The Horse Listeners

Before Devon Combs stepped into the arena at Mirasol Recovery Centers, she felt lost. At just 21 years old, she had already been faking happiness for years, but her battle with depression and bulimia had recently led her to drop out of school, contemplate suicide, and spend time in a Denver psychiatric ward. Then she met equine therapist Marla Kuhn and Jack the therapy horse.

Combs grew up with horses, but it wasn’t until adulthood that she fully embraced what they did for her, and what they can do for many of us. Humans have depended on horses for millennia. In the more than 50 centuries since being domesticated, they have been our partners in work, our comrades in war, and our teammates in sport.

Devon Combs with her therapy horse, Jack.
Powerful bond: Devon Combs was struggling with depression when she was introduced to Jack, a therapy horse. (Courtesy Devon Combs)

Recently, wellness professionals have begun harnessing that bond for another purpose: helping us heal. A wide range of equine-assisted activities — incorporating riding, life coaching, and psychotherapy — are gaining recognition as effective tools for processing emotions, catalyzing change, and treating physical and mental health conditions.

When Combs and her fellow patients piled out of the van at the ranch where Mirasol held its equine therapy sessions, she looked forward to the familiarity of horse time and the opportunity to display her competence with the animals. But when she strutted into the arena, Jack turned abruptly and walked away, leaving her confused and embarrassed. Her therapist told her to stop and breathe and wait. It was in that unexpected moment of vulnerable stillness that things started to shift.

“My inner critic’s voice was nowhere to be heard and I was aware of a connection to my body, which felt foreign. For the first time in a long time, I wasn’t trying to make things happen, trying to change the way I felt, trying to change the way I looked, or trying to make everyone like me. I gave myself permission to just stand still and breathe. Simultaneously, Jack walked straight up to me from the far side of the arena,” Combs recalls.

Healing interactions with horses can come in a number of variations. Some approaches get patients and clients into the saddle. Hippotherapy, for example, takes advantage of the fact that the cadence of an equine’s walk mimics our own. The pelvic movements build muscle and develop balance. Therapeutic riding, on the other hand, teaches skills that help kids and adults with developmental disabilities learn body control and patience and have fun while they’re at it. Other programs keep people on the ground, where they tackle a variety of interactions depending on their particular needs. They might practice leading a horse from Point A to Point B, learn skills for basic care, or engage in talk therapy, relying on the horse’s presence for emotional support.

And across that diverse spectrum of equine-assisted activities, people are experiencing benefits. Riders with spinal cord injuries and cerebral palsy find their neurological and motor functioning get better. Individuals struggling with PTSD report lower stress and greater ability to manage emotions. Those on the autism spectrum develop social skills and empathy. And a growing body of research suggests that just spending time with horses calms our autonomic nervous system, improves self-esteem and self-efficacy, and helps youth learn impulse control, the value of commitment, and the payoffs of having responsibility. But why?

If a person is experiencing extreme grief, a therapy horse might lie down at their feet, groaning, even if they’ve convinced loved ones they’ve recovered.

According to certified horse handler Suzanne Opp, simply sitting atop a horse provides people with a different, more powerful perspective on the world, and riding the animals as they calmly walk around a pen can relax tension and improve mobility. While the precise mechanisms underpinning horses’ health-promoting effects on us aren’t fully understood, most experts credit two innate equine characteristics as the primary factors. First, horses are prey animals. As such, they evolved to be highly sensitive, hypervigilant, and always present in the moment. They are thus able to detect and interpret subtle cues and tiny changes in their surroundings. These traits are most explicitly highlighted when working with veterans with PTSD, who, according to Columbia University’s Man O’ War Project, may recognize and relate to the heightened fear response. Second, horses are social creatures. Whether wild or domestic, they prefer to live in herds and thus seek out relationships with other animals, including humans. A 2016 study published in Biology Letters demonstrated that horses are able to read and interpret people’s conscious and unconscious movements and facial expressions. And they want communication to be clear and congruous. In the therapy session described above, Devon Combs’s contradictory emotions — her attempts at appearing strong when inside she felt a mess — violated this principle and prompted the horse to keep his distance. It wasn’t until she accepted her own emotional state that he approached.

Now a certified practitioner in the Equine Gestalt Coaching Method, Combs works one on one with clients in the Denver area and leads retreats throughout the U.S. She still marvels at horses’ ability to sense things we don’t. “Horses are intuitive, and they’re masters at reading human body language. They naturally pick up on a person’s emotional state and energy. When a 1,200-pound animal reacts based on what they’re reading from us, it can’t be denied,” she says.

This sensitivity is arguably what allows horses to shine light on our inner worlds, particularly if there are gaps between a true state of being and a false façade. If a person is experiencing extreme grief, even if they’ve convinced loved ones they’re now doing fine, the horse might lie down at their feet, groaning. Patients who make a habit of faking fearlessness when frightened will find that their equine partners sense their anxiety and grow anxious, too.

Before she pursued her own career in equine-assisted therapy, Suzanne Opp was one of Combs’s clients. The equines, she explains, serve as a mirror. “Horses help people get in touch with feelings that they may not be able to through talk therapy methods or talking with a human,” she says. “They’re so reflective, the horses bring out things in us that we may not realize are there.”

The therapists, coaches, and handlers who partner with equines in these activities focus on how the animals respond to patients and clients during sessions. Combs refers to herself as a facilitator, stringing pieces of information together. “I’m a horse listener,” she says. “I’m listening and watching, and when needed, asking the client coaching questions that will further help them uncover their truth with the help of the horse. The horse is giving the big feedback.”

