22 Dec

Anxiety and Depression: A Fundamental Difference in Treatment

“Yes, there are two paths you can go by
But in the long run
There’s still time to change
The road you’re on
And it makes me wonder. ”  (Led Zeppelin – Stairway To Heaven)

Helping someone who is psychologically unhealthy become normal, is not the same as helping them become healthy. In this article I want to highlight this distinction and, in so doing, demonstrate the differences in the underlying assumptions, therapeutic efforts and expected outcomes between these two approaches.

While much of our suffering in this world arises from physical  pain, the overwhelming majority comes from emotional/psychological pain.  These experiences have numerous labels such as unhappiness, sadness, fear, anxiousness, loneliness, confusion, and so on.

We all have such experiences. In and of themselves they are well within the “normal” range of experiences and usually dissipate in a short amount of time.

But when they don’t go away, when we cannot get ourselves out of such states and they begin to adversely affect the quality of our life, or if we have have never been able to enjoy life because of them, it seems perfectly reasonable to try and do something about this.

In an effort to make the pain go away, or at least hide it, some people try using alcohol or drugs, some begin to work longer hours, look towards another relationship, start gambling, or any number of other possibilities. If those solutions ultimately do not work, and don’t destroy us, and we are willing to believe someone else can help us, then we might seek professional assistance.

So where are we likely to go for help, what kind of help will we get, and what will we be helped with?

In our society, the primary options recognized for mental health concerns are medical and psychotherapeutic.  Depending on which of these choices is made, there will be important differences in how your suffering is going to be viewed and treated.

Within the standard medical/disease/pain model of illness, such suffering is typically understood to either cause or be caused by an imbalance in our brain chemistry which adversely affects how we think, feel, and subsequently act. Given this level of understanding, it is not surprising that numerous types of drugs have been developed to address such imbalances.

If you go to your GP, family doctor, or a psychiatrist, for the most part they will suggest one of several medications designed to increase, or decrease, the amount of certain neurotransmitters in your brain depending on how your problem is diagnosed.

From the psychological model of illness, while these experiences may indeed have neurochemical correlates, the primary source of the problem is typically understood as flowing from disturbances in our thoughts and feelings.  Given this level of understanding it is not surprising that individual psychotherapy is mainly oriented towards modifying how we think about ourselves and our life, with the implicit understanding that this modification will also affect how we feel and act.

While there have been literally hundreds of therapeutic approaches developed over the years, the dominant therapy today is Cognitive Behavioral Therapy.  As you might surmise, it is designed primarily, to modify how you think.

While these description and explanations are highly simplified, it is nonetheless the case that both the standard medical and psychological approaches follow a similar line of reasoning that goes something like this: because you are suffering, there is something wrong which requires correction. This correction will be considered successful when you no longer report feeling depressed, anxious, stressed, and so on.  In other words, success is measured by the removal of your symptoms.

Certainly these approaches seem sensible. After all, suffering is difficult and painful, and when we hurt it is natural to want to get rid of this pain.

But given that we are seeking treatment from people designated as having expertise in the field of “mental health”, do these approaches actually help people become mentally and psychologically healthy?

If we view the function of mental health experts as offering services designed to help us think, feel and act “normal”, then providing assistance in removing symptoms defined as abnormal fits that definition.

But if one views mental health as referring to an ongoing process of psychological development and maturation, then they do not: removing symptoms or altering how we think offers no avenues or directions for learning – it encourages no growth.

I do not consider being normal as equivalent to being psychologically healthy.  In my experiences, most people seem primarily interested in trying to be comfortable and secure, even though few actually seem to achieve this.  Scratch just below the surface and most people become anxious and uneasy, being very careful about what they let out, and what they let in.

So much of what we are seems to flow from fear.  Directing our energies to protect our self from harm, whether real or imagined, ultimately leads to an orientation in which we avoid, rather than embrace life.  Shutting down rather than opening up is a natural consequence; no wonder we hurt

In keeping with this observation, I would argue that much of what we call “being normal”  is actually unhealthy; a general condition where the particular ways in which we think, feel, and act, actually impairs our growth, and in so doing creates suffering in our self, and unfortunately, also creates suffering for others.  To the extent that this is true, attempting to return people to normal offers a very limited solution to our suffering

The sad part here is that we do not see how much of our suffering is related to how we live and act in our normal lives.  Mainly, we do not seem to recognize the fear-based ways in which we view our self, others, and our world.  Since we seem to possess such a poor understanding of the role this plays in creating suffering, our responsibilities and capabilities for resolving this are also limited.

