Posts tagged depression
Posts tagged depression
Psychosis and Dissociation, Part 2: On Diagnosis, and Beyond
By Noel Hunter, M.A., M.S., Mad in America
“You treat a disease, you win, you lose.
You treat a person, I guarantee you, you’ll win,
No matter what the outcome.”
- Robin Williams in Patch Adams
Recently I wrote an article on MIA entitled Trauma, Psychosis, and Dissociation. Several people responded privately with some very thought-provoking questions that I would like to explore and possibly answer to some extent here. Most of these questions regarded the relationship of diagnoses and treatment, which was a subject that I superficially critiqued but did not explicitly analyze. Dedicated readers of the MIA website are all too familiar with the myriad problems that exist with diagnoses in general, the stereotypical (and often untrue) assumptions associated with these various categories, and their lack of scientific validity or reliability. For those who are not as familiar with this research, there are many on this site who have tackled this issue (see: Harm Reduction, Do Diagnoses Injure, Does DSM-5 Matter, How Reliable is DSM-5, Psychiatry-Based Valid Science). I do not wish to echo what has already been exquisitely written elsewhere, but I do want to address some specifics with regard to dissociation and psychosis.
First, though, I want to state that my area of experience and research is with trauma, psychosis, and dissociation. Surely, the following assertions and arguments could be said about any comparative diagnostic categories or phenomena; however, I do not have the knowledge, experience, or research to back up discussions on phenomena related to categories such as bipolar, depression, borderline personality disorder, etc. That is the only reason that I focus on the categories of Dissociative Identity Disorder (DID) and schizophrenia (and their related labels) – NOT because I believe that some other standard holds true for other categories. As a broad statement to begin with, I want to assert that above and beyond anything else, when an individual is suffering some type of distress (whether understood to an outsider or not) it should be assumed that there is a logical reason that such distress developed.
If this is the first assumption made, then there is no need to search for “what is wrong” with the person; I will repeat until the end of time that the Hearing Voices Network put it perfectly by stating we must seek to understand “what happened” to the person. Until such a time that the person is able or willing to acknowledge/remember/process/understand the complicated interpersonal, familial, and societal dynamics that may have led to the distressing experiences in the present, it should always be assumed (once real medical and nutritional factors are ruled out) that there is meaning in said experience. Placing a priority on diagnosing and categorizing prevents meaning from being made.
“But why?” many will ask; if a diagnosis is “correct” and thereby will inform targeted “treatment” then is it not best practice to proceed in such a manner? Although I recognize that we live in a society that demands immediate results, immediate answers, and immediate eradication of pain and suffering, that does not mean that science must follow suit. The following is my reasoning behind why I unequivocally answer the previous question with an emphatic “No.”
Breaking down the experience
Within the domain of the dissociative and psychotic disorder categories, the following are the most common phenomena that people subjectively and internally experience:
Now, of course, there are many other experiences that could be added to this list when looking at any individual; and that is also kind of to the point: Individual experiences are very individual. Additionally, any individual may experience any combination of the above, to different severities, at different times, and interpret these experiences in different ways. If one interprets such experiences in a manner that goes against consensus belief, then others may claim it is a “delusion,” but a “delusion” is not the internal process or experience … it is just an explanation like anything else. In this sense, even the term “psychosis” ceases to have meaning.
Seeing as how a “delusion” can be seen as a logical explanation for an incomprehensible experience, or an attempt to bring structure to a chaotic internal or external world, then it makes no sense to me that “delusion” becomes a separate “symptom” that defines a specific “disease” that is distinct from all others. How is a person helped by being told that their internal experience is irrelevant, as is their past, because they are “delusional,” and therefore have an illness that must immediately be “treated”? I genuinely look forward to anybody responding with a constructive answer to this question.
Putting the idea of “delusion” aside (because an entire separate article could be written about that), how does diagnosis then fit in to the picture? DID is an interesting diagnosis because it is actually one of the few that has a high degree of validity and reliability when structured interviewing is utilized. Additionally, many individuals who receive this diagnosis may experience some level of relief that: 1) they are officially not “crazy” (i.e., “schizophrenic”); and 2) their trauma has been recognized. Further, trauma-informed treatments designed for DID experiences can be highly effective, validating, and rewarding … though, like any other treatment can also be incredibly harmful as well.
