Structure

Happy new year! May 2015 be better than 2014 seems to have been for many people.

A few years ago, I heard a suggestion about making new year's resolutions: don't. Instead, pick a single word that will be your focus for the year. Just let it seep into your bones and into the thousand little choices that make up each day.

Of course, this method may not work for everyone; some people have clear goals and only need a push to get moving. I used to be one of those people. In recent years, my goals haven't worked out so well. Drifting unconsciously also doesn't tend to work out well, so last year I tried to compromise by focusing on just one word and concept: courage. It will be structure this year—although courage still applies!

In that spirit, it's time to renew my vow to get some kind of exercise daily, if at all possible. I'll make the commitment through this month (and then, hopefully, recommit). It's not about losing weight or 'getting in shape,' although those things would be welcome. What I need most is consistent self-care, plus the reminder that it's not a luxury. If anything, it's a duty.

So back to the structure of exercise. What I need is the power that comes from doing this one thing every day, not just in spite of but because of the fact that my energy has been so low. Here's why:

• It lifts my mood and energy.
• It trains me to face whatever is here (circumstances and my reactions to them) with mindfulness.
• It renews my commitment to live consciously in this world, despite its messiness and my reluctance some days.
• It transforms my defended numbness into emotions that feel alive.
• It makes me breathe, sweat, and let energy flow in and out. When I let things happen, resistance melts away.
• It reminds me that weak muscles (literally and metaphorically) are strengthened by practice, not by rest.
• It builds my courage to do other difficult things.
• Doing it first thing puts priority on my mental and physical health. I owe this to myself and those I love.
• Doing it every day builds consistency and discipline. If I make exceptions, every day will be an exception. Instead:

How to Look on the Bright Side (Part 3)

This is the part where I try to sum up a lot of thoughts about the "encouragement card" given to a woman by her clinic (Part 1) and the study that led to the card's creation (Part 2). Let's start with the obvious, alright?

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The encouragement card (PRCI) did not work for me.

Apparently, I'm in the minority of women who—given only the two choices that were offered in the study—prefer the PMI affirmations over the PRCI card.

It's not that affirmations like "It's great to be alive" feel especially true right now. Actually, that's kind of the point. I see them not so much as true or untrue, but simply as ideals, maybe even fantasies where I can briefly escape. Living with them for a moment is all that's required. Because it's so easy to do, the affirmations somehow bypass the tangled hairball of thoughts in my head and just make it easier to breathe for a minute or two.

In contrast, the PRCI statements get my guard up right away. They tell me to do something that I don't know how to do, and they make it sound easy.

It's not easy. What ARE the "positive aspects of the IVF experience" or infertility in general? It hasn't brought me the closer relationships mentioned as an example (in Part 2). It has led to some wonderful new relationships, while putting others under strain.

I am aware that just being able to try "the most advanced fertility treatment" makes me compare "favourably with others who are less well off," and I'm grateful for that chance, but I'm also aware that it's only a very small CHANCE to do what most people do naturally. A chance is NOT (repeat, NOT) any kind of guarantee. And when it doesn't work, then what?

What have I gained? About 15 lbs. Also, several containers full of used needles. Possibly, on the best days, a slightly better sense of humor and awareness that everyone is fighting some kind of battle, whether it's visible or not. What have I lost? Most of my life's savings, half a decade of my time, and all of this.

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The intention was so good that I hate to criticize the execution.

The introduction to the study (Part 2) does a good, detailed job of explaining exactly what's stressful about IVF. Because infertility can create so much stress and pain, I'm truly glad to see attention being focused on mental health in this context. These people recognized a need and made quite a serious effort to address it. That's great!

Also, just because the PRCI doesn't work for me doesn't mean it doesn't work. Other patients apparently do feel helped by it to some degree. Honestly, those results rattled me, making me question whether bitterness may be obscuring my judgment. After more thought, though, the way I see it now is just that different people prefer different tools, and the two covered in this study are by no means the only ones that exist.

Even if I can't think up "positive aspects" of IVF—the main way these researchers envisioned women using the PRCI card—it did help in one way. It prompted me to make my own encouragement card (in Part 1), remembering other methods I've used to look on the bright side more authentically.

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But let’s be honest: there are problems with the execution.

I see two problems with the PRCI card and, to a lesser degree, with the PMI affirmations. The PRCI's vagueness and repetition (all the variations on "be positive") are the most obvious issue. Underneath is the unquestioned assumption that being positive should be an IF patient's main mental-health goal.

