Trauma Therapy: Eye Movement Desensitization & Reprocessing (EMDR)

If you struggle with painful memories from a past trauma, and are considering what types of therapy might be most useful, let me be your guinea pig today and tell you about Eye Movement Desensitization & Reprocessing (EMDR).

In a nutshell, EMDR basically aims to help you reprocess memories of past traumatic events that your brain has failed to properly process. 

The hippocampus is an organ in the brain that deals with storing emotional memory.  When a traumatic experience happens to a person, the logic and reasoning centres of their brain are overwhelmed, so the hippocampus fails to communicate with them effectively to process the memory of that event.  

This can result in a person experiencing severe distress when remembering this trauma, and sometimes finding they relive the experience as though it were occurring in the present, because the memory has not been properly stored by the brain as a (sometimes very distant) past event.

The purpose of EMDR is to reprocess traumatic memories by manually involving both the emotion side of the brain and the logic side of the brain, given that they previously may not have been working together, to properly place that memory in the past.

During EMDR, I was guided to remember the traumatic memories that I continue to find distressing by bringing into conscious awareness the memories themselves, as well as the thoughts, emotions and bodily sensations that come with them.  

This means that if you are considering EMDR, you need to be willing to experience reliving a distressing memory through recalling it in detail.  Your therapist should help you to come up with a safe place to use if you need it.

This is quickly followed by having to follow the moving fingers of the therapist rapidly for a brief period of around 30 seconds.  And I mean, RAPIDLY.  It was actually a little bit hard to keep up at times!

It is possible for this therapy to be conducted using other external prompts, like sound or touch, but prompted eye movement is usually the most common and most accessible for the majority of patients.

The process produces a distinctive and naturally occurring pattern of electrical activity in the brain, which causes the stored trauma memory to quickly change.

During EMDR the therapist is not meant to talk or offer suggestions.  I was not asked to change any aspect of the memory, but just to notice the experience.  

At the end of each set of eye movements I was asked to report how I was feeling.  I found the emotional and bodily sensations reduced in intensity quite consistently during the whole process.  Sometimes the physical symptoms would change or come back a little bit, but then further "rounds" of eye movement helped those feelings subside again.

The next step is to associate a more useful thought to the now more distant trauma memory.  The EMDR process is complete when the new perspective feels true even when the old memory is recalled.  For me, I worked on accepting ideas that "I did the best I could" and that "I was only a child" to help me experience these memories in a less distressing way, as previously I had been experiencing strong feelings of shame, self-blame and guilt.

It's apparently common to feel tired after an EMDR session, and this was definitely true for me.  I recommend scheduling in time for rest or something soothing afterward.

Whilst EMDR sounds simple (and let's be honest, a little bit like hocus pocus!) there are many important procedural steps for the therapist to follow.  It actually takes over 50 hours of training and supervision to fully train an EMDR therapist.

EMDR can be effective whether it is conducted once or over a series of sessions, depending on the patient's needs.  I am currently approaching my fourth session.

Overall, I can say I do recommend it as being very useful.

Falling Apart & Beginning Again: Jess' Story

Today I've decided to share a bit about my story.  

You may find it interesting or entirely purposeless :) either of which is okay, but I thought it might be useful for giving you an idea of context when reading my blog. 

I'll start when adulthood sort of did...  The first two years out of high school weren't that exciting for me.  I finished school at 16, when the usual age for graduating high school in Australia is around 18, because I was skipped a grade after being told I had a high IQ.  I have my doubts about this!

Aside from a retail job and a hospitality job during school, my first "real" job as an adult was a youth worker position.  This 25 hour per week job had very little support, and I did it while I tried to simultaneously pull off a full-time study workload at University.  I ended up just doing a second-rate job of both tasks and didn't find much fulfillment.  

I also enjoyed a little bit of travel and had a couple of healthy relationships.  I sometimes got the sads, which affected one exam period at worst, but life was alright.

Then at eighteen I entered an industry in which I would spend the next six years of my life and where I would meet some of the best and worst people I've ever known.  I worked full-time in very intense and stressful environments during which I experienced upwards of half a dozen instances of workplace bullying.  (Of course, I am now better able to acknowledge my role in these situations, and no doubt those people were influenced by their own distress in our ridiculously high-pressured industry, but it truly was horrible for me and some people were just jerks... Perhaps a topic for a future post!)  