I might surmise, though no direct studies have been done to evaluate this, that the large portion of the harm done in this type of treatment occurs when an overzealous practitioner insists on his or her framework, pushes too hard for recognition and processing of trauma, focuses on the anomalous experiences at the expense of doing the difficult work, and the more general problems that come with relying on hospitalizations and psychotropic drugs for long periods of time. My point in stating this is to say that I come from a position wherein I believe that the dissociative disorder field has a lot to offer, but errs tremendously in its steadfast reliance on the biomedical categorical system.
On the other hand, the diagnosis piece is another story. The diagnosis of DID is based on one experience: identity alteration with amnesia. It is not surprising, then, that this category would have validity and some degree of reliability. If we took, instead, the experience of hearing voices and turned it into “Hearing Voices Disorder” it would also likely have a high degree of validity. This is because it is referring to one experience that the person has presented with: It is entirely tautological. I do not dispute that people experience identity alteration with amnesia, but this does not equate with having a disease or anything else above the experience itself.
Schizophrenia, however, is quite the opposite; this category is an amalgamation of broad and varied phenomena that may or may not have anything in common at all. As I stated in my previous blog, and certainly what has been articulated numerous times elsewhere, the problems inherent in the assumptions and associations made with this diagnosis are, quite frankly, a travesty.
Even so, there are plenty of individuals who also find reassurance and comfort in formulating their experiences from a disease model and find value in this label. We learn how to explain our experiences through group-mind or society’s authoritarian dictate of accepted knowledge; even those who are deemed “schizophrenic” learn to explain their experiences through the mind of the doctor. Just as the idea that doctors’ insistence that a “delusional” patient must accept consensus reality can be incredibly harmful and completely ineffective, so too is the insistence that all people with lived experience accept the same explanation for their experiences. I do not wish to invalidate their way of making sense of things. But, that does not negate that the travesty exists, nor does it make the diagnosis a valid one.
Any two individuals who experience distress that gets labeled as schizophrenia may have nothing at all in common. One may present with hearing voices, fear, rage, and overwhelming emotions, while the other has a lack of motivation, feels unreal, has a lack of emotions, and physically feels profound anxiety. The first person might have experienced significant sexual abuse, and the voices are the person’s way of making sense of this abuse while the resulting fear and extreme emotions are perfectly understandable responses to such a violation. The second individual may have experienced severe invalidation, a lack of mastery in life, and bullying. Both meet criteria for schizophrenia, and, for argument’s sake, let’s say there is no debate that this is an “accurate” diagnosis. How, then, does this diagnosis help in any way with “treatment”?
It just doesn’t.
Similarly, a person who experiences identity alteration with amnesia, thereby leading to a diagnosis of DID, may also experience hearing voices, fear, rage, and overwhelming emotions due to significant sexual abuse. Her experience is not entirely different from person #1’s experience in the preceding paragraph except for the added experience of identity alteration and amnesia. Do these two people then logically have entirely different diseases? Does “treatment” really logically flow from the diagnosis of either individual? Do these two people really need some drastically different kind of “treatment” at all?
More common within the DID realm is the person who experiences identity alteration with amnesia, fear, lack of emotion, lack of motivation, overwhelming emotion, profound anxiety, hearing voices, seeing/feeling/smelling things that others do not, feeling unreal, feeling the world is unreal, extreme fear, anxiety, hopelessness, sadness, and suicidality. This person now meets criteria for about 10 different diagnoses, DID being only one of them. When the individual does not agree with the clinician about how to explain these ever-changing symptoms, then more diagnoses may be added. Usually this will include several personality disorder diagnoses and, if the explanations sound bizarre to the clinician, then the person is said to also have schizophrenia. Again I ask; how does this help in any way with “treatment”?
It just doesn’t.
At the end of the day, any “diagnosis” or technical, medical term serves to distance everybody involved from the experience itself. It most often leads to internalization of stigma, otherness, inferiority, hopelessness, dependency, and shame. For many, it reinforces the very beliefs that contributed to the development of the distress in the first place: the person is broken and defective and deserved the mistreatment that he or she might have been victim to. It leads clinicians to fall into the trap of believing that any annoying or disturbing behaviors are indicative of disease or personality rather than an understandable response to internal or external events.
