Having it easy

I have been reading a lot of news reports recently about students. Many have been quite negative, with young people complaining that they are being asked to pay full tuition fees for online learning, that their accommodation fees should be reduced, that they don’t want to wear a mask throughout an entire lecture, that the food provided to them while they are in isolation has been sub-standard.

I have also been reading some of the comments on these online stories, that students need to get a grip, that some people have lost loved ones because of Covid-19, that hospital staff must wear a mask for much longer than the duration of a lecture - even that students should not complain as they are facing much lesser challenges than some in Ireland's past. This is true, and I think it’s vital that all of us consider our current situations with a little perspective. However, I don’t think it is particularly helpful to shout down youthful voices because others may have it worse. The class of 2020 has had a very tumultuous year, with the Leaving Cert, in many cases the most pressurised event of their life so far, thrown into disarray by a global pandemic. They are young, they are feeling under pressure to sort out their lives and their futures, and now everything has been thrown into uncertainty. 

There is a widespread notion that students “have it easy”, and most of them probably do. There is also probably some truth in the reports that students have been less likely to observe anti-Covid-19 rules and more likely to have parties… but that doesn’t mean that all of them are doing so, and it doesn’t mean they deserve to be ignored.

We often have a tendency to compare the plight of one person or group to that of another. In one sense this is useful, as it does help to put our own problems into perspective. The experience of nurses working back to back shifts and putting themselves at risk for others is of course more difficult than that of a student whose only concern is that more of their tuition is online than they would ideally have liked. But it isn’t helpful or productive to dismiss legitimate concerns because somebody else has it worse.

I am sure there are many of us who would say we have been relatively lucky during this pandemic, considering the grief, occupational hazards and money worries which some people have had to contend with. But that is not a reason not to recognise that it has still been difficult, and to show understanding where it is needed.

Are you carrying the load?

A friend of mine came over for dinner recently. She lives some distance away so it was the first time we had seen each other since lockdown, and I was really looking forward to our catchup. We were having a good conversation, but soon after she sat down she apologised, her phone was buzzing, it was a message from her husband and did I mind if she took a moment to reply to him? Of course I didn’t – it turned out he was asking her to remind him which of the bins he should put out before she got back.

We continued our conversation, also enjoying a drink and after a while I got up to get us both another glass. When I returned my friend was on her phone again, this time explaining an aspect of the Covid-19 prevention measures at their daughter’s school so her husband could prepare her for the next day. My friend apologised profusely for the interruption, but it got me thinking. It seemed like she was carrying most of the mental load in her relationship.

There are hundreds of small tasks associated with running a household – from knowing which bin goes out when to planning meals and keeping track of what is in the freezer to paying the electricity bill on time. This constant background whirr of trying to keep track of an endless to-do list is often referred to as the ‘mental load’. It’s not necessarily about the action of doing housework or chores, rather about taking action and remembering to do them.

It often happens that one person in a household will be carrying more of this load, even if the chores are split equitably. If for example your partner does the food shop, but you find yourself planning meals, writing a list, keeping track of what’s in the freezer and making sure to notice if you run out of washing up liquid, then you’re also doing a lot of the work. Lots of people have written about and developed the idea of the mental load, in many cases women who find themselves managing the household while a male partner helps obligingly, but only when they are prompted to and given clear instructions.

However, the idea of the load can extend to any household or relationship – whether you are a couple, a group of friends in a flatshare or a parent trying to encourage children to do chores without always having to be reminded. A single-person household is the only situation in which the mental load doesn't come into the equation, as the only person you have to manage is yourself. Many people are perfectly happy taking on the majority of the mental load in their relationship or household, and do so by design. But the value lies in recognising that weight for what it is, and acknowledging that the organisational work of running a household is just as important as the physical work of carrying those tasks out.

Rites of passage

This week we said a sad goodbye to our much-loved family cat of 20 years. Many of you will have seen him when I was teaching Pilates in my studio or visiting my clinic at home, as he would often come out to see what all the fuss was about, appraising these intruders on his territory and sniffing the cars whose owners had cats or dogs of their own.