I also spent most of these years in and out of an extremely traumatic relationship with someone who was twice my age and newly divorced.  They and their ex-wife worked in the same industry as me.  Everyone knew and had to work with each other despite hatred and tension.  It was unpleasant, to say the least.

Throughout these years there was not a single day that my work tasks were limited to working hours.  There was a constant expectation to attend events and socialise with colleagues out-of-hours, which was made all the more unpleasant by the goings-on of my emotional life.  And socially it wasn't that great either - there were complex networks of who liked who, who hated who, and who was undermining who just for the heck of it.  Even my recreational reading time needed to include media and literature relating to work.  I was passionate about the cause and willing to work hard, but geez!  Years of this stuff wears you down.  On top of this, all of the actions and choices in your personal life reflected directly on your career. 

I should also point out that there were some great aspects to the jobs I worked in and that I was very privileged to have had some of the support and opportunities I did.  In amongst the hard times there were some people who were great to me and there was some very cool stuff I loved doing.  I really believed, and still do believe, in the cause behind my work, and I wouldn't change that for the world.

But it was still killing me.  So, why didn't I change anything?  Why did I stay?  And why did I lock myself into a lifestyle that was clearly making me unhappy?

I'm not one of those people who is particularly wrapped up in money or appearances.  I never pay for designer labels and I'd seriously rather shop at K-Mart.  But I locked myself into a cycle of expectations where I had to keep earning money and then keep earning more.  Once you sign a rental lease, you pay that for a year.  Once you've rented one place, you want to rent a nicer one.  Once you have your own place, you pay bills.  And once you are sitting alone in your own place with all bills paid, you eventually get bored or lonely, so you go out with friends or do some activity to keep your mood up.  (Especially when you're always feeling the blues!)  

I also did all this because I just thought I had to, because it was what adults did.  Adults have their own place, buy furniture and groceries, drive their car, go to dinners, work their jobs, get promoted, get new jobs... meanwhile, my mental health kept deteriorating.  I couldn't understand why I was feeling worse and worse despite doing all the "right" things with my life.

I really was trying hard to improve things for myself.  I would complete an extra university subject or make a new friend or try to find hobbies and projects I could volunteer in.  There were even a couple more overseas trips with family and friends.  But my condition kept going downhill.  I began to dream about just throwing it all in and running away to join the circus.  As time wore on, I dreamt about doing worse things.

 

[ TRIGGER WARNING APPLIES ]

And do worse things I would!  Sometimes I was just sad, and I would fill my time with sleep or food to escape.  Sometimes the emotions were stronger.  Emergency rooms and ambulance rides became a nauseating blur.  So many times I fought off the panic of oncoming pain with drugs and alcohol.  If I really couldn't even bear the minutes it would take for those to kick in, I would resort to self-harming - cutting, scratching, burning, hitting.

I've poured boiling water on myself.  I've torn my flesh off in chunks.  I've smashed my forehead onto cement walls.  I know that there are others who have no doubt experienced worse than me, but I can tell you that within myself I went over some cliffs.  Whatever I could do to fight off the surge of emotional pain that was coming, I would do it.  And sometimes the emotions were just a never-ending dull ache that made me choose not to put my seat-belt on when I was driving or be pretty careless about looking before I crossed roads.  I would imagine my funeral or the actual process of dying just to soothe myself a bit that there was an ending available.  In general, it was safe to say I spent upwards of 80% of my life wishing not just for death but for respite from my feelings.

[ END TRIGGER WARNING ]

By the time 2012 rolled around and my family had caught on to all of this, I found myself hospitalised and on four different psychiatric medications.  Something had to give.  Eventually, it all did.  The ridiculously dysfunctional relationship finally began to cave in for good.  (Though, he only ever truly left me alone when he found a new half-his-age partner.  Make of that what you will.)  I couldn't handle being bullied at work each day by my line manager and gave my notice of resignation.  I opted not to renew my lease, sold my furniture instead, and told everyone I was leaving to go travelling overseas.  I didn't know what I was going to do, but I just had to get away.

I was alone in Amsterdam when the nervous breakdown hit.  Hard.  I ditched the rest of my travel plans and came home to a serious psychiatric hospital stay and more medication and even more therapy.

