Shoot the Damn Dog: A Memoir of Depression (26 page)

I’m sure that if most modern therapists, particularly CBT practitioners, took the Twelve Step programme apart, they would recognise many of the principles embedded in their own disciplines.

This is particularly true of two of the newest and most exciting forms of therapy emerging at present; Positive Psychology (emerging out of the US and based on practical solutions that encourage mental health rather than dwelling upon the symptoms of mental illness) and Cognitive Mindfulness Behavioural Therapy (a step on, and up, from the drier scientific model of challenging negative thinking used in CBT to include Buddhist principles of acceptance, faith and self-governance).

These therapeutic models prefer to play to people’s strengths, rather than their weaknesses. They maintain that we need to look to a better future in preference to living in a difficult past. We might consider the past and our part in it, but once we have done so, we need to move on.

And so it is with the Twelve Step programme. It encourages people to look at their own behaviour, and how they might be sabotaging their own happiness. It asks them to look at how they might be at fault, rather than casting blame on others. It asks them to examine and to know themselves, and to work persistently at changing their more destructive behavioural patterns. It does, in essence, what psychotherapists of all sorts encourage.

Here are the principles of the Twelve Step programme, presented as a list. There are more principles included here than there are steps, because each step embraces many principles. I use them on a daily basis to help me with depression, or with any emotional pain that might make me want to self-medicate or drink. Nor are they just for depressives (we have no favourites here) but for anyone who might want a better design for living.

Open up.

Ask for help.

Accept help.

Accept yourself.

Be completely honest.

Take a daily inventory.

Whenever you are in the wrong, make amends.

Face reality.

Reach out.

Communicate.

Show kindness.

Share your concerns and your worries with another human being.

Help another human being, on a daily basis.

Count your blessings, not your failures.

Don’t live in regret or in yesterday.

Don’t project your fears into tomorrow.

Take action, when action is needed.

Deal with your feelings if and when they arise. Don’t sit on them.

People talk about alcoholism as if it were a disease. It is not. You cannot catch it. It is a condition, an emotional illness or a behavioural disorder. It is, if you like, an inappropriate response to difficulty or pain. It is the messenger, not the message. At AA meetings, people rarely talk about alcohol. If they mention sobriety, generally what they mean is emotional sobriety. Meetings, or the support group, exist to help people to express and deal with the pain that might otherwise become so unmanageable that they try to dull it with drink.

For some people, depression is a result of alcohol abuse. Once they put down the alcohol, the depression lifts. For others, depression is a co-existing disorder, known as a co-morbid condition, and is often undiagnosed. When they stop drinking, their depression may worsen. They no longer have an anaesthetic to mask their pain and so they are more aware of it than ever. People have been hospitalised with severe depression two years after becoming sober.

Depressive illness and alcoholism are enduringly intertwined. Studies indicate that where both conditions are present, depression or a mental illness is usually the primary disorder. A report published in the
American Journal of Drug and Alcohol Abuse states
:

Alcoholism is also a physiological illness, inasmuch as the body becomes habituated to alcohol and craves more. I am sure, too, having watched closely for the past five years or so, that there are intuitive alcoholics: people whose systems are so sensitive to alcohol that it will cause them to malfunction, almost from the first drink. The route into alcoholism takes many paths but one of them seems to follow an inherited tendency. I have heard numbers of people in AA (usually with an alcoholic parent or sibling) describe how, at the age of thirteen or even younger, they took their first drink and immediately wanted another, drinking until they passed out. Vomiting, blackouts, toxic poisoning; nothing dissuaded them from pursuing another drink, and then another.

As is the case for most addictions, once the physical addiction is broken, the psychological one may continue. Or it may not. Not everyone who becomes dependent on alcohol stays dependent. I may not, as so many of my friends have pointed out, be an alcoholic, at least in the sense that they understand it. I have never passed out from drink. I do not vomit, smash up furniture, hit people, become abusive, shag strangers or exhibit any of the malfunctioning behaviour popularly associated with alcoholism.

That does not mean that I am not an alcoholic. If I am in emotional pain, my instinct is to take it away. My way of doing that is to drink, as I know that it relieves (if only temporarily) my pain. I have learned a disordered habit of behaviour that, once learned, is difficult to dismantle.

