Tag Archives for burnout

Looking back over group therapy part I: the assessment

Already it’s been almost a week since I left my therapy group. It’s sad to go, because I’d come to really care about that group of people, and to connect with one or two in particular. But at the same time I don’t regret my decision. I learned a lot during my time in the group, but it was keeping me stuck, and I have no doubts that saying goodbye was the right way to move forwards.

I want to write some sort of summary of my experiences in group, to look at what I’ve learned directly and indirectly and come up with a road map for the future. I’m not really sure of the best way to do that, so these posts are something of an experiment as I look back over my blog.

First, to set the scene, this is what I wrote about my individual assessment sessions with Group Therapist in February 2011:

The NHS psychotherapy service, [compared to my previous person-centred therapy with F], really is traditional. The guy who’s assessing me has a couch in his office (mercifully, he hasn’t asked me to lie down on it). He doesn’t say much, as apparently my silences and the things I say to fill them are important. When he does interject, though, it’s to say things that probably have a lot of truth in them but that make me squirm. He asks about my dreams and draws parallels between apparently unconnected areas of my life. I have gained some potentially helpful insights from sessions with him already, but those insights were stated by him and I thought, “OK, yeah, that’s true actually,” rather than me discovering them for myself as I did with F. I find things much harder to take in this way. Maybe there are things I’m not yet ready to learn about myself.

On the plus side, I think he has a really good understanding of my issues. It’s obvious he’s carefully read the reams of questionnaires I had to fill in and remembered what was in them (not exactly rocket science, but it’s surprising how many people fail to do this…) He seems to ‘get’ me and squirmy things I’ve pushed out of my mind notwithstanding, the things he says about my problems are perceptive and accurate. He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.

On the negative side, I feel he doesn’t really acknowledge how far I’ve come and the progress I’ve made in my recovery. I don’t think he disputes it; it’s more as though he feels it isn’t relevant. He makes references to my self-harm and my bulimia when those things are 6+ years in the past. He isn’t interested in whether or not I know my thoughts and feelings aren’t rational, and there’s an interesting spectrum here. The CBT I had was all about learning to challenge my thoughts and look at things rationally – a skill I find quite useful but sometimes invalidating. My approach since therapy with F has been to try to find a balance between validating the way I feel and not losing sight of rational fact. C, however, is at the other end of the spectrum where rationalising masks the true issues and should be avoided, at least in the therapy room. I feel that in a way, therapy with him is a bit like the CBT in that one model is rigorously adhered to and everything else is discarded, much like the similarities between the far left and the far right (oops – humour is a defence mechanism and also best avoided in the therapy room). He says I’ve been pulling myself together all my life and I suspect – though really must ask whether – he thinks a lot of the help I’ve had before has only changed things on the surface. He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.

It’s really interesting to read that back now. A couple of sessions into my assessment, I already had a handle on what would turn out to be the advantages and disadvantages of the whole experience. I loved how seriously GT took my issues, that he’d obviously read my questionnaires closely and remembered what was in them, and that he seemed to understand what I struggled with. He was the first NHS professional who, I felt, recognised the extent of my problems and was willing to help me for as long as it took. At the same time, he didn’t seem to acknowledge my strengths or show much interest in the things that had helped in the past. His ‘style’ of therapy was uncomfortable, and so very different from what had worked for me before – I was open to trying something new, but I still worried that perhaps he was adhering to a model just as rigidly and inflexibly as my CBT therapists had refused to budge from theirs. You’ll notice that the final disadvantage I gave was also one of my advantages: “He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.” This turned out to be a real double-edged sword.

Probably one of the first things I learned from GT was that I have a cycle of pulling myself together and falling apart again, which he compared to bingeing and purging:

I’ve been thinking about what my therapist said about my lifetime of ‘pulling myself together’, and he’s right. As I look back over the years I can see a pattern of falling apart then picking myself up and putting the pieces back together again. Sometimes this is in very big ways (breakdown during finals, took years to rebuild my life), sometimes very small ways (oops, I took on too much last week, I’ll take it easy this week), and everything in between. I suppose the question is how much of this is normal. I’ve observed before that trying to find a balance in life isn’t something you can do once and stick with it; things constantly need reassessing and adjusting. That has to be normal, because a tightrope walker can’t just find his balance at the start then plough across the rope regardless. I guess what concerns me is how difficult and counter-instinctive it is for me to find balance and how much I’m still wobbling around all over the place. Does this mean I need more therapy, or is it just a question of practice? I feel I’ve been practising for years and not improving.

I love the feeling of getting back on track and starting to pick up the pieces (which is where I am with my debts right now), but then I get carried away and take on too many things, and the cycle repeats itself. Perhaps what worries me most is when I first realise it’s all too much, I force myself to keep going and it’s very difficult to acknowledge I can’t cope.