Suzannae Opp with a horse
Animal attraction: “Horses bring out things in us that we may not realize are there,” says equine therapy client-turned-practitioner Suzanne Opp. (Courtesy Suzanne Opp)

Similarly, Opp says that much of the therapeutic interaction hinges on her observations of the horse’s behavior. If the horse lies down and rolls onto its side or back, or licks and chews (a sign of thoughtful processing and relaxation), she points it out to the therapist who then asks the patient to offer an interpretation. Often, the horse’s actions represent something that feels familiar, but that we might not have been able to see or articulate previously: For example, a woman who feels ignored by her husband at home might recognize and articulate that experience only when her equine partner turns away in the round pen.

Part of why these opportunities for reflection work so well, experts believe, is that they are framed through the judgment-free lens of the horse’s behavior. It opens up a route for self-analysis that’s separate from expectation or fear of failure. And it’s typically where surprises are unveiled.

It has now been a decade since Combs became an Equine Gestalt Coach, and the healing power of horses continues to gain acceptance. For many like Combs and Opp, the experience is so transformative it inspires them to become a practitioner themselves. There are now hundreds of certified instructors, horse handlers, and coaches throughout the United States and beyond; and Columbia University Irving Medical Center’s Man O’ War Project is developing research-based guidelines for using horses in the treatment of PTSD. Furthermore, the link between horses and well-being, once a fringe idea, is becoming more mainstream. In addition to therapy and coaching retreats like the ones Combs leads, ranches all over the world are offering programs that integrate horse time with yoga and meditation.

“It was in the arena I discovered that it was okay, in fact healthy, to be myself,” Combs says. “Which is what horses had brought me all along, without judgment or asking anything in return, except for me to be in my heart. Horses came into my life at an early age to be my companions on my journey. They stuck by me through hell and I always drew strength from their wisdom, spirit, and power.”

Equine Therapy: A Guide

Woman stands with a horse while listening to a trainer.
(Courtesy Devon Combs)

Equine therapy has been successfully integrated into treatment programs for adults and teens who are being treated for substance abuse, addiction, behavior disorders, mood disorders, eating disorders, learning differences, ADD/ADHD, autism, Asperger’s, grief/loss, trauma, sex addiction, compulsive gambling, bipolar disorder, depression, and related conditions.Equine-Assisted Learning and Coaching: These programs use activities to promote the development of life skills and goals and to facilitate the processing of emotions. They are typically facilitated by a certified life coach, social worker, or other trained professional, but need not incorporate a licensed therapist.

Equine-Facilitated Psychotherapy: This approach integrates the expertise of a licensed mental health professional, a certified equine handler, and an equine partner to address psychotherapeutic concerns or goals established by practitioner and client.

Hippotherapy: Credentialed occupational, physical, and speech-language therapists partner with horses and horse handlers, using equine movement to improve functionality of sensory neuromotor and cognitive systems.

Therapeutic Riding: Activities that incorporate equine movement and sometimes the acquisition of horseback riding skills to assist individuals with special needs improve cognitive, physical, emotional, and social well-being.

Find a practitioner

This article is featured in the May/June 2020 issue of The Saturday Evening Post. Subscribe to the magazine for more art, inspiring stories, fiction, humor, and features from our archives.

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Mental Illness Treatment in Meltdown

For the past several decades, America’s psychiatric hospitals have been in a state of emergency. There are too few psych beds for too many bodies. Only extreme cases — like the time a woman bit off her own finger because the voices told her to — get quick care. “This is the sad part of this work. People so psychotic they can’t even get to the hospital without doing something terrible to themselves,” nurse manager Jean Horan told the San Francisco Gate in 2006.  Former Bay Area E.R. psychiatrist Dr. Paul Linde described the revolving-door policy in 2018: “You’ve got your chow, you’ve got your shower, you’ve got your medication, you’ve got some sleep, and now it’s time to get out the door.”

Patients are often taken by ambulance to emergency rooms, where they are boarded in general acute hospitals that lack psychiatric care. The hospitals then can’t discharge their patients to psychiatric facilities because, more often than not, there are no beds available. It creates a logjammed system that fails everyone, as movement is stymied in almost every direction except to the streets or to jails and prisons, also known as “the beds that never say no,” said Mark Gale, criminal justice chair of the National Alliance on Mental Illness (NAMI). “These are the choices we are making as a society, because we refuse to fund the completion of our mental health system.”

The U.S. is a minimum of 95,000 beds short of need. It’s now harder to get a bed in New York City’s Bellevue Hospital than it is to land a spot at Harvard University, wrote advocate D.J. Jaffe in his devastating 2018 book Insane Consequences. Sixty-five percent of the non-urban counties in the United States have no psychiatrists, and nearly half lack psychologists, too. If the situation continues as it is, by 2025, we can expect a national shortage of 15,000 desperately needed psychiatrists as medical students seek higher-paying specialties and 60 percent of our current psychiatrists gray out.

And even if you did have access to decent psych care, you’d face the following obstacles: “One or more nurses would take vital signs, complete a brief exam, and gather some of the patient’s history. At least one emergency physician would repeat the process. … The emergency physicians might order a CT scan of the head or other imaging, depending on the patient’s history. … A psychiatrist would review the patient’s chart and any available electronic records. … From start to finish, these evaluations can take hours,” wrote Stanford psychiatrist Nathaniel Morris in the Washington Post.

Most states require that for a person to be hospitalized, she would need to pose a threat or be so gravely disabled and, according to a psychologist, “so disorganized that she would just stand in front of the facility, wander aimlessly in the street, or perhaps stand in the middle of a busy street, with no notion of how to get food or lodging for herself.”