Isn't it important to maintain a healthy attitude? Well, of course. It's one of my main goals every day, and I'll always be willing to try any strategies that are aimed at genuine healing. ALL of them. The more the better! The thing is, I don't always equate "healthy" with "positive."

In Part 1, two commenters wrote about the need to acknowledge all of our emotions, dark and light, as the only way to get through them (not over or around them), and I agree. Forced positivity can invalidate people's real experiences. Positivity becomes forced, I think, when these impulses are at work in the person who's giving the advice:

• Enforcing a smiling decorum
  This mode prioritizes seeming good over feeling good. Some people are just uncomfortable with grief. They want us to feel better. They may think that by acting like everything's OK, we may come to believe it, or at least we'll avoid bothering anyone else. But it comes to feel draining and fake. Suppressed feelings tend to leak out anyhow, sometimes in more damaging ways.
• Lecturing with "at least" statements
  Saying that we can't be sad because someone else has it worse is like saying that we can't be happy because someone else has it better. Actually, it's possible to feel happy AND sad (or other emotions) all at the same time. Appreciating the good doesn't require denying the rest. Denial just makes a habit of disassociating from reality, which can also interfere with feeling good.
• Blaming circumstances on attitude
  Of course, the choices we make contribute to some of the outcomes we have. On the other hand, sometimes shit just happens. But if people can think up a "reason," they can feel smugly assured that similar things won't happen to them if only they don't make the same "mistakes."

I doubt that the people who developed the PRCI were motivated by the impulses above. They were, I'm sure, sincerely trying to help, and the tool they created was based in part on feedback from the study participants.

But I still worry that the shallowness of the statements in the PRCI promotes putting on a happy face (decorum) more than true healing.

One of the stated intentions was to help people focus on "comparing oneself more favourably with others" ("at least" statements), especially other IF patients. While it isn't inherently wrong, I guess, it hardly seems complete. What I hear is, Hey, we know the situation sucks enough that you need encouragement, but let's pretend it's not true by focusing EXCLUSIVELY on the 5% that's OK. That feels delusional.

Finally, acting as if a simple attitude adjustment is all that's needed may leave people blaming themselves (blaming circumstances on attitude) if they end up still struggling.

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Can I frame all this in a more "positive" way?

My goal is to feel not so much positive as whole, which means somehow integrating the most unpleasant truths in my life without getting overwhelmed by them (lost in self-pity, depression, and so on).

How to do that? Well, I'll start by acknowledging that it's not easy! It's probably the work of a lifetime, in fact. Seeking that balance has been the driving force behind this blog for over 100 posts now, and it feels like I've made just the barest beginning. I'm nowhere near done.

And my personal "encouragement card" (Part 1) is not intended to be the final word. It's the result of one evening's worth of brainstorming. It's an attempt to start a conversation.

So again ... what would you add? What strategies have kept you relatively healthy and whole when dealing with the hardest parts of infertility? Also (and this is much harder than it sounds), can you summarize them in a few words that would fit in a pocket-size list?

What would be on your personal encouragement card?

How to Look on the Bright Side (Part 2)

Last time I mentioned an "encouragement card" that another woman received from her clinic. Now, as they say, here's THE REST of the story!

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I've come to learn that the original card wasn't just one clinic's kind but quick attempt to be helpful. In fact, the card was carefully developed and evaluated as part of a double-blind study.

Researchers at Cardiff University in Wales were hoping to help women find effective ways to cope with the stress of IVF. The goal was to develop a "Positive Reappraisal Coping Intervention (PRCI)" card that was based on respected theories, inexpensive, simple to use, and generic enough to be used by other types of patients later. Here's what the researchers proposed:

"One meaning-based coping strategy that seems particularly likely to make (re)appraisal more positive is positive reappraisal coping, which may be understood as 'cognitive manoeuvres' or cognitive efforts ... that change the meaning of the situation. Finding positive meaning may involve appreciating the benefits that the situation has brought to one's life (e.g. closer relationships), comparing oneself more favourably with others who are less well off, or redefining the situation such that it seems more positive ... individuals may focus more on positive aspects of a situation rather than ruminating about (or conversely trying not to think about) negative and distressing aspects. Such efforts in the IVF context may involve focusing on the fact that the most advanced fertility treatment is being tried, or that a partner is especially loving and supportive."