Knowledge of this cycle has been very useful to me. It’s allowed me to take a step back and look at the big picture of my struggles rather than constantly hone in on the details of coping in the moment. In particular, I’m much more aware of the “bingeing” and “must keep going” phases of the cycle and this has helped me to make more sensible choices. I’m very grateful to GT for this piece of information.

My comments on tightrope walking and how to maintain a balance, though, came entirely from me – and were very perceptive. Whereas GT seemed to view my cycle as purely pathological, I think some falling apart and picking up the pieces is going to be inevitable in life. What I’ve come to realise is how my difficulties in ‘set shifting‘ (thank you, Katie, for teaching me that term!) cause me to wobble more than most people. At some point, I’d like to find out more about the cognitive remediation therapy that Katie mentions.

In my next assessment session, GT stated that I use the cycle to avoid feeling. I’m still not sure to what extent this is the case, but I had to acknowledge that one emotion – shame – is problematic for me:

I could write pages about all the different ways I take care of myself when I’m depressed, but with shame there are really only two options: block it out or make changes in my life to make myself acceptable NOW.

There are some other conclusions in that post which I now think may have been erroneous, or at least overstated. I’ll look at those later, when I write about the period where I started to suspect the therapy group wasn’t right for me. For now, I’ll skip ahead to the goals I set for treatment:

  • I want to be able to let myself experience what I’m really feeling, and know that I can cope with it.
  • I want to break the cycle of taking on too much, falling apart and putting myself back together again.
  • I want to get close to people and let them support me without being frightened that my desperation and neediness will scare them away, or that they’ll take advantage of my vulnerability. (People can’t always be trusted, so I guess this also comes down to trusting that I will cope if someone does screw me over, and still being able to reach out to others afterwards.)

It wasn’t long after this that I decided on group therapy. I didn’t see GT again for some time, but I’d like to mention a post I made in the interim. In The one about coping skills, I recognised how being betrayed by people I thought I could trust had rekindled my difficulties in reaching out to people, and acknowledged the impact this was having on my ability to cope:

Yesterday, I said I had not forgotten my healthy ways of coping. I saw pain/stress/dodgy mental health as outweighing those coping skills not because I’d lost skills, but because my circumstances had changed – either life is just more stressful now, or my mental health is inherently worse. I suspect now that this may have been a little white lie.

In 2007 [I was] daring to develop my career after years when simply making it into any kind of job was an achievement. I was winding things up with my private therapist and felt pretty damn well recovered. But perhaps the biggest difference of all is that I had and used a support network. I was an active member of a depression forum, a fantastic group – I thought – of people. I was also working on talking to the people in my life about how I was feeling. The usual pattern was I would sound things out online first, then venture on to the scarier task of face-to-face conversations. I was aware of a need to lean on the internet less and develop my real-life relationships more, but I saw this very much as something within my grasp, as a continuation of a journey that had already been set in motion.

In early 2008, I was very badly betrayed by the owners of that forum. To be strictly accurate, the betrayal had occurred about nine months earlier but I was only just discovering the web of vicious lies they had spread about me while being warm and supportive to my face. On the surface of things, I coped with it very well. I recognised that this was about them and not me; I had not done anything to deserve it. In therapy I had come to realise that I wasn’t a bad person after all, I wasn’t fundamentally unlikeable and I hadn’t done anything to cause the bullying and abuse of my childhood, and when it was put to the test, this view of myself held up. I was also able, for the first time, to confront the bullies and feel proud about it.

It has taken some time to spot the damage that was done, the extent to which I have stopped trusting people and stopped reaching out. I planned to join some sort of more private forum, but there was never really anywhere that seemed right. There was always a tangible reason why a place wasn’t right and it has taken a long time to recognise that perhaps those were only surface reasons. It has taken even longer to realise that my plans to develop my relationships with real-life people, to be more open with friends and relatives and lean on them more, got shelved somewhere along the way.

This realisation has also been very important in helping me figure out what I want to work on and where to go from here.

A few weeks before joining the group, I met up with GT again and we discussed my current episode of depression, leading to some unexpected (but, I feel, accurate) conclusions on self-care and validation:

I suggested that actually, I take care of myself far better when I’m depressed than I do most of the time. I can make sense of depression and I know, through past experience, what helps when I’m feeling this way and what doesn’t. Although my self-critical thoughts increase, I recognise them as part of the illness and in a way I’m forced to stop, or at least slow down, and look after myself. My therapist commented that perhaps becoming depressed after a period of pushing myself too hard could be a healthy thing.

My suggestion then led us in two interesting directions. One was to do with validation. He observed that almost as soon as I realised I was depressed, I began to think about what could have caused it. He agreed with me that this can be useful in terms of understanding how to get out of the dark place and how not to end up there again, but I also agreed with him that my need for self-understanding runs deeper than this. If I can make sense of the way I feel, I can cope with it. It’s when I can’t find an explanation for a strong or negative feeling that I really struggle. I feel that I have no “good reason”, I “shouldn’t” be feeling that way, and then I start to question whether I really am feeling like that at all.

