Saturday, October 14, 2017

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.


More Information

Meetings: Activities and Key Concepts

Insomnia, Anxiety and Depression

Feelings are not Facts

Saturday, October 7, 2017

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


Sunday, October 1, 2017

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:

Wednesday, September 27, 2017

Sarcasm, Humour and Ambiguity

In Recovery we say "you cannot be in temper when in humour", and it's certainly true that it's tough to be angry or upset when you are laughing. There is nothing that is more healthy than an infectious joke shared with your best friends that brings on irrepressible cackling.

I can't remember very many jokes, although one of my best friends is a consummate entertainer and has an endless supply of jokes and funny stories to tell. Years ago he taught his daughter a kid friendly joke, and it's one of the few jokes I can remember today because I heard him repeat it so many times. It goes like this: "A horse walks into a bar with a set of jumper cables around its neck. The bartender looks the horse up and down and says ruefully: 'I don't mind the long face, just don't start anything'." My friend laughed every time he told this joke, insisting that repetition was they key to making it work. The set up is fairly old and hackneyed, which is partly why I remember and like this joke's very simple punchline.


Comedy is an acquired taste. A great deal of why we laugh at a particular joke has as much to do with how the person tells the joke as how good the joke itself is. Jokes are often specific to their era, especially if based on parody. Everybody has their favourites, some comedy ages well, although a lot does not.

The kid friendly joke about the horse works (or tries to work) based entirely on expectation, double entendres, and sudden realization. The double entendre is a cornerstone of comedy often used to deliver the real message, and may employ innuendo, an explicit dual meaning of a word or phrase, or in some cases a homophone, or word that sounds like another word. Jokes often hide truth within their punchlines, and communicate messages on multiple frequencies.

Many people enjoy sarcasm, although in our Recovery meetings we discuss sarcasm as an example of temper. A great deal of modern humour is based on sarcasm, where irony is expressed through intonation. Sarcastic remarks often state the opposite of what they intend, and so when used as insults or cutting put-downs they relieve the speaker of responsibility for the remark. We say "...officer Frank does a greeaat service for our town," although we mean quite the opposite and the listener is queued by our tone of voice as to our true meaning.

As humour, sarcasm is a lazy device, it requires little thought. Some people develop a habit of expressing themselves this way, they seem to think that the cleverness of their ruse is enough to excuse the negative punch of the insult. In Recovery meetings we strongly discourage this conduct. We do encourage good humour as an antidote to temper, although humour without sarcasm or put-downs is a puzzle for some people.

The problem with sarcasm is eloquently illustrated in the following Kid's in the Hall sketch portrayed by Dave Foley, and Kevin McDonald.



[Scene: The snack table at a party. Dave stands there drinking a beer, and Kevin walks over.]

[Note: all of Dave's lines are delivered in an exaggerated tone with elongated vowels and odd emphasis.]

Kevin: Great party, huh? I actually don't know anyone at the party, actually, I'm kinda new to the neighborhood, actually, but my friend Chris said "come to the party, I'll introduce you around, you'll know everybody by the time you leave the party." Chris knows everybody, and soon I'll know everybody! 'Course, Chris didn't show up. So I guess I gotta mingle. So here I am mingling! 'Course, mingling really isn't my game, I'm not really a mingler, per se, I was actually in the corner alone mingling - that means I'm not talking to anyone, actually. I saw you over here, I said "there's a guy by himself, why not go over here, I'll mingle with this guy, this guy looks like a mingler," so hi, I'm Derek, pleased to meet you.

[Kevin extends his arm, and they shake hands.]

Dave: Well it certainly IS a plea-sure to meet YOU, ... Derek!

Kevin: I'm sorry if I bothered you.

Dave: Oh no, you're not both-er-ing me, Derek, far from it. There's nothing I would rather DO than just stand here and CHAT with YOU! Y'know - reeeally get to know yooou?

Kevin: Look, I don't think there's any need to be sarcastic.

Dave: Oh, I'm ... not ... being ... sar-cas-tic! Nooo! This is just a little speech impediment. I can't ... help ... it!

Kevin: Okay, I've obviously said or done something wrong to upset you, I'm just gonna apologize and be on my way.

Dave: No, no, no, please STAAAYYY. It's true. I've talked this way ALL MY LIFE. It's made things veeeerrrry dif-fi-cult for me.

Kevin: Yeah! Right!

[Kevin walks away, with Dave calling after him.]