Now that I am well again, perhaps I could drink again. It is simply a risk that I am not prepared to take. After a long and severe episode of depressive illness, the possibility of relapse is high. Alcohol may precipitate depression by disrupting the already fragile chemical pathways in my head. On top of that, in order to guard myself against intuitive patterns of thinking and behaviour that may lead me back into depression, I need to be alert to my behaviour and thinking at all times. Alcohol is unlikely to help me in that clarity. It is, for me, no solution.

Once I had accepted that, it ceased to be a problem. I never drink alcohol and nor do I crave it. I love somebody who drinks. I always have drink in the house for him. As far as I’m concerned, it’s just another grocery, like milk.

Very occasionally, on a hot summer’s day when friends are drinking cold glasses of champagne I think, oh, wouldn’t that be nice. Or perhaps, at a party where I am feeling nervous, I’d like to be able to have a drink to dull my anxiety or at a dinner where everyone around me is garrulous and repetitive (and, eventually, fantastically dull), I’d like to inhabit the same dimension in order to make the time pass more quickly.

But otherwise, no. Even when my mood is very low and I’d like a sedative or an anaesthetic to blunt the pain, I never consider having a drink. Alcohol reminds me of only one thing. It smells to me of despair.

Once I had got myself off alcohol, I began to address what my psychiatrist called low mood. This is what passes as ordinary, everyday depression. It is no longer clinical, or severe or major. It is what healthy people mean when they say that they are depressed; that low, weary feeling of things being disjointed and difficult, but not impossible.

For me, it felt like an interminable, grey summer. You know the sun is there and you long for it to appear but every morning you wake to a flat, low cloud. After I left rehab, this dragged on for eighteen months, the grey sometimes relieved by a tantalising glimpse of sunlight or a sudden, shockingly blue sky. Those brief passages of normality (or what I call normality) seemed both intolerable (would I be that way for ever?) and a reason to hope. I was further up than I had been for four years, and there seemed no reason why I could not go higher.

I was scared, though, nervous of one of those dizzying relapses with which depression literature is filled. According to research, most depressions go into spontaneous remission. There are those, too, that spontaneously recombust. A longitudinal study of patients who had recovered from an episode of major depression showed that eighty-five per cent had a recurrence over the fifteen years of the study, and even in those who remained well for five years, there was a fifty-eight per cent chance of relapse. The longer the episode of depression, the higher the chance of a relapse.

Then again, every case of depression is unique, just as every individual is unique. And a scientific study, by its nature, relies on a large group of people doing exactly the same (proscriptively limited), thing over a determined period of time. What might be true for that control group may, or may not, be true for me. Or you.

Believe nothing.

Try everything.

That was my psychiatrist’s view.

‘We simply don’t know,’ he said.

And so I became determined to pull myself out of that low, grey mood in whatever way that I could. Now that I know so much more about depression, I look at it like this. It doesn’t much matter how you manage the illness. It just matters that you do.

I manage it in a number of ways, which I include here. Some may work for you and some may not. We are all different.

They are all, though, worth trying.

The first is therapy, which, after my early furious attempts to engage with, I have come to value highly. Yes, even CBT. Anything that challenges the negative thought processes and hopelessness that define depressive illness is valuable. I think of therapy as reprogramming, overwriting the faulty script and replacing it with a fresh, more balanced take.

Scientific studies are beginning to back this up. Recent research demonstrates that psychotherapy significantly changes functions and structures of the brain, in a manner that seems to be different from the effects of medication.

Neuroscientists are discovering that major depression and bipolar illness (manic depression) are more than mere mood disorders. The impairments to function and cognition may last far beyond the course of an actual episode. Although they are not ‘classic’ neurodegenerative diseases such as Parkinson’s and Alzheimer’s, they are illnesses clearly associated with brain cell loss.

In the brain, a horseshoe-shaped structure known as the hippocampus is a centre for both mood and memory. Loss of neurons in the hippocampus is found in depression and correlates with impaired memory and low mood. According to research, when the brain is stressed (the ‘stressors’ known to be so implicated in depression), neurons shrink in the hippocampus, and that seems to impair memory. More recent research suggests that the same thing happens in the prefrontal cortex, which is crucial for decision-making and attention. The other profound loss is mental flexibility. Long-term stress can also enlarge the amygdala, the part of the brain that governs emotional and traumatic memory. If it becomes overactive, it is possible to develop what research scientist Bruce McEwen calls, ‘an emotional memory that is not strongly attached to the world around you.’

