Medication Management and Mental Health

In my career in healthcare, I have seen far too many patients who have been prescribed medication and continue to take that medication faithfully; Yet after a time, they are not really sure why they are taking that specific medication or if it is even helping with the diagnosed issue.  

 What is missing for these patients? Medication management 

Medication management is the process of following up with the healthcare provider on a regular basis to assess the effectiveness of the prescribed medication therapy, discuss any side effects that may go along with the medication, and make adjustments in order to achieve proper dosing. In some cases, the follow-up may be to change the prescribed medication therapy, if it is not providing the desired outcomes. Medication management should be an ongoing process. It should include open dialogue between the patient and provider about the effects of the medication combined with any other therapies or treatments that may be in place. This is to ensure useful data is being collected, so decisions can be made based on the whole picture; not just the medication piece. 

When it comes to psychiatric and mental health services, the importance of quality medication management cannot be overemphasized. Not all people who seek psychiatric help will require medication. In some cases, amino acid therapy may be appropriate or continued therapy and counseling with regular psychiatric follow-up is warranted. If medication is prescribed, the patient should plan to see the psychiatric provider within 2 weeks (in most cases) for the first medication management visit.  Continued follow-up visits should be scheduled monthly, or as needed depending on the individual case. 

During these visits, the patient should plan on communicating openly with the psychiatric provider about their use of the medication, any side effects that they may be noticing, and any changes they are feeling in relation to their mental health diagnosis. At times, genetic testing can be used to pinpoint what medications are more likely to work for each individual patient. This testing can be used not only for patients who are just beginning psychiatric treatment but also for patients who have been prescribed medication therapies that aren’t working. The patient should also plan to consult with the psychiatric provider before taking any other medications. They should inform the provider of other mental health therapies being used or medical complications that may arise during treatment. The patient should expect the provider to ask questions that will direct and lead the conversation, so time is well spent and modifications can be made with confidence. 

Ultimately, the key to effective psychiatric medication management is open and continual communication between the patient and provider. At the Center for Couples and Families, our psychiatric providers strive to provide thorough psychiatric assessment, follow-up, and medication management. 

Originally published on http://utvalleywellness.com/

 

 

Cleaning Out your Marriage Closet: Couples Counseling

People are often worried about drudging up the past with their loved ones. There is controversy as to what is healthy for the relationship. People certainly don’t like to bring up an old fight when everything is going well. The issue is that we all have a closet of sorts where we hide everything that “isn’t worth the fight.” At first this closet is empty and the intention of putting things in there is good, you intend to talk about it later, it’s just not the right time.

The problem is that you enjoy the times you’re not fighting, who wouldn’t! You soon forget about what you’re storing in the closet, and you continue to throw everything “not worth the fight” into the closet. Your closet becomes full, and when you try to fit one more thing in there everything topples over. This is the fight of all fights, this is when you seemingly “loose it” out of nowhere about nothing and everything. This fight happens at a time when something was already “not worth the fight” and you were trying to put it in the closet. Therefore, you are probably not up for resolving everything in that closet either. It’s like if your junk closet toppled over just as company is coming over, you’re going to scoop everything up and stuff it back into the closet because you don’t have time to sort through it. This fight leaves everyone upset and confused and often nothing is resolved in this fight.

So how does one clean out this closet? Well its much like spring cleaning, you are going to take everything out and you begin to sort everything into categories. You evaluate if it is something that only happened once and will never happen again, if this is the case it truly isn’t worth the fight and can be thrown out. If it is something that continues to happen you need to address it, you will be bringing up the past not as a weapon against the other person, but as a justification for bringing it up as an issue. It is absolutely necessary that cleaning this closet is done at a time when your calm and you remain calm to be able to assess what the core of the problem is, what does their behavior tell you about your relationship with them. For instance, If someone is always late, how does their behavior effect you, why does it feel disrespectful to you and how does it create distance in your relationship, what is the message you receive about their feelings toward you. As opposed to judging their behavior as something you wouldn’t do and lecturing them about how it affects them.

When you clean out the closet you are transferring responsibility to the people it will be useful with. You will find that the cleaner your closet becomes the more clarity you will have in your relationships. Your intent in cleaning out the closet is not to change other people’s behavior, it is meant to change your relationships. You will find that some people will choose to become more distant because they are unwilling to make changes, but the relationships that become closer and the internal peace will be worth the distance in others.