If one were to break down the seemingly incomprehensible presentation of distress into the individual experiences that may or may not include any or all of the above, then suddenly things begin to make sense. The clinician or family member might be able to relate, and the experiencer might also be able to relate to others and to his or her self in a more compassionate and humane way. There is no “othering” of the individual; rather, the experience is couched in a way that can be viewed as a very human, very understandable reaction to a very un-understandable world. Additionally, there is no disease or symptom to “cure” or “treat”; instead there is a journey to go on that includes relationship, meaning-making, healing deep wounds, coming to know one’s self, forgiveness, compassion, growth, and spirituality.
The British Psychological Society published guidelines in 2011 for the use of “psychological formulation” that, in theory, could replace diagnoses in mental health treatment (Division of Clinical Psychology, 2011). Basically, and I am really simplifying this here, they recommend that psychologists take an approach that focuses on personal meaning within familial, societal, and systemic contexts that honors collaboration and the role of trauma and chronic stress. Lucy Johnstone, MIA author and the lead author of these guidelines, has discussed this in more detailhere. Using the previously listed phenomena, it might work something like this:
A 20-something-year-old woman presented to the emergency room after family members believed that she might hurt herself or someone else. She reported having large gaps in memory, was accused of being a liar, does not trust anybody, believes the staff of the hospital is going to attack her, hears voices, sees visions, and has a history of suicide attempts.
This is not an uncommon situation, but instead of saying she is “manipulative, attention-seeking, hallucinating, paranoid, delusional, and threatens suicide” the report is just a factual recount of her actual subjective experience. The formulation might go on to say that this individual denies any trauma or abuse, she has a lot of friends, is intelligent, aims to pursue X career, and does not believe that she has anything wrong with her. The psychologist could validate this and say “you’re right, you are clearly experiencing a great deal of confusion and distress and let’s work together to try and understand what might be going on.” The psychologist assumes that some external dynamic or event slowly over time led to the extreme experience in the present and does not insist that this dynamic or event be known right away. Each behavior, statement, or outburst can be seen as an attempt to express the very confusing internal world instead of being viewed as a disease or personality problem. Everything is a clue to finding meaning and reaching the goals of pursuing X career through a focus on strengths and understanding. The person in distress and the clinician can work together to understand what areas may need to be addressed first, how to more effectively cope with overwhelming emotions and pain, and building trust. Eventually, the meaning will come and any trauma or other painful experiences can slowly be processed. Specific techniques or activities can be planned around specific complaints of the experiencer: if she has identity alteration or hears voices … you can, together, get to know them and what they have to say. If she experiences feelings of being unreal or her surroundings being unreal, you can use grounding exercises. If she complains of heart palpitations and difficulty breathing, use relaxation exercises, if she has beliefs that the clinician does not understand or agree with, try to figure out how these beliefs are serving the individual, etc.
Nowhere in this formulation is there a need for diagnosis, “cure,” or an explanatory model beyond the context in which such phenomena developed. Some find comfort in diagnoses because they find comradery or normalization in knowing other people have experienced something similar. The Hearing Voices Network has shown how this same comfort can be found without diagnoses. A person who experiences mania, anxiety, depression (not in the DSM sense), identity alteration with amnesia, extreme fear and distrust of others, etc., can find that same comradery by seeking out others with that same experience; a diagnosis does NOT mean any commonality at all. Two people with the same diagnosis can have COMPLETELY different experiences and have NOTHING in common!
Alternatively, some find comfort in the diagnostic and medical explanations because they validate the lack of will or intention that the suffering individual may experience. This is a serious concern and must be addressed more sufficiently than has been thus far. Just because something is not medical, this does not insinuate the intention of one’s behavior. These experiences are very, very real. They have very real biological correlations. For instance, when one goes into a trance state (or dissociative state in some circles), every part of the brain shuts down relative to the verbal and animalistic/limbic portions of the brain. This is real, but; this is not a disease.