One psychiatric nurse laid out what kind of acting it takes to get care. In the emergency department, “when being assessed, say (regardless of the truth): ‘I am suicidal, I have a plan and I do not feel safe leaving here. My psychiatrist asked me to come here for admission for personal safety feeling I am a grave danger to myself.’ That statement get[s] you back to the psychiatric [emergency department]. Once there, you get interviewed by the psychiatric triage nurse. Repeat the same statement.” Only once past these various gatekeepers, onto the psych floor, and in a bed can the patient start telling people what is truly wrong.

“There’s no way we’d send people who have diagnosed pancreatic cancer to jail because there’s no place to put them while they get treatment.

A 2015 study published in Psychiatric Services documented what happened when a team of researchers posed as patients and called around to psychiatric clinics in Chicago, Houston, and Boston trying to obtain an appointment with a psychiatrist. Of the 360 psychiatrists contacted, they were only able to obtain appointments with 93 — or 25 percent of the sample. (This says nothing of the wait time required for the appointment, nor of the care they would — or would not — ­receive.)

Dr. E. Fuller Torrey, who founded the Virginia-based Treatment Advocacy Center dedicated to “eliminating barriers to the timely and effective treatment of severe mental illness,” said it directly: “People with schizophrenia in the United States were better off in the 1970s than they are now. And this is ­really something that all of us in the United States are responsible for.”

After too many reports of abuses, there was a wave of psychiatric hospital closings starting in the late 1960s. “Reformers” believed that community care was a much better way to treat most patients, but those promises never materialized, and thousands of people were turned out from hospitals (where some had spent most of their lives) and had nowhere to go. In the 1970s, 5 percent of people in jail fit the criteria for serious mental illness. Now it’s 20 percent, or even higher. Nearly 40 percent of prisoners had, at some point, been diagnosed with a mental health disorder, and the most common diagnoses are: major depressive disorder (24 percent), bipolar disorder (18 percent), post-traumatic stress disorder (13 percent), and schizophrenia (9 percent). Women, the fastest growing segment of America’s inmate population, are more likely to report having a history of mental health issues.

These figures also disproportionately affect people of color, who “are more likely to suffer disparities in mental health treatment in general, which results in their being more likely to be ushered into the criminal justice system,” said Dr. Tiffany Townsend, senior director of the American Psychological Association’s Office of Ethnic Minority Affairs.

There are, at last count in 2014, nearly ten times more seriously mentally ill people who live behind bars than in psychiatric hospitals. The largest concentrations of the seriously mentally ill reside in Los Angeles County, New York’s Rikers Island, and Chicago’s Cook County — jails that are now de facto asylums. As someone who knows what it’s like to lose her mind, the only worse place I can imagine for someone going through that than a jail is a coffin.

“Many of the persons with serious mental illness that one sees today in our jails and prisons could have just as easily been hospitalized had psychiatric beds been available. This is especially true for those who have committed minor crimes,” said University of Southern California psychiatrist Richard Lamb, who has spent the bulk of his half-century career studying and writing about these issues.

This is the current state of mental health care in America — the aftershock of deinstitutionalization, which some call transinstitutionalization, the movement of mentally ill people from psychiatric hospitals to jails or prisons, and others call the criminalization of mental illness. Whatever term you want to use, experts agree that what has resulted is a travesty.

“A crisis unimaginable in the dark days of lobotomy and genetic experimentation” (Ron Powers in No One Cares about Crazy People); “one of the greatest social debacles of our times” (Edward Shorter, A History of Psychiatry); “a cruel embarrassment, a reform gone terribly wrong” (The New York Times).

An abstract image of a woman with multiple self-images
(Shutterstock)

Though some credit the rise in the mentally ill population behind bars to the fact that America has the highest incarceration rate in the world and to policies like mandatory minimum sentencing and three-strike laws, it’s clear that whatever the cause, the fallout has been disastrous.

“Behind the bars of prisons and jails in the United States exists a shadow mental health care system,” wrote University of Pennsylvania medical ethicist Dominic Sisti. People with serious mental illness are less likely to make bail, and they spend longer amounts of time in jail. At Rikers Island, which is in the process of shuttering, the average stay for a mentally ill prisoner was 215 days — five times the non-ill inmate average. The ACLU filed a lawsuit against Pennsylvania’s Department of Human Services on behalf of hundreds of people who had been declared incompetent by the court. Problem was, there were no beds available, so they were left in jails — in one case in Delaware County, a mentally ill person, too incompetent to stand trial, languished in jail for 1,017 days. The lawsuit’s lead plaintiff is “J.H.,” a homeless man who spent 340 days in the Philadelphia Detention Center awaiting an open bed at Norristown State Hospital for stealing three Peppermint Pattie candies. During that time, “J.H.” had a greater chance of becoming a victim of assault and sexual violence — all because he was too sick to go to trial. In March 2019, the ACLU took the DHS back to court after it “failed to produce constitutionally acceptable results, with some patients remaining in jails for months at a time.”

In Arizona, men “often nude, are covered in filth. Their cell floors are littered with rancid milk cartons and food containers. Their stopped-up toilets overflow with waste,” wrote Eric Balaban, an ACLU lawyer who chronicled his visit to Phoenix’s Maricopa County Jail’s Special ­Management Unit in Phoenix in 2018. In California, “Inmate Patient X” at the Institution for Women in Chino in 2017 was not given medication despite being listed as “psychotic,” and, after being ignored in her cell after screaming for hours, ripped her own eye out of her skull and swallowed it. In Florida, Darren Rainey was forced into a “special” shower by prison guards. The shower’s temperature climbed to 160 degrees, which peeled his skin off “like fruit rollups” and killed him. In Mississippi, “a real 19th-century hell hole,” non–mentally ill prisoners sell rats to the mentally ill prisoners as pets. In the same place, a man was reported fine and well for three days after he suffered a fatal heart attack. And in the shadow of Silicon Valley, a man named Michael Tyree screamed out “Help! Help! Please stop” as he was beaten to death by prison guards while awaiting a bed in a residential treatment program.

