CHAPTER FIVE
THE SIREN SONG OF DRUGS
‘I need to stop the pain … now!’
I started drinking when I left school when the few friendships I had fell away … the main problem still is that I have no friends … I drink so I don’t feel as lonely, but the drinking is taking over my life. My mum keeps the grog locked up, then I can’t drink all the time, but she hands me out cans when I really need it … The grog isn’t helping as much lately, and I also take heaps of other tablets [anti-depressants] … I often feel so down that all I can think about is dying so I don’t have to feel this way any more. My mum says she’ll help me, if I really have to do it ... I hope I don’t have to do it, but if I do, I think I’ll put a hose on the exhaust pipe.
I’ve always been good with girls … I don’t have any problems in that department. Lots of them want to go out with me … I think they like me and they also like my money … I enjoy the game … I like to collect things … girls come into this category, same as how I like collecting cars or bourbon or guns or knives … But most girls don’t like to know I collect guns and knives, they think it’s a bit weird, so I try not to let them know that … I’m highly sexed, that’s for sure … but lots of girls aren’t so into sex; they pretend they are, but really they want something else.
Only a year ago I was size 12; now I’m about size 28. Every day I lie on the couch and watch TV, eating and eating … I’ve been spending all of my money and going into debt because of spending so much on food … I know I’m eating to stop me thinking about other things. Eating sort of numbs me. Recently I started a Real Estate course and I’m terrified that I won’t be able to do it, so I procrastinate and don’t do the assignments. I eat instead of studying for tests, and the problem just gets worse and worse … I have been quite big before, but I’ve managed to lose the weight … this time it feels harder ... I think I’m more scared … I’m pretty sure it started when I was younger and I felt empty inside, like I needed more love. When there was no love, I think I tried to fill up the hole with food.
No one has been into my house for about eight years. I would be too embarrassed … It’s just so cluttered up with junk. I don’t know why, but I can’t throw things out … the idea of throwing anything away makes me very upset, like I’m getting thrown away … it became really bad after I got cancer … now I collect all sorts of things, glass jars, newspapers, tupperware, plastic bags, paper bags, photos, letters, cards, old furniture, bottles, you name it … you can hardly get into the house, junk is just about up to the ceiling … I haven’t seen the top of my kitchen table for years.
When I was eleven years old, my mother had just split up with her third husband. He had been my main father since I was about four years old and I loved him … he had been very good to me … My mother decided that he was weak, and I was forbidden to see him … she made it clear that I would be betraying her if I saw him. I felt like I had no choice, so I stopped seeing him. It made me feel miserable. I remember every day after school riding around on my bike for hours, just eating junk food … it gave me comfort … I think I’ve often turned to food since then, whenever I’ve needed comfort.
I spent lots of my life in gaol … arson, break and enter, assault, dealing, armed robbery, rape … I keep fit, punching the bag, running up stairs, do the weights, try to turn the mind off, but can’t stop it … been going straight for a while … but have to drink a cask a day or more, take a packet of codeine with it … can’t stop the thoughts … wife’s been shittin’ me lately, she makes it worse … pictures in my head … like real violent, killing things, cutting things … I’ve been lighting fires lots … I can’t stand the pictures in my head, they’re real scary.
THESE PEOPLE ALL SHARE an overattachment to something—food, alcohol, alienated sex, collecting objects, exercise, or drugs. They have become excessively attached to various substances and activities, usually a long time ago, as a strategy to try to stop their own emotional pain.
DEALING WITH CONTRADICTIONS
Since most people who have experienced a negative childhood hold most, if not all, of the assumptions that head each chapter of this book, a compounding effect can occur, whereby holding one assumption increases the propensity to hold another. This effect enables people to maintain a rational and consistent framework for seeing the world, themselves, and other people—at least until a significant, stressful life-event places additional strain upon the structure, rendering the framework inadequate, and usually leading to an emotional crisis.
There are a number of assumptions that compound the likelihood of becoming overattached to substances, objects, and activities. One is the assumption that other people are hostile. Holding this assumption will logically lead to a diminished trust in others and, often, to a search for support from alternative sources that appear more reliable. Alternative objects of attachment are attractive to people with low trust precisely because they reduce reliance upon other people.
Another important assumption that underlies the phenomenon of overattachment, particularly to substances, is the assumption of powerlessness (see Chapter Six). When people feel ineffectual in managing their distressing feelings, they will automatically reach for a substance to deaden their pain. These underlying assumptions compound and bind to each other, providing a coherent and consistent outlook.
This system of internal logic and coherence emerges as people build their brains, enabling them to see themselves as integrated. Humans are not very tolerant of internal contradictions (sometimes called cognitive dissonance). As a result, we face a psychological crisis when we develop too much contradiction. We usually cope with this in one of two ways. Commonly, we resolve the contradiction by reinstating our old assumptions in full. This solution involves the maintenance of the status quo, despite a minor contradictory hiccup in the system. Alternatively, we discover an obvious, new, and better but still coherent solution to the contradiction. This is known as a gestalt shift, when a large part of our whole world-view is quite suddenly turned upside down, and our previously held assumptions are overturned. The gestalt shift is usually accompanied by a sense of great insight and relief, as we immediately view the world through quite different and refreshed eyes.