Finally, following my last individual session, I pondered what needs my perfectionism might be serving:

I have a very firm idea in my head of how I ‘should’ be. When I’m depressed and non-functioning it’s a million miles away, which is oddly easier, because when I’m well it’s tantalisingly close. If I just push myself a little bit harder, if I just stretch myself a little bit more, I’ll be there. I’ll be ‘good enough’. Well done! The problem is that deep down I know I’ll never be there because the goalposts move. It’s always ever so slightly out of reach.

Why do I operate this way? I think a large part of me believes this is what’s needed to motivate myself. That if I didn’t set myself so many goals, if I didn’t always push myself, if I didn’t hold myself up against an image of a Moon Tree who’s just slightly better than I am now, nothing in my life would ever improve. And then what? I’ve been trying to think about a different way, a way where I trust myself, where I am mindful and allow myself to be motivated by what I truly want. I’m not talking about hedonism here – there needs to be a way of taking future needs/wants into account as well as present ones, and of resolving any conflicts. I have an idea that this could work, and that maybe it’s how ‘healthy’ people operate, but I’m not sure of the specifics yet.

The first paragraph sprang from a discussion with GT, but the ideas in the second paragraph – about why I still operate in this way, and what the alternative might look like – are all my own. I don’t think I ever brought them up in group therapy, possibly because I sensed he would disapprove. But that’s a topic for another post, because I’ve reached the end of writing about our assessment sessions and it’s most definitely time for a break.

Attachment and fatigue: the not-quite-plagiarised post

I’ve read a couple of blog posts recently which really spoke to me. I’m struggling for words a bit at the moment (though I will post an update on the fatigue situation), so this post will be mainly one of quotes.

Firstly, from katieinwonderlandx:

I find the theory of an internal parent fascinating. Is that why people like me feel so needy of constant reassurance? Constantly need someone to say they care. Constantly need to turn to someone even if that person cant physcially do the hard work, and you will have to do it yourself in the end regardless.

When you have good parents, they react appropriately to your needs. When you cry, they hold you. They soothe you. They kiss your forehead, they tell you that everything will be alright and they make you feel better. As you get older, you internalise this ‘caring parenting’ they gave you. You adopt it and take it within yourself as an automatic self-soothing response to hurt, upset or pain that is self-manageable. You internalise the parent and when you need that reassurance, it can come from within yourself. You learn to self soothe in the exat same way you were soothed as a child.

For those of us who didnt ever recieve soothing, comfort, care or reassurance as a child….we havent internalised that parent. We dont have that process within ourselves. We have anothger type of parent inside. One who is emotionally abusive. Who lowers our self worth and doesnt care enough to tend our needs. Who is cruel and callous. So we have endorsed it as self loathing.

Maybe if you then, later in life have a figure who does give you this care and reassurance, you have got to find a way t0 internalise it. So that you can call upon it from inside you when you need to be soothed and calmed down. Otherwise you become dependant on it from the person who gives it. You have to take it in, and learn it as a process you can keep inside as a tool when you need it.

When you have never been cared about at the impressionable ages of infancy, you don’t have the innate belief that you are worthy of being loved or nurtured even by yourself. But its not as simple as having someone show you that they care so you understand you are indeed worthy of it. You have to then internalize it, and become self-sufficient and able to self soothe.

My second offering is from Trich Questions on The Power of Doing Nothing:

It can be easy to believe that we can do anything we want at any time, as long as we’re “strong” enough. We’re told constantly that as long as we buy the right products and know the right people and go to the right places, we’re essentially immortal. If you start feeling overwhelmed by how much you’re taking on, it’s probably because you’re weak-willed. Or anaemic. Or depressed (for “depressed” here, read “weak-willed”). Or you’ve got a vitamin B deficiency. Or you’re not doing enough exercise, or getting enough sunshine, or eating enough “super foods”. Essentially, if you’re not feeling well, it’s because you’ve not got enough of something, regardless of what that something is. Attainment is shown as key to your recovery, so you can get back on the treadmill again and start feeling exhausted almost immediately.

As an accompaniment to attainment, you should of course blame yourself for feeling exhausted. It doesn’t matter if you’ve had back-to-back meetings all day and you’re working long into the night, if you feel tired, there must be something wrong with you. Likewise, if you’re struggling to juggle your work, family, relationship, hobbies, friends and health all at once, you should get to the doctor immediately because “normal” people don’t feel at all overwhelmed at any time. [...]

It’s very difficult for me to accept that if I don’t look after myself, there will be consequences, despite seeing those consequences time and time again.

Ten years

On a Tuesday lunchtime ten years ago, I headed into town after telling my flatmate I was going to a medical appointment. I dropped enough hints that he would think it was for a smear test and not ask too many questions. In fact, I was going to my first ever counselling appointment and my first attempt at seeking help for my mental health problems. I was not currently depressed, but the episode I’d had the previous year – when I was living abroad and didn’t have health insurance – had scared me enough that I’d promised myself, when I returned to the UK and the NHS and the university counselling service, I would seek professional help.