It all reminds me of Erving Goffman’s Asylums. Goffman was a sociologist who went undercover at Washington D.C.’s St. Elizabeths Hospital and argued that what he saw there was a “total institution,” no different from prisons and jails. He cited examples: the lack of barriers between work, play, and sleep; the remove between staff and “inmate”; the loss of one’s name and possessions.

“It’s true that the hospitals have mostly disappeared,” wrote Alisa Roth in her 2018 book Insane. “But none of the rest of it has gone away, not the cruelty, the filth, the bad food, or the brutality. Nor, most importantly, has the large population of people with mental illness who are kept largely out of sight, their poor treatment invisible to most ordinary Americans.”

And then there’s therapy — or the farce that passes for it in some prisons. Treatment is often rare and mostly revolves around medication management. When therapy does occur in certain jails in Arizona and Pennsylvania, it involves doctors or social workers speaking to patients through the metal slats in closed cell doors or, in one egregious case, merely handing out coloring books, wrote Roth.

“Prisoners are under a tremendous amount of stress, and they feel a tremendous amount of pain, and they’re not encouraged to think about that. In fact, there’s an incentive not to think about it or talk about it, because nobody is interested in it,” said Craig Haney, a psychologist who studies the effects of incarceration.

The culture of distrust goes both ways. Many guards grapple with threats (real or imagined) that the inmates are malingering or faking because they want out of a bad situation in the general population or feel they’ll get a cushier housing assignment among “the crazies.” Though this does happen, David Fathi, director of the ACLU’s National Prison Project, said that this is not as common as it’s portrayed. More often, people are underdiagnosed and mismanaged: “I mean people who have documented histories of mental illness going back to when they were nine, they get to prison and suddenly they’re not mentally ill, they’re just a bad person.”

Craig Haney agreed, adding that there’s no real incentive to lie and game the system: “What’s the secondary gain?” The secondary gain is that they get taken out of one miserable cell and put into another one that is usually more miserable. If they put you in a suicide watch cell — then you’re in an absolutely bare cell with no property whatsoever, sometimes you’re in a suicide smock, and sometimes they take all of your clothes away and leave you there naked.”

Dr. Torrey does have some solutions. The Treatment Advocacy Center, which he founded, advocates for adding more beds across the board — in state hospitals and forensic settings — which would reduce wait times and get people out of jails and into proper treatment quicker.  D.J. Jaffe, a self-described “human trigger warning” and executive director of the Mental Illness Policy Organization, pushes for the implementation of more mental health courts, where judges can divert people with ­mental illness into appropriate housing and treatment before they’ve been absorbed into the prison system. He also backs the use of crisis intervention teams made up of law enforcement officers, with the assistance of psychiatric professionals, trained to identify and deal with people with serious mental illness. On the more controversial end, Jaffe has written extensively about the necessity of using legal force to get people to take their meds (something called Assisted Outpatient Treatment), pointing out that many people with serious mental illness don’t know that they’re sick (a symptom called anosognosia), and for civil commitment reforms so that more people can be hospitalized against their will before tragedy strikes. He and Torrey have both made the case that though the vast majority of people with serious mental illness are no more violent than people without mental illness, studies have shown that a small subset of people, who are typically untreated, are more violent. To those who say these policies infringe on people’s civil liberties, Jaffe has responded: “Being psychotic is not an exercise of free will. It is an inability to exercise free will.”

Some prisons and jails, resigned to their new roles, have implemented changes to reflect their true roles as society’s mental health care providers. Sheriff Tom Dart of Chicago’s Cook County jail, where a third of the 7,500 prisoners struggle with mental illness, has become a standard-bearer in doing the best with an untenable situation. “Okay, if they’re going to make it so that I am going to be the largest mental health provider, we’re going to be the best ones,” he told 60 Minutes in 2017. “We’re going to treat ’em as a patient while they’re here.” Cook County provides medication management, group therapy, and one-on-one visits with psychiatrists. Sixty percent of the staff has advanced mental health training, and the jail warden is a psychologist.

But we need money to enact real changes. Without the proper allocation of funds, we punish people three times: disinvesting from resources to support them in the first place, arresting them when they exhibit problematic behavior, and then hanging them out to dry when they reenter the community. The system remains broken and people who are sickest continue to be ignored and forsaken.

“If I told you that was the case for cancer or heart disease, you’d say no way, we’re not going to send people who have freshly diagnosed pancreatic cancer to jail because there’s no place to put them while they get treatment,” said Dr. Thomas Insel, former head of the National Institute of Mental Health. “But that’s exactly the situation we’re facing.”

Excerpted from The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness. Copyright © 2019 by Susannah Cahalan, LLC. Reprinted with permission of Grand Central Publishing. All rights reserved.

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You’re Not That Important! Let Go of Self-Consciousness

Is it just me, or are people more self-consciousness than ever before? Thanks in no small part to the Internet in general and social media in particular, it seems like everyone is “under the microscope” these days.

This intensifies a culture where appearance, whether physical or financial, is all important; it can seem like being critical of others is the national pastime. Through the popular media, we also are bombarded by messages that we aren’t good enough, others are better than us, and we can be the best if we really want.

Because of these persistent messages of being judged and compared, it’s so easy to think that everyone is watching and critiquing our every move.

Self-consciousness isn’t necessarily a bad thing. In, fact, in all likelihood, it has been hard wired and enculturated into us as we have evolved as a species and a society. Self-consciousness helps ensure that we act in socially appropriate ways for fear of disapproval and rejection from society.

At the same time, self-consciousness can go well beyond keeping our behavior within a socially acceptable range. It can become a source of tremendous angst and unhappiness. Self-consciousness can create a pre-occupation with how we appear to others, what others think of us, and, often, can cause social anxiety and an inhibition of behavior that we fear others might judge to be less than desirable. I see people in my practice who are paralyzed by their self-consciousness.

