Shoot the Damn Dog: A Memoir of Depression (18 page)

Its greatest virtue is in the treatment of anxiety disorders, which are more susceptible than many other emotional disorders to the sort of logic that CBT proposes. Most anxiety is based on faulty thinking, or misplaced fears, and CBT exercises can both challenge and then dislodge those fears if used consistently. It is also magnificently good at addressing phobias, which, as one psychiatrist put it, ‘have to be bored into submission.’

It is less effective, and this is simply a personal view, in the treatment of severe depression or, at least, a depression that has no obvious, single cause. In the case of a reactive depression, which, as the name suggests, is a depression caused by a reaction to an event, it tends to be more effective. But in depression as pathology, it seems only capable of chipping away at the solid block of frozen feelings, or lack of feelings characterised by the black hole of which so many sufferers speak.

Part of the strategy of CBT is in investing, absolutely, in the belief that emotions are simply thoughts in action. A thought begets an emotion, and not the other way around. I’m not sure that I entirely believe that. Some emotions are inarticulate, they are without words or language. They seem to come from some primitive, pre-verbal base. Memories rely on language to exist, they form a narrative, a continuous loop running in our heads. Without words, memories cannot exist. Or, at least, we cannot access them through our minds. We may, however, be able to access them with our bodies, which perhaps explains the remarkable physicality of emotions—a knot in the stomach, a pain in the neck.

Or it may be that these physical emotions are memories lodged at a time when we were infants and pre-verbal, when words did not exist. This is some of the thinking that goes into analytical therapy, and why it concentrates so emphatically on the first two years of life in an attempt to try to access the subconscious, or unconscious. Now neuroscientists are beginning to discover that perhaps those early thinkers were not as misguided as modern opinion tends to believe. The brain is not, as had been previously thought, fixed, but subtly plastic; so abuse in the early years, or even a failure of mother—child bonding, can cause certain areas of the brain to fail to develop, or to develop abnormally. Inarticulate emotions also go some way towards explaining post-traumatic disorder. When events are too horrific to verbalise or too terrifying to stitch into the verbal narrative of memories, they become lodged in the body and manifest in shaking, sweating and flashbacks.

I don’t know if that’s true, although it makes a sort of sense. It seems to me that nobody understands the genesis of emotions, ungovernable or not, although neuroscientists are beginning to take ever greater strides in understanding the workings of the human mind. Perhaps before too long we shall see the emergence of new forms of therapy.

Right now, we’re stuck within the limits of our understanding, which is how I come to be sitting in a group of people examining my Negative Automatic Thoughts.

First, the therapist says, we must banish imperatives from our heads. No ‘musts’ or ‘oughts’ or ‘shoulds’ are allowed. Words such as these keep us stuck in negative thinking. So we are instructed to replace, ‘I
must
get better’ with, ‘I am
going to try
to get better’.

Or, how about, ‘I
should
love my mother’ with, ‘I am
going to try
to get along better with my mother’.

I put up my hand.

The therapist smiles encouragingly. ‘Yes, Sally?’

‘Isn’t banning the use of imperatives in itself an imperative? We
must
not use imperatives. We
must
not say should.’

‘No, not really, not in the way that we use it.’

I catch sight of Kate. A broad grin has settled on her face. She senses trouble.

I say, ‘In what way do we not use it?’

A tiny frown of irritation knits itself above the therapist’s eyes. ‘Shall we deal with this later, Sally?’

I shrug. I am not being contrary. I prefer to fully understand a method before I can engage with it. Kate’s eyes roll expressively and I catch, just for a moment, a glimpse of who she is. She’s the bad girl who always sits at the back of the class. And I’m the annoying one who likes to challenge authority. Both of which, as it turns out later, are true.

A little later, the therapist assigns us a task. CBT is filled with tasks, or exercises. There’s homework too, or written work, none of which I do. Not because I think that CBT is a waste of time. For some people, it works and it works well. People like Kate and Susie, for example, for whom it worked magnificently. At the time, I was unable to read or write so it was of little use to me. Nor could I engage with it, in part because of the logic it prescribes, which seems to me too limited and prosaic. It assumes that life is logical, when all my evidence shows that it is not. It also assumes that my thoughts, or my mind, are logical, which is assuredly not the case.