The research subjects were women undergoing embryo transfer at a large urban hospital in the UK. Of the 55 women, 28 were given the PRCI card and 27 (the control group) were given a Positive Mood Induction (PMI) card. The women were instructed to read the cards at least two times a day during the 2WW, and then evaluate the cards' effectiveness. Here's the content of the two cards:

(source)

Sure enough, the PRCI was rated to be more helpful and suitable than the PMI, and to have more enduring effects. On the other hand, although the women rated the PRCI the highest of the two, their endorsement of it still seemed fairly lukewarm:

(source)

The researchers suggested that the PRCI may work because the "focus on positive aspects of the IVF experience" (using the PRCI) requires more cognitive processing than focusing on affirmations, which may or may not feel true to the individual (using the PMI).

When affirmations don't feel true, they may even be counter-productive. The researchers cautioned that the perceived benefits of the PRCI, in comparison to the PMI, may be due partly to this effect, and/or to the fact that the PRCI simply provides a distraction from worries.

Along with thinking of benefits and repeating affirmations, simple distraction is also a recognized coping strategy. While the researchers found the PRCI to be promising, they also allowed that different people prefer different coping methods.

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Coming next: my attempt to sum up a whoooole lot of thoughts and feelings about this study.

How to Look on the Bright Side (Part 1)

On a private forum recently, a woman who's been TTC for a while wrote about receiving an "encouragement card" from her clinic. It was a pocket-size card that listed these suggestions:

1. Try to do something that makes me feel positive.
2. See things positively.
3. Look on the bright side of things.
4. Make the best of the situation.
5. Try to think more about the positive things in my life.
6. Focus on the positive aspects of the situation.
7. Find something good in what is happening.
8. Try to do something meaningful.
9. Focus on the benefits and not just the difficulties.
10. Learn from the experience.

Do you see a pattern here? Except for numbers 8 and 10, these tips all seem to be variations on "Be positive." (If there's a difference between "See things positively" and "Look on the bright side," it's too subtle for me.)

Several of us on the forum had the same reaction: after the second or third cliché, we started feeling put off, maybe even patronized. We heard echoes of the infamous "Just relax!" Because while everyone agrees on the need to, say, "make the best of the situation," the huge daily question is HOW.

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Of course, to be used in this format, the "how" needs to be as brief and universal as possible. I know how hard that is, and I appreciate the clinic's effort, since (in the interest of being positive, not just pointlessly snarky), I took a shot at it myself.

How to translate platitudes into actions that I actually know how to DO? Here's what's worked for me personally, or at least as much of it as will fit into a tiny, pocket-size list. (Obviously, whole books could be and are written about each point, and your own points may differ!)

1. Focus on the things I can control, and act decisively.
2. Maintain balance by continuing to do non-TTC-related things that make me feel good.
3. Maintain perspective and connection by sharing support with others who are also struggling in some way. 
4. Allow myself to hope for success, to the extent that doing so feels more uplifting than painful.
5. Consider that what seems like a setback now may have some positive results that are not apparent yet.
6. Consider that, even if I don't have success, growth and joy are still possible in my life.
7. When good things happen, however small, pause to savor them in that moment.
8. Seek out things that make me laugh, not to put on a happy face, but because it feels freeing and brave.
9. Notice what tools help me feel and function better, and make them priorities.

I can only come up with nine points. Is there something you would add, to make it an even ten (or more)?

Also, coming next: some surprising background on the encouragement card!

Contraction / Expansion

Today I came across this post, which (like so much of Dr. Cacciatore's writing) was thought-provoking and, well, validating. She sees grief not as a state to be escaped or fixed, but as a natural—even "evolutionary"—process. I'm not at that stage of acceptance. Still, her words give me hope:

"Contraction only will leave us unmovable – paralyzed with pain for the duration of our lives, fearful of love and life and terrified of more pain. This is a kind of Death for us. Expansion only is a futile endeavor as well, mostly because it is a ruse. It is often a state of self-delusion and inauthenticity that will leave us unsatisfied with our identity, soul-less, and worn out from persistent pretense. The natural course of grief, as in nature, is contraction-expansion-contraction-expansion-contraction-expansion..."

Almost like birth.

"This is the wisdom of the Universe, the wisdom of your body, the wisdom of your heart.

Trust it, and it will save you."

Happy Birthday, Blog

It was a year ago yesterday that I took a deep breath and—with very few expectations—hit "Publish" on my first post here, which was written in the middle of the night, in the middle of a sleepless week. Looking back, I'm surprised that it was coherent. It still does a good job of explaining why I came here.

And what is it about blogging that's made me stick around?