In other words, the depressive’s perspective may become shrouded with an excess of intensity and negativity or what we depressives know as ‘stinking thinking’. That’s the sort of thought process that keeps us dwelling on old emotions or hurts and, literally, playing the same track over and over again. It has little to do with reality but is simply a malfunction of thinking. It is that sort of thinking that therapy seeks to correct.

The good news is that it is no longer correct to talk about our brains as if they are the hard disk of a computer (although it is tempting) or that we are hardwired to behave in certain ways because our brains are not, as was once thought, immutable. They change. They are plastic, or flexible (neuroplasticity as it is known). The cells can grow again (neurogenesis). The self is constantly reinventing itself. The brain can heal itself and one of the ways it can do that is through the talking therapies. Here’s Bruce McEwen, speaking at the 2006 Annual Convention of the American Psychological Association:

When even neuroscientists are telling us that therapy can restore the brain to normal function, we should sit up and take notice.

Or start talking.

The point is, though, that we have to engage. We tend to think that we go to see a therapist in order to get fixed. In other words, we believe that someone else will make us better. This is not so. A therapist can only show us the faults in our thinking. He or she cannot actually change them. It is down to us to do that.

For that reason, therapy is hard, slow work and it is the sort of work that many people avoid or abandon when they are only partway through on the grounds that it is too difficult and frustrating. Well, so is depression.

We learn through repetition. Every skill or talent is the result of a repetitive action, done over and over again until it feels like second nature. Research shows that it takes 10,000 hours to truly master a skill, but far less than that to become somewhat proficient. If the same is true of therapy or learning to think in a new way (and why would it not be?) then both time and repetition are essential.

For two years, I did intensive therapy for four hours a week. On top of that, I attended AA meetings (which last for between an hour and an hour and a half) three times a week. More than seven hours of therapy a week might sound excessive. Well, so was the severity of my depression and if medication couldn’t make my neurons grow, I had to find another way.

I have stopped therapy, but I still go to AA meetings, at least two or three times a week. I go because I need to keep a constant check on my head, which is liable, at any time, to start misfiring, perhaps as a result of those pesky neurons shrivelling up. The meetings help me to correct my faulty thinking. They offer antidotes to my black thoughts, suggestions of ways in which I might think myself around or out of my most difficult responses. They suggest answers and remind me to live, as they say in AA, ‘in the solution, not the problem’.

Group therapy (of whatever sort whether it is AA, CBT or any other form of structured, therapeutic talk) is, I believe, crucially important to the depressive. We get stuck in faulty thought patterns. We start running, faster and faster, on that hamster wheel in our own heads. The nature of depression is that it narrows our focus until we believe that our problems are insuperable and we are the only people who feel the way we do. Understanding that we are not alone and hearing other people express similar thoughts and feelings is quite possibly the best pain relief there is. In depressive or low moods, we are inclined to shut down, believing either that we have nothing to offer or that our moods are contagious to other people. In one way that is true, as anyone who has ever loved or lived with a depressive knows only too well. But the converse is true too; other people are contagious to our moods. Being with other people makes us feel better. It also makes us think better, or more realistically, about our own situation.

Here’s a neat piece of research. It’s about running, rumination and rats but think no less of it for that. Exercise can restore a depressed mind, rumination is proven to be both bad for (and intuitive to) the depressed mind and rats are social creatures, like us. In the study, published in the scientific journal,
Nature Neuroscience
, rats were divided into two groups: one lot was housed and exercised together and another housed and exercised in isolation.

Both groups of rats exercised for twelve days but the impact on brain health was dramatically different. The group of rats that exercised together showed increased neuron growth, i.e., new brain cells. The rats in isolation had suppressed brain cell growth.

Additionally, the study measured blood levels of the stress hormone, corticosterone. Both groups showed similar elevations, but only the isolated rats were vulnerable to a negative influence on new brain cell growth. They also showed higher levels of stress hormones in response to stressful stimuli when compared with the group-housed rats. People with chronic depression have high cortisol levels, which negatively affect brain cell growth. It could be that isolation in the rats led to greater depression, which negatively affected brain growth, whereas the group, or social, rats showed no increase in stress hormones.

