Mental Health Myths, Inkblot Tests and Electro-Shock Therapy

Stigma associated with mental illness can be a serious deterrent that prevents individuals from seeking help. While it is estimated that as many as 1 in 5 of the North American population suffers from a diagnosable mental health issue, 80% of those who are suffering will not seek assistance. Some of this stigma comes from popular ideas surrounding psychiatric treatment, a general confusion about what talk therapy is, lack of clarity regarding the efficacy of the various anti-depressant drugs and other medical treatments available today, and a general misunderstanding of what mental illness entails.

Mental illness is frightening for some people in a way that physical ailments are not. While people are of course afraid of being hurt in a car accident for example, the shame associated with mental illness has no analogue in physical injuries. We sometimes associate mental illness with a moral failing, a bad background, or a lack of will power, and these reactions are simply unfair and unkind. We rarely blame someone who has broken a bone in a sporting accident on the weakness of their personality, or worry that this injury indicates that the person is no longer trustworthy.

These fears have three principal sources, 1) the general lack of understanding surrounding the symptoms of mental illness, 2) the long and complex history of psychiatry, and 3) the cultural myths around the behavior and treatment of the mentally ill.

When I first struggled with depression I went to see several different university counsellors. If you are a university student you should be aware that many campuses offer mental health counselling services to students free of charge. I was able to see social workers at various times during my studies who were happy to meet with me on a semi-regular basis. The counsellors that I saw essentially just listened to what I had to say, some offered more advice than others. My confusion and fear about what was happening to me left me unable to ask direct and clear questions. While I think these counsellors tried to help and were reasonable and decent people, given that my initial symptoms were rather vague, their advice wasn't very specific.

Rorschach Inkblot Image

Free association, and its visual relatives, the Rorschach inkblot test, and the Thematic Apperception test, are all rooted in very early notions of diagnosing psychiatric patients. These methods are grouped under the title of projective techniques, and many people are familiar with them in at least a theatrical presentation of psychiatry. Everything I knew about psychiatry when in university I had learned from movies and television (I was majoring in mathematics and computers at the time), since what I saw on TV was usually some form of free association diagnosis, I thought that this was what I was getting from university counsellors.

The practice of letting a patient explain their worries and concerns, and talk about their past with little guidance from the therapist originates with Freud. In free association an individual lies on a couch, sometimes with the therapist seated behind them out of view, and says whatever comes to mind. In this model it is the therapist's job to help the client connect ideas and feelings that he or she was not aware of. Freud also analyzed dreams in this way. He developed this method in part because at the time hypnosis was being used as a therapeutic method to treat mental illness, and hypnosis did not always work. Freud found that many patients could not be hypnotized, and so he developed free association as a more general technique to explore the psyche of his patients. While some therapists still use a variation of this Freudian method, it is rarely used in this classical form today. In Mental Health through Will-Training Dr. Abraham Low has several very critical things to say about classical psychoanalysis, specifically that it is a very long and expensive process.

There is a recent BBC documentary discussing Signumd Freud's work and life presented by Bethany Hughes. While she credits Freud with inventing modern psychoanalysis she is also careful to point out that there were numerous flaws in how he treated his patients. She makes clear that today most people question the effectiveness of his methodologies and the utility of his basic theories as part of treatment.

In the early 1900s Herman Rorschach experimented with inkblots. He was interested in the sensory processing of abstract images by his patients, and used the images as stimulus for a test similar to the free association method used by Freud. For Rorschach, the content of what was seen in the inkblot was not as interesting as the elements used, for example whether the person saw a whole image, or whether they focused on small details in the blot. Rorschach published a small collection of plates in a book on the subject in 1921. He died shortly thereafter. After Rorschach's death various clinicians adopted the method and used it as a part of their practice. Scoring the Rorschach test is a complicated process that continues to be the focus of scientific debate. While the Rorschach inkblot test has a long history of use, and there have been recent attempts to update and standardize the test, researchers remain critical of its value.

The Thematic Apperception test (TAT) is composed of 30 black-and-white drawings of various scenes and people. Typically an individual is shown 20 cards, one at a time, and asked to create a story about what is going on in the picture. The idea is that by observing the character and themes of an individual's response that it is possible to gain insight into their thoughts. For example, if an individual often talks about one person leaving the other, the therapist might ask whether abandonment is an issue. The TAT lacks scientific evidence that might make it useful as part of developing a diagnosis.

Thematic Apperception Test Image

While some professionals see the value in these projective techniques in terms of their ability to test how an individual responds to ambiguous stimuli, the major disadvantages of these methods center on questions of validity and the test's ability to tell us anything specific.

Because of the visual quality, mysterious character and history of these tests they are often featured in movies and television programs. Before meeting any counsellors or therapists I believed that psychiatry was about lying on a couch while talking about my childhood, my feelings and that as I responded to strange images I expected a therapist to write down lengthy notes. After some time the therapist would tell me something dramatic and enlightening about myself, and this would be my road to a cure. Despite meeting many psychiatrists and counsellors I've never had any of these experiences. Psychiatry, insanity, mental institutions, and treatments for the depressed or suicidal are a common trope of films and literature, and there was a time when this was all I knew about the treatment of mental health. Some of these films are great, truly terrifying, and fantastically suspenseful, but not entirely realistic or helpful for those who have an actual mental illness.

Recently I watched the "Mind-Hunter" series on NetFlix that chronicles the development of the early behavioural sciences unit at the FBI and focuses on the personal difficulties that the investigators have as they learn about the unusual behaviour of serial killers through one-on-one interviews. Another film I enjoyed recently was "A Cure for Wellness", which tells the story of an executive who is sent for an unusual therapy in the Swiss Alps, and learns that once patients enter this idyllic sanatorium they are reluctant to leave. In a "Clockwork Orange" drug based conditioning is used to modify the violent behaviour of Alex, a young gang leader. After a failed suicide attempt Alex takes a version of the TAT test to measure the damage that resulted from his behavior modification. In "Harold and Maude", an affluent teenage boy fascinated with suicide falls in love with Maude, a 79 year old survivor of a concentration camp. Harold's therapist accuses him of sexual perversion, while Maude teaches him about the joys of life. The "Hannibal" TV series as well as its original source material "The Silence of the Lambs" present variations of the fantastical Dr. Leckter, who uses his knowledge of the human psyche as a weapon. "12 Monkeys", staring Bruce Willis and Brad Pitt, is another great example of thriller science fiction that features macabre scenes set in psychiatric wards where the stresses of time travel cause Willis' character to be unsure about reality. The contemporaneous "Fight Club", starring Brad Pitt and Ed Norton has an entire sub-narrative devoted to group therapy meetings, and formed my initial expectation of what I would find at Recovery meetings. These expectations where entirely inaccurate as I learned when I first attended a meeting.

