I hadn't heard from Joe for almost four years. When he recently called to schedule an appointment, I was surprised to hear from him. He'd stopped seeing me abruptly and despite several attempts to contact him, he hadn't responded to my calls or a final letter. "I need to see you as quickly as possible," he shared in a voice mail. "I know it's been a long time, but I'm hoping you'll still see me." I returned his call and we scheduled an appointment within the week.
When I opened the door to greet him, he looked exhausted. His clothes were wrinkled and his shirt was untucked. His eyes seemed glazed and his skin was ashen. He walked slowly into the office, settled into the couch, and began to cry. He told me what brought him back to see me. "I lost my job a month ago and I've been using crystal meth for the past four years -- that's part of why I stopped therapy -- I didn't want to tell you," he hesitated and continued, "I'm HIV-positive now as well. Luckily, I'm participating in a drug trial, so my medication is free, but I have no money. I'm afraid I'm going to lose my condo. I know I need to look for work, but I can't even get myself out of bed in the morning. And ... what will I tell people about why I lost my job?"
Joe originally came to see me because of anxiety and depression. Both his parents struggled with alcoholism and depression and though Joe did not report using substances when we first met, he was worried that he might, given his family history. Joe had no significant long-term relationships and was fairly isolated.
Raymond has been seeing me consistently for a few years. He has been HIV-positive for about 10 years and was diagnosed with bi-polar disorder and anxiety prior to beginning therapy with me. He has held the same job for seven years and has received numerous promotions and increased responsibilities at work, despite his concern that his lack of formal education (no college degree) would hold him back. He has been in a stable and committed relationship with his partner, Francisco, for eight years. Raymond's physical health has been good, with an undetectable viral load, no other serious health issues, and a commitment to exercise and healthy eating.
This past week, he began our session by telling me he felt paralyzed. "I can't function or focus," he said. "My responsibilities at work are increasing. There have been multiple lay-offs and I'm expected to do more with less. I know I don't want to do what I'm doing anymore, but I can't quit. I'll never find a job that pays me what I'm making. Francisco doesn't make enough to support us both. And how will I ever get health insurance?"
Raymond grew up in a fundamentalist Christian home. When his mother and stepfather found out he was gay, he was disowned and has had no contact with his parents and minimal contact with his siblings. His father, though more accepting, has chronic and persistent mental health issues, is frequently homeless, and often relies on Raymond for emotional and financial support.
When Anthony began therapy with me, he was preparing to die. He had been HIV-positive since the late 1980s, had numerous opportunistic infections and wasting syndrome, and had exhausted all possible medication regimens. He could no longer work as a physical therapist and was living on social security disability income (SSDI). His reported reason for entering therapy, however, was "co-dependence" and depression. Anthony reported he consistently put others before himself, focused on others' well-being, tried to manage the behavior of others -- including those who had addictions and were violent toward him (he had a history of being the victim of intimate partner violence).
With advances in HIV medications, Anthony's physical health improved significantly. So much so, in fact, that he began to consider working again. Several years ago, he began to return to work very part-time and, more recently, discontinued SSDI and began full-time work. He also returned to school to pursue a graduate degree.
Despite all these improvements in Anthony's life, he still has periodic health challenges. "I'm scared," he said in one of his recent sessions. "I've decided I'm going to live. I've taken on work and school, but the home health agency I work for might shut down. We've cut staff, we're not being paid in a timely fashion, and we're so small that the hospital we're affiliated with isn't motivated to keep us. I wish I'd never gone off disability. What will I do?"
As I thought about Joe, Raymond, and Anthony, I also thought about the other people I work with who have HIV, who constitute about 40% of those I see on a regular basis, and the extent to which financial and economic challenges impact their bodies, minds, and brains. Some common themes arise.
All three men -- Joe, Raymond, and Anthony -- are dealing with an increased sense of anxiety and a sense of feeling trapped by their current circumstances. Even for those who don't have pre-existing mental health or physical concerns, the economic climate has the potential to create a sense of despair. Savings dwindle, earning potential decreases, and financial debt increases. For those living with HIV, added economic challenges magnify concerns around physical health. Loss of employment may mean loss of health insurance and loss of health insurance could significantly impair maintaining physical health. For those whose health is more tenuous, anxiety about health care has a more immediate impact on physical health and deteriorating physical health magnifies anxiety. This interrelated spiral can lead to a sense of feeling trapped and even a great sense of hopelessness.