Even if you ignore the science, the meaning is clear. We depressives need to get out more.

This, for most of us, is horribly difficult, particularly when we are enduring our blackest Garbo moments. In that state it doesn’t do to be in a group of people who are unlikely to understand our more exotic thoughts such as suicide. But being with a group of people who do understand, and are willing to share that understanding, is undoubtedly helpful.

I no longer take medication, in part because my relationship with it was always so fraught but also because, most of the time, my brain seems to run along quite happily without it.

I took myself off it a year after I came out of rehab. While I was conscious that my mood was sometimes low, I knew instinctively that the depression had lifted. The first time I understood that was when I cried. The tears lasted for five minutes, and afterwards, I felt better.

I rang Nigel.

‘I cried for five minutes.’

‘Well done, Sal. That’s fantastic.’

Now, it might sound mad to call one of your closest friends and boast that you have been crying but in the language of depression, five minutes of tears is healthy crying. Depressive crying has no limits. It can last for hours. It does not make you feel better. It comes for no reason. It does not stop. Any reprieve is merely temporary. Those five minutes of tears taught me one thing; I was getting better.

Shortly after I came off antidepressants, I took myself off sleeping pills too. I was terrified. When I was ill and taking the highest dose, I could not sleep for more than four hours a night. I did not get a full night’s sleep for three years. I was so frightened of not sleeping and the black, blank terror that went with it, that I never forgot my prescription.

One day, I did. It was late at night and I had run out of sleeping pills. It occurred to me then that I no longer needed them. My brain was no longer on full alert.

And so it proved. It was difficult, at first. Insomnia had returned. But it was the insomnia of old, the insomnia that stopped me getting off to sleep, rather than woke me up at three twenty in the morning. I loved it, loved the hours of not being able to go to sleep. My brain was back to normal.

As for antidepressants, I would not rule them out, should I ever need them. I remain optimistic that a new form will be developed for people like me who are resistant to the present variety. Nor would I encourage anyone else to come off their drugs, simply because they feel they ought to. I have never quite understood the ‘ought’ in that sentence. Or the logic in this one: ‘I don’t like feeling dependent on drugs.’

Well, why ever not? If they keep you stable and you tolerate them happily, if coming off them might mean weeks and months of misery, then why even consider it? SSRI medication is not a magic drug—although it may feel like it to somebody who responds well to it when he or she is drowning in the black depths of depression. I feel a sort of yearning as I write that sentence. If only I was one of those people. I am not. But I know people who are. I have known them before taking medication, and after, and the effects are, frankly, miraculous. They can restore somebody to normal functioning. What they cannot do is turn somebody into a person that they are not. They are not character altering. They are character restoring.

Nor are they mind altering. In the same way that depression is an illness and not a character flaw, drugs treat an illness; they do not remedy a personality. The personality was always there. It may have been disguised or distorted by depressive illness but it is, in essence, changeless.

I am, anyway, dependent on drugs. Every morning I take thyroxin and will do so for as long as I live. If I don’t, everything about me including my mood will get slower and slower until, eventually, I shall cease to work.

An underactive thyroid (hypothyroidism) is apt to be dismissed as a minor complaint. It should not be. The symptoms can mimic depression in that they show up as extreme fatigue, lack of focus or concentration, abnormal sleep patterns (often much longer and heavier sleep) and a general greyness of mood. The sharp psychic pain of severe depression is absent, though, and so are the long wearying bouts of crying. But as hypothyroidism may precipitate an episode of depression, it is always worth asking your GP for a thyroid test if you are feeling very low. Some cases of what appears to be depression have turned out to be untreated hypothyroidism.

I also take omega-3 oil, on the advice of my psychiatrist. When I was in hospital, he ordered some tests on my fatty acid levels and discovered that they were alarmingly low. This finding was in line with numerous studies showing decreased omega-3 content in the blood of depressed patients. In one study, medication-free depressed patients, tracked over a two-year period, showed that low blood levels of omega-3 predicted the risk of suicidal behaviour.