Unfortunately, rather than waking up to this condition and finding constructive solutions that could benefit our self and others in our world, we are encouraged to remove or ignore that pain, and almost every other experience we find to be difficult. This, I believe, is a serious conceptual mistake supported by the prevailing medical and psychological framework.  There is little chance we will find lasting solutions through such avenues.

Rather than simply getting rid of this pain, we need to learn from it. Our suffering needs to be re-conceptualized as providing us with a powerful source of motivation for learning about this suffering, and the harmful consequences of our normal ways of doing things.  With these experiences as our teachers,  it  can also provide us with the right motivation for learning how to properly nurture our growth and development.

Otherwise, it seems unfortunate that once we have gone for help, the very motivation which drove us to seek assistance in the first place cannot be put to more productive use than to remind us to take our pill or practice thinking differently.

16 Jun

For Crying Out Loud

Several years ago I was seeing a young woman in my practice who was struggling with depression following the recent death of her mother. In spite of how sad and distressed she looked, she seemed to be struggling to let herself cry.

When I commented that she seemed to be having difficulties accepting her feelings, she responded that this was not actually the problem for her.  Rather, she was concerned that if she truly expressed what she was feeling, other people in the building would hear her and wonder if something was wrong, if perhaps she was being attacked.

She didn’t want to just cry softly.  She wanted to yell and scream and protest that her mother died too young and her loss was too painful to bare.  She wasn’t able to do this in the privacy of her apartment building, and she was also worried about doing it here. She was afraid that if she released this in my office someone might alert security or call the police and she didn’t want that to happen.

I sat in my chair for a while watching her closely and thinking about what she had said.  I could understand she was holding a lot inside and if she let it out it would probably burst like a damn and flood the room.  I was pretty sure I could listen to all of this, but I could imagine that people out side might indeed wonder what was going on and be worried.

I began to think where this woman could go and yell as loudly and as long as she wanted without worrying how others would respond. The more I thought about this the more I realized her concerns were quite valid.

It seems to be remarkably hard in our society to simply and freely express what is in our minds and in our hearts.  Even with loved ones in the privacy of our own homes there always seems to be a limit to what we can say.

Sometimes we just need to let things out.  Sometimes we just need to know that someone cares enough for us to listen to what we have to say, however we say it and whatever it sounds like. Not because we want them to fix it; we just don’t want to hold onto it any longer.

It is not just having a place to express oneself  that is important, but also learning how to do it in such a way that we can truly listen to ourselves. When we cannot experience we cannot learn. As we learn to trust rather than fear ourselves, we experience the freedom to explore further, and so we learn and grow.

When we are afraid to let others hear us it adds one more level of complexity to the already difficult struggle of finding out who we truly are.  The fear that we cannot let ourselves out anywhere to anyone is a disturbing and distressing reality.

If there is any fundamental action I try to encourage in the people I see in my practice, it is for them to find a way to express what could not be expressed before. Most people have not allowed themselves to do this since they were a child.  As adults, most people cannot do it now even if they are given the chance. And they don’t even realize it.

Without this growth there will always be pain and suffering in your life.  Although, even with growth, there will be pain.  But the pointless of it all will end. And when we activate our own compassion and acceptance for that suffering, we will  discover some of the most important lessons life has to offer.

28 Oct

Depression and Anxiety: All Roads Lead to Rome, Don’t They?

Over the course of twenty plus years I have worked with thousands of individuals, a good number who either report as being depressed, or anxious. The really odd thing is, that other than having somewhat similar symptoms, these people were so remarkably different from each other I wonder if we (those who label and treat others) might often be guilty of a fundamental perceptual error.  Let me explain. Read More

19 Jan

Being Here: Depression, Anxiety, Stress and All (Part I)

The only reality we have is this living moment. The only possibility we ever have to make a different choice, to alter a course of action, or to change our mind, resides in “this” moment. Yes, we can plan on doing something tomorrow, but both that decision to wait and the action itself when it occurs will be choices made in present tense, “now” moments.

Oddly, it seems to me for most people the significance of “this” moment, pales in comparison to how important we consider our past and future to be, and our absorption in the “world out there”.  This certainly seems to be true given how much time we spend in reviewing yesterday, planning for tomorrow, and looking at screens in front of us. Indeed for most people, the very notion of “being aware of this” moment seems to have almost no meaning, and subsequently  almost no value.  This is a shame.

In order to grasp the profound implications of this, it is important to first understand an interesting quality of the human mind.