He was an unusually friendly cat, always wanting to be around people and craving attention to the extent that we joked he had got confused and thought he was a dog. For this reason he was very popular with visitors and guests, and in 20 years gathered quite an impressive group of devotees.

Two decades is a long life for a cat, and towards the end there were signs he was on his way out. However he remained cheeky and active to the last, and was caught deliberately knocking over a jug of milk in order to lap it up himself just days before he died. Luckily for everyone involved his time came very quickly, and he was behaving normally right until about an hour before we said goodbye on a patch of grass outside in the sunshine.

Cats are known for their tendency to take themselves off to a secluded spot in order to pass away alone, but ours laid himself down just a few feet from us. He never did behave like a typical cat, and we wonder if he was deliberately seeking company in his last moments as he did so often during his life. He would often wail outside the door of an office or bedroom until he was let in, just to curl up on the floor or a chair in the corner so he could be nearby. He would yowl in protest if we left the house - or even if we went too far away from him in the garden, and if a suitcase or bag was ever left open on the floor he would climb into it and go to sleep as if to try and prevent us from leaving.

I don’t know how aware of our presence he was at the very end, but in any case we found it helpful to be there a short way away from him to witness his final moments. I haven’t been there at the very end of a life since my mum passed away a few years ago, and I was a little taken aback at the comparisons. She went peacefully too, with me at her bedside, holding her hand. It may seem silly to mourn a pet, but the cliché is true, their deaths do bring back the memories of others we have loved and lost. It can be helpful to allow yourself to feel the grief of a pet dying and to mark the rite of passage, especially if this loss brings up other associations. 

For our part we buried our lovely cat in the garden and said a few words. That evening we lit a candle and raised a glass to our furry friend. The following day I recounted this to a friend, and she reminded me that she always lights a candle on the anniversary of a loved one’s death. For some this is a religious practise, for others it’s a way of marking the occasion and processing memories of that person.  In any case, it’s important to allow yourself to acknowledge grief and loss on any scale, including when you say goodbye to a much-loved pet.

Isabella's story

One thing I love about my job is meeting people. Resolving Chronic Pain attracts some truly wonderful individuals - many have endured pain for a long time, most have seen numerous other health practitioners, and all have experienced a sense of despair at times in their pursuit of pain relief. Some of you have told me how much you appreciate hearing the stories of others’ recovery – with their permission and without their real names or pictures – so here is one I want to share.

Isabella had lived with chronic back pain, abdominal pain and fatigue for years. She and her husband had wanted to start a family relatively early in their marriage, but when I first met her this had not yet happened. It wasn’t even her first priority any more, as she had taken so much time off work because of her chronic pain she was worried about her job security and was finding it harder and harder to focus on anything but her pain and fatigue.

Isabella was looking for a solution to her pain. She believed it was caused by a structural problem, which was exhausting her and causing her fatigue. The first step was to address the pain with simple movement patterns which restored Isabella’s confidence in her body. Soon she was moving without pain even though it was still lurking and could flare up at times. This ability to move with relative ease gave Isabella a sense of control, a real impression of progress and hope. From the start we also talked about Resolving Chronic Pain being a two-pronged approach, involving body and mind. We started with movement, while recognising the importance of how the brain perceives pain.

Over time Isabella identified many stressful factors in her lifestyle and difficulties in her childhood. Despite her poor attendance record at work she planned a period of extended leave to go home to South America. This was the catalyst - away from work the pain diminished, only flaring a couple of times in direct response to reminiscent childhood stresses. The importance part stress plays in her chronic pain now made perfect sense to Isabella. Upon her return she worked her notice while planning a new career, including work experience and course interviews for relevant qualifications.