If you hold many of the negative assumptions I describe in this book, you should aim to achieve a gestalt shift. You can do this through the behavioural changes that are outlined at the end of each chapter. Eventually, usually after several years, your behavioural changes will contradict your negative assumptions, putting them under stress until they suddenly flip over, and you will view the world, yourself, and others with much more optimism.
When trust in others is low, people can come to invest large amounts of trust and strong emotional attachment in alcohol, drugs, food, alienated sexual relations, collections, ideologies, exercise, gadgets, or other objects. As can be seen from some of the above cases, over time this can lead to an obvious overattachment to non-human things, and a diminished interest in authentic and close human relationships. This can result in the common situation in which people are asked to choose between a substance and a partner, and they decide they ‘need’ the substance more than the partner.
Which poison?
Which alternative is chosen to rely upon depends largely upon what choices are available within an individual’s environment. People usually choose alternatives from a selection consistent with their own internalised value systems, so that their sense of selfhood is maintained. For example, people raised within a strict religious and teetotalling background have two basic choices available to them. Those who have internalised their religious framework would be less likely to opt for an alcohol or illicit-drug alternative and more likely to choose an overattachment to collections, ideologies, exercise, or other objects. On the other hand, those who have rejected the religious framework, who have formed themselves in opposition to its value system, would be more likely to choose a less conventional alternative that flies in the face of religious values.
The overuse of both illicit and prescribed drugs, and alcohol, is widespread. The attachment to such substances provides comfort, often by chemical numbing of emotional pain and distress. This is usually achieved by rendering the brain so blunted that it is unable to respond properly to both emotional and other stimuli.
THE TROUBLE WITH PSYCHIATRIC DRUGS
Many psychiatric medications are thought to reduce emotional distress by inhibiting brain connections between the frontal cortex and the deeper brain structures. Unfortunately, many of the things that make us human are thought to arise from frontal cortex functions, such as our capacity for creative and divergent thought, flexible problem-solving, objective reasoning, spontaneous behaviour, initiative, complex planning, sustained attentive focus, context-dependent judgement, insight, and awareness of social mores. It is precisely these skills—which are blunted by sedative psychiatric medicines and other sedating substances—that are required for recovery.
To make matters worse, when people assume that they can’t trust themselves and that they are powerless, they seek a magic bullet to immediately do the job for them. These people often want a prescribed pill to fix them, because they believe at some level they are not capable of making the necessary changes to their own behaviour in order to ensure their own recovery. Relatives and close friends sometimes apply pressure on them to seek prescriptive medications, partly because they might also lack confidence in their own capacity to help deal with difficult symptoms. Of course, this is a fallacy: almost all of us are capable of correcting our problem behaviours and achieving the results we want in our lives, as long as we are dedicated to personal change and do not take substances that hinder this process.
Since patients and relatives are often deeply unconfident about their own expertise in regard to recovery, many doctors reinforce the helplessness myth and prescribe medications as the treatment of choice. This is at least partly because psychiatrists have generally been trained in the treatment and management of organic disease during their medical undergraduate years, and it is easy to apply unquestioningly the same ‘pathology’ framework to emotional difficulties without sufficient evidence for doing so. Patients who lack confidence in their own judgements are susceptible to the view that they have a pathological condition, namely a chemical imbalance, which requires chemical rebalancing by means of prescribed medicines.
I want to make it clear that I am not morally ‘anti-drug’ or opposed to the possibility that prescribed medicines could offer benefits to our mental states in the future. But we would need to know much more about the specific interactions between fear-exacerbating behaviours and the effects of prolonged stress on our biochemical and genetic makeup than we do at present. While our knowledge is progressing steadily in these areas, at this stage it remains, at best, rudimentary (see below). Until we have much more precise information, it seems irresponsible to be deliberately interfering with what appear to be normal neural processes in the brains of millions of people.
The bottom line is that, in my clinical experience of over two decades of working in psychiatric units and in private practice, I have never seen even one person recover through medication. Some people initially report feeling less distressed, somewhat numbed, or more euphoric; but they often become terrified to reduce or stop their medicines, remaining permanently medicated and unable to stand on their own feet. These people, hooked on the idea of their brain abnormality, are often resistant to changing their problematic behaviours which are so obviously leading them back into perpetual crises. For them, recovery does not occur in any meaningful sense. On the other hand, I have seen many hundreds of people become significantly and alarmingly worse once they started taking psychiatric medications.
The ‘chemical imbalance’ hypothesis
This section is about some biochemical aspects of the brain. As it is somewhat technical, you might want to read it over several times, or move directly to the section in this chapter entitled ‘You need an alert brain’. I have included this information because I believe it is important for you to be informed and active in your own recovery. This means understanding some of the reasoning behind the administration of medicines, and not just handing over responsibility for important decisions to health professionals.
Many people repeat the rhetoric that anxiety and depression are caused by the imbalance of a chemical called serotonin within the brain. Although the theory is widely embraced by health professionals and drug companies alike, it might surprise you to know that the evidence for it is neither reliable nor conclusive.