That first counselling session was not a success for many reasons. The counsellor was in her late 50s and I worried she wouldn’t be able to relate to me, which made it hard to open up. She resorted to a few too many counselling clichés which made me cringe. At one point, she tilted her head in what I’m sure she thought was a sympathetic manner, adopted an obviously staged ‘sad’ expression and said, “I’m just feeling your pain now.” What? I told her how I’d had to leave an internship two months early because of my depression, that I’d known the bitchy atmosphere, stress of working full time and grey weather weren’t helping so I’d moved further south and enrolled as a part-time university student for the remainder of my year abroad while I convalesced. She told me that sounded like a very healthy decision and, when she found out it was the first time I’d ever turned round and said “no” to something that was making me miserable, focused on what a positive step that had been. Although ostensibly she was right, I saw my recurrent depression as an illness that was disrupting my life and when she didn’t acknowledge this perspective, I felt unheard and invalidated.

But perhaps the biggest reason I didn’t go back was what happened towards the end of my session, at 13:46 in the UK, although I didn’t know about it until a couple of hours later. You may have guessed that this was not just any Tuesday in 2001. It was 11 September 2001 and, after a trip to Ikea, my housemate’s brother got a text message saying, “Have you seen the news? This is fucking scary!” When we learned that terrorists had crashed planes into the World Trade Centre and the Pentagon, when we got home and watched the footage of the towers collapsing over and over without it really sinking in, I made a decision. There were Real Problems in the world. 3,000 people killed, with probably millions injured or traumatised. I did not have Real Problems. I would take the counsellor’s advice, put the whole thing down to a toxic work environment and get on with my life.

I didn’t get very far with this outlook. Within a month I had relapsed, first into anxiety, then depression. By the end of October I had seen my GP and was on medication. But that first counselling appointment proved to be the start of a pattern of years struggling to get my illness taken seriously, by myself as well as by the professionals. I think there were several factors at play, all interlinked. I’ll try to list them:

  1. Although I knew I was depressed, I didn’t want to accept that this affected my ability to function. I felt I should be able to push through it, but trying to do so only made me more ill, as did beating myself up when I ‘failed’.
  2. Many of the counsellors and therapists I saw, like that first counsellor, viewed my depression and other issues as a normal reaction to having been severely bullied and emotionally abused as a child. They encouraged me not to think of myself as ill. Although I’m sure it wasn’t their intention, this fed into #1.
  3. The CBT I had, while teaching me useful techniques for challenging my negative thoughts, also encouraged me to ‘get more active’ and behave as though I wasn’t depressed. (I’ve written more about this in my second What’s wrong with CBT? post.) What’s more, to help prevent relapse, I was advised that when I developed the early warning signs of depression I should ‘look for alternative explanations’ rather than seek help. This also fed into #1.
  4. The medical profession first failed to diagnose me with depression (I was initially told it was ‘normal final-year stress’ and prescribed beta blockers and sleeping pills), then wrote me off when the second antidepressant they tried didn’t work. I was actually told by one GP that as I’d had a traumatic childhood, medication wouldn’t work for me – but I couldn’t access effective therapy (see #2 and #3, then add in NHS waiting lists and limits on sessions) or crisis support either. The fact that they didn’t seem to take me seriously fed into #1.

When you take into account the fact that antidepressants have been the only thing to lift my depression (and I don’t think I could handle proper therapy without them), you can probably understand why I have a thing about being taken seriously, and why being viewed as ‘ill’ when I am depressed is important to me. To this day, I can’t read Dorothy Rowe’s Depression: The Way Out of Your Prison because she argues that depression is not a medical illness. So many people have recommended it to me, and intellectually I recognise that her viewpoint is (a) one valid perspective among many and (b) probably not the main point of the book, but it’s just too triggering. Even if my childhood has caused me to develop or be more vulnerable to depression, I need to believe that brain chemistry is involved, whether because there’s an endogenous side to it too or because trauma has changed my brain chemistry. You might think that’s an entirely logical conclusion since the meds work (even if they haven’t been able to stop me relapsing), but I think it goes deeper than that.

What does it mean to be ill? What does being ill mean to me? These are the questions I’m pondering and I think it comes down to two things. Firstly, being ill means medication can be appropriate, that treatment from GPs and psychiatrists as well as counsellors and therapists is appropriate, and that’s important given what I now know about what works for me and my depression. But secondly, being ill means it can be appropriate to take time off work and time out from responsibilities. If I am ill, I am allowed to cut myself a break. I’ve probably mentioned before that I’ve become good at taking care of myself when I’m clinically depressed, but I really struggle with perfectionism and pushing myself too hard the rest of the time, making relapse all too likely. My current therapist – thankfully in a way that makes it very clear he does take my problems seriously – says that depression for me may be a healthy response, a way of getting the rest I need. Ill yet healthy. It’s a strange dichotomy, but I’m starting to suspect that deep down I feel it’s only OK to take care of myself when I am ill. The rest of the time, I have to prove my worth.