Throughout her career transition her pain would occasionally flare up as she managed the stress of limited finances, academic deadlines and baby-related anxiety. As a couple her and her husband decided that IVF was not an option, and alternatives were time consuming and uncertain. Isabella qualified and started her new career last year. In her words she felt recognised, her contribution was valued and her once over-active stress response settled down. Sometime later, she became pregnant. Her son was safely delivered last month, and today Isabella is happy and pain free, with a new and more welcome kind of exhaustion.

Number one

They tell you to put your own oxygen mask on first. The idea is simple, though it could be lifesaving. Take care of yourself first because if you don’t you might not be able to take care of others. I used to wonder, in the moments before take-off when despite all the well-worn statistics about flying being safer than driving a car the recesses of my imagination never quite seemed to have got the memo, would I be able to put my own mask on first? In the moment of panic would I be able to pause and look to my own needs before those of my nearest and dearest?

That was back when getting into an aeroplane was an option, of course. Now it’s been six months since I’ve even considered the idea.  Until recently lockdown was steadily easing across the country, and even now with new uncertainties and restrictions re-introduced in the midlands, people are still returning to a kind of normal compared to the situation in recent months. But building a new sense of normal is going to be different for everyone, and everyone has the right to follow government guidelines at their own pace. I have noticed in recent weeks trying to find a way to say “no” to requests and suggestions from friends and family who are in a different headspace. No to the group of friends who have invited me out for a meal because I don’t feel comfortable taking the train at a peak time to get there. No to the elderly neighbour who wants me to come in because I can’t countenance putting them at risk.

Some people characterise themselves or others as people-pleasers, but I think to an extent we all are. It’s what we’re hard-wired to do – the more we please others, the more we fit in, the safer and more stable we feel. Sometimes the word “no” can feel like the hardest word to grasp for, as we’re faced with yet another request for our time, energy or resources. Often there’s no request at all, we just find ourselves in the familiar position of doing something we don’t really want to do because we feel like we don’t really know how to say no to it.

It’s easy to think you don’t ‘deserve’ to be finding the crisis difficult to deal with, perhaps if you have not been as badly affected as others. But there is nothing to be gained by that – support your friends and family who are struggling, donate to charities helping the most vulnerable, but also recognise that you yourself need taking care of too.

Small discomforts

About a year ago I joined a new art class. It was local, the timing suited me, and I had been wanting to make more of an effort to bring out my ‘creative side’, so I went for it. What I didn’t realise until I got to the first session was that this wasn’t a class following a set programme, with a new cohort of students every few months. This was a steady group, many of whose members had been there for years, and which rarely saw new entrants. I was the only new joiner for many months.

This art form worked in a particular way with a very specific technique and certain key equipment – this is why there was a class running, as even with years of tuition pupils still needed guidance. I had not worked with any of these techniques or equipment before, and I could tell immediately that I was going to stick out. Try as I might to learn quickly, in the first few sessions I could feel that I was slowing the class down, making repeated mistakes, and frustrating the instructor with my lack of progress.

It was really difficult. But that was the joy of it. I had chosen to put myself in this difficult situation, I wasn’t at risk of any danger or hardship, I was just having a hard time. I had signed up to this class to try something new, and I was definitely getting that. I was reminded of a very simple but profound realisation outlined by Roz Savage, a woman who left both her job and her husband to row solo across the Atlantic in 2005. As you might imagine, she finds the experience quite challenging. One day she is so frustrated, exhausted and lonely that she goes up to the front of the boat and begins to scream at the water. This venting of her frustration leads to an epiphany.

She writes: “When I was preparing for this, every time someone asked me why I was doing it I said I wanted to get out of my comfort zone. And getting out of my comfort zone is, by definition, going to be uncomfortable. Being uncomfortable doesn’t mean I’m failing, it means I’m succeeding. The impact of the epiphany caused me to lose my grip on the roll bar and I lost my balance. I nearly tumbled head-first into the water, but I regained my handhold just in time and considered this startling new discovery.”