The most famous story featuring a psychiatric ward is perhaps "One Flew Over the Cuckoos Nest". The film version is an adaptation of a 1962 novel by Ken Kesey of the same title and is considered by many to be one of the great films of the 20th Century. Wikipedia summarizes the plot thusly:

In 1963 Oregon, recidivist criminal Randle McMurphy is moved to a mental institution after serving a short sentence on a prison farm for statutory rape of a 15-year-old. Though not actually mentally ill, McMurphy hopes to avoid hard labor and serve the rest of his sentence in a relaxed environment. Upon arriving at the hospital, he finds the ward run by the steely, strict Nurse Ratched, who subtly suppresses the actions of her patients through a passive-aggressive routine, intimidating the patients.

I think of Nurse Ratched as the ultimate evil movie villain. In rewatching this film it is Louise Fletcher's performance in the role of Ratched, the sadistic psychiatric head nurse who employs shock therapy to control patients, which I found both brilliant and riveting. Her endlessly cool control of the ward and her conflict with Jack Nicholson's character McMurphy as he escalates his disruptive behavior are what make this film a masterpiece.

I believe that it is important to be able to enjoy media and remain critical of it at the same time. Having recommended all these films as great examples of modern television and cinema featuring scenes of psychiatric wards and people suffering from mental illness, I think it is important to point out that while these films borrow from the truth, they don't tell an accurate story about either mental illness or its treatment. In all of these examples the mythology of psychoanalysis and its associated treatments are used to create suspenseful and intelligent narratives based on the truth, but not necessarily fully representative of the truth.

These good stories create real stigma for people seeking mental health treatment, and they also create confusion about what one might reasonably expect as treatment. Electro-shock therapy or as it is more formally known, Electro Convulsive Therapy (ECT) was used widely in the 1940s and 1950s before anti-depressants drugs were developed. The treatment is still available today in a somewhat modified form. The modern version is usually coupled with muscle relaxants and is only recommended in extreme cases for people that don't respond to other therapies due to its rather nasty side effect of memory loss. What some people know about ECT comes from Nurse Ratched's abuse of her patients in "One Flew Over the Cuckoo's Nest". Setting aside the complex question of ECT's benefits versus its hazards, many people are terrified of the treatment, and by extension those who have received it, because of this film. This film is extremely realistic, and while the author may have been telling a very legitimate story about the abuse of power through medicine, the impact that this story has had on those suffering from mental illness has not necessarily been positive. This particular story has become "the" narrative of psychiatric wards for many people.

My grandmother received ECT treatment in the 1960s. All I know about this part of my family history was that despite being an intelligent and productive individual in her youth and middle age, she fell ill in her later years and my father and grandfather argued at length about the decision to give her this treatment. I don't recall meeting her, she died when I was very young. I just had this basic information from my siblings that the treatment didn't go that well, and then I saw the Jack Nicholson film at some point, and this is what I knew about mental health treatment growing up. This wasn't a nice picture.

The other issue with the dramatic presentation of mental health cures is that they create the notion that psychiatry, and mental health treatment are complex and unreliable voodoo like procedures. My father certainly thought this way about psychiatry. He expressed a great deal of suspicion about doctors, and especially psychiatrists while I was growing up. In Abraham Low's interviews with patients he often comments on how patients distrust his recommendations and expect to be probed with complex methods. In the chapter "Simplicity Versus Complexity In Combating Fears", Low, as the examiner (E) recommends that the patient (P) command their muscles to do what they fear to do.

P: Frankly, that sounds a bit too easy. It doesn't just seem possible that I should cure my fears by moving my muscles. It should take more than that.

E: It will be difficult for you to convince me that it is "a bit too easy" for persons to command their muscles to move if  they feel paralyzed by the fear of making another step. You did not mean to say that my suggestion sounds too easy; you thought it sounds too simple. I shall not enter into a detailed discussion of this very important distinction. I shall merely tell you that I do not want my patients to believe that cures and remedies must necessarily be complex, involved and timeconsuming. It is easy to sit in a chair and to be given lengthy and interesting explanations about how fears arise and develop. That is complex but easy. But if a boy is afraid of swimming or diving it is not at all easy to make him move his muscles for the purpose of a resolute jump. That jump is simple but difficult. Do you realize that you expect to be cured of your fears by means of complex but easy and sometimes glib explanations instead of by means of simple but exacting directions? You want to be studied and analyzed and discussed but you do not want to be told what to do and how to act. What will the most lucid explanations profit you if you are seized with a deep anxiety or a paralyzing panic? In a condition of this kind you are utterly unable to make use of the ingenious and fascinating explanations you may have been given. If in a panic you try to remember what you learned and to reason out what is the sensible thing to do your mind will fail you disastrously. The panic weakens your memory and blots out your reasoning power. All you will be able to do in a commotion of this sort is to apply simple rules. Their very simplicity renders them capable of being employed in a situation in which complex thought is impossible.

P: I do not mean to be contrary, doctor. But it seems to me that when I get into a panic I will not be able to carry out even simple rules.

E: That may be correct for the first and second trial. But if you continue to practice you become ever more proficient in the application of these simple rules.

...

Recovey methods are not complex, they do not require a deep understanding of one's history, motivations, or the basic causes of an illness. Recovery methods are exercise for the mind, and have a similar effect that exercise on the body can have, in that they provide general strength and an overall sense of well being if practiced regularly. It can be difficult to get into a routine of physical exercise. Despite the simplicity of going for a walk every day, many people will not find the time to develop this basic habit, preferring to drive or stay indoors. Practicing Recovery methods is as simple as taking a daily walk, although reaping its benefits can be as difficult because it requires work and consistent effort.