• Fluidity:  Mainly, as mentioned in that first post, facing the reality of difficult emotions helps me to keep them fluid. It keeps anger and sadness from congealing into bitterness and despair.
• Release:  This is hard to explain to those who haven't felt it, but it feels like there are just things I have to say. In daily life, I'm not a big talker. I especially try to avoid overloading friends with TMI about TTC. No-one wants to be a bummer. That's not to say that I let it all hang out here … just that no-one has to come here, you know? So I don't feel guilty about focusing on the same basic topics, which take up a huge and important space in my life right now.
• Clarity:  Writing makes me more mindful of emotions, thoughts, beliefs, and patterns that are normally just below the surface of awareness. The more precisely I can describe them here, the better I can see and respond to them "in the wild."
• Guidance:  Without really setting out to make it happen, I now have a record of what's helped and what hasn't during this very hard year, which can serve as a guide the next time I'm feeling lost.
• Connection:  When I see how many people struggle with similar feelings (if not the exact same circumstances), it helps my heart expand rather than shrivel up in self-pity. I don't have to take it personally. It's not "my pain" or "my joy," just pain and joy, things I share with absolutely everyone.
• Support:  Other people's posts have given me such good food for thought. They've led to new perspectives, posts of my own, practical tips, books and articles to read, questions to ask my doctors… Thank you all!
• Warmth:  Reading a person's blog is a little like visiting a room in her home. Personality comes through not just in words, but also in the layout of the place, the pictures on the wall, how often she's there, who else drops by… I get to know someone better in her own space than when she's one username of hundreds or thousands on a forum.
• Acceptance:  I tend to publish posts when I feel about 95% done and ready to move on. Completing that last 5% would take longer than all the rest and turn something fun into a self-absorbed chore. I can always go back later and make a sentence more precise (hey, it's not journalism) or write some kind of follow-up. My writing, like everything in my life, will always be imperfect and unfinished, and that’s OK. 

Resolution

New Year's Eve was always one of my favorite holidays. As a child, I thought it was awesome to stay up late, of course. But it wasn't just party time. As I sat on the couch watching the Times Square events on TV, I'd earnestly write out all my goals for the coming year. What serious business was on my 12-year-old mind? It's long forgotten now.

That routine didn't change much in the next decades. As a teenager and young adult, I still saw New Year's Eve more as a chance to reflect than as a chance to party. (Fourth of July was the time for partying, duh.)

Then there were years, the last few years, when I didn't make any resolutions at all. My goal was to endure. However I managed to do that, pretty much, would be OK.

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This year I'm aiming for the middle ground: no perfectionistic lists, and also no giving up. My single resolution is to have resolution. As in:

Resolution (n.): tenacity, firmness, determination, steadfastness, perseverance, purpose, resolve.

So I got a book from the library called This Year I Will…, which has been helpful. Author M.J. Ryan says:

"Because it takes work, often a lot of work and sacrifice, you have to really want to bring something into being. Deeply, truly, honestly ... Joan Borysenko, Ph.D., encourages us to go beneath the surface to find what she calls our soul resolutions, which are 'based on saying yes to your deepest longings ... Goals rooted in what really matters are far easier to keep.'"

Ryan also recommends making the goals "SMART"—specific, measurable, achievable, relevant, and time-bound—then gives many tips for sustaining motivation.

My specific goal is to get up an hour earlier each morning and walk on my elliptical machine, at least through January (and then I can recommit). Officially, I'll do it for a minimum of just 10 minutes a day. But getting out of bed is the worst part.

Once I get up, get prepared, and get on the machine, the hardest part is over and 10 minutes easily turn into 20, 30, or more. Sometimes I plod along at a steady pace with my nose in a book. Sometimes I bust out the silly dance moves. Often I turn up the music and run flat-out, like something awful is right on my heels.

Even 30 minutes a day is not a big goal. It feels big to me, though, and sometimes a grand (even foolishly so) gesture is just what I need to shake things up.

I know that I need—on the soul level that Ryan talks about—the power that will come from doing this one thing every day, not just in spite of but because of the fact that my energy has been so catastrophically low.

Yes, I really want this goal. I really need the life energy and the will.

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I've felt increasingly beaten down by the TTC waiting and now—worst of all—the relentless bad news about people I dearly love and can't seem to help. It feels awful. Clinging to anything I can control and "fix," I've wondered which parts of the awfulness might be within my control, a product of clouded perceptions or mental story lines...

So much to analyze. Really, though, how much does it matter? In her book, Ryan says this:

"Over the past forty years, I have gathered dozens of theories of why I am the way I am ... But to change something in myself, to bring something new into being, I need to engage a different part of my brain—my right brain, where innovative thinking happens. The right brain is future oriented. It's where our aspirations, our dreams, our longings reside...