Written by Madison Price, MS, LAMFT – therapist at Holladay Center for Couples and Families

Shared originally by the Holladay Center for Couples and Families

Latino and Hispanic Mental Health Care

There are many trials one might face in this lifetime, and finding proper mental health care should not be one of them. Specifically, there is an issue for Latino and Hispanic persons to be able to receive the proper care that they need. Throughout this article, I will be using both the terms ‘Hispanic’ and ‘Latino’ interchangeably to describe members of this beautiful population, while meaning no disrespect to those who identify by either Hispanic or Latino.  

Currently, there are over 400,000 Latinos living in the State of Utah (Roughly 14% or 1 in 7)1. According to the National Alliance on Mental Illness (NAMI), 46% of Latino women and 20% of Latino men have struggled with depression2. However, less than 10% of Latino individuals suffering mental illnesses reach out to mental health care specialists. Additionally, Hispanic students between the 9th and 12th grades are more likely to commit suicide than their black and white peers3. Furthermore, first and second-generation Hispanics are more likely to experience depression than immigrants. 

Stigma/Cultural Differences 

There is a stigma surrounding mental health issues in most cultures. Within the Latino population, there is a fear of being labeled as “locos” (crazy) that can cause shame and fear to seek out the treatment that they need. Approximately 1 in 5 people are affected by a mental illness2. This statistic is no different for those within the Latino population.  

Understanding that there are few differences in regards to those who can be affected by mental illnesses, it is important to note that there are some differences in the way mental health treatments should take place among different cultures. I personally have visited and done humanitarian/therapeutic work in many countries, including: Spain, Costa Rica, Chile, Perú, and México. I understand that each of these countries have their own unique culture as well as do the other countries and cultures within the Hispanic and Latino communities. Finding a mental health care professional that can understand the cultural differences and possibly even the language is a big challenge and something that needs to be taken into account when looking for someone who can help you the best.  

Uninsured and Undocumented 

The fear of finding affordable health care is a real struggle if you do not have insurance or proper documentation. I have spoken to many individuals who do not seek out mental health care out of fear deportation. If this is a fear for you, it is important to seek out clinics and providers that care for all persons, regardless of legal status.  

Resources 

If you are uninsured, the Affordable Care Act is a resource available to you to see what you can qualify for. To learn more, go to https://www.cuidadodesalud.gov/es/ 

According to NAMI’s website, you can go to the website: findtreatment.samhsa.gov or by calling the National Treatment Referral Helpline at 800-662-HELP (4357). If you do not have papers, contact local Latino organizations that might be able to help or provide a referral. Additionally, you can search NAMI’s Compartiendo Esperanza to learn more about the importance of mental health awareness within Latino communities. 

 

1-US Census, 2015. 

2-National Alliance on Mental Illness 

3-Centers for Disease Control and Prevention, 2015. 

Originally published on http://utvalleywellness.com/

Hidden Signs of Depression

Studies show about 1 out of every 6 adults will have depression at some time in their life. This means that you probably know someone who is depressed or may become depressed at some point. We often think of a depressed person as someone who is sad or melancholy. However, there are other signs of depression that can be a little more difficult to detect.  

Trouble Sleeping 

If you notice a change in a loved one’s sleeping habits pay close attention as this could be a sign of depression. Oftentimes depression leads to trouble sleeping and lack of sleep can also lead to depression.

Quick to Anger
When a person is depressed even everyday challenges can seem more difficult or even impossible to manage which often leads to increased anger and irritability. This can be especially true for adolescents and children.  

Losing Interest 
When someone is suffering from depression you may notice a lack of interest in past times he or she typically enjoys. “People suffering from clinical depression lose interest in favorite hobbies, friends, work — even food. It’s as if the brain’s pleasure circuits shut down or short out.” 

Appetite Changes
Gary Kennedy, MD, director of geriatric psychiatry at Montefiore Medical Center in Bronx, New York cautions that a loss of appetite can be a sign of depression or even a sign of relapse back into depression. Dr. Kennedy also points out that others have trouble with overeating when they are depressed. 

Low Self-Esteem 

Depression often leaves people feeling down about themselves. Depression can lead to feelings of self-doubt and a negative attitude.  