Today my thoughts and prayers are with the victims of 9/11 and everyone who has been affected by the tragedy, but I’m also looking back on ten years of my own mental health treatment. I hope it won’t take another ten years for me to truly believe that I have worth just by being who I am.

“I’m not good enough”

That’s the thought I had when I was speaking to Group Therapist about my tendency to push myself too hard. I didn’t voice it aloud to him because I know it’s not rational. I don’t know when I’ll get my head around the fact that it’s OK to bring irrational thoughts to therapy; there’s still a part of me that expects to be told off for my ‘twisted thinking’, even though I know GT isn’t like that.

The thought surprised me because I thought it was a core belief I’d already dealt with. In therapy with F, I learned how my perfectionism had developed. The bullying I faced as a child, the total lack of friends, and my crippling shyness all led to me feeling like a failure socially. I thought I must be deficient in some way that meant I would never have a normal social life. Schoolwork was a different matter, though; that was something I knew I could be good at. So I threw myself into it, both as a distraction technique and as a way of compensating for my ‘shortcomings’ elsewhere, and all my self-esteem hinged on my ability to perform academically.

When I realised that there was nothing wrong with me socially, when I recovered from social anxiety disorder, when I went on to have a normal social life, I thought that need for academic and career perfection had gone too. In truth, I am less perfectionistic than I used to be. Doing well in my career feels far less ‘life or death’ now that there are other areas of my life I can feel happy with, or even proud of. Therapy with F has helped with this issue. And yet I still push myself to the point of relapse. Why? It’s possible I have some sort of biological predisposition to depression, and can’t afford to push myself as far as ‘healthy’ people can, but I suspect this isn’t the whole story. What other needs is my perfectionism serving? I’ve been thinking a lot about this over the past few days.

What I did tell GT is that I have a very firm idea in my head of how I ‘should’ be. When I’m depressed and non-functioning it’s a million miles away, which is oddly easier, because when I’m well it’s tantalisingly close. If I just push myself a little bit harder, if I just stretch myself a little bit more, I’ll be there. I’ll be ‘good enough’. Well done! The problem is that deep down I know I’ll never be there because the goalposts move. It’s always ever so slightly out of reach.

Why do I operate this way? I think a large part of me believes this is what’s needed to motivate myself. That if I didn’t set myself so many goals, if I didn’t always push myself, if I didn’t hold myself up against an image of a Moon Tree who’s just slightly better than I am now, nothing in my life would ever improve. And then what? I’ve been trying to think about a different way, a way where I trust myself, where I am mindful and allow myself to be motivated by what I truly want. I’m not talking about hedonism here – there needs to be a way of taking future needs/wants into account as well as present ones, and of resolving any conflicts. I have an idea that this could work, and that maybe it’s how ‘healthy’ people operate, but I’m not sure of the specifics yet. And what’s more, it terrifies me. I can be impulsively self-destructive with things like overspending, overeating, and trich. What if all those goals, rules and ‘shoulds’ are what’s needed to keep my self-destructive side in check?

I have to keep reminding myself that the goals, rules and ‘shoulds’ are self-destructive in themselves.

I recently read an article on cognitive analytic therapy (it’s aimed at mental health professionals and is fairly technical, so I’ll paraphrase here). The author explains that CAT is based on the theory that normally, if something isn’t working for you, you re-evaluate and either tweak the way you do things or go back to the drawing board. In this way, human beings are able to overcome most of the problems they face. However, there are certain ways in which people get stuck. One is the ‘trap’, which I would call a downward spiral or vicious circle, where the consequences of your problem themselves make the problem worse. For example, you’re depressed, which makes you stop opening your post or paying your bills, which leads to creditors on your back, which makes you more depressed, making it even harder to tackle your debt problem. Another is the ‘snag’, where you think of a potential solution but fear its negative consequences too much to try it out. The author gives the example of a gay man who has to keep his identity a secret at any personal cost because he believes coming out to his family would kill his mother.

However, the one that interests me today is the ‘dilemma’, which I think of more as a pendulum. This is where an attempt to tackle one problem leads you to another, and trying to tackle the second problem takes you back to the first. So, I set myself lots of goals and push myself hard. Eventually, this becomes unsustainable and I end up too exhausted to function. Recognising that my behaviour has been unhealthy, I drop all the goals and take some time out to heal. If I’m not careful, I may self-destruct at this point, for example spending wildly in an attempt to cheer myself up or simply ‘dropping out’ of my responsibilities rather than letting people know I’m ill and need some time off. As my mood lifts, the sense that I have failed becomes intolerable and my solution is to set more goals and push myself even harder to make up for it. At first, I feel loads better for this. But the pendulum is swinging and I’m right back where I started.

