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Depression

‘Drugs are having a positive effect for some people – but they clearly can’t be the main solution for the majority of us.’ Photograph: Alamy

For various reasons I needed recently to look into the current state of thinking about depression. As a result I stumbled upon this article by Johann Hari with which I strongly resonate. The closing paragraph hits a very important nail exactly on the head:

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs – for deep connection, to the things that really matter in life.

Below is another short extract: for the full post see link.

I started to research my book, Lost Connections: Uncovering The Real Causes of Depression – and the Unexpected Solutions, because I was puzzled by two mysteries. Why was I still depressed when I was doing everything I had been told to do? I had identified the low serotonin in my brain, and I was boosting my serotonin levels – yet I still felt awful. But there was a deeper mystery still. Why were so many other people across the western world feeling like me? Around one in five US adults are taking at least one drug for a psychiatric problem. In Britain, antidepressant prescriptions have doubled in a decade, to the point where now one in 11 of us drug ourselves to deal with these feelings. What has been causing depression and its twin, anxiety, to spiral in this way? I began to ask myself: could it really be that in our separate heads, all of us had brain chemistries that were spontaneously malfunctioning at the same time?

To find the answers, I ended up going on a 40,000-mile journey across the world and back. I talked to the leading social scientists investigating these questions, and to people who have been overcoming depression in unexpected ways – from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore conducting a startling wave of experiments. From these people, I learned the best scientific evidence about what really causes depression and anxiety. They taught me that it is not what we have been told it is up to now. I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise – alongside two real biological factors (such as your genes) that can combine with these forces to make it worse.

Once I learned this, I was able to see that a very different set of solutions to my depression – and to our depression – had been waiting for me all along.

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Graph of the Model that states Psychosis is Distinct for Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

Graph of the Model that states Psychosis is Distinct from Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

The British Psychological Society (BPS) has stated that ‘clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences … but which do not reflect illnesses so much as normal individual variation… This misses the relational context of problems and the undeniable social causation of many such problems’. The BPS Division of Clinical Psychology (DCP) has explicitly criticised the current systems of psychiatric diagnosis such as DSM–5 and ICD–10. It has suggested that we need ‘a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model’.

(From Understanding Psychosis and Schizophrenia published by the BPS – page 28)

What has this to do with EMS?

EMS stands for Everybody Means Something. My work as a clinical psychologist was with people who were experiencing what our culture calls a psychosis. When I started work in the NHS most people felt that these experiences were meaningless. I disagreed. I found myself using those three words as a kind of mantra to remind myself of my conviction. It was a no-brainer to use them as the title for my blog.

Various experiences reinforced my scepticism about the medical model with its prevailing assumption that such experiences are largely biologically determined. I came increasingly to believe it was significantly incomplete, possibly seriously flawed.

Before I move onto psychosis in particular there is a story from my earlier experiences in clinical psychology, which served to reinforce my scepticism and which clearly illustrates how this default assumption can operate as a potentially damaging blinker.

Laura had been given a diagnosis of endogenous depression, ie one that was not explicable in terms of her life situation. She used to believe that her parents were more or less perfect. The work we were doing became very stuck and seemed to be going nowhere.

We had plateaued on bleak and distressing terrain, more tolerable than her previous habitat but too unwelcoming to live on comfortably for the rest of her life, and yet with no detectable path towards more hospitable ground.

Frustrated by the protracted lack of movement, I began to see discharge as a very attractive option. I discussed this with my peer supervision group. We decided that I should continue with the processes of exploration but make sure that I did not continue my habit of stepping in relatively early to rescue her in sessions from her frequent experiences of intense distress. I continued to see her, having agreed with Laura that I would allow her to sink right into the “heart of darkness” in order to explore it more fully and understand it more clearly. The very next session, when we first put this plan into action, after I had left her alone in her silence for something like half an hour, Laura came to a powerful realisation at the heart of a very intense darkness. She said: “I think my mother threw me away even before I was born.”

This paved the way for deeper and more fruitful explorations of the reality of her childhood, the nature of which I will come back to later in this sequence of posts.