I'd quit my job and relationship.  All my things were sold or packed up.  I had almost no friends left.  (My social circle had become entirely full of work relationships and pretty much no one was interested in me once I quit my job - like I said, they weren't the nicest of people.) 

It feels like a doomed airplane was careening and breaking apart through storm after storm for so many years, as I desperately taped its wings together and pumped the fuel lines and wrestled the yoke, like some maniacal pilot... when what I really needed was for the whole mess to finally plummet into the sea.  Now I'm sitting on a life raft, alone, at last able to tend to my wounds, and rest.  I'm bobbing along in this deafeningly quiet stillness.  You get the metaphor.  It's over.

And it's a new year, I've had a break and a lot of treatment, and I'm officially "stable" according to three doctors.  So does this mean I'm almost Recovered?  HAHAHA!  No, wow, not even remotely close.  What I am is (finally) Beginning to Recover. 

Or, more accurately, I will be in a process of "Returning to Work/Study" for some years to come - which is an Australian concept of only having one job or course of study at a time, and only doing this on reduced duties, while incrementally returning to a full-time capacity, under the supervision of treating doctors.  This means I can do things, but they will need to be balanced with medication and therapy for a long time.

I've chosen to move to a bigger city and go back to University.  I'd like to study so that I can enter a new industry, and because I truly enjoy it.  I also think a new city is going to give me the space I need from old friends and old habits.  I'm still keeping some of the support with me though, as my best friend and her lovely sister are also moving at the same time.  (Plus the city is super cool and much bigger than my boring old home town.)  My family have even agreed to help me out with financial support and ensure that I'm returning home very frequently for stability.  This all fits in with my doctors' plans, so it's looking good.

In finishing my story, here are some lessons I have taken from my years of misspent youth which I implore you to consider lest you ever find yourself in the same place I was in...

A job is a huge part of your life, and any problems at work should be taken seriously.  How you are treated and whether you have a healthy work-life balance are especially important.  Report instances of bullying or harassment.  Talk to your boss about fair expectations from you as an employee.  And if you just don't enjoy your job, keep looking around for others until you find a better fit.

Try not to get stuck in one mindset and never cut off your own options.  All the cliches are true, the world truly is full of limitless possibilities and if you want to wake up tomorrow and do something completely different, DO IT.  

Screw the norm.  You don't need a big house, car, or impressive-sounding job, to be truly happy.  In fact, you can have all these things and be very unhappy.  Believe me!  What really matters is family, friends, and doing what you love.  The rest is negotiable.

Never sell yourself short because you really do deserve every good thing in life.  You deserve happiness.  You deserve a vocation that you love.  You deserve happy and healthy relationships.  Even if you have some crazy dream job or lofty ambition, give it a go!  You'll never regret the immense love and respect you show for yourself when you seek to achieve your goals.

If I could speak to my seventeen year old self, they are the things I would tell her.  Instead I have written a long and boring blog post to you!  If you have managed to read it, please know I am sending you a genuine and heartfelt thank you for doing so. 

P.S.  Of course, I should say that my mental illness likely required a genetic predisposition and would have involved contributions from other traumas in my life.  But, would I have ever reached such a severe point of crisis had I spent those years in a normal workplace and normal relationship where I was not prevented from living a healthy life?  No.  Never.  (Again, I'm an adult, and I am responsible for my choices.  But seriously, I encountered some messed up people and was put in some extremely distressing situations.  TO THE MAX.  If I ever write a book it'll be titled "Crap After Crap TO THE MAX" and no one should read it.)

P.P.S.  If I can somehow keep myself intact despite many attempts to achieve the opposite, I truly believe that other people going through mental health challenges can get there too. 

Braaains

Anyone who has suffered through a mental illness knows all too well that it is not something you just "get over" or "snap out" of.  Mental illness is real and tangible suffering.

Need proof?  Here is a link to a very excellent science blog that lists hundreds of recent studies, tests and trials that scientists are working on around the world: The Neuroscience of Borderline Personality Disorder.

The more research that is done on BPD and other psychiatric conditions, the more that science is unfolding the physiological structures of the brain that contribute to their symptoms.

From the bits and pieces I've read so far, when it comes to BPD symptoms, the overwhelming trends are prefrontal cortex and amygdala dysfunction relating to structure and reactivity. 

When we talk about balancing Emotion Mind with our Reasonable Mind - in order to use both and be in our Wise Mind - it's possible to understand the regions of the brain that affect each.