In preparing for the change you're about to make, allow your right brain to help you. All it takes is switching from 'why' thinking to 'what could be possible' thinking. Ask 'what' questions rather than 'why' questions: 'What can I do to have more balance in my life today?' rather than 'Why am I a workaholic?' ... Do you notice the difference in the two choices? One leads to rumination and stuckness; the other to creative possibilities and forward momentum."

Frankly, talk about innovation, aspiration, and longing makes me tired. I'm concerned most with today. But even in that small context, I do get what Ryan is saying about staying stuck in analysis vs. building some kind of forward momentum. My exercise resolution is all about the latter. I'll try to articulate why:

• Over time, it may lift my mood and energy.
• It trains me to face whatever is here (circumstances and my reactions to them) with mindfulness.
• It renews my commitment to live consciously in this world, despite its messiness and my own deep reluctance some days.
• It transforms my default state of defended numbness into anger and sorrow, which at least feel alive.
• It makes me breathe, sweat, and let energy flow in and out. When I let things happen, resistance melts away.
• It reminds me that weak muscles (literally and metaphorically) are strengthened by practice, not by rest.
• It builds my courage to do other difficult things.
• Doing it first thing in the morning puts priority on my mental and physical health. First responders like EMTs are taught that, before they can be most useful to others at an accident site, they need to ensure their own safety. I owe the same thing to myself and those I love.
• Doing it every single day builds consistency and discipline. If I make exceptions for a poor night's sleep or a busy day ahead, etc., every single day will end up as an exception. Instead:

Taking in the Good

Lately I've heard several people talk about the importance of gratitude. I wish that counting my own blessings made me feel good in the way that these people described. When I think of the best things in my life, what I feel instead is FEAR: Oh please, don't let me lose this, too! I couldn't stand it! The fear is paralyzing. It makes me feel like there's nothing to look forward to.

How to let the good stuff sink in, to feel gratitude in my heart as well as think it in my head? I'm trying to do what Rick Hanson and Richard Mendius suggest in their book Buddha's Brain: savor the good and even neutral moments as they come up, in a vivid and physical way, to balance out the negative bias of memory.

Buddha's Brain: The Practical Neuroscience of Happiness, Love & Wisdom
by Rick Hanson, Ph.D. with Richard Mendius, MD

They explain how our brains evolved to pay more attention to negative experiences than to positive ones, because the negative ones usually had more impact on survival. As a result, our baseline state is one of vigilantly scanning for threats. Also, our brains tend to detect negative information faster than positive information, then emphasize it more in memory. Hanson and Mendius explain how these changes happen neurologically. Then they summarize:

Your brain preferentially scans for, registers, stores, recalls, and reacts to unpleasant experiences; as we've said, it's like Velcro for negative experiences and Teflon for positive ones. Consequently, even when positive experiences outnumber negative ones, the pile of negative implicit memories naturally grows faster. Then the background feeling of what it feels like to be you can become undeservedly glum and pessimistic. 

Sure, negative experiences do have benefits: loss opens the heart, remorse provides a moral compass, anxiety alerts you to threats, and anger spotlights wrongs that should be righted. But do you really think you're not having enough negative experiences?! Emotional pain with no benefit to yourself or others is pointless suffering. And pain today breeds more pain tomorrow. For instance, even a single episode of major depression can reshape circuits in the brain to make future episodes more likely (Maletic et al. 2007).

Oh great, another thing to fear. But they do have a suggestion. Instead of "thinking positive"—sweeping negative realities under the rug while reading a mental list of all the reasons we should feel happier—here's what they suggest:

The remedy is not to suppress negative experiences; when they happen, they happen. Rather, it is to foster positive experiences—and in particular, to take them in so that they become a permanent part of you… 

Turn positive facts into positive experiences. Good things keep happening all around us, but much of the time we don’t notice them; even when we do, we often hardly feel them…Whatever positive facts you find, bring a mindful awareness to them—open to them and let them affect you. It’s like sitting down to a banquet: don’t just look at it—dig in! 

Savor the experience. It’s delicious! Make it last by staying with it for 5, 10, even 20 seconds; don’t let your attention skitter off to something else. The longer that something is held in awareness and the more emotionally stimulating it is, the more neurons that fire and thus wire together, and the stronger the trace in memory (Lewis 2005). Focus on your emotions and body sensations, since these are the essence of implicit memory. Let the experience fill your body and be as intense as possible...

Finally, there's this:

Positive experiences can also be used to soothe, balance, and even replace negative ones. When two things are held in mind at the same time, they start to connect with each other. That’s one reason why talking about hard things with someone who’s supportive can be so healing: painful feelings and memories get infused with the comfort, encouragement, and closeness you experience with the other person.