Since I started this blog almost eight years ago now, my interests have ranged widely across many topics, and psychosis has only featured in a relatively small number of posts. Decluttering has triggered me back into my fascination with ‘psychosis’ as the recent posts on out-of-the-ordinary-experiences illustrates.

When I trawled through my backlog of journals I found no other article dealing with that topic. On the web as a whole my most important find is a book edited by Isabel Clarke titled Spirituality & Psychosis which touches on it in places. I will need to buy a copy of that and read it carefully before I can even begin to comment, but the Chapter headings and their authors on the Google version certainly whetted my appetite. How could I resist a book dealing with two of my favourite obessions?

I have found a few other titles on related themes via the British Psychological Society website and it is on three key papers from among those that I wish to focus now.

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

We’re on a Continuum

Bethany L. Leonhardt et al, right from the beginning of their article[1] arguing that psychosis is understandable as a human experience (page 36), ask us to regard the symptoms of psychosis ‘as part an active meaning-making process, regardless of whether or not that meaning is adaptive.’

They explore how the use of literature, particularly novels, can help those who work with people who are having psychotic experiences tune into their predicament more empathetically. As a result of their use of this method, they offer some interesting perspectives.

For example, (page 47) they ‘suggest that exposure to novels and related literary genres may help prevent therapists from surrendering to the view that psychosis is not understandable as anything other than a collection of abstract symptoms or from infantilizing patients by offering of paternalistic direction or protection from life demands.’

As we have seen in the previous sequence on out-of-the-ordinary experiences (OOEs), the attitudes of others has a powerful effect upon how well or how badly a person is able to deal with their bizarre and often frightening experiences. An assumption that what people have experienced is meaningless is at best patronising and at worst confrontational and undermining. One of my own early observations was that most of the clients I saw were expecting me to dismiss everything they were saying, either by ignoring it, refusing to discuss it in any way that resembles their own terms or by frankly rubbishing and pathologising it. They seemed both surprised and relieved when I did my best to engage with them in an attempt to understand it, which is of course not the same as endorsing everything they told me as objectively true. It was though a way of taking what they said seriously and respectfully. For a fuller explanation of my approach click on the posts listed below.

On the occasions where I was unable to sustain this at a sufficiently high level I risked damaging the relationship. I can remember one such occasion. A client was convinced that the devil was plotting against him and kept bringing forward the evidence he thought proved it. My approach clearly aroused his suspicions as to my beliefs about the devil, and he repeatedly pushed me to disclose what my own beliefs were. After several repetitions of this over a number of sessions I concluded that my holding back was blocking further progress. I made the mistake of letting him know that I thought that the devil had no objective existence but was a metaphor to explain evil. He discontinued therapy at that point.

In retrospect I realised that I could have given a more authentic response from a deeper level of my thinking and stated that, while for practical purposes in my own life I did not operate on the assumption that the devil existed, I had to admit that there was no way I could dogmatically state or absolutely prove that he didn’t: agnosticism on that point would have been a better and perhaps more honest answer. Though I may have failed this client, I learnt something very helpful for future interactions.

Equally importantly, Leonhardt et (ibid) ‘acknowledge that our views largely draw on the idea that psychosis can be understood as existing along the continuum of human experience. Our use of novels and related literary genres indeed seems predicated on the idea that individuals experiencing psychosis are not inherently different from anyone else, and that some of the strangest and most bewildering experiences can be made sense of while reading literature and engaging in other reflective activities.’

This ability to find ways of empathically recognising that psychosis is a point on a dimension we all share in some way is a key requirement of a true understanding of what psychosis is in my view.

Next time I will explore the role of trauma in the formation of psychosis.

Related Posts

An Approach to Psychosis (1/6): Mind-Work & Trust
An Approach to Psychosis (2/6): Surfaces & Depths
An Approach to Psychosis (3/6): Complicating Factors
An Approach to Psychosis (4/6): The Mind-Work Process (a)
An Approach to Psychosis (5/6): The Mind-Work Process (b)
An Approach to Psychosis (6/6): Fitting It All Together

References:

[1] The article was published in the American Journal of Psychotherapy, Vol. 69, No. 1, 2015.