Movies and television often present mental illness as terrifying. The underlying themes show mental health professionals as cruel, incompetent, or abusive individuals who are applying cures that are hideously complex, ineffective or dangerous. While there are real life examples of this conduct, and the mental health industry has numerous issues, most practitioners are genuinely concerned about the people that they are attempting to help. While the mythology around mental illness is fascinating and fun from a theatrical perspective, if one finds oneself suffering from mental illness the many untrue and confusing ideas gleaned from modern media don't provide much helpful or accurate information. At Recovery meetings we emphasize the use of simple tools, these tools can help anyone regardless of the degree of their illness.

Cognitive Behavioural Therapy techniques, like Abraham Low's very simple recommendation to do the things that you fear and hate to do so long as there is no danger, are safe, effective, and not complex. These methods do require sustained effort, and this is one of the reasons that we hold Recovery meetings every week. We provide support for those who want to learn better habits. We are always happy to meet new members, and we encourage you to come to a meeting.


More Information

Suicidal Ideation, Helplessness and Hopelessness

Effectiveness of Peer Support for Depression

About Recovery Hamilton

Games People Play

We usually think of a game as an activity that involves a contest where there is a winner and a loser. Games are fun when all the players know the rules and have agreed to play, and the consequences for winners and losers are not that dire. Video games surpassed movies in profitability in the last decade. Childhood games like 'hide-and-seek' or 'cops-and-robbers' are played around the world, and sports, both amateur and professional remain popular. Innocent games of this sort are played for their enjoyability, as a structured way to get to know other people, or sometimes as a way to learn basic skills in a fun setting. Mind-games, on the other hand, usually are not fun for anyone but the winner.

Mind-games have several characteristics that distinguish them from games played merely for fun. Usually either the rules of the game are not well known to both players, both players are not willing participants, or one player or the other is not fully honest about what they are trying to get out of playing the game.

We sometimes associate mind-games with dating. Dating is a terribly complex exercise, something I was never very good at, and happily something I haven't done in years since I met my current partner. Years ago I used several different web sites for singles. I noticed an odd pattern while reading advertisements. Some individuals (both men and women) would post very aggressive adds giving lists of things that they didn't want, and not saying very many positive things about themselves or anything else. They would say things like, "don't message me if you don't have a photo" (men + women), "don't message me if you wear a hat in your photo, it means you are balding and I won't date a bald man" (women), "don't message me if you say you have a few extra pounds, that just means you're fat" (men) and most frequently of all "don't message me if you are into mind-games" (men and women).

How these individuals ever got a response with advertisements like these never made any sense to me. While none of these things applied to me (I had a photo where I wasn't wearing a hat and never had any intention of playing mind-games with anyone), I would never contact people who wrote adds like this. Maybe the good looks in their photos were enough to attract people, or who knows maybe there are people who didn't see these anti-requirements as a deterrent or indicitave of an unpleasant and rigid person. I didn't want someone who was interested in playing mind-games, but to my thinking, saying you wouldn't play such games didn't mean that you wouldn't. If anything, denying that you played mind-games hinted to me that you might be a very smart game player. I reminded my partner of these advertisements, she suggested that they might have been examples of "negging", a particularly ugly dating strategy where an individual insults someone to undermine their self-confidence and make them more vulnerable to advances. Yuck. Being out of the dating scene, however, hasn't relieved me of the requirement of playing games where I don't fully understand all the rules.

At Recovery meetings we have a few tools that relate to games, one thing we say is "Avoid symbolic victories" and we also say "Treat your mental health as a business and not as a game". The first one is easy to spot and extremely common. In Recovery we talk about a symbolic victory as an unimportant contest that someone enters into and stubbornly refuses to give up their position because they just must be right in the scenario. They dig in during a disagreement, stop listening to what the other person is saying and insist that their position is the best/smartest/most-righteous/correct etc. The trouble in this situation is that they often present the scenario as though they are trying to sort something out, but in fact they really have no interest in any opinion but their own. Their goal is either to prove how smart they are by not giving in, or sometimes simply to stir other people up and call a lot of attention to themselves. In either case the stated goal of "lets figure something out" isn't at all what they are after. What they really want is attention, and to establish their dominance over others.

In Dr. Low's book MHTWT, the chapter "Temper, Sovereignty and Fellowship", he quotes a discussion conducted by his patients.

Annette: I will quote an example of my own. An elderly aunt of mine, we shall call her Aunt Jane, was the type of person who enjoyed temper tangles. She had never lived with anyone, but during the depression we had to take her into our home. When she came I decided I'd make an effort to get along with her. I felt I could do that because she confessed to be fond of me. But what I actually did was to try to convince her that she was wrong and that of course ended up in pretty terrific temperamental outbursts on both our sides. One time, after a rather heated argument, I awoke in the middle of the night with a very odd sensation in my abdomen. I felt as though something awful had happened and I was going to burst. I was frightened but did not know at that time that these were nervous symptoms. But the sensations followed so regularly on temperamental spats I couldn't help realizing that they were closely associated with my temper. Several years later after I had undergone a good deal of Recovery training I had occasion to get in contact with Aunt Jane again. A friend of mine let me use her car and I invited Aunt Jane to join us on an automobile ride. This time I had a good opportunity to notice how I had changed while my aunt had not. Whenever I found myself wanting to prove her wrong and myself right I knew at that very moment that all I was out to accomplish was a symbolic victory. I stopped short instantly and instead of getting provoked myself or getting her worked up I merely answered her remarks with "maybe" or "is that so?" The argument didn't even get started. On leaving the car my aunt was obviously irritated and said, "I am just worn out. I never spent such a boring day in my life." And if that remark didn't provoke me into a sharper answer I realized that I must have learned the technique of giving up the battling for trivial symbolic victories. 

The trouble of course is that it feels good to win, and like you are a bit of a wet fish if you always give in. In Recovery one of our goals is to change our habits for the better. While it might feel good to be right most of the time, this is relatively selfish thinking, especially if what you are "right" about is something not very important, like the exact day and time that summer starts on, or whether the halibut fish has both eyes on one side of its head, or just an oddly shaped head.

