn to coexist with it. I’m not quite there yet, but I’m making progress and that matters a lot.

These marionette hands are really my own: committing to a daily mindfulness challenge

My whole life I’ve been disconnected from my body (and described by others as “spaced out”). The way I see it, my actual “self” is located somewhere at the base of my skull, just above the back of my neck. Everything below that is kind of like a marionette that I operate rather awkwardly and absentmindedly when I remember to — while other times the marionette parts are left to their own devices, just swinging around and improvising . I’ve been living like this so long that I can’t even imagine what I might be missing by not being fully present in my body.

The demonstrated effectiveness of mindfulness practice for issues like these, as well as for other aspects of psychological well-being, is very persuasive. (I always teach my students about it.) But actually doing it isn’t so easy. Years ago, merely attempting meditation of any sort made me extremely anxious. When I’ve tried it in therapy more recently it was relatively peaceful, but I still haven’t been successful at getting myself to practice it on a regular basis.

So I’ve been inspired by Amanda Wang to embark on a daily mindfulness challenge, and encourage you to join us too. (Please see the link to her insightful and beautifully written blog below.) My personal commitment is to do a three-minute body scan exercise every day for the month of August. I’ll keep you posted and see how it goes from there….

References:

Are we getting something out of this all-encompassing trip?

I am in my late 40’s with a Ph.D. in clinical psychology, working as a relatively new college professor. Most people in my position are nearly 20 years younger than me, but that’s because along the way I lost a lot of time.

I first remember long periods of inconsolable despair at age 4.  I was prescribed antidepressants at age 8 — and this was in the 1970s, when the available antidepressants were more dangerous and it wasn’t common for people to take them, let alone talk about them. My parents threw the prescription away and also refused to let me go for counseling. I kept getting good grades, so my parents probably figured my problems must not be too serious. My father said it was just that I acted too weird, and he thought he could cure me of that with enough criticism and frequent fits of rage.

Leaving my high school friends for college was very hard. I started going to the college counseling center, and they recommended therapy several days each week. (My father said I was being selfish, wasting money paying someone to talk to me because I couldn’t make real friends.) After a period of starving myself and experimenting with faster ways of ending my life, I decided it was time to try medication, but it didn’t help me as much as I needed it to. Late at night I would sometimes try to study in public areas, because I was afraid that back in my room alone I would be unable to fight the urge to hurt myself. My college eventually decided that it didn’t want responsibility for me, and I was no longer allowed to live in the dormitories. With nowhere else safe to go, I admitted myself to the hospital. It was clear that moving back home would not be good for me, but I was not ready to live completely independently. So I was eventually discharged from the hospital to a residential program for adults with severe and persistent mental illness. From there, I resumed college classes and applied to graduate school.

Over the next 25 years I tried just about every medication and psychotherapy available. I was never really free of depression, social anxiety, OCD, and nightmares — but usually managed to get by. MAOIs and IPT both helped me through some very rough times. Then a few years ago I was offered my dream job — a tenure-track faculty position in an excellent department — and I decided to take it. My symptoms got so much worse, and I was hospitalized. Though ECT caused memory problems it did help for a while. But after that I was back to hating myself and unable to get out of bed, even while taking a ton of medication.

Ketamine treatment

Since the spring of 2015 I’ve been regularly receiving ketamine infusions (in addition to some other medications, therapy, nutritional supplements, and exercise). Within days after my first infusion it was as if a light had been switched on somewhere inside that had been always dark before. Suddenly I was able to feel at peace with myself, and do things, without paralyzing self-doubt. Ketamine treatment isn’t covered by insurance, and the effects of each infusion only last a few weeks, but since this actually works I plan to stick with it until I have other options. To stop hating myself after 40 years is not only really expensive, but priceless.

I live quite far from the nearest ketamine clinic so about once each month I travel all day to get hooked up to an IV bag, and let the medication drip into my hand while spacing out and listening to “Present tense” on repeat through headphones. The infusions are typically very peaceful and pleasant. Sometimes I feel my fingertips against the chair arm and can get fascinated by that. Or stare at my hands. Often I find that something will make me laugh, just because it is a little strange. Like when I see the leaves on the tree outside blowing, and for a split second they look like they are waving at me or waving along with the music, though I still know that they really aren’t. After an hour it feels like I’m waking up, feeling progressively more alert and less dream-like. And an hour after that I feel enough like my usual self to leave and get on a crowded train.

At my treatment session last week my doctor and I decided to try increasing the ketamine dose to see if maybe this might help the benefits last longer. This was the first time that I’ve felt more than mild psychedelic effects and it was so similar to movies about psychedelic trips that it was almost like a cliché. I thought I could see myself as a tiny dot among millions of moving and flickering dots. I could see the dots interacting with each other, and I also saw some of them disappear. I was certain that this image represented life, and that the only significance of each individual dot was what it meant to the others around it. But soon after seeing what I thought was the meaning of life, I saw my own dot disappear. I sat there stunned, believing that my little story was suddenly over.

I realize that what I experienced under the influence of ketamine last week was kind of like a dream, and no more important than a dream, but it felt so much more real and has lingered in my thoughts. All week I have found myself anxious about my mortality (which is highly unusual for me), and also grieving for the years I lost.

I wish I could tell my younger self to hold on and believe that a life worth living is possible. Not that living with my illness is easy — even now that I’ve finally found a treatment that really helps, maintaining my mental health takes a lot of work. But the difference is that now my life actually matters to me. I want to stay and make my time here count.

References:

About ketamine treatment for depression:

About IPT: https://en.wikipedia.org/wiki/Interpersonal_psychotherapy

Present tense (Pearl Jam, 1996) : https://www.youtube.com/watch?v=Tlx3GPsRD9M

Present tense (Lyrics)

Do you see the way that tree bends?
Does it inspire?
Leaning out to catch the sun’s rays
A lesson to be applied
Are you getting something out of this all-encompassing trip?

You can spend your time alone, re-digesting past regrets, oh
Or you can come to terms and realize
You’re the only one who can’t forgive yourself, oh
Makes much more sense, to live in the present tense

Have you ideas on how this life ends?
Checked your hands and studied the lines
Have you the belief that the road ahead, ascends off into the light?
Seems that needlessly it’s getting harder
To find an approach and a way to live
Are we getting something out of this all-encompassing trip?

You can spend your time alone re-digesting past regrets, oh
Or you can come to terms and realize
You’re the only one who cannot forgive yourself, oh
Makes much more sense, to live in the present tense

Let’s see tomorrow*

*There is indecipherable chanting at the end of the song, and “let’s see tomorrow” is just how I hear it.