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depression

Illustration by Sébastien Thibault

Yesterday’s Guardian posted an article by Tim Lott that simply won’t wait. I feel I must post the link to it today. It is heartfelt, insightful and powerful, and deals with a phenomenon that most of us understand only poorly if at all, but which affects innumerable people at some point in their lives. Below is a short extract: for the full post see link.

Darker than grief, an implosion of the self, a sheet of ice: no matter how you describe it, this is a terrifying state to be trapped in.

This is Depression Awareness Week, so it must be hoped that during this seven-day period more people will become more aware of a condition that a minority experience, and which most others grasp only remotely – confusing it with more familiar feelings, such as unhappiness or misery.

This perception is to some extent shared by the medical community, which can’t quite make its mind up whether depression is a physical “illness”, rooted in neurochemistry, or a negative habit of thought that can be addressed by talking or behavioural therapies.

I’m not concerned about which of these two models is the more accurate. I’m still not sure myself. My primary task here is to try to explain something that remains so little understood as an experience – despite the endless books and articles on the subject. Because if the outsider cannot really conceptualise serious depression, the 97.5% who do not suffer from it will be unable to really sympathise, address it or take it seriously.

From the outside it may look like malingering, bad temper and ugly behaviour – and who can empathise with such unattractive traits? Depression is actually much more complex, nuanced and dark than unhappiness – more like an implosion of self. In a serious state of depression, you become a sort of half-living ghost. To give an idea of how distressing this is, I can only say that the trauma of losing my mother when I was 31 – to suicide, sadly – was considerably less than what I had endured during the years prior to her death, when I was suffering from depression myself (I had recovered by the time of her death).

So how is this misleadingly named curse different from recognisable grief? For a start, it can produce symptoms similar to Alzheimer’s – forgetfulness, confusion and disorientation. Making even the smallest decisions can be agonising. It can affect not just the mind but also the body – I start to stumble when I walk, or become unable to walk in a straight line. I am more clumsy and accident-prone. In depression you become, in your head, two-dimensional – like a drawing rather than a living, breathing creature. You cannot conjure your actual personality, which you can remember only vaguely, in a theoretical sense. You live in, or close to, a state of perpetual fear, although you are not sure what it is you are afraid of. The writer William Styron called it a “brainstorm”, which is much more accurate than “unhappiness”.

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WebsterA recent Guardian article by  points up the evidence that is beginning to call into question the reigning assumption that Cognitive Behaviour Therapy (CBT) is not only the most effective but also the cheapest form of therapy for most common mental health problems.  It seemed a good time to flag this up when I have just finished blogging about Mark Edmundson’s sceptical attack on Shakespeare and Freud, and quoting Richard Webster in support. Burkeman looks at the relative merits and drawbacks of both forms of therapy in this probing article (no Freudian pun intended!). It niggles me even so that insufficient emphasis is still being placed on the need for the inclusion of a spiritual dimension in all therapeutic models if they are going to work for more than the circumscribed needs of a narrow band of clients. Burkeman rightly emphasises at the end of his article the primary importance of the relationship between client and psychotherapist. Below is a brief extract: for the full post see link.

Cheap and effective, CBT became the dominant form of therapy, consigning Freud to psychology’s dingy basement. But new studies have cast doubt on its supremacy – and shown dramatic results for psychoanalysis. Is it time to get back on the couch?

Freud (this story goes) has been debunked. Young boys don’t lust after their mothers, or fear their fathers will castrate them; adolescent girls don’t envy their brothers’ penises. No brain scan has ever located the ego, super-ego or id. The practice of charging clients steep fees to ponder their childhoods for years – while characterising any objections to this process as “resistance”, demanding further psychoanalysis – looks to many like a scam. “Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say” than Sigmund Freud, the philosopher Todd Dufresne declared a few years back, summing up the consensus and echoing the Nobel prize-winning scientist Peter Medawar, who in 1975 called psychoanalysis “the most stupendous intellectual confidence trick of the 20th century”. It was, Medawar went on, “a terminal product as well – something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.”