Attempts to win arguments about nonsensical, trivial, or inconsequential things creates stress for everybody involved. If you are often the instigator of this sort of contest, by either contradicting things other people say, or refusing to let an argument go, the impact that this habit has may not be obvious to you. In small doses the pleasure of getting attention and winning may hide the long term consequences of increased stress and social alienation. There are individuals that I simply don't bother to engage with because I know that when they disagree with me they aren't interested in a discussion, they are only interested in being right and dominating me. I've excised a number of people like this from my life, and I often don't bother to explain the details to them. I would be wrong anyway, so what would the point be in trying to explain myself?

I also engage in this sort of behavior myself, although I am working on doing it less. Its fun to be right, and its tough to let this go, but not pursuing these symbolic victories is an important part of getting along with others and being "group minded" as we say in Recovery.

"Games People Play" is the title of a fascinating book written by Dr. Eric Berne that I first read many years ago. This book formalizes the idea of a psychological game, and distinguishes it from other interactions with people that are described as pastimes, occupations, or rituals. This book is short, and although written for a layperson parts of it are a little tough to get through, especially the theoretical framework presented in the introduction. When I first read it I was immediately drawn to the catalog of games presented in the second part of the book, all of which have familiar sounding names. Included in the game catalog are 'Look How Hard I've Tried', 'Kick Me', 'See What You Made Me Do', 'If It Weren't for You', 'Ain't it Awful', 'Why Don't You- Yes But' and many others.

The basic structure of the games described by Dr. Berne requires that each player takes on one or two roles from the basic set: Adult, Parent, or Child. Each game starts with what usually looks like a harmless exchange, often a realistic question, statement or request framed from one Adult to another. There is usually a secondary exchange going on, implied by the moves or the game framework that is rooted in a non-rational exchange between Parent and Child ego states, or two Child ego states. The ego state of Parent or Child is something that Dr. Berne argues that all people resort to in both healthy and unhealthy scenarios. Child-like behavior can be exuberant, playful or fearful. Parent-like behavior can be nurturing, instructive, or domineering. Adult behavior is always realistic and goal oriented, but in a game is often used to hide ulterior Child-like or Parental intentions.

Games have two chief characteristics that differentiate them from other behaviors, 1) that they have an ulterior quality- that is, are based on implication and do not clearly state their goals or rules and 2) that there is a payoff, or something that the winner can get out of the exchange. The payoff is often something more complicated than simply dominating the other player by winning. Sometimes the payoff is collecting reassurance that you think you can't simply ask for, or it may be showing how a class of people are unworthy without saying so directly.

Dr. Berne describes a game that Dr. Low also talks about. This game comes up in therapy sessions and Dr. Low talks about it when he refers to "but-knockers" in his chapters on sabotaging mental health. The "but-knocker" will say anything to subvert his physician's recommendations. This game also comes up in everyday exchanges and is one of the most common and easy to observe games described in Dr. Berne's book. Dr. Berne call's this game 'Why Don't You- Yes But'. Dr. Berne presents the following example, using the players names "White", "Black", "Red" and "Brown" to illustrate the game:

White: "My husband always insists on doing our own repairs, and he never builds anything right."
Black: "Why doesn't he take a course in carpentry?"
White: "Yes, but he doesn't have time."
Black: "Why don't you buy him some good tools?"
White: "Yes, but he doesn't know hot to use them."
Red: "Why don't you have your building done by a carpenter?"
White: "Yes, but that would cost too much."
Brown: "Why don't you just accept what he does the way he does it?"
White: "Yes, but the whole thing might fall down."

...

'Why Don't You- Yes But' can be played by any number. The agent presents a problem. The others start to present solutions, each beginning with "Why don't you ..." To each of these White objects with a "Yes, but..." A good player can stand off the others indefinitely until they all give up whereupon White wins.

...

Since the solutions are, with rare exceptions, rejected, it is apparent that this game must serve some ulterior purpose. 'Why Don't You- Yes But' is not played for its ostensible purpose (an Adult quest for information or solutions), but to reassure and gratify the Child. A bare transcript may sound Adult, but in the living tissue it can be observed that White presents herself as a Child inadequate to meet the situation; whereupon the others become transformed into sage Parents anxious to dispense their wisdom for her benefit.

While each move in the game is amusing to the instigator, where White gets to repeatedly reject each suggestions, the real payoff is the silence at the end of the game. This demonstrates that all the other Parent players are inadequate.

The thing that is truly enjoyable about this book is that it provides interesting counter moves to the games that it describes. I've found myself stuck in this game on many occasions, usually I play the one trying to offer advice, but sometimes I also play the one refusing to accept advice. The solutions suggested by the other players are usually obvious and a 'Why Don't You- Yes But' player will in most cases have thought of them, or if not, in many cases will come up with a reason why the suggestion is no good regardless of its actual value. This is the purpose of the game, not to get suggestions, but rather to reject them. The ultimate over arching goal of the game is to both prove that others want to dominate, but also that they are in fact inadequate, and not able to.

The counter move suggested by Dr. Berne is simply not to play. So if someone tries to start a game with "What do you do if..." and this person is a known 'Why Don't You- Yes But' player, a suggested response is "That is a difficult problem. What are you going to do about it?" If the game starts in the format of "X didn't work out properly," the response then should be "That is too bad." Both of these are polite enough to leave the instigator at a loss and disrupt the game, or if not fully disrupting the ulterior request at least to coax them into being specific and asking for what they really want.

I don't have a good instinct for dealing with these sort of games. I really like Dr. Berne's book because it presents a collection of templates that are easy to follow and it helps me to understand when someone doesn't have my best interests at heart. While sometimes I can spot a negative social exchange the next day, in the moment, I'm often not sure what to do, and I sometimes just feel bad or cornered. Recognizing that sometimes people do have ulterior motives is helpful. Instead of accusing them of playing a mind-game, which may or may not be the case, Berne's book provides simple civilised strategies that involve recognizing the game and refusing to play.