The therapist asks us to imagine something, an activity, which we hate most to do. I have two. They are driving (about which I had a full-blooded phobia for ten years) and public speaking. Both of them seem to me to be eminently sensible things to be afraid of. One may kill you or somebody else, which seems a good enough reason to dislike it, and the other forces you into full sight of crowds of people, a situation I have never enjoyed.

‘Sally, what’s the thing you most hate doing?’ asks the therapist.

‘Public speaking. I’d as soon have tacks put through my eyes.’

She winces slightly. ‘An interesting choice of words.’

‘But descriptive.’

‘What would happen if I made you do it now?’

‘I would shake. My voice would tremble. The palms of my hands would grow clammy. I might feel as if I was going to faint.’

‘And that would frighten you?’

‘Yes, of course. Those are all physical symptoms of fear.’

‘What frightens you exactly?’

‘That those things would happen.’

‘And what would people think of you?’

‘That I’m afraid.’

‘And why is that bad?’

‘We all avoid fear. None of us like it.’

‘Would people thinking you are afraid make you feel like less of a person, like a bad person?’

‘No. It would make me feel like a frightened person.’

‘And you prefer not to be seen in that way?’

‘Of course.’

‘Why?’

‘Because it makes me vulnerable.’

‘And you think vulnerability is bad?’

‘No, it’s fine in its place. But public speaking is not its place.’

‘Why not?’

I am trying, really I am and I can see where she is trying to lead me. It’s just that I don’t believe that the route is valid.

‘Authority is necessary in public speaking if you are to be in any way convincing.’

‘And you don’t think that you have it?’

‘No, I think that I am frightened of public speaking. That has nothing to do with authority. It has to do with fear of other people.’

‘Why are you afraid of other people? Do you think that they dislike you?’

‘No, I think that a crowd of people can be frightening because they can be unpredictable.’

She tries another tack. ‘What would feel so bad about shaking and your hands growing clammy?’

‘It would feel uncomfortable.’

‘Would it make you a feel like bad person, for feeling that way?’

‘No, it would make me feel bad. There’s a difference.’

I know what she wants me to say, but I just can’t do it. I’d like to help her out. She’s trying to help me to challenge my automatic negative thoughts. She believes that at the base of every depressive is a person who feels bad about him- or herself. She is trying to challenge that negative belief. Which might work, if I did feel bad about myself. But I don’t. I don’t suffer from low self-esteem. I suffer from blank, alienating despair. There’s a difference but it’s one that too often gets blurred in group therapeutic practice or in a one size fits all prescription, such as CBT.

She makes me read a poem out loud, in front of the group.

I do.

She claps her hands excitedly, like a child. There is something endearing about her pleasure. ‘But that was wonderful. You read that beautifully. How did it feel?’

‘Terrible.’

Her face falls and, momentarily, I feel sorry. ‘I didn’t say that I couldn’t do it,’ I explain. ‘I said that I didn’t like to do it.’

‘But you can do it. Doesn’t that give you a sense of achievement and make you feel better about yourself?’

‘No.’

Later, Kate says to me. ‘You’re difficult. I like that.’

I say that I’m not trying to be difficult. I am trying to understand.

She gives me a hug. ‘You think too much.’

Nigel is, if anything, even worse than I am. In group, he bats away words like flies. It is how I notice him in the first place. He wears a navy hoodie and black combat trousers, scuffed at the hems. He hunches down in his chair, arms crossed, legs crossed. I watch him trying to join in with the sincerity that CBT demands. He can’t do it although he tries, a lot harder than I do. After a while, we start to bat off each other, which does neither of us any good—at least, not in any therapeutic sense. We enjoy ourselves in another, equally therapeutic way, by becoming allies and, later, friends.

Then, one day, it is just three of us in a group session. Me, Nigel and a man called Michael who, like us, is suffering from suicidal depression.

The session begins. Nigel and I, as usual, are chucking around ideas and words. Core concepts, as they are known in CBT. We are enjoying ourselves. Michael says hardly a word, although we try to encourage him to join in.

After a while, the therapist says, ‘Michael, how do you feel?’

Michael shakes his head slowly. ‘I feel bad. Really bad. I don’t understand it and I can’t use words like these two can. I don’t know enough words, or words like the ones they use. So all I’m going to say is that I feel bad.’