At this stage, not much is known about how the brain works. We do know that brain cells (neurons) communicate with each other by means of electrical impulses moving along the nerve fibres, which are tentacle-like extensions protruding from the cell bodies. These impulses can be helped to cross small gaps between neurons (called synapses) by chemical neurotransmitters. Serotonin is a neurotransmitter. We do not know how many neurotransmitters are at work in our brains, but there are probably in excess of one hundred. At this stage, the most studied of them are dopamine, acetylcholine, serotonin, and adrenalin.
These neurotransmitters act as messengers: they are released by the first neuron (pre-synaptic) into the gap, whereupon they must then connect to receptors on the second neuron (post-synaptic), making the second neuron ‘fire’ its electrical potential. These electrical and chemical processes continue until the impulse is inhibited. Communication between the neurons will be either facilitated or inhibited at the synapses. Once neurotransmitters have assisted conduction across the synapses they are taken back (a process known as re-uptake) into the pre-synaptic nerve, where they are stored until they are required again. Neurons within the brain are named according to which transmitter chemical they produce and use. Some nerve cells use serotonin, and are called serotonergic nerves; others use dopamine, and are called dopaminergic nerves; still others use adrenalin or noradrenalin, and are called adrenergic nerves.
The biopsychiatric serotonin-imbalance theory is based upon the notion that serotonin facilitation becomes slowed or sluggish, resulting in reduced communication between neurons. It is assumed that insufficient serotonin is produced or released into synapses, resulting in depression and anxiety. This deficiency is almost always assumed by biopsychiatrists to arise from abnormal gene function, although no abnormal gene has yet been identified in this assumed process.
Important advances have occurred in our understanding of normal learning processes. We now know that learned fear is dependent upon genes being switched on so that protein synthesis can result in the building of more synaptic connections. In this way, the normal process of learning is materially observable in the brain through synaptic growth and density. However, learned fear does not appear to result from any abnormal gene. Instead, long-term memory storage of fear (so that it becomes learned) seems to be directly induced by exposure to environmental insult. For example, when animals are exposed to repeated electric shocks in the environment, specific protein kinase enzymes are imported into the cell nucleus and act upon the DNA, switching on a cascade of gene expression that results in learned fear that can be observed through measurable synaptic strengthening. It is the repeated environmental insult that initiates the normal gene to become activated.1
Another important problem with the biopsychiatric theory is that imbalances in serotonin have not been directly demonstrated in the brains of psychiatric patients. Nearly all studies test metabolites (breakdown products in the chemical reactions) of serotonin in the spinal fluid or urine (which may or may not correlate with brain serotonin levels). But even these studies are inconclusive, with many studies finding no differences in levels of metabolites between controls and patient groups.2 However, administration of ‘treatment’ medications that block or delay the re-uptake of neurotransmitter substances would be expected to create a biochemical imbalance in the brains of patients.
Even if a biochemical imbalance of insufficient serotonin could be established, it would be poor science to assume that the cause arises from an underlying brain pathology. Psychiatric patients are often assumed to have brain pathologies and defects—when there is little data to support this conclusion—which label and disempower them at a time when they are distressed and vulnerable. Any such imbalance could just as easily come about as a normal compensatory response to a serious life crisis. In other words, external stressors could lead to normal biochemical changes (within the context of continuing stress) as the brain tries to deal with the environmental insult. It is pseudo-science when the cause–effect is assumed—without evidence—to be one-way.
Although no biochemical imbalance has ever been unequivocally established in biopsychiatry (despite millions of dollars having been spent in this pursuit), it is unlikely that the discovery of an imbalance per se would shed much light on the problem of anxiety or depression anyway. This is not an argument against scientific progress. Clearly, we need a strong biological and material understanding of the brain, and I am a keen advocate of progressive scientific research as long as the science is good. Instead, I am arguing about a fundamental error of logic within the current biopsychiatric paradigm.
To make this clearer, picture an improbable situation in the future, where we had the entire genetic and descriptive biological aspects of the brain mapped. Would we be any further in our understanding of anxiety and depression? The answer has to be in the negative. This is because we ultimately need to understand the context in which these difficulties arise in order to understand them. We have to know more about why some people are more exposed to environmental trauma than others, and how to reduce that damaging exposure. We must learn about how people typically respond to these assaults and how their behaviours then interact with their mental state (or mind). Biopsychiatry tries to reduce and solve this mind–brain problem by eliminating the mind from the problem. This will never help achieve our goal of understanding ourselves, because humans are mindful. This means that any biological finding is meaningless if it is not connected to a real-life concern about the human mind. If there were no distress of mind in anxiety or depression we would not even bother researching it. It is precisely because people feel distress in their minds that the mind cannot be ignored in the scientific pursuit of knowledge.
Despite the lack of evidence for the serotonin-imbalance theory, numerous anti-depression and anti-anxiety drugs have been released onto the market to deliberately alter the brain serotonin levels in those who take them. These medicines are called selective serotonin re-uptake inhibitors (SSRIs), with some of the common ones being Prozac, Luvox, Cipramil, Aropax and Zoloft. These drugs are thought to inhibit the re-uptake of serotonin, prolonging the presence of serotonin within the synapses, thereby stimulating neural communication. Yet anti-depressants thought to impact on the adrenergic system seem not to appreciatively differ in their clinical efficacy, casting further doubt on the simplistic serotonin-imbalance theory.