In Recovery we encourage people to be both realistic and civilised. It would be niave to assume that this is true of everyone that we need to deal with. It is helpful to know that even when others are being unpleasant or dishonest, we can recognize this, and that in many situations there are easy answers, like declining to play the game, whatever it might be.

If you find social situations upsetting and feel like you get 'played' a lot, you can learn simple tools that will help in these situations at Recovery meetings. If you are an unconscious player who has alienated a lot of people, you may learn to recognize your bad habits by first looking at whether you pursue symbolic victories. All meetings follow a regular prescribed format, we don't allow teasing, judgement, sarcasm, or advice giving, and we try to thus ensure that no games with unwritten rules are played at meetings.


More Information

Sarcasm, Humour and Ambiguity

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Does Depression have a Physical Cause?

Some people believe that depression is caused by genetic factors, others believe that it has roots in social upbringing or traumas experienced in childhood, others tend towards the idea that it is caused by a chemical imbalance in the brain, or express concern about environmental influences. With these many possible causes at work how can we know what treatment will be successful? If you are reading this blog to try to decide whether peer support might work for you, how can you know? It seems logical that if your problem is truly genetic, chemical or biological that peer support or talk therapy might be a waste of time.

To the best of my knowledge the jury is still out on what causes depression. In David Burn's book "Feeling Good", Chapter 17, he discusses this subject at some length, he writes:

At least two major arguments have been advanced to support the notion that some type of chemical imbalance or brain abnormality may play a role in clinical depression. First, the physical (somatic) symptoms of severe depression support the notion that organic changes might be involved. These physical symptoms include agitation (increased nervous activity such as pacing or hand-wringing) or enormous fatigue (motionless apathy- you feel like a ton of bricks and do nothing). You also may experience a "diurnal" variation in your mood. This refers to a worsening of the symptoms of depression in the morning and an improvement toward the end of the day. Other physical symptoms of depression include disturbed sleep patterns (insomnia is the most common), constipation, changes in appetite (usually decreased, sometimes increased), trouble concentrating, and a loss of interest in sex. Because these symptoms of depression "feel" quite physical, there is a tendency to think that the causes of depression are physical.

A second argument for a physiologic cause for depression is that at least some mood disorders seem to run in families, suggesting a role for genetic factors. If there is an inherited abnormality that predisposes some individuals to depression, it could be in the form of a disturbance in body chemistry, as with so many genetic diseases.

The genetic argument is interesting but the data are inconclusive. The evidence for genetic influences in bipolar manic-depressive illness is much stronger than the evidence for genetic influences in the more common forms of depression that afflict most people. In addition, lots of things that do not have genetic causes run in families. For example, families in the United States nearly always speak English, and families in Mexico nearly always speak Spanish. We can say that the tendency to speak a certain language also runs in families, but the language you speak is learned and not inherited.

I don't mean to discount the importance of genetic factors. Recent studies of identical twins who were separated at birth and raised in different families show that many traits we think of as being learned are actually inherited. Even such personality traits as a tendency towards shyness or sociability appear to be partly inherited. Personal preferences, such as liking a particular flavor of ice cream, may also be strongly influenced by our genes. It seems plausible that we may also inherit a tendency to look at things either in a positive, optimistic way or in a negative, gloomy way. Much more research will be needed to sort out this possibility.

I had many of the symptoms described by Dr. Burns when I was very unwell including: feeling like a ton of bricks and doing nothing, a worsening of the symptoms of depression in the morning and an improvement toward the end of the day, disturbed sleep patterns, loss of appetite and most bothersome to me, trouble concentrating. I was a university student when I was first diagnosed with depression and there were spans of months that dragged into years when I was completely unable to concentrate. I had been reduced from an active student achieving good grades to a tired out blob only capable of concentrating on daytime television shows. I watched a lot of gossip based talk shows like Jerry Springer, Maury Povich and Montel Williams while depressed, and slept for most of the rest of the day.

These physical symptoms were part of what convinced me that my brain was not functioning correctly, and the problem was either chemical, genetic or structural. It never occurred to me that anything other than pills or brain surgery might be the correct cure. Since my initial luck with medication hadn't been good and I figured brain surgery wasn't a realistic option I thought my case was hopeless.

Before attending Recovery meetings I spent 10 years talking to a psychiatrist. In my conversations with him I picked up the idea that depression was nothing to be ashamed about. He certainly thought that a genetically influenced chemical imbalance was the most likely explanation for me. With this "physical" diagnosis, I felt relatively at ease that my depression was not my fault, and reassured that something could be done.

At a recent Recovery meeting we were discussing stigma and shame associated with mental health issues and to what extent people needed to be convinced that they are suffering from depression or anxiety versus some physical ailment. I was surprised to learn that many of our members initially thought they had a physical illness, not a nervous condition.

While some of our members were aware of the idea that a chemical imbalance might cause depression, their initial concern was that their nervous symptoms were caused by a weak heart, a stomach ulcer, or some other physically diagnosable illness. In Recovery we discuss symptoms a great deal, and we encourage members who suffer from physical symptoms to see a medical practitioner to rule out as many causes as possible.

My belief in this idea that there was a physical cause to my emotionally troubled landscape has changed as I've learned cognitive behavioral techniques. In Recovery meetings we do not talk about what the true cause of your depressive symptoms are. It is not our job to diagnose one another. However, we do acknowledge that nervous persons suffer from a variety of sometimes very intense physical symptoms that are a result of their thoughts and feelings. The notion that physical symptoms are tied to your thoughts in a complex fashion is something that we focus on. This is a new idea to some people. In MHTWT, the chapter "The Myth of 'Nervous Fatigue'", Dr. Low as (E)xaminer reports an exchange with a (P)atient:

P: I don't know what to say. The fact is that I am all in no matter how well I slept. If you call that a subjective feeling you must think it is mental. But I didn't even have time to think about it. It is there the moment I wake up. 