In many ways this is a very obvious statement, but the clear way that Roz expresses it made me stop and think. She continues: “If I could find the strength to stay out here, in the zone of my discomfort, eventually my bubble of comfort would expand, and catch up with me. Its boundary would extend to include this place which right now felt so new and scary. Given enough time and repetition, the uncomfortable would become comfortable, and I would have achieved my objective. Until now I had not appreciated that the discomfort was an integral and necessary part of the process, but now I could see my situation from a different perspective. I perceived that discomfort was actually my friend, because it meant that I was on the right track.”

I think it’s important to emphasise that Roz is speaking about discomfort, not hardship – there is a limit to this theory and it isn’t advisable to push yourself too far in the name of personal growth. On top of this it’s not always the right time to seek out discomfort, sometimes just getting through each day is challenge enough. But sometimes in those tough moments it can help to think of the positive side of that discomfort. I began to relish being the worst student in my art class, and eventually, after much tutting and headshaking and having to re-do poorly executed tasks, I can say that I have improved! I suspect my learning curve will continue to rise steeply for some time, but I love this new skill with all its challenges.

Ticked off

A friend of mine recently told me she had been ‘verified’ on Twitter. If you’re not familiar with the social media platform, being verified is when Twitter classifies a person’s account to be both authentic and of public interest, resulting in a tell-tale blue tick being added to their account name. While it’s not directly linked to the number of followers a person has, or how famous they are, there tends to be something of a correlation. In a very superficial way, people in the public eye sometimes joke that you have ‘made it’ once you achieve this verification.

There is no doubt that Twitter’s blue tick is an extremely important feature of the platform. It is most useful when differentiating between the genuine account of a public figure and other accounts with a similar name, either by coincidence or because they are parodies. But when it comes down to it, the feature can be used as the ultimate popularity contest between those who use Twitter in a work capacity. Those wishing to influence others consider verification a goal to be achieved, and I have more than once heard of grown adults behaving in a hostile manner towards others over jealousy caused by that small blue tick.

When my friend, I’ll call her Emily, was verified on Twitter, it caused her to re-evaluate her attitude towards the site. She needs to use it for work, but in the past has been very careful to resist the temptation to check her feed in the evenings and weekends. A good trick for her was to only ever log in on her work computer. However, through working at home during lockdown, she found the lines between work and home becoming blurred, and began checking for updates on the site more regularly. Then her work arranged for all its employees to be evaluated for Twitter verification, and she got her blue tick. Not everyone did though, and Emily was intensely relieved that she had not been left off the list while colleagues who she is in competition with were. She told me she found herself searching for the names of former colleagues and current competitors, and feeling pleased to see that many of them did not yet have a blue tick. It gave Emily a small sense of joy every time she saw a tweet from other people who were still not verified – some of them with hundreds of thousands of followers, and high-profile careers, books or TV shows to their name.

It probably won’t surprise any of you to know that these petty comparisons did not make Emily happy. After several weeks she decided to take a break from the social media site in order to reset, as she can do her job in the short term without it. She told me she had always been proud of her good habits around social media, but the fact that she was drawn into unhealthy behaviours so quickly shows how important it is to continuously evaluate and maintain good habits. In my sessions I often speak about the difference between the intense but brief pleasure of external validation and the longer-lasting steady trickle of self validation. External validation is sometimes compared to a drug – a hit of it feels great but quickly fades, so you find yourself seeking more and more, but no matter how much you get, it is never enough. Emily has now managed to break the bad habit she fell in to, and while in no doubt that her Twitter verification is a useful tool, she recognises that her work, and that of her competitors, has value regardless of whether or not it comes with a small blue symbol attached.

When to stop

I recently took part in a day-long event over video call. It was similar to the meetings and sessions I would have during a normal work day, but it continued for the whole day with no respite, and by the end of it, I was absolutely exhausted. This is normal for many people working from home, with hours of back to back videocalls day after day leading to ‘Zoom fatigue’, a well-established phenomenon by now.

I tried to limit the effects of this as best I could, including turning the video of my call off whenever possible and positioning my screen so I was looking at it at an angle rather than directly. It did not surprise me however that by the end of the day I was completed burned out. What did surprise me were my actions after the call had finished. Although I was tired and my eyes ached, during my evening of rest I found myself again staring at screens, from my phone to my laptop to the TV.