For most of us, losing a job or becoming unemployed carries with it a sense of shame, even when unemployment occurs during a recession. Questions about competence, how we might have handled a situation differently, or even the shock of job loss create a sense of isolation. As a society, we have preconceptions and judgments about those who "can't keep work" or "can't find work." When unemployment is concurrent with HIV, another historically stigmatized condition, these two unrelated experiences have the potential to magnify one another, with a greater vulnerability to feeling unworthy and somehow "bad." And if we feel unworthy and bad, we are even more likely not to take care of our physical selves. When multiple stigmatized identities "collide," each is individually more difficult to manage.
Joe's substance use, he came to find, was one of the causes for his job loss and, he realized, made him more vulnerable to less safe sexual behavior (resulting in HIV). Now, his substance use was interfering with his employment search and escalating financial concerns. Long histories of recovery and abstinence can be challenged when we're uncertain if we can maintain our home and/or if we're uncertain where our next meal may come from. Even without a history of substance use, financial and economic stressors can lead to a desire to escape. And for many, escape comes in the form of alcohol and other drugs. Substance use and abuse certainly impact physical health and an ability to find and retain employment. When unemployment creates a desire to escape, and the strategy to escape makes re-employment even more difficult, another cycle is created where body, mind, and brain unwittingly enter into and maintain an unproductive and downward spiraling cycle.
If we understand and integrate a mind-body-brain approach to our lives, we can intervene in any one of these areas and be confident the other two will be influenced. Thus, despite economic, physical, and emotional challenges, there are ways for Joe, Raymond, Anthony, and the rest of us to take care of ourselves to enhance mental health in times of economic illness. When forces like the economy are involved, however, it's also important to remember there is no "one" or "quick" fix that will solve the problem. I will, however, offer a daily "practice" comprised of five basic components that, if engaged, will most certainly enhance mental health.
Normalize distress. Feeling anxious, depressed, fearful, or angry are all "normal" responses to "abnormal" circumstances. These are extremely difficult economic times. In fact, the economy has not been as challenged since the great depression. If we allow ourselves to see that our distress about current circumstances is normal, we are less likely to label ourselves as somehow unhealthy or alone in our feelings.
Suspend judgment. When we notice ourselves having some sort of negative self-commentary or criticism about our reactions or feelings in response to current stressors, practice noticing these responses without labeling them as good or bad. We are prone to feel worse especially when we judge our feelings negatively. When we suspend judgment, our feelings become our feelings, neither good nor bad. We learn to accept them as a part of life.
Meditate. For some folks, the idea of meditating may be formidable. Research studies show, however, that meditating regularly reduces stress -- and if we reduce stress, we enhance hope, and if we enhance hope, we feel better. When we feel better, we perform better. We can more easily do the things we want to get done. Begin by spending just several minutes per day quietly noticing breathing, physical sensations, or sounds. When thoughts interrupt your meditation, simply notice them (without judgment) and return to meditation. Slowly build to twice-daily meditation -- morning and evening -- with the goal of 10-12 minutes per meditation period.
Move your body. I have recently been experimenting with "therapy on the fly." Instead of sitting in my office with clients -- especially those who feel immobilized by depression -- we are walking. In a therapy hour, we can perhaps walk 2-3 miles depending on our clip. Everyone who has engaged with me in this manner talks about feeling better after walking. You don't need to be in therapy to move your body. There are simple ways to move your body on a daily basis, recognizing that acts of physical movement help release us from emotional "stuckness" or feelings of being trapped. The body changes the brain and the brain changes the mind.
Be with others committed to the strategies above. Practicing strategies of self-care with others creates new patterns of being and moving through the world. The more we practice, the more natural these strategies become. We know from current research that it has taken lots of "practice" for our brains to work the way they do, our minds to think the way they do, and our bodies to respond the way they do. To change what we've learned takes repetition and practice.
By engaging in this five-step practice on a regular basis, we change our brains, we change our minds, and we change our bodies. Consequently, we feel better physically and emotionally.
Joe, Raymond, and Anthony are dealing with extremely difficult and complicated circumstances. As I've previously mentioned, there is no one or quick way to manage such challenges. It is also not possible for me to reduce such complicated dynamics to a recipe for mental health. I offer suggestions for understanding the impact of economic hardship on physical and mental health and for experimenting with and practicing strategies that change our brains, change our minds, and change our bodies. First and foremost, perhaps, is practicing hope.
Jeff Levy is a social worker, co-founder, and CEO of Live Oak, Inc. (www.liveoakchicago.com) in Chicago. He is also adjunct faculty at the University of Chicago's School of Social Service Administration. He can be reached at firstname.lastname@example.org.