What to do
If you suspect you or someone you love may be suffering from depression talk about it, encourage him or her to get professional help and once he or she does be supportive. Remember that at times symptoms of depression need to be treated just like any other medical condition.

Originally published on http://utvalleywellness.com/

 

Telling Your Kids About Divorce

Making the decision to divorce is hard enough when thinking about only the spouses involved, add kids to the mix and things get ten times more difficult. If you are going through a divorce, most likely you are concerned about how your decision to separate will affect your children, and how are you going to tell them? As parents we are constantly trying to protect our children from any pain and suffering, the reality is that the news of your parents’ divorcing, no matter how carefully delivered, is going to cause some kind of pain, hurt, or confusion in the eyes of your child.  Although you can’t control how you or your child will feel during this stressful time in your lives, you can make the choice to commit to seeking out effective ways to handle and offer a positive healthy source of support for your children. Committing to this will allow them to adjust to the divorce in a positive way, and in their own way as you lovingly guide them through the process.

TIPS  

  • If possible the news of the divorce should come from both Mom and Dad together as a family.  During this conversation stress the fact that even though family life is going to look very different, you will both continue to love them.
  • Tell the children that the divorce has nothing to do with anything that any of the children may have done or not done. Reassure them that they are not the cause of the divorce.
  • Children thrive on structure, especially during transition periods. Keep a daily routine with school, activities, and their regular everyday life. Keeping as much consistency as possible helps the children to feel more secure.
  • Having some kind of a plan of what life might now look like for them can be very beneficial. It is comforting for them to know where they will be going to school, where they will be sleeping, and how often they will see mom or dad. Nothing is permanent in this arrangement but offering them some sort of idea of how their lives will and won’t change will again help them to feel secure.  
  • Address your children’s concerns. Encourage them to talk, scream, cry or celebrate. Help them to feel safe in expressing their feelings.
  • Lastly make sure that they are told how much you both love them and how that will never change.

Studies show that children do best and have fewer long term emotional, social or academic problems, when parents can establish a healthy, respectful, co-parenting relationship. Transitioning into a new type of relationship and putting aside the hurt and anger that are associated with the broken marriage can be extremely difficult for many parents to accomplish. But through patience with each other and hard work it can be done. Divorce changes families but it does not end your commitment to your children. Make sure you take the time to find the solutions that work best for your family to ensure a positive outcome for you and your children.

**If you or your children are struggling to deal with the life transitions involved with divorce, seek out professional assistance for individual or family therapy. The therapist can assist in encouraging better communication, and helping all families member to properly heal and process the trauma of divorce.

 

Brandi Hess, MA, LAMFT

Brandi Hess has a passion for helping people to work through life’s difficulties, assisting them in finding joy, and the strength to reach their full potential. Brandi strives to ensure that she understands each of her clients’ unique needs. She provides therapy and counseling sessions tailored specifically to obtain her clients’ goals, in an individual or family setting. She offers a kind, honest, and straight-forward approach in therapy, allowing for trusting relationships to be built. She specializes in couples and family distress, pre/post-divorce, and adolescent treatment. One of Brandi’s many strengths is being able to connect with adolescents by creating a therapeutic environment where the adolescent feels safe and willing to start the process of change. Brandi works with a variety of concerns such as depression/anxiety, women’s issues, and trauma. Brandi received her Bachelors of Science in Human Development and Family Studies at the University of Utah, and her Master’s degree in Marriage & Family Therapy from Argosy University.

What to do if you are on a path of divorce – Couples Counseling

Marriage is never easy. Have you ever wondered how so many people seem to look so happy in theirs? Well – they might be, but chances are, they struggle too. The difference might be how you handle the struggle as a couple that can bring you happiness or not. It’s important to know that how you argue with your spouse matters more to the life and longevity and healthy of your marriage than the simple fact or presence of arguments in the first place – according to marital researcher John Gottman. Learning how to argue or fight fair is crucial to building a relationship that lasts. John Gottman outlines several important types of fighting that can harm your marriage. The first is criticism. This is where you directly complain and nitpick at your spouse. The second is contempt. This is harsher than criticism because you start to attack the character of your spouse instead of just what they are doing. The third is defensiveness. This is where you react with a defensive posture to things that your spouse does or says. Lastly, stonewalling. This is where you cut your spouse off emotionally and don’t engage in any way. John Gottman found that when these types of interactions are present in your marriage, that it’s in trouble. Come to counseling to find out what to do if you are engaged with your spouse in these ways of fighting. They can help fix and turn things around.