E: I do not know what precisely you mean when you use the word "mental." Presumably you refer to the possibility that you may have the thought of fatigue in your mind and instantly feel the fatigue in your muscles. This instantaneous response of the muscles to a thought seems to puzzle you. I do not see why it should. You have certainly gone through similar experiences hundreds of times. Remember the occasion, for instance, when you were at a meeting and were called upon to make a speech. Instantly, your heart began to palpitate, your face reddened, your abdomen trembled and the knees shook. To use your own words, you "didn't even have time to think" of the speech; you merely heard your name called, and the muscles of your heart, abdomen and legs were thrown into violent tremors "in no time." In the instance which I quoted the thought in your mind which caused your muscles to shake was the fear of not being able to deliver a well constructed address. It was a fear, or you may call it a fear idea, or the idea of danger. Do you understand now that if an idea strikes or occupies your mind the muscles may respond with a violent reaction in a fraction of a second? 

P: I understand that. But when I get up in the morning there is no idea of danger in my head. 

E: The question is what you mean by danger. If you wish to indicate that, in the morning, you are not trembling with the fear of being killed or trapped or burned I shall fully agree with you that no such idea may occupy your brain immediately after awakening. But there are subtler forms of fears and dangers. These subtle anxieties and apprehensions go by the name of preoccupations. I happen to know from your own account how readily you fall victim to such preoccupations. Let me remind you, for instance, of the anguish you experience whenever you expect visitors for the afternoon or the evening. You fret and worry days in advance, anticipating some bungling or clumsiness while performing the part of the hostess. You know that when finally the much dreaded day arrives you feel troubled and helpless "the very minute" you awaken. The day stares you in the face as a threat, as an event fraught with heavy responsibilities. You are without pep or zest. Your vitality is at a low ebb. A heaviness seems to descend on your limbs. Everything is done with effort. You have to drag yourself, feel "all in," exhausted, lifeless, fatigued. Do you understand that all of this is caused by your preoccupation, and that the preoccupation is based on the idea of danger? 

Both at work today, and as a student years ago, I have given many presentations. These are often stressful. I always suffer from some physical symptoms prior to giving a talk to a difficult audience. Sometimes I'd also have a similar response when I was meeting with my boss and had to discuss a difficult subject, or even before what should be a pleasant social engagement. I have experienced a dry mouth, shaking legs, stuttering in my speech, an upset stomach, and a racing heart for example. To me it was usually obvious that these physical symptoms were caused by an event, the difficult meeting or presentation.

In Recovery we talk about generalizing this experience and understanding that many of our physical depressive or anxious symptoms are caused by subtle experiences and daily thoughts. These symptoms can seem to have no obvious cause in part because they are a reflection of our habitual thoughts and attitudes. The example where we are fully aware of the cause, feeling wobbly while giving the talk, may be the same experience you have when you simply "get-up" in the morning and still feel tired out. When I was unwell, I was extremely upset when I awoke in the morning, I never felt awake, and often went back to sleep for a large part of the day.

A big part of what made me believe that my depression was rooted in a chemical imbalance was the intensity and persistence of the physical symptoms that I had on a day-to-day basis. While there still may be some truth to the idea that a chemical imbalance was at work, there is also clear truth in the idea that an emotional upset will also result in physical symptoms. My worry about the collapse of my life after quitting school was a real cause of my exhaustion in the morning, although that was not obvious to me.

In Recovery meetings we talk about these less obvious symptoms. Being tired out as soon as someone starts talking about bills is a signal that you are going into temper, possibly anger that you are being asked to pay more than your share. A feeling that you are having an upset stomach when you run into an old boyfriend or girlfriend may be connected to a fear about whether they will hurt you with some news of how well they are doing without you. An inability to think clearly when going to work or school may be related to your disgust or frustration with the job. Tunnel vision experienced during a discussion or the inability to hear or understand what someone is saying may be a result of your intense worry about what might be said.

In meetings attendees give examples of the use of Recovery tools. We use a four part example template where attendees:

1. Give a summary report of a situation involving temper.

2. Report both the physical and mental symptoms experienced.

3. Talk about the tools used to address the situation.

4. Describe how they have improved.

The second step of the four part example process includes reporting the observation of both physical and mental symptoms. We recognize physical symptoms as warning signs, indicators that a person is going into temper. Usually attendees have no trouble connecting angry or fearful thoughts with a difficult situation, but of equal importance is recognizing the physical symptoms that occur. People don't always connect physical symptoms with their thoughts and feelings; we encourage each other to try to make this connection.

Observing physical symptoms helps us to know that we are in a situation where we are likely to respond impulsively. Recognizing the pattern of our symptoms also helps us to reduce the impact of the vicious cycle. I know that I tend to get an upset stomach before a meeting or social engagement. I try not to worry about the symptom itself, and instead just acknowledge that it is something that I often experience in these situations. Instead of multiplying my problem by saying, I have both a social engagement that I'm worried about and a terrible upset stomach which might be the flue, I recognize that they are both the same worry. I know that if I can be realistic about the social engagement that the physical symptom of the upset stomach will usually resolve itself.

From past experience I know that the symptom only gets out of control if I let it. I also know that some physical symptoms are subtle and less obvious. Headaches, tiredness, irritability, small aches and pains, a sore throat, all of these physical symptoms may be connected to frustration, fear, upset or anger. In the past I might have dismissed them as a cold coming on, or perhaps lack of sleep the night before. Today I recognize these minor aches and pains as a signal that I'm feeling pressured and upset by what is going on around me, and that I need to be aware of how I respond to my situation.

We don't know why some people get depressed and why others seem resilient in the same situation. If we did that might help facilitate a cure. We do know that physical symptoms are tightly linked to both fearful temper and angry temper. We also know that regardless of the cause of your anxiety or your depression there are ways you can change your behavior and your thinking to reduce the intensity of your physical symptoms.

We regularly remind attendees to consult with a physician if they are having serious physical symptoms. If you experience heart palpitations you may have some sort of heart condition and you should go and see a doctor if you believe you are at risk. However, if you think you are experiencing depression or anxiety and your doctor has given you a clean bill of physical health, you should consider that your physical symptoms might be associated with a nervous condition. You may be able to experience relief from those symptoms by learning about the Recovery tools.