Dave: Hey! Where ya goin'? Come back! I really wannna be YOOUR friend! [to the camera] I'm sooo lonely.

The sarcastic guy skit works because it makes obvious the problems with sarcasm, this is the truth revealed in this 2 minute drama. I think what is brilliant about this bit is that it isn't clear if Dave, the sarcastic guy, really is being sarcastic, or whether he genuinely does have the sarcastic-sounding speech impediment that he claims to have. Either way it doesn't matter, he is alone at the end of the skit, he has effectively alienated his audience with sarcasm.

I worked for a manager for several years who tried to encourage staff through the use of innuendo and suggestive comments. Her remarks about performance, bonuses, and expected work hours were often couched in statements that made implications and were less than clear.

She would occasionally make remarks in staff meetings like, "... every year the management staff compares notes on all the employees, and you know, ... sometimes HR sends out pink slips." This thinly veiled threat carried the bite of telling us that she would see that certain individuals who didn't work sufficiently hard would be fired, however, she didn't say it explicitly. The threatening message was implied and at the time nobody asked for clarification and none was ever offered. I found these sort of exchanges extremely vexing and upsetting. I wasn't sure whether my manager was threatening our work group, whether she was trying to be funny, simply not saying anything very specific, or to what extent these remarks were directed at me personally.

Recognizing the pattern of my frustrations with this manager and how it led to temper took me a long time. In Recovery we say "suppress your temper, express your feelings" although expressing your feelings can be quite difficult at times. I spent a lot of time suppressing my temper around her and only after I was reassigned to work with someone else did it dawn on me that I ought to have been expressing my feelings of confusion by asking for clarification.

Dr. Abraham Low gives an even simpler example where he talks about meeting someone on the street who smiles at you. He writes:

The difficulty begins, however, the moment you go beyond the domain of observation and pass into the area of interpretation. After observing the smile on the man's face you may ask yourself, for instance, what precisely that smile means. It may mean warmth of feeling and joy of seeing you. The proper interpretation, then, would be: fellowship, friendship, good will. Or, it may mean nothing more than conventional politeness. That would be: indifference. If the smile is associated with strained features the proper interpretation might be: annoyance or resentment of your intruding. And finally, the smile may have an expression of irony or sarcasm. In that case, the proper label would be: haughtiness, disrespect and perhaps hostility. This simple example indicates that the pitfalls of thinking reside in interpretation rather than observation. The trouble is that once you have made an observation you feel an imperative urge to interpret it. And if interpretation is difficult even in outer observations, the attempt to apply it to inner experiences increases the obstacles to such an extent that only a mind trained in the techniques and rules of the thinking process can be expected to conquer them.

The puzzle that we encounter here is that even given the simplest of scenarios, we can get tripped up by interpretation of the situation. In Recovery meetings we often use the tool "to know is not to know", which is a reminder that you often do not have a complete understanding of any given situation.

We often feel pressure to be in-the-know, to be cool and hip and to follow the implied meanings of others. For some reason asking for clarification seems either awkward, or something that we feel we should avoid. We may genuinely have misunderstood the statement that someone made. It is also possible that we understood their hidden meaning all too well, however leaving certain statements implied can excuse the speaker of responsibility and prevents the remark from being challenged. Leaving strong implications unaddressed can lead to confusion, frustration, irritation, fear and anger. By asking for clarification and recognizing that we don't have all the information we are applying the tool "to know is not to know".

Humour is good for us, and excellent fun. Lets keep telling jokes as best we can, but lets also be aware that some jokes are expressions of temper and told at the expense of others. I used to try to entertain through the use of sarcasm, and often thought of myself as clever and witty, although I can't say for sure whether my audience was impressed. If you are bad at telling jokes like I am, (I can only get so much mileage out of the story about the horse that walks into the bar) consider that sarcasm may create confusion and temper in others and often won't make you a hit at parties.

Communicating can be hard work for nervous persons, not everyone is an expert joke or story teller. Clever or cutting remarks might make you feel in control, as expressing temper often does, but these words will be poorly received. Using a light conversational touch that does not express temper can be a far more effective strategy. Lately, I've found that patient attempts to learn about the interests of others and share my ideas and experiences are good ways to get to know people. I also tell bad jokes, have you heard the one about the horse that walks into a bar with a set of jumper cables around its neck...


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Fear is the Mind Killer

Sunday, September 24, 2017

Fear is The Mind-Killer

As a teenager I loved horror and science fiction films. I still do today. I know lots of people who simply don't like horror films and won't go see them under any circumstances. These films show us images that are by definition unpleasant, and I think on average many people tend not to like horror films regardless of how good the acting and story telling is.