Studies are able to show BPDs often have a smaller and hyperreactive amygdala.  This is the organ in the brain that plays a crucial role in emotional learning, memory and responses.

It's even been demonstrated that the larger your amygdala, the larger and more complex your social circle is likely to be.  This doesn't mean that BPDs are unpopular, but rather that we are more likely to struggle with emotional activities like intense social interactions, and so perhaps do them less.

The prefrontal cortex of the brain (essentially the forehead part) is responsible for the type of executive-level thinking that makes us humans as opposed to just cavemen by giving us the ability to visualise what is not physically visible - for example, the future consequences of making a decision. This means you need this part of the brain to work well in order for decision making, planning, moderating social and emotional behaviours, impulse control and goal setting.

Research in this area has shown that BPDs often demonstrate difficulty in getting parts of the prefrontal cortex to coordinate with other parts of the brain, especially the amygdala.

Generally speaking, this means it's possible to see on MRI scans the physical aspect of the struggle between Emotion Mind and Reasonable Mind when someone with BPD is emotionally triggered.

While it might be some time before we fully understand the neuropathophysiologic (yes, that's a word apparently!) basis of BPD, there is no doubt as to its existence, and no one should ever be made to feel that their mental health is any less "real" that their physical health.

BPD & Object Constancy, Or, Why I Love Presents

Anyone in therapy or studying a form of psychology might be familiar with the concept of "object constancy".  This refers to a person's ability to recreate or remember feelings of love that were present between themselves and another person after the other person is no longer physically there.
 
For as long as I can remember, this has been something I have struggled with.  Even in primary school, I can recall how much I'd treasure scraps of notepaper from class that would "prove" I had interacted with a friend via some scribbles, or any other token or souvenir that could only be attained by being someone's friend.  Photos or presents are ideal.  Whatever the keepsake, I never have enough.  It never feels like enough.
 
This is because of my ineptness at maintaining object constancy.  I always struggle to feel loved by a person unless they are in the process of demonstrating it to me - I just can't feel it unless I'm seeing it, touching it, or hearing it.  Otherwise I feel totally disconnected, and potentially abandoned.

It's not that I don't love or appreciate the aspects of relationships that have lasted over time, it's just that I just can't remember them on my own.  I need prompting.  I have to be reminded of individual events, stories, and resulting emotions from throughout the relationship to get the full benefit of them having occurred. 

I can only imagine how exhausting this is to those who love me.  My relationships are a never-ending quest for the other person to prove their loyalty, devotion, and caring.

But because my brain can't preserve those efforts, it's the emotional equivalent of typing up a Microsoft Word document that can't save.  Every time you close the window, whatever you've written is gone, and you have to start again.

I'm not sure who gets the worst end of the deal with this symptom.  My loved ones, who can never do enough, or myself, given I can never feel permanently loved.

It's entirely feasible that a boyfriend of years has met a new partner since I saw them two hours ago, or that a best friend hates me after one cranky text message, or that a family member has disowned me because I didn't give them a Christmas hug.  It's feasible that people would do this to me, because I could do it to them.

It's that classic BPD trait of being able to "switch" or "split" and see someone as either all good or all bad.  Lacking object constancy is a big part of what makes this possible.  It's easy to switch to hating someone for one wrong move if you're unable to remind yourself of the many, many times they've done something right.

In reverse, I can honestly say that it is entirely possible for me to love a friend I have known for one day as much as a friend I have known for one decade, if the chemistry is right and if I view them as "all good".
 
Researchers have linked problems with object constancy to dysfunction in the area of the brain that deals with emotional memory.  The memories are there, but some parts of the brain just aren't talking to each other for me to be able to access them.
 
Dealing with this symptom is just another case of having to intervene in my thought processes manually, where a mentally healthy person would enjoy it on automatic.  

For me, I find it helpful to carry around pictures and notes from loved ones, as well as any gifts I've been given. Also, on the more extreme end of things, I've got my four closest family member's names tattooed on my back.  Every morning I look in the mirror and am reminded.

If I come up with other ways to deal with this, I'll be sure to post them here.

The Up-Sides Of Mental Illness: Compassion

Recently, a friend shared with me a practice he's been using at the end of each day to boost his confidence, mood and sense of self.  Interestingly, this friend is of good mental health, but still finds it necessary to work on "improving moments" from time to time.