Some drug studies have found reductions in anxiety and depressive symptoms following administration of SSRIs,3 but there could be a number of reasons for this finding. Most clinical trials conducted in order to get SSRIs released onto the market have only lasted for four to six weeks, which is not sufficient time to properly evaluate their effects. Many of these trials also allowed patients to take other sedative or calming medicines while the trials were being conducted, thereby completely confounding the results, and masking probable agitation effects. This is especially relevant because a number of researchers have argued that SSRIs have an amphetamine or ‘speed’-like effect that is inclined to elevate mood and, when taken for prolonged periods of time, would be expected to carry the same risks as other amphetamines—such as sweats, mental agitation, obsessions, nightmares, poor judgement, impulsive behaviour, speech pressure as a result of ‘racing’ thoughts, irrational euphoria, mania, and even psychosis. Although some of these symptoms are relatively unusual, they have all been observed following the commencement of SSRIs.4
In my view, many of the clinical trials to test SSRIs have not been sufficiently rigorous in their research methods. Many clinical drug trials confound treatment groups by combining psychological therapy with drugs, instead of testing these groups separately. These groups are often not separated in clinical trials because the drug effects on their own are frequently statistically ‘non-significant’ without the boosting effects obtained by the psychological therapy. Indeed, one of the rare large-scale research projects, which examined nineteen double-blind clinical trials, covering more than 2000 patients, found that most (75 per cent) of the treatment effect in the ‘drug’ condition was a placebo effect.5 Often in trials, potent psychiatric drugs, including anti-psychotics, anti-depressants, and anti-anxiety medicines, have been shown to perform only marginally better than a placebo (sugar pill), and often they have performed worse.6
However, finding proper double-blind studies is difficult. Many studies of SSRIs have failed to impose proper double-blind procedures and to use control groups for comparison purposes. Other studies ‘drop’ patients who do not conform to expectations, with one United States Food and Drug Administration study being left with a sample of only eleven patients.7 From these poorly executed clinical trials, it is difficult to determine whether SSRIs work at all.
If by some chance SSRIs do work, it is not known how. The serotonergic system affected by SSRIs is the most widespread of any neurotransmitter system within the central nervous system. Any significant alterations to the serotonergic system produce many non-specific brain effects. Moreover, SSRIs have been shown to indirectly alter other brain systems, making the claim for their ‘specific’ effects on serotonin completely unfounded. For example, the administration of SSRIs indirectly stimulates the adrenergic system, altering the number of adrenergic receptors in the brain and activating stimulant responses. SSRIs also produce effects on the dopamine system. In clinical practice I have seen many people (particularly children) become extremely mentally agitated on SSRIs, and their anxiety symptoms become worse. Since SSRIs affect so many brain systems with direct and indirect results, their mode of action remains speculative.
It has been argued that SSRIs increase serotonergic activity by preventing the re-uptake of serotonin from the synaptic gap. The need to retain serotonin for prolonged periods within the synapse implies that it is a deficiency of serotonin that is causing the anxiety problems. This deficiency view has not been substantiated in research. In fact, it stands in stark contrast to the findings of Eric Kandel,8 a highly respected molecular biologist who won the Nobel Prize for his decades of work unravelling the nervous system of a marine snail. Kandel has developed a model of chronic anxiety that he claims is similar in humans and other animals capable of learning, which involves a long process of biological events that are highly complex, and that ultimately culminate in excessive serotonin pulses causing chronic anxiety. According to this model, SSRIs would be expected to exacerbate anxiety symptoms—a response which is often observed in clinical practice.
With these contrasting perspectives, it is unclear whether anxiety patients suffer from a deficiency or an excess of serotonin; whether there is a dysfunction in the interaction between the serotonergic system and various other biochemical systems within the brain; a combination of these; or none of the above. Even apart from the fact that it is an unsubstantiated theory, there is a further basic problem with the serotonin-imbalance theory: medicines take only a brief time (about six hours) for maximum concentrations in the blood to be achieved, and yet it takes about four weeks for an effect to be noted following commencement of the drug. This delay makes the drug action more than a little speculative. One possibility is that, after weeks of drug administration, the brain attempts to return itself to normal and to counteract the excessive serotonin by taking drastic measures, perhaps damaging itself in the process.
All of this leads me to one of my main objections to the widespread use of SSRIs. It is simply not known whether they can cause permanent damage to the brain. Several studies have found that post-synaptic receptors down-regulate and slough off, in response to an excessive accumulation of serotonin within the neural synapse. Losses as high as 60 per cent can be detected in certain important brain regions, and the net efficacy of neurotransmission is reduced.9 The reduction in receptor density is presumably the brain’s way of counteracting or minimising the overconductive effect of the drug. Alarmingly, these receptors had not regrown a couple of months after the drug was withdrawn. To my knowledge, longer time frames have not yet been tested. But if post-synaptic receptors have not re-established themselves after a couple of months, this is a real cause for concern that they may never regrow. Where this damage is sufficiently widespread, it could conceivably interfere with neural transmission and brain function permanently. Even if people taking SSRIs enjoy their euphoric effects, it seems irresponsible to market these medicines without much more rigorous testing.