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Meetings: Activities and Key Concepts

Insomnia, Anxiety and Depression

Feelings are not Facts

Suicidal Ideation, Helplessness and Hopelessness

Recovery meetings are attended by volunteers, and there are limits to the subjects that we can adequately address. Having said that it would be inappropriate for a group dedicated to discussing depression to not say something about depression's most serious symptom, suicidal ideation, or thoughts of death and wishing to die. These thoughts almost always arise from a feeling of helplessness or an inability to address immediate and pressing difficulties. To someone suffering from depression it can seem as though there is no end to suffering within sight.

From Dr. Burn's book "Feeling Good", Chapter 15, he writes:

Dr. Aaron T. Beck reported in a study that suicidal wishes were present in approximately one-third of individuals with a mild case of depression, and in nearly three-quarters of people who were severely depressed. It has been estimated that as many as 5 percent of depressed patients do actually die as a result of suicide. This is approximately twenty-five times the suicide rate within the general population. In fact, when a person with a depressive illness dies, the chances are one in six that suicide was the cause of death.

...

Ask yourself, "Is there anything that is preventing me from committing suicide? Would I hold back because of my family, friends, or religious beliefs?" If you have no deterrents, the possibility is greater that you would consider an actual suicide attempt.

SUMMARY: If you are suicidal, it is of great importance for you to evaluate these impulses in a matter-of-fact manner, using your common sense. The following factors put you in a high-risk group:

1. If you are severely depressed and feel hopeless;

2. If you have a past history of suicide attempts;

3. If you have made concrete plans and preparations for suicide; and

4. If no deterrents are holding you back.

If one or more of these factors apply to you then it is vital to get professional intervention and treatment immediately. While I firmly believe that the attitude of self-help is important for all people with depression, you clearly must seek professional guidance right away.

The Crisis Outreach and Support Team is a program of St. Joseph's Health care Hamilton. The Hamilton crisis line is available 24 hours - 905-972-8338, see:

http://coasthamilton.ca/

The Toronto Distress Center fosters hope and resilience one connection at a time. For immediate support call 1-416-408-4357 (HELP), see:

http://www.torontodistresscentre.com/resources/find-help-now

The Distress Centre Niagara provides support to individuals in distress or crisis and education to the Niagara community which assists people to take ownership of personal choices and manage their lives in a healthy manner. See:

http://distresscentreniagara.com/

CASP is not a crisis center but provides educational material, resources, and links to regional crisis centers. See:

https://suicideprevention.ca/need-help/im-having-thoughts-of-suicide/

I only discussed suicidal thoughts with professionals in a diagnostic setting on a few occasions. Since you may have a similar experience I'll describe how I was admitted to St. Joseph's psychiatric ward, and what happened afterward. I found that when I was severely depressed and my mind was filled with self destructive ideas counselors that I spoke to would often ask me point blank; "Are you having suicidal thoughts?" I answered yes to this question a few times, the one time that I described those thoughts in detail was immediately prior to my admission to the psychiatric ward at St. Joseph's.

I was extremely cynical at the time, and I wasn't impressed by what the doctors and counselors that I spoke to said. They seemed tired out to me and not very engaged and as though this question "...was I having suicidal thoughts?" was the only tool that they had. If my answer was yes, their response was a prescription. If my answer was no, then my case wasn't that serious and I should wait for 3 months to get an appointment with a psychiatrist. I felt embarrassed giving this answer, frustrated by the response I got for it, and after a while, I stopped providing a lot of details about what I was thinking. I had the rather dangerous idea that if I wanted to succeed in killing myself then I should stop talking about it and say that while I didn't feel well I was doing okay, and that I should probably leave the hospital soon. After about 10 days I was released. I went back to my apartment, threw out the prescription that was given to me, closed my blinds, and isolated myself as the winter set in resolving to "wait" and see what would happen.

So... if you are in that same position that I put myself in, refusing to talk about suicide, and yet haunted by partial plans, worrying about failing, crippling or scarring yourself through an incomplete attempt, or being found out, please reconsider and contact one of the above distress centers. I was lucky, my parents extracted me from my apartment after many months of isolation and refusing to answer the phone and took me to see a very patient and decent psychiatrist who saw me immediately, and followed up with me several times per week for an entire summer. I still didn't tell him every detail I was thinking, however I did meet with him regularly for many years. I took the medications that he prescribed, accepted his advice and ultimately he was a big part of my initial improvement. My refusal to fully trust professionals, especially after having a few bad experiences, made my journey very, very long.

At Recovery meetings we do not dig through deep dark secrets. We are not qualified to do so, and we believe that an incautious exploration of explosive feelings can amount to re-experiencing them and risks inappropriate comment or judgment from volunteers. We encourage attendees to see a professional if they want to discuss extremely troubling situations. We stick to trivialities and developing tools to handle common traps and everyday problems.

While we can't provide emergency support or address some of life's most difficult experiences in our forum, what a peer support group can offer is an interesting insight; others do improve. At first, I didn't believe my psychiatrist when he told me I would get better. I thought, "What does he know? He's got a good job, a nice home and family, and clearly he has never been depressed." But when I met healthy individuals at meetings who talked about how bad things used to be, and how they were doing much better this impressed me. I could relate to the guy who had been out of work for several months and just got a new part-time construction job. While I'd never worked construction I could see his pain, and how he was working on it, and the progress he was making. Others have been to horrible places, and others can confirm that taking small steps makes things easier. While we cannot help you in an emergency, we can help you with small things so that you won't get to a place where it is an emergency, and we have proof, we did this. You can too.

In Recovery we make a distinction between feeling helpless, and the diagnosis that your case is hopeless. We acknowledge that people do feel helpless, they feel exhausted, disgusted with themselves and the world, as though nothing will ever change and they can see no solution. However, feelings are not facts, and while it may be true that you feel helpless, you do not have all the information, you cannot draw the conclusion that your case is hopeless. In Recovery we say that no case is hopeless, not even yours. Dr. Low writes:

A patient is competent to describe his present condition, his pains, pressures and palpitations, his lack of strength and vitality, his fears, panics and compulsions. If he wishes to place the label of "helplessness" on any of these experiences I shall not quarrel with him. I have not seen a patient who was not helpless, totally or partially. Patients are helpless to stop their pressures, they are helpless when they find themselves seized with air-hunger or night terror. And if any patient claims to be helpless I shall not challenge the correctness of his statement. But when a patient declares himself hopeless I shall warn him that he has presumed to make a prognosis and has trespassed into my territory. The physician alone is capable of deciding whether a condition is hopeless or hopeful. The patient who assumes the diagnostic or prognostic function of the physician sabotages his authority. The patient can declare himself helpless but he has no right to pronounce himself hopeless. Description is the domain of the patient, prediction is the province of the physician. 