In the late 1970s my parents took me to see an evening screening of a gothic horror film staring Frank Langella titled simply "Dracula". I remember walking home from the theater with them after the movie and being impressed by how dark and quiet the city streets were at night. There is a scene in this film where the vampire hunter, Van Helsing, opens the grave of one of Dracula's recent victims to find that the newly undead vampire has clawed a hole in the bottom of its coffin and escaped into the catacombs beneath the church graveyard. Van Helsing climbs down through the hole and into the catacombs where he is confronted by the wraith in a flowing white gown staring at him with glowing red eyes.

This image kept me awake at night for years. While falling asleep, on the edge of awareness I would slip into a semiconscious state where the red eyed wraith would confront me. I would jolt back into wakefulness, heart pounding,  feeling completely unnerved and sensing the breath of the thing in the room with me. I had a copy of Frank Herbert's novel Dune at the time, which I read cover to cover to distract myself at night before falling asleep. I might have read it twice, it seemed to take forever to get through.

Within Dune there is a scene where the main character is given a test where he puts his hand in a box that induces pain, although he is told that the box will not actually harm him. He is also told that if he cannot control his impulse to withdraw his hand from the box he will fail the test- and that failure will amount to death. To control his fear he recites the following litany:

I must not fear.
Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear.
I will permit it to pass over me and through me.
And when it has gone past I will turn the inner eye to see its path.
Where the fear has gone there will be nothing. Only I will remain.

I typed out this short poem on a small piece of paper which I carried around with me. Eventually I memorized the litany and often recited it at night to try to manage my fears. Probably tracking the long details of outer space politics described in Herbert's novel Dune had the strongest effect in putting me to sleep, but I believed in the magical power of the litany to dispel fear and I remembered it for years.

I still enjoy horror films although they very rarely induce the same sort of terror that they did when I was young. The quality of what frightens me on a day-to-day basis and prevents me from falling asleep now is quite different. My beliefs have changed, for better or worse I am quite convinced that there are no vampires or ghosts that can hurt me while I sleep, and so when my rational mind is in control these fanciful spectres are easily dismissed.

Today it is the details of the practical and the mundane that have far more power over my subconscious than any subterranean wraith.

I think the insidious difference is that my fears today do not recede in the daylight but will manifest there as compellingly as they do late at night. Years ago the stigma of mental health issues bothered me immensely. When I would go out in public I would struggle with the idea that people knew what was wrong with me, that they knew I was unemployed, and that they could tell that I was the type of person who had spent time recuperating in a psychiatric hospital ward.

It has been many years since my hospitalization and today stigma is less of an issue for me than it was in the past, nevertheless some nights I still lay awake worried and unable to sleep. I worry about certain bills, whether my job will still be there at the end of the year, what should I do about the awkward social exchange I had with some person that I met the other day, and on and on.


While these fears are perhaps less intense than my preternatural childhood fears, they have a persistence that I find very difficult to dispel. At times these practical worries have dominated my thought process in a way that blotted out meaningful experiences. My daytime waking nightmares would permeate my mind and take me prisoner, dulling my ability to think clearly and act. What they lacked in heart throbbing intensity and jump scare factor they more than made up for in tenacity. The day-in-day-out quality of the paranoid realistic experience of "practical" worries at times became a marathon of endurance testing my ability to withstand the endless unresolvedness of the issues.

Dr. Abraham Low writes:

If phobias, compulsions and obsessions dominate the symptomatic scene the resulting fear is that of the mental collapse. After months and years of sustained suffering the twin fears of physical and mental collapse may recede, giving way to apprehensions about the impossibility of a final cure. This is the fear of the permanent handicap. The three basic fears of the physical collapse, mental collapse and permanent handicap are variations of the danger theme suggested by the symptomatic idiom. 

Another source of defeatism is temper. The patients are taught that temper has two divisions. The one comes into play when I persuade myself that a person has done me wrong. As a result I become angry. This is called the angry or aggressive temper, which appears in various shades and nuances: resentment, impatience, indignation, disgust, hatred, etc. The other variety of temper is brought into action whenever I feel that I am wrong. This gives rise to moral, ethical and esthetic fears or to the fear of being a failure in pragmatic pursuits. I am afraid that I sinned, failed, blundered, in short, that I defaulted on a moral, ethical or esthetic standard or on the standard of average efficiency. This is called the fearful or retreating temper which may express itself in many different qualities and intensities: discouragement, preoccupation, embarrassment, worry, sense of shame, feeling of inadequacy, hopelessness, despair, etc. The fearful temper is likely to lead either to a feeling of personal inferiority or to the sentiment of group stigmatization. Whether it be of the angry or fearful description, temper reinforces and intensifies the symptom which, in its turn, increases the temperamental reaction. In this manner, a vicious cycle is established between temper and symptom.