Finally, it must be acknowledged that pharmaceutical companies have an enormous economic interest in research results and in maintaining relationships with medical professionals. For example, the American Psychiatric Association is widely known to receive millions of dollars of financial support each year from drug companies. ‘Gifts’ to medical professionals are often forthcoming. From my own experience of working in hospitals, I know that lavish drug-company lunches are frequently held to promote specific products and good relationships between health professionals and pharmaceutical companies. At present, many clinical drug trials are funded and sponsored by pharmaceutical companies who have a clear interest in the findings. Often, findings from clinical trials are not readily available, and efforts to obtain these results are met with strong resistance. The vested commercial interest in research results greatly increases the need for independent scholarship.
Medications can lead to serious problems of addiction
Apart from the lack of evidence for the serotonin-imbalance theory and the medications arising from it, there are other good reasons why people might decide not to take any medications to deal with their psychological distress. One compelling reason is that many of those medications can be addictive, despite doctors often assuring patients that they will not become dependent. This is particularly the case with the benzodiazepines (such as Valium, Serepax, Ativan, Temazepam, or Xanax) that are often used in the treatment of sleep problems and anxiety. These medicines are often given in combination with SSRIs in an attempt to counteract the agitation effects. Benzodiazepines are very habit-forming, with dependency usually occurring after only a few weeks of consistent administration.
Benzodiazepines create such strong physical dependency that, if people want to stop taking them, they require very slow withdrawal. Where withdrawal is not sufficiently slow, death can occur from continual epileptic seizures. These seizures occur as a result of brain agitation or the ‘rebound effect’ that follows from having had a highly chemically sedated brain and then removing the chemical restraint. As with any sedating substance, withdrawal from prescribed substances should always occur, ironically, under medical supervision. Withdrawal can sometimes take up to a year (or more) to complete the process. Physical dependency on medications can severely hinder recovery. Addiction can just create another, serious, and continuing problem on top of the original one.
Apart from SSRIs, it is worth being aware that most medications for psychological distress act as central nervous system depressants, leading to brain sedation. Excessive dosage can cause mental dullness, slurred speech, impaired co-ordination, intellectual deficits, coma, and death. These ‘slowing’ medicines include some anti-depressants, anti-psychotics, anti-anxiety medications, and medications for sleep difficulties. Many of these medications essentially work by sedating and thereby impairing the function of the brain, until the brain loses its responsiveness to such an extent that the distressing symptoms, along with other brain functions, are temporarily suppressed. This sedation tends to lack specificity and acts on the brain globally, blunting brain function and intellect as a whole. Not only this but, once the medication effects start to wear off several hours later, the mental agitation tends to recur with a vengeance (known as the ‘rebound effect’). This increases the perceived need to take the next dose, keeping patients on the ‘pill dependency’ merry-go-round.
YOU NEED AN ALERT BRAIN
As I have discussed, psychological crises tend to occur following significant stressful life-events when additional strain is placed upon an individual. In my view, impaired brain function is the last thing people need at a time when they specifically have to find new, innovative solutions to a life crisis. To find your way out of such a crisis you need every scrap of your intelligence, and indeed this is exactly when you need to build more emotional and intellectual intelligence. There seems little point in blunting your brain function through medication, even if it provides some temporary relief, if it is going to impair your capacity to find the very solutions that would allow you to recover properly. Instead, treat your symptoms as a wake-up call: they are telling you that you need better, more effective, and more sophisticated life-strategies.
If you blot out your brain by taking more and more pills or substances, and do not correct the behavioural patterns that are causing you distress, you will never address the cause. Indeed, taking medications rather than addressing the cause can lead to long-term dysfunction. You might even find yourself in the revolving-door syndrome, rotating in and out of psychiatric units and hospitals. As time progresses, it is easy to start seeing yourself as a crippled, dependent human being who needs drugs just to barely function.
Let yourself experience your distress
It is important to remember that when you have experienced a difficult childhood you are often deeply afraid of your own distressing feelings. You might worry that you will not be able to stop these feelings once they start. As a child, your distressing feelings may have felt overwhelming, and you learned a strategy of pushing them away in order to cope. As an adult you may still be using the same avoidance strategy because you are still afraid that the distressing feelings will overwhelm you and push you further down into a pit of despair. You may feel powerless to stop this process.
From this perspective, it is logical and consistent behaviour to reach for a pill to stop the pain. But taking pills and other mind-numbing substances is, in reality, one of your biggest barriers, because it is largely the avoidance of distress that is preventing your recovery. To recover, you must let yourself experience distressing feelings, so that you can resolve those feelings and learn that you can deal with them. Now, as an adult, you can cope with and process extremely distressing emotions.
Stop teaching yourself that you cannot cope: you can!
Every time you take a pill you are reinforcing the underlying assumption that you cannot trust yourself to get through a crisis, and that you need to rely upon and invest your trust in a substance rather than in yourself. Every time you take a pill, you are reinforcing the underlying assumption that you are powerless to deal with difficulty. Taking pills to numb the pain reinforces your belief that you are a victim who is helpless in the face of distressing feelings. You need to stop this cycle. You must get back in charge. You are not helpless. As intelligent beings, we all have distressing feelings: they are a normal part of life. You just have to get used to them.