Many of us suffer through depressive symptoms and years later when we are doing better we can look back on those times and realize that it wasn't that our situation was bad, it was more that we had unrealistic thoughts about our life. Everyone who is depressed will object to this and say "... but my life situation truly is horrible and I can't tolerate it". It is the case that some people are in truly horrible circumstances, and here is an odd fact, there are people who are suffering from great physical, financial or situational struggles that are not depressed and do not believe that their life is hopeless. Dr. Burns writes:

The conviction of hopelessness is one of the most curious aspects of depressive illness. In fact, the degree of hopelessness experienced by seriously depressed patients who have an excellent prognosis is usually greater than in terminal malignancy patients with a poor prognosis.

An even more compelling account is the one given by Viktor E. Frankl in "Man's Search for Meaning". Viktor Frankl survived a Nazi concentration camp as much by refusing to give up hope as by sheer luck. There is a good summary in the foreword to this book by Harold S. Kushner who writes:

Clearly, many prisoners who desperately wanted to live did die, some from disease some in the crematoria. But Frankl's concern is less with the question of why most died than it is with the question of why anyone at all survived.

Terrible as it was, his experience in Auschwitz reinforced what was already one of his key ideas: Life is not primarily a quest for pleasure, as Freud believed, or a quest for power, as Alfred Adler taught, but a quest for meaning. The greatest task for any person is to find meaning in his or her life. Frankl saw three possible sources for meaning: in work (doing something significant), in love (caring for another person), and in courage during difficult times. Suffering in and of itself is meaningless; we give our suffering meaning by the way in which we respond to it. At one point, Frankl writes that a person "may remain brave, dignified and unselfish, or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal." He concedes that only a few prisoners of the Nazis were able to do the former, "but even one such example is sufficient proof that man's inner strength may raise him above his outward fate."

Finally, Frankl's most enduring insight, one that I have called on often in my own life and in countless counseling situations: Forces beyond your control can take away everything you possess except one thing, your freedom to choose how you will respond to the situation. You cannot control what happens to you in life, but you can always control what you will feel and do about what happens to you.

Frankl's book is short, about 170 pages. I read it years before attending any Recovery meetings and it impressed me because of its overall simple message, that we can choose how to respond to suffering, and that it matters what we choose. I did not fully respect or trust many of the counselors I met in person because I believed that they were speaking from a position of affluence and ignorance. Several told me that they had never experienced depression, this created a feeling of distrust for me. Frankl's story is one where he expresses a clear understanding of the impact that suffering has. He talks not only about accepting the failings of those who suffer, but also about finding a solution within suffering.

Viktor Frankl

I found Frankl's story inspiring because of the fact that despite the impossible situation that he was in, one where suicide would seem to be a rational solution, he was still able to find hope. During the darkest part of my depression I saw no difference between my feelings of helplessness, and my notion that life for me was hopeless and without chance for improvement. Reading Frankl's story in part lead me to consider whether my illness was the root of both notions, and whether there might be hope despite me not being able to see it.

Feeling exceptional is one of the traps that we fall into. I believed that I was exceptionally unwell and no doctor could dissuade me from that idea. Reading Frankl's account made me start to question whether it was my situation that was the problem, or how I looked at my situation. When I started to attend Recovery meetings I believed the stories told by others, I found them convincing. What kept me coming to Recovery meetings was not just being inspired by the success of others, but that the meetings taught tools, simple things that I could do to make my life more peaceful.

If you feel helpless and are worried that your case is hopeless I encourage you to come and meet us and learn about some of the tools we use. Our group is attended by regular everyday people, we teach simple and easy to remember techniques that address small frustrations. If you can eliminate many of the little problems from your life you will find that the big problems are much easier to manage.


More Information

Who Can Attend

How Does This Work?

Feelings are not Facts

An Austin Psychologist Talks about CBT

Dr. Sandy Andrews works as a clinical psychologist in Austin Texas. She specializes in Cognitive Behavioral Therapy techniques. In a blog post she talks about the experiences her patients have at Recovery meetings. From her blog:

I've had a few patients attend these groups. I have been consistently impressed with the quality of the skills taught there. I often refer my clients to the group in the hopes they will use it as a place to practice the cognitive skills learned in my individual therapy sessions, learn new skills above and beyond what our sessions have covered, and gain social support. I also refer individuals who are not attending therapy but would like some free-of-charge group support.

Recovery International, in short, teaches people tools to help cope better with situations that provoke unpleasant feelings and emotions. They call these tools "Recovery Language."

One typical example: Many people experience significant anxiety walking into a support group for the very first time. Anxiety that, for so many, is anticipated ahead of time to such an extent that they fail to go to the group at all. Typical thoughts are, "I won't know anyone and I'll feel stupid." "I won't know what to say." "I'll be too nervous to talk and then I'll look ridiculous." "What if I walk into the room and everyone stares at me?"

I had many of the feelings that Dr. Andrews describes when I attended my first meeting. We all had this experience, this is average. I pushed myself to go to a meeting partly because I had been through the experience of waiting for my symptoms to pass for years, and I knew that this wasn't helping. I figured anything would be better than another day of intense anxiety and depression spent by myself.

Trying new things is hard and attending your first peer support meeting can be extremely difficult for many people. We understand this. We don't ask that new members answer questions or take part in any meeting activities that they are not comfortable with. There are many opportunities for new members to learn about Recovery and participate in meetings, however nothing is required other than your attendance.

To see Dr. Sandy Andrews' full blog post check out the following link:

http://bloggingbehavioral.blogspot.ca/2009/05/recovery-inc-cognitive-tools-support.html


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About Recovery Hamilton

Meeting Activities and Key Concepts