The technique is something most of us have probably heard of in one form or another.  It's to list three things at the end of each day that you are grateful for.

I initially didn't think much of this, until I actually gave it a go.  It's really helpful. 

Some days, even if it's been a really bad day, I am still grateful for something as simple as sanitation.  If this sounds like it's not that big a deal to you, then I am almost certain you have never been to China - believe me, when that pork dumpling platter started to go south on me, and there was nothing but a hole in the ground behind the restaurant where kids were playing... Well, you can take my word for it, access to a sanitation system is a blessing.

I've decided I'm going to use this more often, to get in the habit of changing my perspective on things to see all the angles.

So, I'm starting a series of posts about the positives of having mental illness.

Lately I've noticed that my own mental health struggles have allowed me to be much more compassionate to others experiencing the same.  This seems obvious, but it pops up in places I wouldn't expect.  

Today, when I was stopping by the shops to pick up some groceries, a man was being arrested in the car park and was causing quite the kerfuffle.  

It took four police officers to hold him down, and two more to keep pedestrians away and prepare the police van to transport him.  He was screaming and shouting that these weren't police officers, but were secret police, that had poisoned his water.  Most people were standing around rolling their eyes and shaking their heads.

But my first thought was that the guy probably suffered from mental illness, and that if he had a choice, I was sure he wouldn't want to be in the situation he was in.

I can guarantee that a few years ago, before becoming mentally unwell myself, there is no way I would even have considered that.  I still probably wouldn't have been as judgmental as the people standing around, but it wouldn't have immediately occurred to me how involuntary his predicament was.

In all honesty, I can say that I appreciate being able to access this compassion and understanding for anyone who is let down by their brain in the same way that I have been.  

This isn't to say that I'm Jesus or anything, but I think it actually feels better to experience the emotion of compassion rather than emotions like judgment or disgust.

Is It Hot In Here, Or Is It Just Me?

It's ALWAYS just me.   Today I will be telling you about my struggles with anxiety and... sweating. Please accept my apologies for grossness in advance.

As you may be aware, one of the telltale signs of Social Anxiety Disorder, or any form of anxiety, is sweating.  There are others - such as blushing, trembling, palpitations, nausea, stammering, and rapid speech.  And I experience all of these too.  

Blushing, however, can be overlooked as nerves, or a sign of alcohol ingestion.  I've also had a person tell me they just assumed I put on too much blusher make-up!

Trembling and palpitations can be hidden.  Even when holding a drink, it's possible to steady your arm across your body.  And nausea is also invisible to the naked eye.

Stammering and rapid speech are noticeable, but often written off as behavioural or personality traits.  Ironically, it sometimes happens that people will assume you're so relaxed you aren't even bothering to speak too formally!

But sweating.  Ugh, sweating.  Sweating is the give away.  Sweating is obvious, awkward, and embarrassing.  

It can't be hidden.  It can't be stopped or slowed on cue.  And everyone knows what it means - you're embarrassed, you're very uncomfortable, or there's just something wrong with you.

Here are a list of things that make me sweat:

• Being outside my house - this will often begin during the car journey
• Entering or exiting a store, restaurant, cafe, pub, building, or other venue
• Talking to anyone, be they friend or stranger
• Doing anything whilst being watched, by friends or strangers
• Meeting new people (this one's a killer)
• The point of check out and payment when shopping (also a killer)
• Lastly, the "normal" causes, such as hot weather or exertion

 

When I sweat, it's always concentrated on the eyebrows, forehead and upper lip.  If I'm trapped in the situation and can't leave, this will extend to the eye area, chin, and hairline.

The worse is when I sweat to the point of it being visible in my hair.  It's humiliating.

And that's just my face!  I don't have enough hours in the day to go through all the places one sweats on the body, but suffice to say that anxiety promotes sweat better than anything...

So, if you ever see me in public, I'll usually be dabbing away.  Eventually it will become too much sweat, and the panic about sweat causes more panic, and I have to leave.  My options are usually only the bathroom.

Alcohol makes it worse.  Nicotine makes it worse.  Caffeine makes it worse.  Even a hot meal exacerbates the situation.

Basically anything you do socially can make it worse, but even if I stood there with a glass of chilled water, I'd still be sweating away.