Self-consciousness can prevent people from being who they are, expressing what they are feeling, doing what they want to do, and all because they are afraid of what other people will think or say about them.

For the vast majority of us, this self-consciousness, and the anxiety that is associated with it, is painfully misplaced. Here is a simple reality that should be liberating if you are overly self-conscious. Nobody is watching you. Nobody is thinking about you. Very few people even care about you. Why such a seemingly harsh pronouncement? Because you’re not that important!

Nobody outside of your immediate family and circle of friends really cares very much about you because you don’t impact their lives. Most people are focused predominantly on themselves. They have neither the time nor the energy to devote to people that have little effect on them.

Plus, somewhat ironically, the only concern most people have for you is their own misguided self-consciousness about what you are thinking about them!

When you think other people are thinking about you, it’s actually you who is thinking about you. When you believe others are being critical of you, they’re not, you are. Are you a mind reader? Of course not — we humans aren’t clairvoyant (though we like to think we are). So when you think someone is thinking badly of you, it’s really you thinking badly of you. Now that, not what other people are supposedly thinking of you, is something to be really concerned about.

Of course, this epiphany is a double-edged sword. It can lift a huge weight off of your shoulders because you no longer have to worry about what other people are thinking or saying about you, and you are free to think, feel, and act in ways that are true to yourself. The downside (sort of) is that we all want to live under the illusion that we are worthy of others devoting time and energy to thinking about us. But, as the saying goes, the truth will set you free!

Tips to Help You Let Go of Your Self-Consciousness

  1. When you feel self-conscious, look around and see if anyone is actually looking at you.
  2. Remind yourself that what you think others are thinking is actually what you are thinking.
  3. Take a risk and act in a way that might make you self-conscious and see what happens (probably nothing bad).
  4. Say “F&%# it” when you feel self-conscious and instead act in ways that you want to.
  5. As the saying goes, “dance as if no one is watching.”
  6. If your self-consciousness is interfering with your happiness, find a good therapist.

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Facing the Demons of Chronic Anxiety

The word recovery has always frightened me when it came to my own mental health. For years I’ve asked myself, how exactly do I recover from something that is with me for the rest of my life?

My anxiety can overwhelm me when I’m trying to sleep. Sometimes, as I’m about to drift off, I imagine a person is hovering over me. Although I’m fully aware that no one is actually there, my hands start to sweat and my feet turn to ice. A feeling of nausea builds until I’m about to vomit. If I try to stand up, my legs may collapse like cooked spaghetti. Other times, my anxiety sends me lurching out of bed to vacuum imaginary spiders from the corners of my ceiling.

When I was 17 and first realized that I had a mental illness, I spent the entire next year in complete denial, telling myself that one day I would wake up and the anxiety would have vanished — that I would forget I ever had to suffer from the voice in my head telling me that with every step I take, I will die. But after waking up over hundreds of mornings to find that my irrational fears were still with me, I realized this wasn’t going to change overnight.

That wishful thinking as a teenager only made my situation worse, especially when it came to my unorthodox methods of self-care. I left scars on my arms from both cigars and razors. I started to drink in the morning before school, and I took any prescription pill that I could find in my parents’ medicine cabinet, only to find myself now becoming physically ill as well.

All these negative behaviors were attempts to ward off the pain. And throughout my early 20s, I remained optimistic that I would someday find a simple cure for my anxiety, but reality wouldn’t set in until I received the greatest advice ever given to me — advice that would end up saving my life.

I left scars on my arms from both cigars and razors. I started to drink in the morning before school, and I took any prescription pill that I could find.

By the time I was 29 years old, though I was married and had a job, I was spiraling out of control. I was drunk every morning before work, and my marriage was failing. I was in the darkest depression. I had seen many therapists, but they all seemed to be telling me what I wanted to hear just to shut me up and shove some medication down my throat.

Searching for mental health answers isn’t easy, especially with the hundreds of different types of medications that are available. On the ­advice of therapists, I had tried Prozac, Effexor, Zoloft, Xanax, and Clozapine. The Prozac and the Zoloft made me tired all day. Effexor gave me ­terrible mood swings, horrific nightmares, and erectile dysfunction to boot. Xanax and Clozapine both worked wonders for my anxiety by completely eradicating all my fears. But aside from being highly addictive, their major downside was forgetfulness. Sometimes I would come home and not remember a single thing I had done all day. And then there was the chronic drowsiness: I could fall asleep at the dinner table mid-chew.

One day, I happened to drive by a Red Cross blood donation bus. I associated the Red Cross with needles and pain — but pain always heightened my senses, so I decided to give it a try. I had never donated blood before, and after I entered the bus and filled out the paperwork, there was the option of a 10-minute blood donation or a one-hour plasma donation. I figured the longer that I could sit in this bus with a needle sticking in my arm, the longer I would be able to focus on something other than my anxiety, so I chose to donate plasma. It actually worked. The pinch of the needle delivered just enough pain to quell my angst. Two years later, it had become a ritual of sorts; I was donating plasma every couple of months. It helped, but only temporarily. I only wished the pain would last longer.

When I finally found a cognitive behaviorist, I could immediately tell that something was different. The first thing he told me was that he didn’t prescribe medication. Then, when we started our sessions, he refused to coddle me when I poured my heart out; he just wanted to get to the solution. After a few visits, he sat forward in his chair and said to me, “Ricky, your anxiety is real, and it’s with you for life. You will never wake up one morning to find that it has magically disappeared. Now, when you feel yourself having an attack, just repeat this to yourself, ‘This sucks! But I am not losing my mind; this attack is not real and will only last 10 minutes.’”