I need to find a sustainable way of being. I don’t think most of my goals are unreasonable in themselves. For example, I want to reduce my debts, and as a newly qualified professional I want to develop my career. The problem (in my opinion) is the way I go about motivating myself and trying to achieve those goals – and above all that I cannot tolerate the divide between how I am now and how I think I ‘should’ be. Yet I’m afraid that letting go of how I ‘should’ be will cause me to become unmotivated and swing to the opposite extreme. Aargh! I don’t have a solution to this yet, but at least I know what I need to work on.

Depression self-help books, or what’s wrong with CBT? part II

Yesterday afternoon I had an appointment with my GP. My depression is much the same, and there wasn’t a lot she could do: we’re still waiting for the citalopram to kick in, I’m not ill enough to need the crisis team, and my sick note won’t run out for another three weeks. Perhaps because of this, she decided to mention the PCT’s books on prescription scheme. The gist of it is that clinical psychologists have recommended a number of self-help books which patients can borrow from local libraries. All the books are CBT-based.

Three books are listed for depression and as a self-help junkie, I wasn’t surprised to find them pretty familiar. One is Mind Over Mood, which I’ve already read, owned and blogged about. Another is part of an extensive series of CBT-based books and is one of the few from that series I haven’t read. The third caught my attention as at first I thought it was one a fellow mental health blogger had recently recommended – as soon as I read the book’s description, though, I realised I’d been mistaken (it turned out I’d confused a book with “five” in the title with one with “seven”). Anyway, this is what the leaflet said about it:

Overcoming Depression: A Five Areas Approach
Chris Williams

Readers learn how to: discover why they feel as they do; develop better problem solving skills; rebalance relationships by becoming more assertive; become more active and rediscover the fun in their life; build helpful responses to life stresses; improve sleeping patterns and quality; learn how to change unhelfpul, biased negative thinking; make choices that encourage and support a healthy lifestyle; and plan for the future in order to maintain the newly emerging wellness.

Now, you might think that all sounds reasonable enough and reassuringly comprehensive. Indeed, a few years ago I would have jumped to borrow (or even buy) this book, but today that description sets alarm bells ringing in my head. Why? For me there are two warning flags: one is a synopsis which reads like a lengthy “to do” list for the depressed reader, and the other is the telltale phrase “become more active”.

As a rough estimate, I’ve probably read at least 20 CBT-based self-help books for depression, and they all seem to boil down to the same two things. One is the cognitive side of CBT, the “change unhelpful, biased negative thinking” cited above, and I’ve written about my experiences with that approach (helpful, but not the miracle cure that’s often promised) in my first What’s wrong with CBT? post. The second is becoming more active. If you are depressed, you are not supposed to sit around feeling low, as apparently that only makes matters worse. Instead, you should do things which give you a sense of achievement, get back to the activities you would normally enjoy, and generally keep busy to distract yourself. The theory behind all of this seems to be that reduced activity in depression is mainly a problem of motivation, and that if you force yourself to get moving, you will feel better for it.

To be fair, there is some truth in this. There definitely have been times I’ve spent the morning in bed feeling absolutely rotten, then dragged myself to the shops or whatever and my mood has lifted. I like to set myself between one and three small goals every day – depending on how ill I am, they can be as little as taking a shower or watering the plants – because that helps to offset the guilt I feel at not being able to function normally. I also think it’s important to look for fun wherever I can find it – this often involves gallows humour or silly cartoons – and to stay in touch with friends so that I don’t become too isolated. I have developed my own approach which works for me, but what I’ve described so far doesn’t sound all that different from what the CBT books advocate.

The problem is that there’s a flip side to all this, and I can illustrate it from my own experience.

From the point when I first encountered CBT-based self-help in 2002, I was the good little patient. I dutifully challenged all my negative thoughts, which did bring me some relief, albeit temporarily, and I also tried to increase my activity. I did things I would usually enjoy, only to feel even worse because I couldn’t get any pleasure out of them. In some cases – such as reading novels – I couldn’t do them at all, and it only served as a stark reminder of how far removed from my usual self I was. I tried to push myself to get things done, to sort out the horrendous mess of sick leave and benefits and unpaid bills I had got myself into. I beat myself up for failing to do this, because I believed I was failing to take the necessary steps to improve my life and get myself well. Trying to increase my activity wasn’t helping, but the books – and the “therapy” I’d had – all said it would, so I mustn’t be trying hard enough. Between periods of utter exhaustion, I pushed myself again and again.