A jumble of therapies emerged in Freud’s wake, as therapists struggled to put their endeavours on a sounder empirical footing. But from all these approaches – including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on – it’s generally agreed that one emerged triumphant. Cognitive behavioural therapy, or CBT, is a down-to-earth technique focused not on the past but the present; not on mysterious inner drives, but on adjusting the unhelpful thought patterns that cause negative emotions. In contrast to the meandering conversations of psychoanalysis, a typical CBT exercise might involve filling out a flowchart to identify the self-critical “automatic thoughts” that occur whenever you face a setback, like being criticised at work, or rejected after a date.

Yet rumblings of dissent from the vanquished psychoanalytic old guard have never quite gone away. At their core is a fundamental disagreement about human nature – about why we suffer, and how, if ever, we can hope to find peace of mind. CBT embodies a very specific view of painful emotions: that they’re primarily something to be eliminated, or failing that, made tolerable. A condition such as depression, then, is a bit like a cancerous tumour: sure, it might be useful to figure out where it came from – but it’s far more important to get rid of it. CBT doesn’t exactly claim that happiness is easy, but it does imply that it’s relatively simple: your distress is caused by your irrational beliefs, and it’s within your power to seize hold of those beliefs and change them.

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Could depression be a form of ‘sickness behaviour’? Photograph: Mads Perch/Getty Images

Could depression be a form of ‘sickness behaviour’? Photograph: Mads Perch/Getty Images

It was my good friend, Barney, who drew my attention to a recent Guardian article. It resonates slightly ironically with my recent investigation into the possible sources of subliminal sorrow. It would indeed be an anticlimax if the deep sense of exile which occasionally bursts into my consciousness was simply a symptom of man flu. I’m doubtful of that as I can’t claim ever to have experienced the harrowing distress of true and intractable depression.

If this research can lead to more effective treatment it is to be welcomed: if it simply turns out to be another over-optimistic way of medicalising an emotional problem I hope it is quickly discredited.

Below is a short extract: for the full post see link.

A growing number of scientists are suggesting that depression is a result of inflammation caused by the body’s immune system

Barely a week goes by without a celebrity “opening up” about their “battle with depression”. This, apparently, is a brave thing to do because, despite all efforts to get rid of the stigma around depression, it is still seen as some kind of mental and emotional weakness.

But what if was nothing of the sort? What if it was a physical illness that just happens to make people feel pretty lousy? Would that make it less of a big deal to admit to? Could it even put a final nail in the coffin of the idea that depression is all in the mind?

According to a growing number of scientists, this is exactly how we should be thinking about the condition. George Slavich, a clinical psychologist at the University of California in Los Angeles, has spent years studying depression, and has come to the conclusion that it has as much to do with the body as the mind. “I don’t even talk about it as a psychiatric condition any more,” he says. “It does involve psychology, but it also involves equal parts of biology and physical health.”

The basis of this new view is blindingly obvious once it is pointed out: everyone feels miserable when they are ill. That feeling of being too tired, bored and fed up to move off the sofa and get on with life is known among psychologists as sickness behaviour. It happens for a good reason, helping us avoid doing more damage or spreading an infection any further.

It also looks a lot like depression. So if people with depression show classic sickness behaviour and sick people feel a lot like people with depression – might there be a common cause that accounts for both?

The answer to that seems to be yes, and the best candidate so far is inflammation – a part of the immune system that acts as a burglar alarm to close wounds and call other parts of the immune system into action. A family of proteins called cytokines sets off inflammation in the body, and switches the brain into sickness mode.

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Van Gogh's Prisoners Exercising: nine out of 10 prisoners have mental health issues when they enter prison. Photograph: Alamy.

Van Gogh’s Prisoners Exercising: nine out of 10 prisoners have mental health issues when they enter prison. Photograph: Alamy.

It is an indictment of our society’s approach to mental health that effective treatment for many forms of mental problem is not sufficiently available to meet the need. The strength of Layard and Clark’s book – Thrive is to draw this forcefully to our attention. The Guardian Review quoted at length below gives a good sense of the case they make.  