Lastly, using the formulation approach requires a bit more work for the professional engaging in such a practice. There is no automatic categorization, prediction, prescription, and rigid, manualized “treatment” plan, although there could be a place for all of these things based on the collaborative assessment of specific complaints. Instead, there is a need to practice an art of relating, collaborating, engaging, and dealing with really frightening, overwhelming, and uncomfortable emotions on BOTH parts. Diagnoses and medical/symptom-based approaches help the practitioner, and sometimes even the experiencer, maintain a comfortable distance from the traumatic, death-anxiety-provoking reality of life. But, we must move past this. We must do better. Again, back to the Hearing Voices movement: “Nothing about us without us.”
* * * * *
Division of Clinical Psychology. (December, 2011). Good practice guidelines on the use of psychological formulation. Leicester, United Kingdom: British Psychological Society.
When it came to pharmacological solutions to life’s despairs, Aldous Huxley was ahead of the curve. In Huxley’s 1932 novel about a dystopian future, the Alphas, Betas and others populating his “Brave New World” have at their disposal a drug called soma. A little bit of it chases the blues away: “A gramme” — Huxley was English, remember, spelling included — “is better than a damn.” With a swallow, negative feelings are dispelled.
Prozac, the subject of this week’s video documentary from Retro Report, is hardly soma. But its guiding spirit is not dissimilar: A few milligrams of this drug are preferable to the many damns that lie at the core of some people’s lives. Looking back at Prozac’s introduction by Eli Lilly and Company in 1988, and hopscotching to today, the documentary explores the enormous influence, both chemical and cultural, that Prozac and its brethren have had in treating depression, a concern that gained new resonance with the recent suicide of the comedian Robin Williams.
In the late 1980s and the 90s, Prozac was widely viewed as a miracle pill, a life preserver thrown to those who felt themselves drowning in the high waters of mental anguish. It was the star in a class of new pharmaceuticals known as S.S.R.I.s — selective serotonin reuptake inhibitors. Underlying their use is a belief that depression is caused by a shortage of the neurotransmitter serotonin. Pump up the levels of this brain chemical and, voilà, the mood lifts. Indeed, millions have embraced Prozac, and swear by it. Depression left them emotionally paralyzed, they say. Now, for the first time in years, they think clearly and can embrace life.
Pharmacological merits aside, the green-and-cream pill was also a marvel of commercial branding, down to its market-tested name. Its chemical name is fluoxetine hydrochloride, not the most felicitous of terms. A company called Interbrand went to work for Eli Lilly and came up with Prozac. “Pro” sounds positive. Professional, too. “Ac”? That could signify action. As for the Z, it suggests a certain strength, perhaps with a faint high-techy quality.
(X is a pharmacological cousin to Z. Both letters are somewhat unusual, worth many points in Scrabble. It is surely not a coincidence that a striking number of modern medications contain either Z or X, or both, in their names, like Luvox, Paxil, Celexa, Effexor, Zantac, Xanax, Zoloft, Lexapro and Zocor, to name but a few. Not surprisingly, confusion can set in. Zantac or Xanax — remind me which one is for heartburn and which for panic disorder?)
Pendulums, by definition, swing, and the one on which Prozac rides is no exception. After the early talk about it as a wonder pill — a rather chic one at that — a backlash developed, perhaps unsurprisingly. Grave questions arose among some psychiatrists about whether the S.S.R.I.s increased chances that some people, notably teenagers, would commit suicide or at least contemplate it. No definite link was confirmed, but that did not end the concern of some prominent skeptics, like a British psychiatrist, Dr. David Healy. He has dismissed the notion of S.S.R.I.s as saviors as “bio-babble.”
If some users deem Prozac lifesaving, others consider it sensory-depriving. A loss of libido is a common side effect. Some writers and artists, while often relieved to be liberated from depression’s tightest grip, also say that Prozac leaves them mentally hazy. In his 2012 book, “Antifragile: Things That Gain From Disorder,” Nassim Nicholas Taleb offered this: “Had Prozac been available last century, Baudelaire’s ‘spleen,’ Edgar Allan Poe’s moods, the poetry of Sylvia Plath, the lamentations of so many other poets, everything with a soul would have been silenced.”