Many people believe, wrongly, that recovery means an absence of distressing emotions. They want the fear and distress to go away completely. They want it stopped now! This is called distress intolerance, and nearly all people who have experienced a difficult childhood feel this way. In reality, recovery means no longer being afraid of distressing emotions that we all experience. In other words, a central feature of recovery is realising that you can tolerate distressing feelings. Of course, the less afraid you are of these emotions, the more they go away. The important point is that you start to realise that you don’t need to be afraid of the feelings. Instead, as I have said, see them as a wake-up call, guiding you to find better life-strategies. As you develop these better strategies, the distressing feelings will gradually reduce on their own.
Realise that other drugs are no better
In a nutshell, many people deteriorate by taking prescribed psychiatric medications. Not only are these medicines a major barrier to recovery, but often they worsen the patient’s prognosis. As well, apart from the hazards of prescribed medication, other mind-numbing substances such as alcohol or marijuana are no better for you. Indeed, alcohol is a central nervous system depressant and uses the same neuro-receptors as benzodiazepines, compounding the effects if used simultaneously. Some doctors claim that when patients ‘self-medicate’ with, say, alcohol, it is preferable to place them on prescribed medication instead. In my view, this rationalisation is wrong. Such patients need to be given strategies to get off the alcohol and simultaneously to be educated about why no substances offer them the best chance of recovery.
Prolonged or intense use of mind-altering drugs, such as marijuana or LSD, is strongly associated with dissociative thinking patterns, and can lead to psychotic episodes. Believe me when I tell you that, if there is one thing in life you want to prevent, it is the development of a psychosis. A psychosis is a type of break with reality, when people experience perceptual disturbances such as hearing voices that are not there, or seeing things that are not there, or perceiving conspiracies or plots against them that are not true. When people have major perceptual disturbances, they respond very inappropriately in public. It can lead to peculiar behaviour, such as the kind we have all witnessed on public transport, when a person might speak or yell back to a vacant seat, ‘I did not say that. Go away and leave me alone!’ This type of perceptual disturbance is very serious, and it will usually severely impair a person’s capacity to function independently in the world.
Amphetamines or ‘speed’ are also linked to agitated thinking patterns, erratic behaviour, paranoia, and psychotic breaks. Although people taking speed often feel euphoric and believe themselves to be ‘bulletproof’, this could not be further from the truth. In fact, people on speed typically make poor judgements, lack insight, have racing thoughts and speech pressure, and show signs of confusion and agitation. Extended use of amphetamines renders the brain highly vulnerable to psychotic fracture.
MOIRA
When I met Moira I was working in a psychiatric unit. One day, a fit and healthy-looking lawyer in her early thirties arrived at the unit accompanied by her husband. Moira had never set foot in a psychiatric unit before; there had never been the need. On the day she first arrived, she was highly anxious and tearful. She had not been sleeping well for the past several weeks, and she had been experiencing frequent panic attacks. When Moira was assessed in interview, she explained that a couple of months previously her brother, to whom she had been very close, had been diagnosed with a terminal degenerative disease. This was a huge shock to everyone in the family. Moira had become very distressed about her brother, crying and grieving about his illness and the anticipated loss of their relationship.
Not long after, she started to worry that she might also develop the disease. Moira stopped seeing or talking to her brother. The worry was repetitive, and would not go away. Moira lost confidence in herself. She did not think it was fair to burden her husband with her feelings, so she tried to refrain from talking. The week before her arrival at the unit, Moira had become so upset that she had quit her job with the law firm, deciding that she needed more time to herself to help her cope.
Leaving her job did not help Moira. It was not a good strategy; by leaving her job, she had lost something else besides her brother that was highly significant in her life. Her career had obviously played a pivotal role in maintaining her self-esteem. Without her job, her mood deteriorated and her anxiety soared. Moira became terrified, thinking something serious was wrong with her. She became so scared she asked her husband to take her to a hospital.
It was at this point, in my view, that Moira should have been given a grief-crisis therapy session, with a few more sessions booked over the following couple of days or weeks. Then she could have gone home, with some clear explanations about the very normal responses to grief that she was experiencing. Clearly, Moira had been a very high-functioning person before her brother’s diagnosis. She was just going through a significant crisis. She needed to be encouraged to go back to work, but to work fewer hours, giving herself time with her sadness. She needed to be encouraged to write about her feelings and to talk about them with her husband, with whom she had a strong relationship. Moira needed encouragement to talk with her brother, and have the risks of avoidance explained to her. She needed to understand her symptoms and the fact that they would gradually resolve, and to realise that losing confidence is just a normal part of grief. Instead, Moira was admitted into the psychiatric unit.
Because Moira had never experienced these frightening and intense emotions before, she thought that maybe she was going mad. Madness was something foreign; she had no idea what to do about it, so she quite reasonably took the advice of the medical professionals. Rather than deal with the cause of Moira’s distress, the biopsychiatrists prescribed medication to deaden it. She was given benzodiazepine medication to begin with, three times a day and whenever she needed it.