Pornography Addiction: An Epidemic

Pornography is a big business. Americans spent 97 billion dollars on pornography over the past five years. The monetary cost of this epidemic is only a part of the real cost of this problem in our country. Over the past decade, increasing attention has been given to the damaging effects of pornography on the brain and, by extension, the lives of individuals and families. The accessibility of pornographic material and the multitude of technologic means by which it comes into our lives has brought this issue increasingly into the spotlight. In fact, you may be reading this because pornography has impacted you, personally, or someone you love.  

There has been controversy in the psychiatric literature about whether those who struggle with pornography are “addicted.” Whether or not it is formally designated in the professional literature as an addictive disorder, it certainly has been shown to affect the brain and the lives of its users in ways consistent with other addictive disorders. As with any addiction, an understanding of the process is key. Let’s start with how the brain responds to pornography. Our brains are designed to catalog our experiences with the end goal of preserving life and eliminating threats to our safety. Essentially, our brains are effective at remembering what feels good and what doesn’t. While this process is complex, a basic understanding of a few key brain chemicals is critical. 

The brain responds to pornography by releasing a powerful chemical called dopamine. Dopamine is released whenever we have pleasurable experiences. The release of dopamine and another powerful chemical called epinephrine (adrenaline) floods the brain in connection with pornography. With repeated exposure, a neural pathway in the brain is created that links arousal and associated neuro-chemicals dopamine and adrenaline with pornography use. As pornography exposure and dopamine release increases, dopamine receptors are eliminated. This “flooding” of the brain creates habituation or tolerance, resulting in the need for even greater stimulus (more explicit and “hard-core” pornography, novelty and intensity) to achieve the same effect.  

Dr. Donald L. Hilton, Jr. MD, a neurosurgeon at the University of Texas, has written extensively about the effects of pornography on the brain. His research and other reviews conclude that the effects of pornography on the brain are comparable to potent drugs, such as cocaine. He also explains that when the body orgasms, the brain produces a particular neurotransmitter called “oxytocin” which creates bonding. Oxytocin is also secreted in the brains of babies and moms during breastfeeding. So we are literally bonding to pornography (a digital image) when we reach climax. In an article published in the Harvard Crimson, Dr. Hilton states that “pornography emasculates men—they depend on porn to get sexually excited and can no longer get off by having sex with their women alone. What happens when you are addicted to porn is that you crave it. Real sex even becomes a poor substitute for porn, and you lose interest.” ¹ 

A final neurophysiologic effect of pornography is the damage created to the impulse control center of the brain, the pre-frontal cortex. With constant flooding of the brain with dopamine and epinephrine, there is a reduction in size and control of this area. Essentially, the ability to self-regulate and exercise impulse control is reduced until, ultimately, the addiction drives appetites, desires, and behaviors. As individuals fall into the grip of this addiction, they often experience other effects, such as isolation, depression, anxiety, sexual dysfunction, and relationship distress, among others – all of which spiral the individual away from resources that can lift and help them toward recovery and healing.  

As awareness of this issue increases, so do resources aimed at educating and assisting those affected by pornography addiction. A relatively new campaign called “Fight The New Drug” (www.fightthenewdrug.org) is an excellent resource for those seeking more information regarding the impact of pornography. There are also many religious/spiritually-based programs available², many of which are based on the twelve-step program utilized by Alcoholics Anonymous (AA).  

An Ethic to Live: Building Barriers to Suicide Around Ourselves & Those We Love

In cities throughout the world, notable high buildings and bridges increasingly have additional fencing built atop of them with the specific purpose of preventing suicides. Suicide fences tend to work because research has shown that suicidal actions are frequently impulsive, hence such fences serve to forestall that impulse and buy individuals precious time to further think about their decisions. In studies of suicide fences, it appears that individuals don’t leave such barriers to go look for another bridge or tall building to end their lives from, but instead return to the business of living for yet another day.  