Let me begin by noting that most people are only nominally tuned into the thoughts they are having at any given point in time, their current emotional and body level feeling states, running memories, decision making processes, and most of the impulses which drive the actions in which they are engaged.  As such, they are not conscious of  most of the essential  experiences one could describe as being “me”. 

The fact of the matter is that almost everything we do is done with very little awareness. A very large percentage of our day is spent on automatic pilot, and only in very particular circumstances do we actually “wake up”  and pay attention to what we’re doing.

And yet, for the most part, none of this is a problem.

Our essentially non-conscious self system functions like this because we have already practiced and learned how to behave and respond to our life during our many years of growing up.  As one example, having learned to talk a long time ago I don’t have to start relearning every day. The same goes for driving my car, shopping, interacting with others, and on and on.

But what happens if I have to do something different than what I’ve learned to do? What if my ways of being in the world aren’t working for me and I have to utilize more adaptive and productive behaviours? Somehow I have to be able to override the purely habitual and automatic quality of those learned responses which are not working for me, and modify or adapt them to become proper and effective responses.

But here’s the rub; I cannot change something if I am not aware of what I am doing. If I have any hope of being able to change or over-ride my cognitive and emotional responses and reaction patterns,  I have to be  aware of them in the moment of their activation.

But if I am am right in my previous assertion that most people spend too much time not being present to “this” moment, then herein lies the problem.

If my previous life lessons were inadequate in some way, it will be the automatic behaviours that flow from those lessons that will lead to my  constant bumping and scraping up against this life, and inevitably creating varying levels of distress for myself, and for others. Given that my choices and actions didn’t work the first time, it’s unlikely they will succeed the second.

When my normal ways of solving my life problems don’t work despite repeated attempts, it creates a very interesting scenario, almost always accompanied by some anxiety. Eventually, if enough efforts fail and my situation worsens I can even get depressed.

The series of articles on Mindfulness look at this position I am expressing in more detail. I invite you to read them and see if they help  answer any doubts or or questions you have about what I am saying. and  my approach with such issues.

19 Feb

Being Here: Depression, Anxiety, Stress and All (Part II)

In my previous article (Being Here: Depression, Anxiety Stress and All (Part I))  I was arguing that we cannot truly make choices and therefore changes in our life, if we are not aware of, or conscious to, our own experiences. Since most people seem to think they are already quite aware, then either I am making a weak argument, or we are talking about very different things. This article focuses on my definition of this notion of being aware of our experiences, and also looks at some of the implications which flow from it.

To begin,  let me ask a simple question; “Do you know what rain feels like on your face”?

I am betting you would probably say, “Of course I know what rain on my face feels like”.  So let me push the question a little further; “When was the last time you chose to stand in the rain and let it fall on your face, so you could intentionally experience it”?  Now I would  guess that you may never have done that, or if you have, you haven’t done it very often.

I would guess, if you are like most people, what you were talking about when you said you “know” about the experience of rain on your face, was  perhaps your  experience of what happened when you unexpectedly got caught in the rain, and then reacted in some way so as not to have rain in your face.

My point is that there are many experiences which we say we “know”, or which we say we are familiar with, which should more appropriately be called, “experiences we tried not to have”.

Take sadness for example. Who doesn’t know what it feels like to be sad? But have you ever taken the time to really feel sad; intentionally, purposefully? Really sit with it and listen to it, hear how it speaks, where it lives in your body, what kind of memories come up and whatever else is connected to it?

I am trying to clarify that the quality of “sadness” one experiences when “Trying not to feel”,  and the experiences of sadness which arises should one choose to “feel” it,  are not the same experiences. “Trying not to feel” sad is an active attempt to suppress and alter that experience.  “Feeling” sad opens up a whole range of experiences that simply do not and cannot exist otherwise.  

My next guess is that reading about this, the idea of letting yourself feel your sadness, anger, your frustration, or any “negative” reaction, actually seems strange,  if not questionable to you. After all, these experiences hurt, they are painful. And if there is anything our evolutionarily programmed survival system does well, it is too move us away from pain, usually before we even have to think about it.

But  most likely, when you think of the painful experiences what you are thinking of  are those “Trying not to feel” experiences, which I am suggesting actually have different qualities to them than when we allow ourself to be aware of our experiences.   Expressed another way, moving away from, or trying not to have,  an experience has more painful and complicated effects than when we move towards it. 

I would think most people do this suppression/avoiding thing most of the time. There is nothing odd in doing this. But I believe there are many unfortunate consequence which arise from doing so.