In Recovery we say "replace an insecure thought with a secure one", and I think this tool can be quite difficult to use. The first step is always to simply identify the insecure thought, for me its often something like "...I will crash the car into oncoming traffic," or "...I will lose my job within the next six months due to the incompetency of the director," or "...I have nothing to say to anyone at this social function; I'm awkward and people don't like talking to me."

The quality of the fear in each of these cases has a quiet unspoken irrationality to it, in this way these grown up fears are the same as my childhood fears. They whisper nonsense in the back of my mind, through implication and innuendo they suggest the things that will go wrong and pretend that they arise from some hard to speak truth. If I fan the flames of these irrational fears by buying into them they become more real, more persistent, and can spin up into a vicious cycle that grips me day and night.

These thoughts for me are all rooted in partial truths, so to me they are compelling, but in each there are flaws. The first thought, about crashing the car, is related to a false belief regarding my inability to drive competently. I don't like driving, and I am not a practiced driver, but I am not so hopeless that there is a high probability that I will drive in the wrong lane. In Recovery we acknowledge that nervous persons often have "the passion for self-distrust", and that this perspective is not realistic.

If I practice Recovery methods and I spot the physical symptoms associated with the fears; I notice that I am griping the steering wheel, that I'm hunched in the drivers seat or that my leg is tense as I switch between the brake and the accelerator. By noticing these physical symptoms I can control my muscles, and intentionally relax my grip on the wheel and lean back in the seat. By forcing my muscles to relax I also reduce tension in my mind. By noticing my thoughts, where I imagine veering into oncoming traffic I can label them as false beliefs. This won't necessarily make the fears go away immediately but it does keep in the fore front of my mind that I am having a fearful temperamental response and that the ideas aren't real.

By spotting my fearful temper I am able to suppress the vicious cycle, I refuse to feed the fear by buying into it as a reflection of reality. I label the fears for myself as they happen which gives me a better chance to realize that they are no different than my childhood fears of vampires, hobgoblins and glowing eyed wraiths. My adult fears are real in appearance, but this is just a mirage created by my adult mind to give these fears credibility.

Fears don't go away overnight, I still struggle with many, but I now have tools to work on them. Like childhood fears, adult fears are most often rooted in false beliefs, although those beliefs are not so simple as red eyed monsters under graveyards. If we work at it we can identify beliefs which are untrue, and learning to tolerate fears when they do arise, and not respond to them impulsively, enables us to survive them. Much like the poem about fear I learned many years ago, we let the fear wash over us, and after it has gone only we remain.



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Does Depression have a Physical Cause?

Saturday, September 23, 2017

The Power of Peers for Brain Health Recovery and Advocacy

An article describing Recovery International written by Brandon Staglin appears in the Huffington post this week. He writes:

As today in the United States, the healthcare system faces serious challenges meeting the treatment needs of the population with psychiatric illness, such recovery-oriented organizations can play essential, supportive roles in empowering individuals and their communities toward better wellness.

Through a longtime supporter of my Brain Waves webcast, advocate Anthony Ferrigno, I have learned of a peer-to-peer brain health support group called Recovery International(RI), a nationwide organization that, using cognitive-behavioral-therapy-like techniques, empowers consumers to train one another toward better resilience, stability, and recovery prospects. Anthony has enthusiastically endorsed RI’s positive influence in his own life and those of his peers, and has sent me documentation from a 2011 nationwide survey of RI participants orchestrated by the University of Illinois at Chicago, which shows many significant reductions in symptoms and in dependence on the healthcare system among participants. It stands to reason that, since cognitive-behavioral therapy (CBT) delivered by trained laypeople or even computer programs can be effective to treat depression and anxiety, supported peer-driven CBT-style instruction such as RI offers might help consumers live healthier lives. Anthony is quick to point out that RI seeks not to replace but to augment psychiatric care as a support tool to ultimately help participants live more independently. Anthony says that RI, founded in 1937 by Dr. Abraham Low, is unfortunately the recovery movement’s “best-kept secret”, but he evangelizes passionately to spread the word.