It reminded me of some thoughts I noted down months ago about the idea of ‘stopping cues’ popularised by Australian psychologist Adam Alter. He addresses the question of why we all seem unable to tear ourselves away from the screens in our lives, and I found his ideas compelling. I put them on hold for a little while as during the height of lockdown I didn’t think anyone’s first priority was trying to achieve less screen time. We were all overwhelmed by our new situation, and if Zoom calls with family and endless TV programmes eased the upheaval a little then it was worth it.

But now we are so many months into lockdown, into long-distance relationships with friends and family, and for many into working from home, that it’s worth thinking about how to make our relationships with those screens more sustainable.

Adam Alter argues that in the past, almost every activity we took part in had a ‘stopping cue’, to let people know when it was time to stop and move on to something else. For example, you would finish a newspaper or magazine, get to the end of a chapter in a book, or reach the end of a television programme and have to wait until next week to watch the next one.

Nowadays there are no stopping cues – we are encouraged to keep scrolling and scrolling and scrolling with no end on social media, games continue from level to level and videos and television programmes continue on autoplay. There is no end to the web pages we can search through, no end to the online shopping catalogues we can browse.

One solution Alter offers to this is to create artificial ‘stopping cues’, limiting use of screens in a certain location or situation. Alter, for example, does not use his phone at dinner time. Many people recommend the tactic of not using your phone in your bedroom, although for some this is too ambitious. Set times of day also help – for example not looking at any screens in the first half hour after you wake up, or the last hour before you go to bed, or simply using a stopwatch function to show yourself how much time you have spent in one screen-time sitting.

Part of the problem with this in the context of lockdown is finding other things to do in that time. I have found audiobooks a lifeline, as they provide entertainment without me having to look at the screen, and being read to is much easier than reading after a long day. I like to listen to them on loudspeaker, as I find earphones to be almost as wearing as looking at a screen, which opens up opportunities to share audiobooks with others.

The Center for Humane Technology suggests making a few alterations to your phone settings to make social media less addictive. These include turning off all notifications which are not comments or messages, so that the only nudge you get to use the app is when it involves interacting with other people, or changing your apps from colour to greyscale to make them less appealing. It also suggests not choosing the ‘stay signed in’ option on any sites so that there is one extra step to make you think about whether or not you want to be there. The Google chrome extension Inbox When Ready is another useful tool, which delivers your email in regular batches so you are not distracted by every one that arrives.

Alter cites research that divides phone use into two groups; functions that make us feel good, and those that make us feel bad. Among the bad group are unsurprisingly social networking, gaming, entertainment, news and web browsing. In contrast, relaxation, exercise, reading and education were all uses that made people feel good. Now more than ever as we are leaning so heavily on technology to help us through the crisis, it is vital we free more time up for those positive uses and cut down on the negative ones.

Making the right choice about spine surgery

For some time I have been wanting to take a look at some of the contributors to the book which I co-edited, Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment. In this blog I’ll focus on the chapter on back pain. David Hanscom MD is an orthopaedic spine surgeon based in the US, and is one of the professionals who shares his expertise.

He himself suffered from symptoms of Psychophysiologic Disorders (PPD) for 15 years before he finally managed to resolve them. He didn’t understand how until he heard a lecture by Dr Howard Schubiner, which informed his own approach to patients with PPD. He has since launched his own website and written two books: Back in Control: A Surgeon’s Roadmap out of Chronic Pain, and Do You Really Need Spine Surgery? Take Control with Advice from a Surgeon.

Over the last five years Dr Hanscom and I have developed a supportive relationship. I’ve been impressed by his enthusiasm and determination to consider the welfare of the patient from every angle when assessing spine pain. He has no qualms about the use of surgery when necessary, but through his experience he recognises that a ‘hyper vigilant’ nervous system may be playing a significant part in the patient’s pain.