I was taken aback by the doctor’s words at first, but my illness of 12 years suddenly seemed to make so much sense to me in a matter of seconds. Still, I was surprised when the mantra the doctor gave me worked — the very next day.

Since just waking up in the morning could be a trigger for my anxiety, as I had to go through the lengthy process of convincing myself that I was real and not stuck in an alternate dream universe, I made sure that I had the doctor’s words memorized so I could be ready. As soon as I woke up, I immediately recited the mantra out loud. In a nervous but confident voice, I said the words he’d prescribed, right down to the part about how it would end in 10 minutes. And it did! My first panic of the morning subsided, and my breathing slowed down. I felt a calm that I had not felt in years.

Despite this seeming miracle, the doctor informed me that it didn’t matter how many positive affirmations I repeated to myself daily, the mantra included; if I was truly going to get better, it was also necessary to work hard to help myself — and the most important thing I needed to do was to love myself above everything else.

Coping with a mental health disorder is a full-time job, and after ­being diagnosed with generalized anxiety disorder, depression, PTSD, and de­personalization disorder, these are the self-care steps that I take every day to maintain my ­equilibrium:

Facing reality: Every morning, as soon as I wake up, I remind myself that I have a mental illness, and that it’s not going to magically disappear. My anxiety is something that was manifested in my mind from experiences throughout my childhood. And because I know I will live with this invisible illness for the rest of my life, I must not run from it. I remind myself that today and for the rest of my life, I will live with this disorder, but it is okay. I’ll be just fine as long as I follow the next four steps.

Finding joy: For the empty feeling of depression, I make it a point to find something that brings me happiness. One of my go-to remedies is watching something funny on TV, which makes for an inexpensive and easily accessible self-care fix. For example, a single episode of The Office has brought me back from multiple anxiety attacks and bouts with depression. If it’s a nice day, taking a walk with my wife and the dog works wonders.

Accepting dark thoughts: Whenever I feel anxious, which for me is all day and every day, I use the mantra that I learned from the cognitive behaviorist. If that’s not working, I’ll take three deep breaths and focus my attention on the negative energy that’s plaguing my thoughts and rid them from my mind. Sometimes I just have to remain calm and do my best to remember that I am stronger than my anxiety.

Using natural remedies to sleep better: Trying to fall asleep, let alone staying asleep, might be the hardest and most concerning of all my problems. Each night when I lay my head on the pillow, my mind starts to race with horrible thoughts that have haunted my sleep for years. I’d remember the years of abuse that I suffered at the hands of an older relative who would tiptoe into my room while I was sleeping, hover over my body, and punch and kick me. Years before I got sober, I would easily take four Clozapine pills and wash them down with a tall glass of merlot, but now that I’m sober, I find that essential oils, such as lemon, mint, and eucalyptus oils, work miracles. I rub them on my wrists and chest every night. This way, no matter which position I am sleeping in, I can breathe in the soothing aromas. I also keep a vial of oil in my car and at work. To complement the oils, I keep a humidifier next to the bed to help me stay cool at all times, and I play soothing nature sounds quietly in the background. (Thunderstorms or seagulls usually do the trick.)

Eating a wholesome diet: I used to binge eat to make myself feel better. Nine out of ten times it was greasy fast food or Kit Kat bars. After a binge episode, I would feel terrible self-loathing, of course. About two years ago I made a transition to a vegan diet, and I can’t even begin to explain the benefits that resulted from the switch. I feel healthier than I ever have before, I’m less tired, and my mind is clearer — not to mention the weight loss. Overall and most importantly, my self-esteem and confidence are at an all-time high. Today, I feel proud of myself for committing to a strict diet and lifestyle change, and for the first time since I was a teenager, I feel good about myself when I look in the mirror.

 

There are many different forms of self-care, and what works for one person might not work for someone else. Maybe medication works for you, and maybe it’s therapy, or both. For me, there are two ways of getting help: the stubborn way and the logical way. For years I tried the stubborn way, which was living in denial, hoping that the anxiety would cure itself.

The lesson I’ve learned is that while life will sometimes seem impossible and anxiety will feel unbearable, as long as I’m willing to put in the work, it will get better. For those of you who have experienced similar feelings, there will undoubtedly be days when you might feel that no one in the world knows what you’re going through. During those lonely moments, just remember that someone just like you wrote this article. If you hit a wall, turn around and try a new route, because at the end of the day, your determination to persevere in life will shine through the darkness. All you have to do is take those first steps to finding happiness.

Be kind to yourself, love yourself, and never give up.

Richard De Fino is a New York-based writer and columnist whose work has appeared in Chickpea Magazine, The Bronx Magazine, and Stigma Fighters, as well as in his former column for Feminine Collective. For more, visit richarddefino.com.

This article is from the November/December 2018 issue of The Saturday Evening Post. Subscribe to the magazine for more art, inspiring stories, fiction, humor, and features from our archives.

Can Writing Save Your Life?

Girl next to a typewriter
Shutterstock

A student of mine has PTSD. Pam, 56, is a 31-year veteran of the National Guard who was stationed in Kuwait and is now a virtual shut-in in her rural New England town. Plagued by anxiety and distrust, Pam appeared in one of my online writing classes several months back and has found, to both our amazement, that the chance to explore her feelings on paper is dramatically improving her mental health.

“The paper is such a gift,” Pam tells me on the phone. “It does not judge. I can feel my emotions without as much fear rather than just being numb. My anxiety isn’t so overwhelming. It helps to have a good cry sometimes.” When we began our work together, Pam’s writing was flat, distant, and self-mocking. As time went by and she felt more at ease, her assignments opened up as well, revealing her wicked sense of humor (“The truth is, I like doughnuts better than people”) and the details of her troubled life, including early childhood sexual trauma. By the end of our third online class, Pam had become a markedly different woman. “I’m ready to take my life back,” she says during one of our teleconferences. “All because of writing.”