Presently suicide is the leading cause of death among young people ages 10-17 here in Utah, and over the last decade, it’s also doubled amongst adults in our state. As concerned friends, neighbors, and parents, how do we help our community build more barriers to suicide; protecting and empowering those we love? Over the next year, I’ll be writing a series of articles in answer to this question; offering my perspective as both a therapist, who has stood on sacred ground in helping others walk back from suicidal thinking, and as one who’s felt and ultimately rejected the dark pull to end my life amidst heavy times.   

Perhaps you’ve already noted that there’s no way to build suicide fences everywhere or to somehow block all of the endless ways in which someone might consider ending their life. Sound public policies on prevention and physical barriers like suicide fences are only some of the important ways to help. So in addition to these forms of prevention, the focus of my writing will be on how to build barriers to suicide directly into the thinking and values of individuals, and into the culture of our community as a whole. In this first article, I want to introduce how we help foster an ethic to live within ourselves and in others as a key barrier to suicide.  

An ethic to live means valuing our lives and holding a commitment within ourselves to continue living — even when we’re unsure of how we’ll cope or move forward. In my experience, helpful conversations about consciously building an ethic to live, begin by first taking care to turn our attention to the reality that to live is to be vulnerable to an array of difficult life experiences, with the potential to evoke within us the thought to end one’s life to escape them. Throughout human history, individuals and peoples have had to confront extremely painful and unjust challenges which have overwhelmed their sense of being able to continue on, and it’s important to acknowledge that when we confront such considerable pain, it is the most human thing in the world to want relief from it. This is real; excruciating human suffering beyond one’s current sense of how to reduce or stop it is real, and in these concentrations of pain, we may find ourselves having suicidal thoughts.  

When we acknowledge and honor that such excruciating life experiences do show up for many of us, it’s then that we can locate where we need to begin building internal fences to prevent suicide. It’s here that we recognize the need to develop a strong ethic to live even though there are times that we might not yet fully know how we’ll cope or be able to see brighter ways forward. It’s also here that we find the need to define as individuals what makes life worth living with specificity to our own life experiences, as well as the need to find a listener who we can turn to and voice what’s going on inside of us. 

As you navigate life’s difficulties, no matter how hard things may get, make the commitment now to live and identify your personal reasons to do so. Additionally, identify suicidal thoughts as a  sign to find a listener who you feel safe enough to talk to. It’s worth thinking about right now who it is you might feel comfortable turning to during your hardest times. By doing so, you’ll begin to build your own internal fence between you and suicide as well as have greater insight as to how to help others you care about to do the same.  

* If you or someone you care about is currently having thoughts of ending their life, caring help is available 24/7 by texting 741741 from anywhere in the USA or you can call 1-800-273-8255 to speak directly with a Counselor from the National Suicide Prevention Lifeline. 

Bio: Laura Skaggs Dulin holds a master’s degree in Marriage and Family Therapy from San Diego State University. She currently sees clients at the Spanish Fork Center for Couples and Families and at Encircle LGBT Youth and Family Resource Center in Provo.  

Forced Apologies

My four-year-old daughter placed herself in the middle of our living room to play with blocks. She was so engrossed with building a wooden castle that she didn’t notice her two-year-old sister walking towards her with her right arm stretched far back to slap her older sister across the head. When that slap came, my older daughter went from happy to surprise to anger and then lots of tears. She ran towards me seeking justice. “Mommy, she hit me!” My younger daughter remained still, looking innocent. I immediately walked over to her with my older daughter in hand and said, “Hands are not for hitting. Say sorry for hitting please.”  I’m sure many parents can relate to this scenario. Teaching our children the skills for making amends is an important life skill and is not so much about saying the words “I’m sorry”.  

There is a belief amongst some parents that enforcing premature apologies on children is not effective. Their reasoning is that premature apologies teach children to lie and encourage insincerity. It also creates shame and embarrassment. Other studies show that young children have the ability to be empathetic even before they can speak; therefore, parents should encourage apologies (Smith, Chen, Harris; 2010). As I reflected on my research and my knowledge as a Marriage and Family Therapist, I recognized several things we can do as parents to create productive apologies: 