Nigel and I look at each other, ashamed. Michael’s right. We tell Michael that he’s right, that we are both just bored, or trying to avoid the real, the central issue of why we are there. Which is that we feel bad. No other words, really, are necessary. And then we all start to talk, to actually say the way that we feel. It makes us all feel better.

I don’t mean to dismiss CBT entirely. It has its uses, the most profound of which is that it teaches us to challenge negative thoughts and to question why they might exist in the first place. As a tool, it is useful, but thinking is just one aspect of what makes us depressed, or human. I worry too, about the assurances that are given, that CBT ‘works’ in a limited time frame, that we are ‘cured’ and that our most destructive thought processes can be altered in a matter of hours. Recovery is not like that. It is slow and stumbling; a profound understanding of oneself, of the impulses and emotions that drive us, comes in fits and starts. Then again, one should not blame CBT for that. The ability to feel right in our own skins can sometimes take a lifetime to achieve, if it is achieved at all.

The best therapy seems to me to lie in being understood, or in sharing with another human being our most unmanageable emotions. The central idea that we are all fragile, faulty and flawed in some way, that no single one of us is exempt from difficult feelings is, for me, the most reassuring form of therapy, and the best and most precious communication of them all.

I feel lonely. I have many, and good, friends and still I feel lonely.

A therapist once said, ‘When I look at you, I think you may be the loneliest person I have ever met.’

I was astonished. It was perhaps the only interesting thing that particular therapist ever said to me, but it was not that which astonished me or got my attention. I was astonished because I thought I hid it so well. At the time, I was neck deep in depression and addiction, both of which are sometimes called diseases of loneliness. So perhaps it was not surprising. More surprising was that, in more general terms, I think that he was right. I am conscious, often, of a deep-seated sense of loneliness. It has been present since I was a child. I know I am not alone in this. Many depressives suffer from it but it is rarely analysed or discussed, even in group therapy. CBT, for example, would try to challenge it by establishing the facts and using them to challenge the notion of loneliness.

Here are the facts: I have a child, who I love well; a man, who I love well; a house; a cat; a family who loves me; many friends; a successful career. Those are the facts. My loneliness has nothing to do with reality. It is, instead, some existentialist yearning for meaning, for sense or connection.

When I was depressed, I thought I had found the reason for my loneliness. I thought, of course I feel lonely. I feel lonely because I cannot function, at least not in any effective or meaningful way. Is function then the opposite of depression; is function the very meaning of life? Or is it perhaps the meaning that gives life? My battle is not in finding out how to function, my battle is in finding a point to functioning. Or in finding, in other words, what is the point of me. Perhaps that’s what depression is, then. It is losing the point of oneself. If so, how does one rediscover it? Forget rediscover. How does one discover it at all?

These are my questions and they are not best served by CBT, which might teach me how to function more happily and effectively but it does not teach me what the point of functioning well (or badly) is in the first place. Perhaps there is no point? Perhaps there is only acceptance that there is no point. Perhaps that’s the point. Perhaps our expectations are simply set too high and Freud had it right when he said, ‘Much will be gained if we succeed in transforming your hysterical misery into common unhappiness.’

I have always rather disliked the notion of hysteria when applied to mental illness, perhaps because of its modern connotation of exaggeration. I have always rather disliked Freud too, although not as a thinker. Some of his thoughts are good. What I dislike about him is his legacy, the frigid practice of psychoanalytical psychotherapy, but perhaps he should not be blamed for that.

It may have been different lying on the great man’s couch in Vienna, rather than sitting on a shiny green sofa in a bland room in North London. Perhaps he might have smiled, in an avuncular way, or exuded some personal charm or magnetism. Perhaps he might have said ‘hello’ as I entered the room instead of bestowing a chilly little nod or presenting me with a face so wiped of expression that I felt as if I had somehow entered the wrong door.

This is the modern face of analysis, which most people think of as therapy. I know I did. Before I finally understood the extraordinary life-enhancing benefits of good therapy (or therapy that was good for me) I stumbled through (or should that be past?) four different therapists, all of whom practised in the psychoanalytical school. One left me standing in the rain for five minutes, because I had arrived too early. She didn’t answer the doorbell despite being there and, from what I could see, unoccupied. Nor, once she finally allowed me in, did she offer me a cup of hot coffee or even a towel. Such touches of simple humanity supposedly interfere with the therapeutic process.