Round about 2005 or ’06, though, I encountered a different sort of self-help book. Through a book-swapping website, I ended up with a copy of Alexandra Massey’s Beat Depression and Reclaim Your Life. In a way this wasn’t a book that applied to me – it focused mainly on the type of depression that’s been triggered by some sort of loss, such as a bereavement – but the author’s approach intrigued me, because it talked about the importance of rest. It was so very different from the standard CBT approach and I hadn’t realised there were people who advocated other approaches. I got in touch with the woman I’d swapped with to ask what she’d thought of the book and she recommended a second book to me: Tim Cantopher’s Depressive Illness: The Curse of the Strong, which is specifically about stress-related depression.

To avoid repeating myself, and because difficulties concentrating mean this post is taking a very long time to write ;) here’s the review of the book I wrote for Amazon:

This book has revolutionised the way I view myself and my depression.

It’s not a self-help book as such. It provides information on stress-related depression, with occasional bits of advice. There are no exercises to complete. Intead, Depressive Illness: The Curse of the Strong helps you to understand how your illness developed, why you need to be gentle with yourself and what you need to do to get better.

I first became ill with depression after pushing myself too hard during my final year at university. For years, I thought of myself as weak. I struggled to cope with everyday life, was often too depressed to work, and I hated myself for not being able to function like a “normal” human being. Tim Cantopher turned that view of myself on its head. He argues that those who develop stress-related depression are actually hard-working, perfectionistic people with a strong work ethic who burn themselves out. This was very true of me but in the mire of negative thoughts that’s part and parcel of depression, I hadn’t been able to see it until someone else pointed it out.

Before reading this book, I’d tried many CBT-based self-help books with practical exercises to complete. These were very helpful on one level – challenging negative thoughts makes a huge difference – but on another level they just fed into my perfectionism issues. I always felt like I should be doing more to fight against my depression. I pushed myself too hard and it was a vicious circle.

Since reading this book I’ve completely changed my approach to depression. I still use CBT, but in moderation, and I make sure I take some time out every day to relax and do something I feel like doing. With the help of medication and a therapist, I’ve now recovered from depression and am living the life I want to lead.

If I have one criticism of this book, it’s that the explanation of how antidepressants work is a little simplistic, and theories are presented as facts. Cantopher stresses the need for medication, which was true in my case, but I’m not sure it’s true for everyone. However, even if you’re against the idea of drugs, don’t let that put you off the book. The rest of it is truly life-changing.

Like Alexandra Massey, Cantopher advocates rest as an essential part of depression treatment. He actually recommends a wall-to-wall diet of Australian soap operas as a distraction from how you feel (not my thing, but hey). As you start to feel better and to want to get things done, he suggests leaving tasks half-finished as soon as you find yourself becoming tired. If you push yourself too far, he says, you’ll end up feeling much worse for the next 36-72 hours. Apparently a pattern of good days and bad days is normal in depression recovery, but if you overdo it on the good days, the pattern becomes exaggerated, you’ll have more bad days and take longer to recover. It literally can be a case of one step forward, four steps back.

The book is not without its flaws. Firstly, Cantopher makes a lot of assumptions about the depressed reader. One of the reasons I found The Curse of the Strong so helpful is that they all applied to me, but if they don’t apply to you, you’re likely to feel pissed off, not to mention disturbed that he “almost never bother[s]” to make enquiries as to his patients’ personality because he knows it all already. Secondly, he states his own theories and beliefs about the biological side of depression as though they were undisputed scientific fact. Although this sort of thing is common within the medical model, I don’t believe there is sufficient evidence to claim that depression is a physical rather than a mental illness; nor do I believe that in almost all cases it could be diagnosed with a lumbar puncture showing reduced levels of serotonin and noradrenaline. (Surely if that were the case, LPs would be performed in cases of diagnostic doubt. I realise it’s an unpleasant and risky procedure, but then severe depression is just as unpleasant and life-threatening.) I think this is all part of Cantopher’s rhetoric to convince the reader that they are not weak or to blame for their illness, but frankly, any scientific “facts” that you come across in his book I would check elsewhere.

Anyway, despite these problems, Cantopher’s theories on how stress-related depression develops and how to recover from it make a lot of sense to me. Looking back at my severest episode of depression, I can see just how much suffering was caused by me essentially trying to force myself to function as though I wasn’t ill. The bizarre thing is I’ve found if I allow myself time off from my responsibilities, depression isn’t “that bad”; it still sucks, but for the most part it’s tolerable. It’s incredibly painful to remember how I used to yo-yo around all over the place, desperately trying anything and everything that might make me feel even the slightest bit better, taking on responsibilities which I then wasn’t well enough to handle, telling my GP and myself I was fine now and didn’t need any help just because I was having a slightly better day… Acceptance is a much better path for me. I used to beat myself up for not being able to hold down jobs and sort out my debt problems, but now I look back and think, “That girl was clearly so unwell. She didn’t need another reason to blame herself, she needed a suport worker to help her apply for benefits and contact her creditors. Why didn’t anyone realise this?”