Then, too, S.S.R.I. critics express doubts that these drugs have proved themselves significantly more effective than placebos. Some among them question the very concept that serotonin levels, on their own, cause depression or prevent it. One psychotherapist in that camp is Gary Greenberg, an author of several books on mood disorders. Writing in The New Yorker last year, Dr. Greenberg said that scientists had “concluded that serotonin was only a finger pointing at one’s mood — that the causes of depression and the effects of the drugs were far more complex than the chemical-imbalance theory implied.”
“The ensuing research,” he continued, “has mostly yielded more evidence that the brain, which has more neurons than the Milky Way has stars and is perhaps one of the most complex objects in the universe, is an elusive target for drugs.”
More broadly, this retrospective on Prozac introduces a discussion of whether the medical establishment, and perhaps society in general, has gone too far in turning normal conditions, like sadness, into pathologies. And have we paved a path — shades of soma — toward wanton reliance on drugs to enhance life, not to conquer true illness?
This is what a prominent psychiatrist, Dr. Peter Kramer, has called “cosmetic psychopharmacology,” a Botox approach, if you will, to matters of the mind: Why not take Prozac and its S.S.R.I. mates even if you are not clinically depressed but believe that they can boost your confidence, or maybe help you make a stronger pitch at the sales meeting?
A response from others in Dr. Kramer’s field is that we are taking traits that are normal parts of human nature and casting them as diseases simply because remedies now exist. For instance, shyness is now regarded by some as a condition in need of treatment. In its more severe form, it is placed under the heading of social anxiety disorder. Then there are those much-heralded life enhancers, Viagra and its erection-aiding cousins. They are marketed not only to men with sexual dysfunction but also to those whose aging bodies are enduring normal wear and tear.
One area of shyness that the S.S.R.I. class has helped overcome is discussion of depression. Decades ago, Hollywood stars and other celebrities dared not touch the subject. Now they routinely go public with their anguish. Robin Williams was an example.
Of course, there are those in other realms of society for whom the topic remains taboo. Take one man who confesses to his wife that he is on Prozac but cautions her to tell no one. “I’m serious,” he says. “The wrong person finds out about this and I get a steel-jacketed antidepressant right in the back of the head.” This is Tony Soprano talking to his wife, Carmela. An extreme example from a work of fiction? Sure. But in all likelihood many Americans have similar fears about what others might think, and keep depression to themselves.
The video with this article is part of a documentary series presented by The New York Times. The video project was started with a grant from Christopher Buck. Retro Report has a staff of 13 journalists and 10 contributors led by Kyra Darnton. It is a nonprofit video news organization that aims to provide a thoughtful counterweight to today’s 24/7 news cycle.
An online platform that helps people with bipolar disorder self-administer therapy has proven to be successful in a small trial, with 92 percent of participants saying they found the content positive.
Nicholas Todd, a psychologist in clinical training at the NHS Trust, has developed the site as part of a project he’s running called Living with Bipolar.
In it, he asked 122 people to use a sort of e-learning environment that uses audiovisual models and worksheets, incorporating parts of cognitive behavioral therapy and psycho-education known to be effective in bipolar patients. There’s also a peer support forum, which is moderated by a member of Todd’s research team, and motivational emails were periodically sent to those on the trial.
"Service users were encouraged to access the intervention flexibly and use it as and when they felt appropriate," Todd told Wired.co.uk. That’s because, as he presents in a paper on the platform, for patients “recovery is defined as people living a fulfilling life alongside their condition”. As such, it needs to fit in around them, their lifestyle and their changing needs.
One participant comments: “….for me recovery is certainly not about being symptom free… it is about coping and having a reasonable quality of life, being able to work productively and enjoy things outside of work.”
Thus, Todd explains, “service users did not focus on a ‘cure’ as their desired outcome but instead personally defined recovery goals and improved quality of life.”
By the trial end, Todd found that on average, users who stayed till the end completed 60 percent of the program. Of the people that completed the whole thing — 15 modules — 74 percent took under three months to do so.
The platform took a year to develop, spent looking at the most effective components of psychological therapy for bipolar disorder. As this was narrowed down, the group carried out five focus groups and tested it online via a consultancy group.