In the psychoanalytical culture, this is normal behaviour. The analyst behaves as a blank screen, inferring from your response your primary areas of emotional damage. Now, I am not good in no-speak situations at the best of times. I am worse when expected to leak my wounded heart across someone’s sofa.

I know people who have been going to see a therapist for years, with no obvious benefit. This is partly because they do not know what therapy really is, or the difference between good therapy and bad. Nor do they know that they have a choice. Apathy, fear, resignation and misplaced good manners keep a lot of people in thrall to bad therapy.

So does pain. We want to be fixed and we don’t know how to do it ourselves. Self-regulation goes against the culture in which we live, which is to hand all our power and responsibility over to experts. Most of us know so little about therapy we don’t dare question it. To be honest, we don’t even know the questions. As a result, there are few other service industries (and therapy is one, make no mistake) where we happily hand over money for negligible results. This is partly because of the pseudo-scientific, medical cloak in which therapy is shrouded, but it is more to do with the stigma around mental disorders, which stops them, and the successful treatment for them, being discussed with any vigour or transparency.

I was once furiously reprimanded by an acquaintance for mentioning that a mutual friend was in therapy. My friend is perfectly open about this himself but I was told that such matters should not be mentioned in public. I countered by asking, if he had cancer, should it not be mentioned that he was consulting an oncologist? No, that was fine. There is a difference, apparently, between seeking help for your physical or your emotional health or even just talking about it.

Even the basics are little understood. When I was ill, if I ever mentioned that I saw both a psychotherapist and a psychiatrist, people were apt to look confused. Why both? Because my psychiatrist monitored the levels of chemicals in my head and adjusted my medication accordingly, while my therapist monitored the levels of distress in my head and adjusted my therapy accordingly. One is a drug cure, the other a talking cure. Therapists, having no medical training, are not allowed to prescribe drugs. Psychiatrists are allowed to talk but as most approach the human mind at a fairly high empirical level, I wouldn’t recommend most of them as counsellors of the heart.

Then there’s the accompanying jargon—denial, resistance, transference, projection, boundaries, issues, core beliefs—which is apt to make the average person feel like a stranger in an even stranger land.

There are also personal issues. At one psychiatric unit, the leading therapist constantly put me down, telling me I was too clever, too intellectual, that I used fancy words like armour. I’m a writer, I said, that’s what I do. My head is always filled with words. He was relentless. In the end, I gave up speaking, retreating still further into myself. My sense of loneliness and isolation increased. As a child, I was bullied for showing any cleverness. When I pointed that out, and said to him that he was making me feel more rejected rather than less, his reply was that he was ‘breaking down my intellectual defences, so I could really feel the feelings.’

I understood his method, but not his manner. Many of us are capable of overruling our hearts with our heads, of denying feelings that can literally make us sick. I also knew that this was personal. He did not feel sufficiently clever himself; he was playing out his own insecurities by undermining those he thought might challenge his authority. And the therapeutic environment, filled as it is with fragile souls, gave him full permission. Anyone who thinks that every therapist checks their prejudices and neuroses at the door before they enter a room, needs their head examined. The best do, but some don’t.

Then there is the pill versus talk debate. One therapist told me that I might get better without medication, but I would never get better without therapy. Yet another was downright hostile to my taking any antidepressant medication, maintaining that chemicals mask the pain so the real issues underlying the depression would never be confronted.

This attitude is completely irresponsible. If you give a healthy person antidepressants, they have no impact other than drug-induced side-effects. Antidepressants do not mask or take away pain—that’s the Disney version—they simply bring the brain back into some sort of focus. Without that focus, it is impossible to engage in therapy at all. Therapists themselves disagree, often quite violently, on such issues. Many embrace medication as a necessary part of recovery, others embrace a whole slew of spiritual practices such as meditation, yoga or a Twelve Step programme—which another branch mock. A CBT therapist may be highly dismissive of psychoanalytical psychotherapy, rejecting the form as outdated, expensive and time-heavy. Still more condemn CBT as short-term intervention, or a temporary sticking-plaster. Little wonder the average person finds it difficult to get their head around the subject. I tried, really I did. When I was at my most ill and trapped in the heart of severe depression, for over a year I attended therapy religiously, twice a week, in order to analyse the causes of and reasons for my unhappiness. I was told I would not get better otherwise.