It is my opinion that “trying not feel” over an extended period of time, especially when our experiences are powerful and highly charged, leads to depression, anxiety,  and stress, just to name a few.  Further, as I have discussed in other articles,  “trying not to feel”,  also characterized as avoiding our experiences, can also lead to other complications such as gambling, drinking and other addictions.

Finding our way back once we have gone down one of those roads is remarkably difficult.  So I really only see one of two options.  Either we begin to learn how to actually have our experiences, to begin the practice of Mindfulness,  or we cross our fingers that we are going to find something else that is going to work that we haven’t been able to accomplish for our self.

31 Mar

Being Here: Depression, Stress, Anxiety and All (Part III)

In previous articles on Mindfulness,  I have suggested that most people  have only a limited awareness of their own experiences.  Rather than utilizing our capacity to be aware of and learn from those experiences we are effectively blind to most of them, and don’t even know we are doing this.  This article examines one of the implications of how this limited approach to our own experiences effects our lives.

My “world” as I know it and respond to it comes from my experiences of  that world.   Similarly, who “I  am for you”  is the sum total of  the many complex and varied experiences you are having of me when we are together and how you act towards (or against me) flows inexorably out of those experiences.    While those momentary experiences and actions arise as a result of a vast number of  historical, social, biological  and intrapersonal factors, I am concerned here with the degree to which we are more or less conscious of  those experiences.

If I am not conscious of who you are for me, then what do I really know about you?  What can I say about you? If I am not conscious of my experiences of you in the moment of our being together and of my reactions to being in your presence, then what  sense can I make of those reactions and how could I possibly explain them to you if you asked.

From a larger perspective, if I am out of touch with how I am experiencing you and how I am experiencing my world,  then who am I?  And if my life is not working for me, or I want to improve it, how can I even begin to start making informed and wise choices about this.

Generally, when our world or relationships are not progressing smoothly we try to “think” our way through this.  We sit down with our self and try to rationally assess what is going on, how we have behaved or reacted to a situation, what others have done to us and so on.  While this effort is better than simply blaming someone or something else, or not even worrying about what has happened, it is unlikely to be of  much help in actually addressing the situation.

Trying to recollect and think about such complex and complicated processes after they have happened is a notoriously problematic way of making sense of events . If you have not been paying close and careful attention to your experiences as they were occurring, you will have to reconstruct them from memory.  Trying to recall what happened some time ago and then converting that limited and selective information into a certain form of rational-logic we call thinking has to result in a distorted if not inappropriate assessment of the situation.

There is a very high probability that the choices and actions flowing from this process will lead to further complications and/or conflict and then it becomes even more difficult if not impossible to resolve. Such is the situation most of us face on a daily basis.

If  I am confused about who I am, who you are and what I am doing, and you are equally confused then what kind of relationship can we have?   How can I possibly relax with myself  in a world that fundamentally doesn’t make sense.  No wonder people feel anxious and can eventually get depressed about their life and their relationships.

Surely there has to be a better way.

I think there is a better way, a more useful and productive path to follow and hope that the articles on Mindfulness will begin to present that way.  I encourage feedback and responses to what I am writing and  look forward to some dialogue on this issue.

09 Nov

Lies and Uncertainties

Trust versus mistrust. Perhaps this capacity is the greatest factor in determining whether someone can truly enjoy their life and love, or whether they spend it in survival mode and fear.  Almost assuredly if we are to be happy we have to be able to trust another, and trust our self.  This article considers this distinction in more detail.

One of the frequent complaints I hear from patients in my practice concerns their difficulty in trusting people.  When this issue arises my first question to myself is directed at the possibility that there is something I am saying or doing which may be triggering this issue at this time.

Following my own inquiry, I then ask the patient to explore this issue in more detail and eventually inquire with them directly about my own actions.  If there is something amiss between us then we have an opportunity to work this out until hopefully, it is resolved.

Typically however, the complaint being expressed by that person is in reference to the “masks”  people wear or the “games people play”.   I think it is generally true, that in order to function in our complicated world, that people do this.  For some it is simply part of being human in a complex world, while others really are two-faced and manipulative.

Generally my own experience of such behaviours is not one of alarm or disgust but rather an acceptance that this is what we do.  For many others however, the varying roles adopted by others seems almost overwhelming, generating such discomfort in the person that they cope by either withdrawing or becoming confrontive and challenging with the other who is seen as being false.

What I typically wonder about is whether these sensitive individuals have developed those fear responses because they have learned form their experiences early in life that people they should have been able to trust were not actually trustworthy? Did they find, perhaps in their family of origin, that parents said one thing but did another? Was it because the child was made the scapegoat for the parents frustrations with each other, or might there even have been emotional, psychological or sexual abuse involved in the name of love?  Even if the parents were fairly straightforward and reliable, what about teachers, family relatives, clergy, or others in authority positions that may have betrayed trust?