What is it about expressive writing that heals us so dramatically? Why have our ancestors down through the ages turned to diaries, journals, and letter writing as sources of solace and self-understanding? Scientific studies have begun to unravel this mystery, and the results are nothing short of dramatic. Writing for as little as 15 minutes a day can improve physical and mental health in grade-school children, nursing-home residents, arthritis sufferers, medical school students, maximum-security prisoners, new mothers, and rape victims. Writing about our thoughts and feelings strengthens the immune system, lowers stress levels, and decreases time spent in the hospital. According to one  New Zealand study, physical wounds heal more quickly when we do expressive writing. Seriously ill individuals are able to dramatically improve their quality of life by examining their experience in writing and thinking about their disease from a different perspective.

Writing can even help you find a job. In a study conducted at the University of Texas, 50 middle-aged professionals who’d been suddenly terminated from a large Dallas computer company were split into two groups. The first group wrote for 30 minutes a day, five days in a row, about their personal experience of being fired. The second group wrote for the same period of time on an unrelated topic. The contrasting results were startling. Within three months, 27 percent of the expressive writers had landed jobs compared with less than 5 percent of the participants in the other group. After a few more months, 53 percent of those who had written about their thoughts and feelings had jobs, compared with only 18 percent of the others. Dr. James Pennebaker, the author of the study, explains how writing differentiated the two groups. “Those who had explored their thoughts and feelings were more likely to have come to terms with their extreme hostility toward previous employers and present themselves as more promising job candidates,” he says. “When our need for self-expression is blocked, it produces tension.” This tension can deter us from making positive changes in our lives. Pennebaker is quick to add that, in order for writing to have a healing effect, it must be expressive. It’s not enough just to report the facts; we must include how we feel about our experience and what it has taught us.

“Writing practice brings you below the surface to really meet what you see, think, and feel.”

E.M. Forster said the same thing in different words a century ago. “How can I know what I think until I see what I say?” mused the British novelist. “Writing helps you meet your true mind,” agrees Natalie Goldberg, author of the classic Writing Down the Bones and a dozen other books. Indeed, Goldberg has devoted her entire career to helping people access this “true mind” through writing practice. “We spend most of our lives in discursive thinking,” Goldberg tells me from her home in Taos, New Mexico. “I want this. I don’t want that. I have to go shopping. Those kinds of things. Writing practice brings you below the surface to really meet what you see, think, and feel. By going to that lower layer,” she believes, “we become who we are.” Self-discovery is not just for seekers and artists. “I have businessmen reading my books,” Goldberg says. “They tell me, ‘This is about good business.’ In the practice of good business, you have to have integrity. You have to know who you are. You have to know where you stand. You have to know what you want. Writing practice can help all of that.”

It’s a matter of widening our own perspective. “When we begin to tell the story of our experience, we create a coherent, consistent narrative about it,” explains Kathleen Adams, founder of The Center for Journal Therapy in Denver, Colorado, and one of the world’s foremost experts in therapeutic writing. “This helps us to discover meaning, the Aesop’s fable moral of the story. What is the teaching in this? What is the lesson that I am being asked to learn?” Adams likens this perspicacity to having “a good angel on our shoulder.” Caryn Mirriam-Goldberg, a poet, professor, and author of The Sky Begins at Your Feet: A Memoir on Cancer, Community, and Coming Home to the Body and The Divorce Girl, a novel, recalls being saved as a teenager by her good angel. “I was 15 years old,” she remembers. “My parents were having a horrendous divorce, a bit like The War of the Roses. I realized that I needed words to survive, to find some ground of hope, a place where I could stand, to begin to believe that my life wouldn’t always be like this.” Self-expression carried her through this dark time. “Putting words down on the page opened up the tunnel between what was happening on the surface of my life and whatever possibilities there might be for the future.”

Writing about unsayable things is what frees us from suffering in silence. “There are things that people don’t talk about,” agrees Sheila Bender, a poet and essayist best known for her popular books on writing instruction, including Sorrow’s Words: Writing Exercises to Heal Grief. “Writing heals us for the same reasons that so many people are afraid of it,” Bender says. “It comes from a very vulnerable part of ourselves. We cannot heal from grief and trauma, in my experience, without facing that vulnerability. We must allow it to speak instead of disguising it. The transformation lies in the fact that what was swirling around inside of us now has a name and a shape.”

This process is not without pitfalls, however. Writing about traumatic events can sometimes get us into trouble. Dr. Louise DeSalvo, author of Writing as a Way of Healing, advises caution when diving solo into scary waters. “It’s a mistake to expect writing to replace therapy,” says DeSalvo. My student Pam, for example, has been seeing a therapist while taking my writing courses. “There are things that writing can do that therapy can’t and things that therapy can do that writing can’t. Together, they’re a very nice balance. But when dealing with traumatic experience,” DeSalvo stresses, “the simple act of writing isn’t going to do anything.”

Journaling expert Kathleen Adams (who is also a psychotherapist) agrees. “The first premise of all healing practice is do no harm. If writing is making you feel worse instead of better, that’s a signal to stop and take another look.” With such clients, Adams recommends using “sentence stems” that prevent them from getting lost in their pain. “I tell them to begin with statements like ‘Right now I want,’ or ‘Today I feel,’ or ‘What I’m most afraid of is.’ This helps them keep it short and simple. Containment gives us the freedom to write about difficult experiences while taking it in small pieces.”