The system gets users to identify their own mood using an established scale, the idea being they — and the system — can track their own ups and downs. “Service users would then receive information about the most appropriate modules, given their mood symptoms,” says Todd.
The forum, he says, played a key role in the project’s success. One participant commented, “…part of it [bipolar disorder] is feeling very alone… you don’t get that and I do think that the forum works extremely well with the intervention…” Todd explains how participants used it to support each other not only through the new intervention process, but through life events.
"A balance was struck between allowing participants to offload, and posts which encourage or talk about acts of suicide, self-harm, harm to others and are unhelpful to participants’ recovery." A total of 70 percent of the users signed up to the forum, and 1,927 posts on 130 topics were accumulated. "The participants who used the forum tended to complete more modules, and all participants who completed the entire program used the forum, albeit in different ways."
The idea behind the platform is to help bridge those periods between appointments, or those appointments that a patient misses. As with depression, health services can be known to administer solely medication to help alleviate symptoms. More and more, the NHS is striving to ensure psychological therapy is integrated alongside a prescription for mood stabilizers, such as lithium. “However, severe inequalities in access to psychological interventions for bipolar disorder currently exist in the NHS,” Todd says. “This intervention aims to increase access to psychological intervention.”
Todd tells us the NHS is actively training more staff to deliver psychological therapy, to plug the gap. For now, that initiative is being piloted for severe mental health conditions. “This intervention may fit as part of this initiative in giving service users with bipolar disorder greater access to psychological therapy.
"Computerized interventions are not about replacing face-to-face interventions, but giving someone another option to receive psychological support. In fact, some people prefer accessing psychological support in this way as it fits better with their lives."
For one woman in particular the experience has been, in her words, “life changing”.
She said: “I have encountered insights in the modules that have significantly helped me to survive the blackest moments. I cannot measure the value of this, as it has contributed to their difference between life and death. My husband and I are sincerely grateful for the immeasurable impact this has had on our family.”
Is it melancholy to think that a world that Robin Williams can’t live in must be broken? To tie this sad event to the overarching misery of our times?
– Russell Brand, comedian/actor
Like millions, I am sitting with the fact that one of the funniest people to grace the planet has died by his own hand. Robin Williams’ death has hit people of my generation, Generation X, especially hard. After all, his face flashed often across our childhood screens. Mork and Mindy episodes were a source of solace for me as a little girl, as I bounced around between foster homes and family members’ homes, while my single mother cycled in and out of the state mental hospital, fighting to survive. I could laugh and say “nanu, nanu – shazbot” and “KO” and do the silly hand sign and forget for just a little while about living a life I didn’t ask for.
“You’re only given one little spark of madness. You mustn’t lose it,” may become one of Robin Williams’ most famous quotes. I was always struck by how he moved so seamlessly between wacky comedy and the most intense dramas. He was so magnificently able to capture the human experience in all its extremes. He threw all that intensity right into our faces, undeniable, raw, frenetic. He showed us our own naked vulnerability and sparks of madness and gave us permission to laugh in the face of all that is wrong in this world.
In the wake of his death, many people are understandably jumping to identify causes. Depending on who you talk to, Robin Williams’ suicide was caused by depression, it was caused by bipolar disorder, it was caused by the drugs, prescription or otherwise. We just don’t know.
As a suicide attempt survivor myself, I can attest that it’s not that easy to find any single cause for the urge to die. It’s true that along with street drugs, SSRI antidepressants and other psych drugs can certainly increase suicide risk in some people. A decade ago, I was one of many who fought and won to get to the FDA to put a black box warning on SSRIs to warn the public of these very real risks. While a drug, legal or illegal, may give us the impetus we wouldn’t otherwise have had to act on suicidal thoughts, for some of us it’s more complex than that.
Our reasons for wanting to die are as varied as our reasons for wanting to live. That, I believe, is the great mystery of suicide.
But I invite us all not to fear the mystery; not to be struck hopeless by it. We can save each other’s lives; better yet, we can find and share reasons to keep on living. If we have 20 seconds, we can share information about a hotline or a warmline. But if we want to really see this horrific epidemic end, we all have to get more involved.