These days, my approach to managing depression is all about balance. For the most part, I listen to my body’s demands for rest. However, at least once a day, I try getting something done to see how it makes me feel. If it leaves me even more exhausted, I know more rest is needed. On the other hand, if – as often happens – getting active motivates me, I try to take advantage of that, but always paying attention to my energy levels and feelings so that I don’t overdo it. I make mistakes. I overdo it. But I remind myself that my needs and abilities are different when I’m depressed, and by and large, this approach works for me. I believe it helps me cope with depression far better and also makes it easier to recover through therapy and medication.

What I don’t understand, and what really makes me quite angry, is why none of the CBT books mention this need for balance. They only talk about one side of the coin with seemingly no concept that it has its limitations or can make matters worse if taken too far. Are the authors really so clueless about depression that they don’t know about this? Do they assume that everyone with depression is the type of person who tends to do too little rather than too much? For me the subtext of these books, however compassionately they’re written, seems to be, “Depressed people are lazy and should get off their arses.” Of course that’s a depressed perspective, but then they’re writing for a depressed audience.

I could be overgeneralising. The middle book on the Books on Prescription leaflet, Overcoming Depression by Paul Gilbert, is of course CBT-based but the description says, “The book is split into manageable sections and Gilbert advocates flexibility in terms of using the book [...] Depression is understood as being caused by overstressed systems rather than personal weakness or inadequacy.” This spoke to me and I’ve ordered a copy from Amazon. It’s quite possible I’ll find it’s more of the same and send it back for a refund, but could this be a CBT book that takes a more balanced approach? Watch this space.

Edited to add: If you read the comments below, you’ll see that both the Overcoming Depression books I mentioned include sections on pacing and/or the need for rest. This is really encouraging.

Playing the piano

When I was six years old, there was nothing in the world I wanted more than to learn to play the piano. I begged my parents for lessons, until finally, a few days before my seventh birthday, I was taken to see a teacher in a nearby town. I could barely contain my excitement as I seated myself on the stool, my feet dangling above the pedals, and learned to play a piece called “I am C”. (Can you guess what the only note was?) It was brilliant.

Less than three years later, I refused point blank to go to another lesson, and that was the end of my piano-playing career. Why? It wasn’t that I’d lost my love of music; although I’ve changed instrument (twice), rehearsing and performing remains a huge part of my life. Nor is it that I have something against the piano in particular; at Christmas, I’m still the one who leads my family in choruses of “The First Nowell” from the Easy Carols for Piano book. The problem was that my teacher was unnecessarily strict. Every evening, my mum had to write down how long I’d practised for, and I mean every evening, whether it was the day of a lesson, my best friend’s birthday party or my sister had just been sick all over the carpet. If we were staying with relatives, we had to take an electric keyboard so that I could practise. If we were camping in the middle of nowhere, I had to sit down at the picnic table and “practise” on a piece of paper with piano keys drawn on it. I kid you not.

In therapy with F, one of the (many) things I learned is that the “wants” and “shoulds” in my life were out of balance. I had been brought up to obey the rules, work towards goals and value achievements, and feelings weren’t given much importance. I don’t mean that I never do what I feel like – one look at my credit card bill should disprove that one ;) – but my spending sprees and meals out are more often an impulsive reaction to the pressure of all those “shoulds” than a reflection of what, deep down, I truly want. I am particularly prone to assuming that any step taken towards a goal I want must inherently be a good thing and therefore I am enjoying it, because I said so.

I suppose it’s easy, when you’ve learned a lot of different things in therapy, for some of them to get lost in all the hustle and bustle of life. Every time I’ve relapsed, I have reminded myself not to push myself so hard. I have got the hell out of jobs I knew were making me miserable and I left a (later) therapist who kept setting me 1,001 tasks to do. But those are still all the big, goal-related things. I haven’t looked at the day to day stuff, or paid attention to what I feel like doing right now that isn’t connected to some sort of goal, and maybe that’s why I find myself clinically depressed again despite everything. I know that metaphorically I want to play the piano, I am absolutely positive about that and can’t understand why it’s making me ill, but what I’ve forgotten is that I’m seven years old a human being (not to mention possibly a spoonie) and perhaps my methods could do with a little tweaking.

While I’m off sick, I’ve been paying attention to what I feel like and trying to reconnect with those “wants”. So far, I have eaten cake, read a book of cartoons, watched an episode of Mock the Week and played with the cat. Those are all things I might do anyway but this time I’m doing them because it’s what I feel like in that precise moment, not “I should do that because I like it”. I am also resting a lot. I’m hoping that once I’ve got back into the habit of doing this again, I can move on to mastering the basics of life (such as having food in the house), connecting with friends more, and eventually ease myself back to work part time. Whoops – did someone mention the word “goal”? Well, there’s nothing wrong with goals per se, and I know some “shoulds” are needed to create a balance. I think the most important thing for me is that I keep paying attention to how I feel throughout, and don’t try to take anything too fast. My default is to assume that what was right for me yesterday will be right for me in three years’ time, but I need to accept that human beings don’t work this way.