Moira thought she was there to get better. So when the pills started to wear off after a few hours and her anxiety came back stronger than before, she knew she wasn’t yet fixed. Moira would ask the staff for more doses, to try to get rid of the anxiety again. Very soon Moira was taking very large doses, and she was becoming increasingly agitated when the medication started to wear off. She started to scratch her skin until it bled when she became agitated, because of the drug ‘rebound effect’.
Moira was now prescribed large doses of an anti-psychotic medication and additional sleeping pills. The reasoning among the biopsychiatrists was that she was slipping towards a psychotic depression, and that her self-mutilation and vegetative state were evidence of her deterioration. During conversations with Moira, I found no evidence of psychotic features. There were no loose mental associations or ‘word salads’, no paranoid ideas, no magical thinking, no delusions or perceptual disturbances. But Moira did seem disoriented, confused, and so overly sedated that she was barely functioning.
Over the next few weeks Moira’s thinking became markedly slowed and confused; she gained excessive body weight in response to the slowing effects of the medication; and she became insensitive to social mores. In short, she started to look dull, stupefied, and brain damaged. She became estranged from her husband; he could no longer relate to her, nor she to him. Even if she had wanted to go back to work, the concept of which she could not even comprehend by this time, she would not have functioned adequately.
I was frustrated by the treatment she was receiving, which I thought was ridiculous and damaging, and highly irresponsible. I talked to the biopsychiatrists and other staff. Everyone seemed to agree that she would have deteriorated on her own. I objected that I had seen people much more distressed than she had been on admission get over their grief without incident.
In a dilemma, I decided to talk with Moira. I explained that there were other ways for her to get over her crisis apart from taking sedatives. I tried to impress on her the importance of trying to take back control over her own life. Unfortunately, less than twenty minutes after the conversation Moira had lost all memory of it.
I stopped working at the unit, and decided to focus on my own private practice with a view to keeping people out of psychiatric units in the first place. Since then I have worked with some extremely distressed people, far more so than Moira. Yet I have never admitted anyone to a psychiatric unit, I have never had a patient suicide, and I have never had anyone continue, more than briefly, with self-harming behaviours.
After I left the unit, I heard that Moira was given a course of electro-convulsive therapy, presumably to electrically ‘jolt’ her out of the stupor the medications had almost certainly caused. If Moira was anything like she was when I last saw her, she would have been so confused and disoriented that she would not have had a clue what she was signing up for.
One of the most sobering aspects of Moira’s case was that her deterioration from a high-functioning and competent lawyer who was experiencing a life crisis to a chronic psychiatric patient took less than five weeks. It is important to realise that this is not an isolated case; I have seen many similar cases within the psychiatric system.
HOW TO CHANGE
The main thing you can learn from the case study of Moira is how not to hand over control of your life, and especially your brain, to someone else. Once you are caught in the revolving doors of the psychiatric system, you will usually be so medicated that you will have lost the ability to think clearly. You may not even be able to think clearly enough to realise that you cannot think clearly. Not only this, but you may well have a physical addiction, and therefore may have been drawn into senselessly continuing the medication just because without it you feel agitated. It is easy when you are not thinking really clearly to attribute this increased agitation, caused by the rebound effect of medication, to a worsening of your condition.
In short, my message is that prevention of this situation is easier than trying to correct it after it has already happened. From experience, I can assure you that it is very difficult to pull people back from the excessive-medication syndrome. It is also very difficult to bring people back from full psychotic fracture following excessive use of marijuana, LSD, or speed. Some people recover, and some people are not able to. It is definitely better to prevent psychosis than to try to deal with it once it has developed with full, florid intensity.
There are many clear psychological indicators that usually occur well in advance of a psychotic episode. In my work, I often recognise the early and middle signs of a developing psychosis when people first come to see me. So far, as long as the fracture is not a full one, I have always been able to pull people back from further progress into psychosis. There are many opportunities to foresee and correct the thought derailment, loosening of associations, and delusional themes before a full break with reality occurs. In my experience, psychotic breaks tend to occur when these indicators are repeatedly ignored over time. If you are concerned about psychosis, obtain professional assistance, but do not assume that medication is the only alternative to it. It is not.
For you to be able to prevent a serious psychological deterioration in times of crisis, the main thing you need to know about are the pitfalls I have outlined. Employing substances to deaden your distress is one of the main pitfalls you should avoid. Instead, try to become self-reliant in sorting out your difficulties:
• Part of this self-reliance is about learning that you can tolerate distress without needing to avoid it in any way. You learn this by just letting yourself sit with your distress, whatever it may be. If you need some help with this, watch films or read books or listen to music that evoke the emotions you need to feel.
• Self-reliance is also about practising being confident enough in yourself to ask other people for help when you need it. Ask for care from your close friends. Being nurtured is important at a time of crisis. Massage, cuddling, and touch are helpful.
• Ask for help in talking things through. Two minds are often better than one. Talking helps you learn to trust and become close to others. Talking will help you to put unresolved feelings to rest, and it will also help you get clarity and find viable solutions.
These adaptive approach-strategies simply require practice and changing your behaviour.