  1. Keep yourself in check: It’s frustrating to see your children fight, especially when it happens at inconvenient times. However, it’s important to remain calm and model for your children how to handle frustration.   
  2. Be immediate when possible: When you see an incident occur between your children, address it. The best time for learning and growth is when the incident is still fresh in their minds. However, when there are time constraints and the issue cannot be addressed right away, it is important to tell your children when and where it will be addressed. Be consistent when using the alternative and follow through.  
  3. Ask instead of tell: Avoid lecturing. Ask questions instead. “Tell me what happened?” “What were you feeling when you hit your sister?” Validate the expressed emotion and help them to understand that it is okay to feel frustration and sadness; however, it is not okay to hit or throw things. Help them to also make the connection between emotion and action. “Look at her face, how do you think she’s feeling right now?” Asking these types of questions enhances empathy. 
  4. Problem Solve: Ask questions about what they think they should do when they feel frustrated or sad. Help them to come up with solutions.  Ask questions about how they can make things better with their sibling/s. 
  5. Have them practice a do-over: When your child identifies the solution, have them practice it with the other sibling/s. Praise them for their efforts at the end.    

What is more important than the phrase “I’m sorry” is what children take away from the experience. We can facilitate and enhance learning opportunities by not focusing on the phrase “I’m sorry” but instead more on what can be learned from this situation and how can we improve.  

Looking for Happiness and Finding Addiction

Our community is the epitome of mainstream America. We have deeply rooted family values, safe streets, moral standards, and most families stand guarded against outside influences that threaten our happiness. Recently, however, Utah achieved the 7th highest drug overdose rate in the nation. How can a community named Happy Valley have some of the highest rates of adult mental illness and teenage suicide in the country? 

Treating addiction is clearly a necessity. However, explaining these alarming and confusing statistics may also come down to understanding some myths, or assumptions, about happiness.  

Myth No. 1: I Should Be Happy All the Time 

Some aspects of our local community amplify and reinforce the well-intended message that “good people” or “my kid” should not or would not encounter pain. At times, we may even feel entitled to getting our way and therefore feel betrayed when we stress and we encounter unwanted but normal life struggles. These challenges show up as: loneliness, divorce, work stress, relationship issues, domestic violence, bullying, prejudice, low self-esteem, and chronic pain to mention a few.  

Myth No. 2: If I’m Not Happy, Something is Wrong with Me 

For decades, mental health symptoms have been twisted and misunderstood to the point that painful or overwhelming thoughts and feelings are now presumed to be products of weak, faulty, and unworthy minds. Labels like ‘Anxious’, or ‘Addict’ are now used so frequently and in such negative ways it distracts us from the real issue at hand. Those labels not only build a wall but also mask the reality that we all struggle in similar ways. Combine these objectifying terms with a competitive culture this myth grows more powerful and exponential.  

Myth No. 3: For a Better Life, I Must Get Rid Of Negative Feelings  

Every single one of us experiences self-judgment, fear, and shame of not measuring up. It can be overwhelming and discouraging. Unfortunately, we live in a culture that promotes numbing and hiding as the solution to any pain or discomfort.   

Anger, over-working, blaming, over-booking schedules, and isolation has been dependable sources of distraction for years. Some argue how safe and how little impact these behaviors have on themselves and others. Ironically, they assume that dependent or ‘addictive’ thinking and behaviors are only appropriate if describing illicit drugs and alcohol. Recently, more camouflaged options like sugar, caffeine, over the counter medication, smoking, power drinks, and trendy diets have become legal and justified ways to remedy unwanted thoughts or deal with social pressures. All of these behaviors, and others, are designed to alter reality, enhance social performance, and reduce stress. Unbeknownst to us, we end up trading one form of addiction for another.  

Everyone considers himself or herself an unwilling and/or unaware accomplice and each would avoid the road of undue suffering if possible. Here are three practical take home ideas that can help you start breaking yourself free from the shackles of these myths and identify and strengthen your core values so you can stay connected with reality.  

  1. Take time and energy to notice core values that you have and may share with others. Write down and/or share thoughts, feelings, and memories that help identify and strengthen your core values. Yoga, meditation, and other quiet activities will improve focus and self-awareness. 
  2. Compare less. Look for opportunities to learn about and accept the uniqueness of others. Admitting and accepting our weakness and vulnerability to others actually creates meaningful emotional and social bonds.  
  3. React less. Take a deep breath and refocus values that you can practice today.  

All of us long for acceptance, empathy, and connection from others but sometimes get stuck in the attractive web of addictive behaviors. If help is needed, reach out to others or professionals. Enjoy the search for happiness in the everyday pursuit of values, not distractions.