The only time the sweating stops is when I am sitting in a cooled area and not talking to more than one person.  Or when I go home.

 

To be honest, it's horrible.  It gets in the way of every single thing I do outside of my house - work, meetings, university, friends, family, dates, shopping, errands, doctors.  I sweat them all.

And it's not just the embarrassment of being sweaty.  It's also deeply upsetting that your body is misrepresenting who you are to the world.  

Excessive sweat makes it look like I'm a deeply nervous person, or a drug/alcohol addict,  or someone who dislikes being around others.  There is nothing wrong with any of these things - but they aren't accurate about me, and I just want to be myself!  

I don't want to be sweating, I don't need to be sweating, I'm not hot/nervous/drunk - why so much sweat?!  

 

It's because anxiety is your body letting you down.  Anxiety is the firing of a bunch of physiological responses to perceived dangers or threats that aren't actually there.

To try and stop the sweat, I've tried botox, aluminum based skin products, and altering my diet.  No good results.  I've also used more natural alternatives, such Aloe Vera and Witch-hazel based skin products, which have helped a little more. 

And I am working through Cognitive Behaviour Therapy with my Psychologist so I can use better skills in everyday life.

So, that's my sweaty story.  I am sorry to post about something less than palatable, and believe me, it was a difficult post to write.  But I did it because I think it's important to to be speaking openly about symptoms of mental illness, and because maybe one day another sweater will read this, and feel just a bit less like an alien.

Delayed Sleep-Phase Disorder

I thought I would take a moment today to tell you all about another (yes, another!) condition I am living with: Delayed Sleep-Phase Disorder.

Essentially, your body clock runs between two to six hours behind everyone else, evidenced by its timing of sleep.  It sounds innocent at first, but bear with me!

 

Delayed Sleep-Phase Disorder (DSPD) belongs to a group of sleep disorders known as circadian rhythm sleep disorders - where individuals experience chronic sleep disturbance due to misalignment in their body's circadian timing.

    

   

For example, an individual whose circadian rhythm, or "body clock", is delayed may find that their ideal time for sleep is 4am with a rise time of 12noon. 

 

This schedule does not match the typical sleep window of most adults; and thus the main problems of those with DSPD relate to attempting to fall asleep (before their body clock is ready to) and attempting to wake up in the morning (before their body clock is ready to).

 

Now, I know what you're thinking, and trust me - people with DSPD are used to it!

"Just get out of bed you lazy bugger!"

"You're such a night owl!"

"Why don't you just go to sleep earlier!"

  

We spend our whole lives hearing this, because DSPD is a life-long condition.  Since I was a baby my parents would struggle every night trying to get me to bed.  Every.  Single.  Night. 

Sleep disorders are hugely under-diagnosed, because people often assume the problem is just a personal or behavioural trait.

Other than being life-long, the main diagnostic criteria for DSPD include:

• No other problems with length or quality of sleep once asleep,
• Not to be confused with insomnia,  
• If allowed to go to sleep when ready and rise when ready, can enjoy a normal balance of sleep,
• Sleep delay not caused by substances or other medications,
• Can be proven with testing of body temperature and polysomnographic monitoring, for example at a "sleep clinic".
   

Right now, it's 11:21pm, and I can feel my body shifting up a gear.  This is my prime time for creativity, productivity and energy.  Convenient, huh?

 

My body will not fall asleep naturally until after 3am.  That's when it thinks the sun goes down.  And, obviously, I won't get up any earlier than 12noon.

This of course has negative effects on, well, everything.  I'm known for running late.  People ask if we're meeting at our agreed time, or at "Jess time", which allows an extra 30 minutes.

It has caused me significant, repeated problems in attending school and work.

And the treatment for DSPD is - not a lot!  There's nothing that works in the long term, or that "fixes" the problem.  Melatonin and "bright light therapy" only work as long as you're actively using them; once you stop, your body goes back to its ways.  

 

Of course, you need to keep up good sleep hygiene (e.g. avoiding caffeine, regular bed times) but this won't alter the body clock of someone with a sleep disorder.

 

Luckily (sort of!) for me, my current psychological conditions mean I am on several medications, one of which puts me to sleep.  So for now, I can artificially control my bed time. 

 

I just have to aim to have a job that fits into an afternoon or night shift fixture when the day comes that I'm not on medication.  If that day comes!