I was assigned a therapist by my psychiatrist. Let’s call her Margaret. She was large, with long dark hair and a liking for colourful full skirts, smock dresses and shawls. There was an air of self-conscious vanity about her; here was a woman who was not happy in her own skin. So why, I wondered, did she think she could make me feel happy in mine? But she was kind and well intentioned, determined to do good and be of help to her patients, and had a motherly air of comfort about her. She was intelligent, too, and well read in her particular field, although her mind was not original or surprising. She cared about me, and my distress.

I could not stand her.

I went to see her, every Monday and every Thursday, not out of pleasure or even a sense of duty, but out of pure desperation. I knew that I had to have therapy in order to get well. I had been told as much, in no uncertain terms. The best treatment for depression is medication and therapy, in combination. Nobody, though, told me which particular therapy might work for me. It was just ‘therapy’ just as a therapist was simply a therapist, a person who practised a particular skill or discipline, rather than another human being with whom you might engage—or not.

And, because I knew no other way and I was not, at that time, capable of making up my mind because I had no mind to speak of, I kept going back, week after painful week. The cost ran into thousands of pounds. I don’t mind that. Money is there to be spent, or be wasted. Time is not. I can’t get it back. That I do mind.

‘We must try,’ Margaret was fond of saying, ‘to contain you.’ In other words, we must try to contain the pain that is threatening to swamp you, to overwhelm you so badly that you can bear it no longer and want to take your own life.

‘Do you feel more contained now?’ she would ask at the end of a session, eyes bright with anticipation.

‘Yes,’ I would say, even though it was not, for me, a finite position. I might feel less contained, or more contained, but I never once felt the comfort of the safety that word implied.

It didn’t help that I loathed the process. It irritated and pained me and, eventually, I behaved so thoroughly badly that Margaret must, surely, have come to hate her sessions with me as much as I did. Most of the time I was angry, irritated by a methodology that seemed to me to make no sense.

The relationship model, which Margaret kept banging on about, literally drove me mad. ‘What relationship?’ I asked, week in, week out. I knew nothing about her. There was no dialogue. She refused to answer a question. How, then, could we have a relationship? This impersonal approach, in the analytic tradition, supposedly allows the therapist to gauge and address your emotional responses. The relationship model simply means that the therapist extrapolates from the ‘relationship in the room’ (the way in which you react to a therapist during a session) a direct interpretation of your conduct in the world. If my conduct in that room bore any relation to my conduct in the world, Margaret should have assumed that I was a madwoman, given to shouting at blameless strangers.

‘What relationship?’ I kept asking. ‘We don’t have a relationship. I know nothing about you. You know everything about me. The balance of power is completely unequal. How can that possibly be the basis for a relationship?’

‘Does it upset you,’ she said, ‘when you get angry with me?’

‘No. That’s what I pay you for. Does it upset you when I get angry with you?’

She did not answer me.

What little I knew of her, and most was gathered through body language, mannerisms, dress and all the other silent methods of communication, made me believe that we had absolutely nothing in common, other than my illness. Almost nothing she said interested me, or pulled me up short enough to make me think she might have a better take on life. Had I met her in the outside world, in the relationship outside the room, I would have had absolutely nothing to say to her.

I continued with it because I believed it would make me better. I believed she had a particular training in the conditions of the mind, and I did not. I carried on because I did not know what else to do.

It was only later that I understood that it did not have to feel so alien or so cold and that a therapist is simply another expert who we consult when we are ill. And who, just like any other expert, if we are not happy with the results, we leave. As a depressive, I am not interested in either sympathy or theory. I am only interested in getting better. And that, as far as I am concerned, should be the one and only golden rule. If you do not like a therapist, if you are not getting results, then leave. Go and find another.

I know that this, for somebody in the throes of severe depression, seems intolerably difficult, but I cannot urge you enough to try or ask friends or family to help you. The best therapists usually come by personal recommendation so it’s worth asking anyone you can think of. This, of course, requires you to be open about your illness, but there is no shame in trying to make yourself well. If you were searching for any other sort of specialist, it would be natural to ask around. Why should therapy be any different? Keep trying until you find somebody who you are comfortable with and who, after a session, allows you at least a brief moment of respite.