The data the authors refer to in the book include the fact that (page 381):

. . . while over 90% of diabetes sufferers receive treatment for their condition, under a third of adults with diagnosable mental illness do so. This is largely because good evidence-based psychological therapy is not readily available. 

They are also quite scathing about the absence of adequate provision for children, a position which Wednesday’s BBC News item suggests is apparently shared by the government:

Mental health services for young people in England are “stuck in the dark ages” and “not fit for purpose”, according to a government minister. Norman Lamb told BBC News he was determined to modernise the provision of psychiatric help for children.

Although some reviewers have reservations about some aspects of the book, in my view the relevance of its message to the desperate needs of this group of people makes it vital that it be read, understood and implemented in terms of its basic case.

It is interesting also, from my point of view as a retired clinical psychologist and Bahá’í, that they recognise that there need to be changes in the thinking, practice and values of the wider society if we are to prevent, rather than simply fight, the fires of depression, addiction and anxiety to name only the commonest problems.  

Emotional well-being should be taught in school (page 387), our society should become ‘less macho, with more emphasis on collaboration and less on competition.’ We also need to see a continuing ‘feminisation of our values – with more importance attached to relationships and to peaceable and harmonious living. This will be helped greatly as more women come to the top of their professions.’

They also recommend (page 388) that there should be ‘a cabinet minister for mental health’ and, no surprise this one, they hope that ‘mindfulness may become a regular practice taught in schools and practised by many adults.’

Some reviewers have felt that this prescription for society goes way beyond the evidence and, by implication, their brief. I don’t share that view. The book is a powerfully worded invitation to think about the issues facing our society in its approach to mental health. Obviously there is far more to be said, but this is a good place for anyone to start.

Below is an extract from the Guardian Review: for the full article, see link.

Guardian Review

“I once broke my leg in 10 places. As I was taken to hospital, someone shut the door on my leg. You can imagine the pain. But I can tell you the pain of depression is many times worse.”

This powerful quote from businessman Dennis Stevenson illustrates how mental pain can be just as real and even more agonising than physical pain. It opens a punchy polemic that demands action to tackle the misery of mental illness, pointing out the strange inequality that sees broken bones treated but shattered spirits ignored.

Many readers will know this from personal experience. One in six British adults suffers from depression or anxiety disorders that disrupt, even destroy, lives. Mental illness is often more disabling than chronic conditions such as angina, arthritis or diabetes, while it shortens life expectancy as severely as smoking. One in three families contains someone who suffers mental illness, with one in 10 children having diagnosable mental disorders – yet fewer than one-third of these people receive treatment.

Such shocking statistics litter the pages ofThrive, the latest blast by former “happiness tsar” Richard Layard in conjunction with David Clark, professor of psychology at Oxford University. Lord Layard is a celebrated labour economist who deserves plaudits for promoting the concept of placing wellbeing alongside wealth as a government goal – an idea promoted by David Cameron in opposition, then sadly shunted aside in office after coming under fire from critics who failed to understand the issues.

The book’s central point is that the failure to place mental illness on a par with physical illness costs the country dearly. This is perhaps most obvious with suicide rates. The vast majority of people who kill themselves are mentally ill – and as many people die worldwide at their own hand as from murder and warfare combined. Twice as many men take their own lives as women, something I have seen from traumatic personal experience like too many people – and perhaps most poignantly, youth suicide is rising in most nations.

Beyond these individual tragedies, the authors argue, the entire country suffers from this mental health crisis since it imposes such costs on society. “The scale of mental illness is mind-boggling,” they write. It accounts for almost half of absenteeism, keeps big numbers out of work and drives up the benefits bill; the combined effect on the economy reduces national income by an astonishing 4%. Nine out of 10 prisoners also have mental health conditions upon entering prison.

This barrage of data is bad enough. “But what is really shocking is the lack of help,” say Layard and Clark.

It may not make for the most scintillating reading but it is hard to argue with their case that the failure to help those in mental distress is an injustice. Anyone with the slightest experience of mental illness knows how crushing these conditions can be; we should be thankful that the courage of some sufferers, in discussing the impact in public, is starting to end an irrational social stigma. It also makes economic sense, since helping people to recover from their problems generates immense savings for national economies.

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