It is also important to remember that there is no need to be afraid of the symptoms we all experience at a time of severe crisis. It is normal, following a significant crisis, to experience severe sleep disturbance, loss of appetite, high levels of fear and anxiety, loss of confidence, tearfulness, mood swings, searching behaviour, and repetitive thoughts. Do not be afraid of these symptoms, even though they feel very distressing. Instead, accept the symptoms, and use them as an indicator that you could do with some better life-strategies to help resolve your current crisis. As long as you adopt this approach and do not avoid the symptoms, they will lessen and resolve over time. If you are struggling and the process seems too difficult, obtain professional assistance. But do not hand over control to someone else; you need to stay in charge.
Reduce other overattachments
Overattachment to other substances and activities can also stand in the way of recovery. These behaviours tend to promote and reinforce withdrawal strategies, rather than encourage approach strategies.
Overeating can also become a self-reinforcing cycle, in which avoidance is a key feature. The focus on eating is a way to avoid having to deal with other emotional difficulties. The cycle usually goes as follows. There is temporary relief and comfort provided by eating that allows you to briefly avoid distress. Often, ‘feel good’ brain endorphins are released when you eat particularly high-calorie foods such as chocolate. When the overeating is finished, however, feelings of guilt and other self-recriminating emotions occur. Intolerance of these distressing emotions usually leads you to re-indulge in the overeating in order to avoid the emotional distress caused by the initial overeating.
Sometimes, the cycle can be slightly more complicated. The first part is the same. Overeating allows you to avoid distressing emotions, but it still leads to later feelings of guilt and shame. Then your intolerance of the negative emotions of guilt and shame can lead to over-restrictive and inflexible eating behaviours. Rather than tolerate the feelings of guilt and self-recrimination, you might become excessively self-punishing and restrictive. For example, you might decide that every fattening food is off the menu forever. This over-restriction often cannot be maintained, as it is simply too unforgiving and harsh. It tends to lead to periodic episodes of bingeing and starving, thereby maintaining the cycle.
As the time spent on the overeating cycle is expanded, you have less time or perceived need to maintain relationships. This leads to an increased withdrawal from others. Needless to say, this prevents recovery, since you never allow yourself to learn that you can tolerate the feelings of distress without either overeating or starving. Neither does it allow you to learn that the comfort received from other people is vastly superior to that gained from overindulgence in food. You remain locked in your own withdrawn world.
In this predicament, you should only eat when you are physically hungry. A wide variety of foods must be eaten for good health, and creating rigid categories of ‘good’ or ‘bad’ foods is not useful. Listen to your body: eat what it needs. When you are psychologically ‘hungry’, address the cause, and approach a close friend or partner for nurture and conversation.
When you are successful at maintaining an excessive dietary restriction, it is usually because you have gradually developed a phobia about becoming fat, as in anorexia nervosa. That is, the idea of becoming fat triggers disproportionately high levels of anxiety. You then try to avoid nearly all food in an attempt to avoid your feelings of anxiety and distress associated with food intake and the notion of becoming fat. The anxiety never gets resolved because it is constantly avoided. In reality, you prevent yourself from learning that you could cope with the distress of having a normal body weight, and indeed that the distress would disappear over time.
Overattachment to other activities, gadgets, and ideologies can also be problematic. This is not to say that the attachment itself is problematic, but rather it is the overattachment aspect that often occurs at the expense of developing emotional connections with other people. This means that you invest too much time and mental energy in the activity relative to other aspects of your life. You have an excessive and disproportionate amount of emotion attached to the activity, and extreme reluctance to even consider reducing it or giving it up. When you give up the activity, you may often experience huge outpourings of sadness and other feelings. In a similar way to those who rely on alcohol and mind-numbing substances, you have avoided past intense emotions by maintaining an overattachment to the activity, gadget, or ideology.
Overattachment can occur in relation to almost anything. It may be exercising, making or saving money, gambling, computer games, computer hacking, political dogma, religious fixations, collecting objects, alienated sexual relations, shoplifting, sporting fixations, cross-dressing, excessively masculine or feminine roles, electronic gadgetry, and so on. Often, the overattachment is rigid, and not responsive or open to other influences. For example, some people may be so attached to the notion of cross-dressing that they will continue with it, despite knowing that to do so risks causing a marriage break-up. Others may be so overattached to collecting objects that they go on with the activity even after being reduced to dysfunctional and overcrowded living conditions. Or, they may be so attached to the notion of exercise that acute or chronic injury will not stop them. Often the behaviour is so important to them that it will continue, even when it is clearly self-sabotaging and harmful.
One of the best ways to reduce such overattachments is to build other, serious emotional attachments. You may not want to lose the overattachment altogether, but you should reduce it to a level where it does not limit your capacity to build other, more meaningful, connections.
The most meaningful attachments are probably best achieved with other people. Choose people you respect and want to become attached to, and try to persevere in building trust. To build a close, meaningful relationship takes time and skill. You should expect to take at least a year to form the basis of a trusting relationship with another person.
Persevere at learning the skills involved in building close relationships. Ironically, one of the most important skills is perseverance. You must struggle your way through misunderstandings, outright conflicts, insecurities, vulnerability, tolerance, openness, and forgiveness on your way to creating an authentic closeness. You need to find your own pathway in building closeness. Forming a truly attached relationship is not easy but, if you keep at it until you learn the skills, you can make it happen. If obstacles seem insurmountable, do some brief relationship work with a therapist to give you some ideas and help you build more skills.
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