As someone who has looked into the void and longed for it more than once, I can attest that anyone who reaches out in those darkest of times is truly remarkable. It is, tragically, when I am most distressed and most in need of love and acceptance, that I have the hardest time reaching out. This is not an absolution of personal responsibility, because we all must accept some measure of that; rather a recognition that we shouldn’t put the full onus on a suicidal person to “reach out” and “ask for help.” We need to reach out and help. I have written about the problems with the master narrative of suicide prevention, and how punitive and dehumanizing much of the “help” out there currently is. This blog isn’t about that. I’m talking about help that heals.
My point is that we must change the way we relate to ourselves and one another. In revolutionary ways. We must wake up to the fact that we have been socialized since birth to hide the fullness of who we really are. Robin Williams got to act it all out and the world loved him for it. He expressed the madness, the wildness, that we have been conditioned to hide. We are generally chastised for laughing too hard or crying too loud or being too sensitive. We have been trained to put on a proper face and act like all is well. If for some reason we can’t naturally do that (and most of us can’t), we devise ways to cope with the awful unbearableness of it all. They may be fairly innocuous, like binge watching Orange is the New Black in bed all weekend long. Or we may seek to stop the pain in innumerable ways that we know will kill us in the end — from binge eating to chain smoking to staring down a bottle of whiskey or pills.
If we only realized just how many people walked around carrying heavy burdens that are invisible to the world, and were doing every fucking thing possible to keep from cracking under the weight, we would stop feeling so alone and isolated carrying our own. We could put down our burdens and rest, in the all-encompassing field of our human vulnerability and strength.
“Be kind, for everyone you know is fighting a hard battle,” said theologian Ian MacLaren. I am struck by the imperative need for us all to take up the challenge to be kinder to ourselves and others. There is so much suffering in the world. How often do we ask ourselves, in the midst of responding to Facebook posts, Tweets, and emails: how can I relieve suffering? At the very least, how do I not add to it?
No one person can fix this mess we have gotten ourselves into as a species, but we can each be a part of bringing more compassion and acceptance into the world. First, we have to learn to practice it with ourselves. We can be the antidote to the fear and sorrow that exists within us, in other people, and in the world “out there.” Kindness is dismissed as bullshit in a world that values power over others. But as mindfulness teacher Sharon Salzberg reminds us, kindness is a “force.” If unleashed in vast quantities, it could literally reverse the cycle of misery on this planet.
When will we stop walking around in these miraculous, vulnerable human bodies seeing ourselves as separate? What will it take for us to realize our interconnectedness; to act from a deep understanding that suicidal people are not to be feared and judged, but to be embraced and held in the light of understanding and true empathy? Empathy sees that we are all connected, and thus demands well-being for all.
I think of the people who report walking to the bridge and said to themselves, “if one person smiles at me or talks to me, I won’t jump.” Lately I try to go out of my way to smile at people, to talk to people, even if they look at me funny because they aren’t used to random strangers smiling at them or talking to them. Come to think of it, I think talking to strangers is definitely a symptom of some severe mental disorder in the DSM-V.
But seriously, folks. It strikes me that breaking down our collective walls of isolation, of chiseling away our carefully constructed masks, of taking care of ourselves and each other, of judging less and loving more, may be among the most important things we can do with our lives. We can simply value people, not for what they do or what they achieve in the world, but because they are alive on this planet with us, right now, sharing these troubled, turbulent and painfully beautiful times.
In the end, we are stunningly diverse, yet there are basic human needs that we all have in common. The ancient practice of lovingkindness exhorts us to wish for ourselves and all beings to be safe, to be healthy, to be free, to live with ease. How can we create a world where these universal human needs are met? I think this is one of the primary questions we should all be asking ourselves right now, and figuring out the answers together.
I don’t claim that smiling at the person who makes your coffee or talking to a stranger on the metro will save the planet. What I do believe is that if we all made human connection, safety, and a sense of shared belonging among our top priorities, if we all tried in ways large and small to end our collective isolation and suffering, this world would be a safer place to be human. And a lot of people might not be eager to leave so soon.
Nanu, nanu, Robin Williams. Rest in peace.