Writing about unsayable things is what frees us from suffering in silence. ”

Mirriam-Goldberg, a cancer survivor who facilitates workshops for people with serious illness, points out that “writing can heal us without necessarily curing us. When I was living through cancer, I wrote a lot,” she says, “but there’s a difference between healing and curing. Finding greater meaning and vitality in your life can be a very healing endeavor, but it may not cure the disease.”

All agree that both writing and healing share a spiritual component, however. Julia Cameron, whose book The Artist’s Way introduced millions of readers to the benefits of what she calls “morning pages” — daily freestyle journaling — believes that writing heals by connecting us to a higher power. “The minute you put pen to page, you start to alter your consciousness,” Cameron tells me. “The more writing you do, the more closely connected you are to this higher power. Some people call it the muse. Others describe it as God, the Tao, or simply the universe. Whatever you care to call it, we do morning pages in order to touch base with it, to connect to our own consciousness and to a larger something.”

My student Pam agrees with this. “I don’t buy the ‘higher power’ part. But spirituality is part of my healing, for sure. For me, that means working toward real honest connection with people, and becoming a kinder, more genuine person. The god of connection and the god of self-love are a work in progress for me.” Encouraged by how much more open she’s become since she began writing, Pam is even thinking of tackling a memoir. “I want to write my memoir for justice,” she says, “to show myself — and others — that even though I had some really bad luck, I am a whole person. I am not a victim. I am turning my life around.

“I am more powerful than I think.”

Mark Matousek is a teacher and speaker whose work focuses on personal awakening and creative excellence through transformational writing. The best-selling author of Sex Death Enlightenment; When You’re Falling, Dive; and Ethical Wisdom: What Makes Us Good is working on his next book, Writing to Awaken, due out July 2017.

Ready to get started? Read 9 Tips to Starting Your Journaling Routine.

Understanding Adult ADHD

ADHD

Brook Ochoa, 42, doesn’t fidget or squirm or bounce off walls like an 8-year-old child with ADHD. That’s primarily because she’s an adult, and adults tend to lack the hyperactivity part. The single mother of two has plenty of other symptoms, however. “I read seven books at a time, have never finished a project in my life, and when I get bored with a job I just walk away. I never knew until recently that that wasn’t normal. If it’s boring, I’m done.”

“Boring” is the kiss of death to adults with ADHD (attention deficit hyperactivity disorder or just ADD if they lack the hyperactivity component). And her inability to stay interested in any one subject for long may explain why Brook quit several jobs as manager and assistant manager of stores like Target and Wal-Mart. Brook is certainly competent enough to handle a heavy workload. She did well in school and earned a master’s degree in human resources; she can focus and finish assignments when they interest her. But around the house, she struggles with such simple tasks as washing dishes after meals. “Every dish in the house has to be dirty before I notice,” says Brook with a sigh. (See also “Symptoms of ADHD.”)

But at least she knows where her demons lie. For adults who were not diagnosed as children—and anyone who was already an adult when ADHD became widely recognized in children in the 1990s is unlikely to have been—having a label affixed to their struggles allows them to finally seek help. Perhaps even more important, it lets them make sense of a lifetime of bewildering experiences, of feeling hopeless or helpless in the face of their mental dysfunction, and, in many cases, wondering why they never achieved what they felt they could have.

“The more she described ADD the more the light bulb lit up for me,” recalls Robin Bellantone, 61, a mental health counselor in Portsmouth, New Hampshire. She had no idea adult ADD existed when she had the life-altering conversation during her graduate-school internship at the Massachusetts College of Art and Design in 1999. It was there that she heard a fellow staffer who specialized in working with artists with ADHD talking about the disorder: “It explained so much about my own history”—her inability to focus, her difficulty paying attention, her constant search for new stimulation.

Stories of adults who finally learn they have ADHD are as unique as the people themselves, but they have at least one thing in common: a sense that what was once shrouded in mystery is now lit with understanding, that a weight has been lifted and a puzzle solved. The National Institute of Mental Health estimates that 4.1 percent of adults have ADHD in any given 12-month period (compared to 9 percent of children). In the young, three times as many boys as girls have ADHD, but by adulthood the prevalence is the same in both sexes.

For adults, having the ADHD label affixed to their struggles allows them to finally seek help.

If it sometimes seems that everyone has some form of ADHD in today’s disjointed world of smartphones, tablets, and the like, the formal diagnosis is indeed on the verge of becoming more common. The newest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, scheduled for release in May 2013, is expected to loosen the diagnostic criteria for the disorder substantially, lowering the number of symptoms required. (See chart, “Symptoms of ADHD,” next page.) But, even so, there are misconceptions about what it takes to qualify. For example, inability to focus and being easily distracted—with no other symptoms—wouldn’t be enough. You do not have ADHD if you simply like to flit from task to task at work. You do not have ADHD if you get bored doing housework. You do not have it if your mind wanders when reading dense, boring prose on a topic you have no interest in; if you get fidgety during boring sermons or hours-long presentations from a financial planner; or if you start reading another book or magazine before you finish the previous one you’ve started.

Moreover, the symptoms must appear in at least two settings: If you only show these behaviors at work, then you do not have ADHD. You probably just don’t like your job.

Still, the condition is underdiagnosed. Today, for every adult whose ADHD has been identified, there are at least three adults whose ADHD has not, according to Dr. Mary Solanto of Mount Sinai Medical Center in New York. Underdiagnosis reflects that adults can compensate for ADHD by choosing jobs that fit their brains—for instance jobs that present constant new challenges rather than jobs where one does the same task over and over.

That probably explains why Ruth didn’t receive her diagnosis until age 74. As a young woman she had few friends, felt isolated, and often blurted out what she felt without much thought for the consequences. Then, after marrying and raising a family, Ruth—who did not want her full name used—went to nursing school at age 46. She adored her new career. “I was busy all of the time. It’s never boring,” she says.