The complaints of these patients have profound implications for their day to day interactions with others, and in terms of their own self.

Obviously if one does not feel sure about another, about their motivations or intentions, it is impossible to relax. Always the doubts are swirling and questions being raised – “What does he mean by that”?, “What does she want from me”?, and so on.

There is no room for trust, and a limited or distorted ability to experience or give pleasure in being with someone.

As for the person them self, the constant inability to relax means a chronically heightened level of stress and anxiety creating a wearing on their body.  There is an overuse and draining of their energy supplies all being funnelled towards one particular goal of trying to read between the lines and assess if they are safe or not.

From this place of fear and doubt there is little we can learn from others that is positive and helpful.

When our psychic energies are primarily and singularly directed towards to checking the motivations of others there is little energy available to be directed towards our psychological growth and development.

Across time it means the separation between our chronological age and psychological age widens disproportionately – we get older but no wiser.  In effect we become increasingly immature.

As I have presented in other articles, this failure to grow is a primary source of suffering, often reflected in depression, anxiety, and relationship conflict.  It is a very unfortunate price to pay due to the sins of others, and it is a horrible and sad way to waste a life.

30 May

Personality Disorders Versus Neuroses

Over the last 30 years, numerous empirical studies have suggested it is possible to arrange defensive mechanisms into a hierarchy of relative psychopathology beginning in severity with “psychotic defenses”, and ranging through “immature defenses”, “intermediate defenses”, and finally, “mature defenses”.  This article considers the immature and intermediate defenses. Read More

24 Jan

The Development of Personality Disorders

In an effort to explain the different psychological and behavioural profiles between the diagnostic categories of “personality disorders” and “neurotics”, current clinical thinking and practice offers a neuro-social model of psychological developmental.

The heart of this model is that there are fundamental differences in the character structure of individuals associated with these two diagnostic categories which originate from the early stages of neurological and psychological development; a position supported by increasing evidence in genetic-biological studies as well as psychodynamic-psychoanalytic research.

This model suggests that during the early years of childhood, a predictable and invariant sequence of distinct and increasingly complex psychological stages accompanies normal brain development. As each successive stage unfolds, unique psychosexual, cognitive, moral, and affective capacities come into existence; the emerging combination of which produces noticeable developments in the personality of the infant.

If a sufficiently healthy environment is provided for the child, then the fundamental groundwork for a normal healthy adult will be laid. However, should trauma occur during any of these stages, pathological development results which if not corrected early, will manifest in personality disturbances in later life.

Accordingly, when trauma occurs during any of the stages of development, a variety of physiological reactions are triggered within the child.

The greater and more prolonged the trauma, the more these reactions occur.

It is hypothesized that these charged physiological states induce lasting neurochemical alterations in brain chemistry, produce significant modifications in neural connections between and within various brain structures, and also become encoded into the existing memory system of the child.

Not only do children develop different neurochemical and psychological processes in response to trauma, but every subsequent stage of mental and emotional development will be affected by these changes.

Over the years and into adulthood a psychological structure still develops, but it is a structure based on neurological and psychological distortions reaching far back into the infantile stages of development.

Based on this reasoning, the earlier that trauma occurs, the greater are the number of subsequent stages of development which will then be affected, and thus the greater and more serious is its effect.

Thus, an individual diagnosed with a personality disorder is understood to have suffered some form of trauma at an earlier developmental stage than the neurotic because their emotional and cognitive processes are generally more poorly developed, their defense mechanisms more immature, their behavioural responses to stress typically less effective, and their relational capabilities more limited.

What is of most importance to emphasize from a psychological perspective however, is that the degree to which the diagnostic categories of personality disorders and neurotics do reflect real and enduring differences in character structure, then specific treatment approaches are also required.

For example, psychoneurotic versus borderline depression and anxiety are two very different phenomenon, each requiring different treatment modalities. The same is also true for reports of relationship disturbances, self-esteem issues, mid-life crises, and almost every other psychological symptom which people experience.

Any effective and appropriate intervention thus depends upon an accurate diagnosis. This in turn rests upon a skilled understanding of the particular types of needs, motivations, cognitions, defense mechanisms, and pathologies presented by the patient which reflect disturbances originating during specific and identifiable stages of early development.

It is the failure to recognize this fact that has led to many unsuccessful therapy hours which have been frustrating for both the patient and the therapist.