To Know Suicide: Depression Can Be Treated, but It Takes Competence
By Kay Redfield Jamison, The New York Times,
BALTIMORE — When the American artist Ralph Barton killed himself in 1931 he left behind a suicide note explaining why, in the midst of a seemingly good and full life, he had chosen to die.
“Everyone who has known me and who hears of this,” he wrote, “will have a different hypothesis to offer to explain why I did it.”
Most of the explanations, about problems in his life, would be completely wrong, he predicted. “I have had few real difficulties,” he said, and “more than my share of affection and appreciation.” Yet his work had become torture, and he had become, he felt, a cause of unhappiness to others. “I have run from wife to wife, from house to house, and from country to country, in a ridiculous effort to escape from myself,” he wrote. The reason he gave for his suicide was a lifelong “melancholia” worsening into “definite symptoms of manic-depressive insanity.”
Barton was correct about the reactions of others. It is often easier to account for a suicide by external causes like marital or work problems, physical illness, financial stress or trouble with the law than it is to attribute it to mental illness.
Certainly, stress is important and often interacts dangerously with depression. But the most important risk factor for suicide is mental illness, especially depression or bipolar disorder (also known as manic-depressive illness). When depression is accompanied by alcohol or drug abuse, which it commonly is, the risk of suicide increases perilously.
Suicidal depression involves a kind of pain and hopelessness that is impossible to describe — and I have tried. I teach in psychiatry and have written about my bipolar illness, but words struggle to do justice to it. How can you say what it feels like to go from being someone who loves life to wishing only to die? Suicidal depression is a state of cold, agitated horror and relentless despair. The things that you most love in life leach away. Everything is an effort, all day and throughout the night. There is no hope, no point, no nothing.
The burden you know yourself to be to others is intolerable. So, too, is the agitation from the mania that may simmer within a depression. There is no way out and an endless road ahead. When someone is in this state, suicide can seem a bad choice but the only one.
It has been a long time since I have known suicidal depression. I am one of millions who have been treated for depression and gotten well; I was lucky enough to have a psychiatrist well versed in using lithium and knowledgeable about my illness, and who was also an excellent psychotherapist.
This is not, unfortunately, everyone’s experience. Many different professionals treat depression, including family practitioners, internists and gynecologists, as well as psychiatrists, psychologists, nurses and social workers. This results in wildly different levels of competence. Many who treat depression are not well trained in the distinction among types of depression. There is no common standard for education about diagnosis.
Distinguishing between bipolar depression and major depressive disorder, for example, can be difficult, and mistakes are common. Misdiagnosis can be lethal. Medications that work well for some forms of depression induce agitation in others. We expect well-informed treatment for cancer or heart disease; it matters no less for depression.
We know, for instance, that lithium greatly decreases the risk of suicide in patients with mood disorders like bipolar illness, yet it is too often a drug of last resort. We know, too, that medication combined with psychotherapy is generally more effective for moderate to severe depression than either treatment alone. Yet many clinicians continue to pitch their tents exclusively in either the psychopharmacology or the psychotherapy camp. And we know that many people who have suicidal depression will respond well to electroconvulsive therapy (ECT), yet prejudice against the treatment, rather than science, holds sway in many hospitals and clinical practices.
Severely depressed patients, and their family members when possible, should be involved in discussions about suicide. Depression usually dulls the ability to think and remember, so patients should be given written information about their illness and treatment, and about symptoms of particular concern for suicide risk — like agitation, sleeplessness and impulsiveness. Once a suicidally depressed patient has recovered, it is valuable for the doctor, patient and family members to discuss what was helpful in the treatment and what should be done if the person becomes suicidal again.
People who are depressed are not always easy to be with, or to communicate with — depression, irritability and hopelessness can be contagious — so making plans when a patient is well is best. An advance directive that specifies wishes for future treatment and legal arrangements can be helpful. I have one, which specifies, for instance, that I consent to ECT if my doctor and my husband, who is also a physician, think that is the best course of treatment.
Because I teach and write about depression and bipolar illness, I am often asked what is the most important factor in treating bipolar disorder. My answer is competence. Empathy is important, but competence is essential.
I was fortunate that my psychiatrist had both. It was a long trip back to life after nearly dying from a suicide attempt, but he was with me, indeed ahead of me, every slow step of the way.