In his chapter, Making the Right Choice About Spine Surgery, Dr Hanscom explains why spine surgery is not always the best solution for back pain, and argues that in many cases in the US it is overprescribed and can even be harmful. In his former practice he used to act as ‘salvage surgeon’, treating patients following a failed operation. But, he says, he could rarely return those patients to the condition they had before the failed surgery.

Dr Hanscom divides patients with spine pain into two groups: those with a structural abnormality which shows up on an x-ray, CAT scan or MRI, and those without. In the cases of a structural abnormality which corresponds to the pain, he advises that surgery is an option after the nervous system has calmed down. Without evidence of a matching abnormality, so the pain is non-structural, he does not consider surgery an option.  

He explains that because many people with spine pain also have significant stress and/or other psychophysiologic issues, surgery or treatment of just the spine does not solve the problem. He says: “Rather than assessing for psychosocial stress, many patients and health care providers consider surgery as the definitive solution. Operating in the presence of a hyper vigilant nervous system often makes the pain worse, in spite of a well-done procedure. Just because rest, physical therapy or injections have not worked doesn’t mean a patient should head for the operating room.”

Dr Hanscom advocates for the patient to be more involved in the recovery and decision-making process, and for medical professionals not to assume that surgery is the definitive solution when there is no structural abnormality. Surgery should only be done for a structural problem with a calm nervous system.

Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment is available here, and you can find out more about David Hanscom and his work at his website here.

Stormy weather

Yesterday I was speaking to a friend who told me she doesn’t want lockdown to end. She has become used to working from home and shopping and socialising remotely. As she spoke, I couldn’t help remembering that this was the same friend who in March had been saying how much she hated the idea of working from home, that she wouldn’t be able to cope without going shopping in person, and that she couldn’t imagine being at home all the time with her young children.

The things she said she was worried about were exactly the opposite in each case, but the thing she was really worried about was the same: change. Most people are resistant to change, it’s a well-known part of human nature, even if it doesn’t necessarily make sense. Change is just as capable of being good as it is of being bad, but perhaps it comes down to the old wisdom of ‘better the devil you know’.

It’s not unusual to be worried or angry about a restructure at work for example – in fact a family member went through one of these recently and described the extreme resistance to the change from colleagues, despite many of them being perfectly happy with it after it had taken place. A large part of the reason for our resistance to change is fear of the unknown – in a work context this might be fear of losing your job, or finding yourself with a less amenable boss.

This got me thinking about types of change I don’t find myself resisting. Moving house, changing job, getting a new pet, these are all exciting and positive changes, in part because we choose them ourselves. That is the crucial difference – the changes we don’t feel resistant to are the ones we believe can control.  But the reality is that the outcome of these changes is never really guaranteed – nor, when it comes to it, is the outcome of every day we live. Anything could happen, at any time.

In her memoir 'The Rules Do Not Apply' American journalist Ariel Levy tells the heartbreaking story of how the life she worked so hard to piece together dissolved into tragedy caused by factors outside of her control. She writes in the introduction: “Until recently, I lived in a world where lost things could always be replaced. But it has been made overwhelmingly clear to me now that anything you think is yours by right can vanish, and what you can do about that is nothing at all. The future I thought I was meticulously crafting for years had disappeared, and with it have gone my ideas about the kind of life I’d imagined I was due.”

The book does not have a simple happy ending, as there is no easy fix for Ariel’s suffering. However, there is a sense of building resilience over the course of the memoir. She loses her house, her partner and her job in one fell swoop, and the only thing Ariel has left is herself.

As we’ve discussed before, a good tactic for coping with big changes and feelings of helplessness is to create small areas of life where you can feel in control in a healthy way, such as keeping a certain part of your house in good order. However, there are still going to be huge areas of your life outside of your control, and that is not just true of the aftermath of the coronavirus pandemic. You can adapt to changes whether you control them or not. In these cases, it’s important to remember that the one thing which will remain constant is yourself. Both your body and mind will evolve of course but the essence of you, what makes you you, can weather any storm.