So he listened, and I told him how I felt as if I could die at any time; it wasn’t that I wanted to, but all the same it seemed so implausible that I should keep surviving, day after day, when everywhere I went there were a hundred stupid little senseless deaths lying about, waiting for me to trip over them. Every time I crossed the road, I said, I wondered how I’d made it to the other side intact. Often when I stood at a pelican crossing, I said, I was aware of how easy it would be, in a moment of absent-mindedness, say, to step out at the wrong time and get fatally squelched by a juggernaut.
‘Do you think there might be some suicidal ideation behind that thought?’ he asked me.
‘It would make sense,’ I said, ‘though I’m not aware of any conscious intent.’
I didn’t want to die, but I feared for my life. Many times a day I would feel some mute, destructive urge, in me but not of me, which it took all my energy to resist. I didn’t want death, but it – something, the death instinct, whatever it was – kept propelling me towards it. In June I noted these ‘[a]larming mental events – or in the brain? – urge to swallow glass penguin’. The glass penguin-swallowing obsession was quite possibly the most bizarre I’ve ever had, even more absurd than what if I can’t find my shoes? It started while I was wrapping up our ornaments in newspaper, ready to move to the house that was so much to my liking. The penguin was a tiny thing, only about an inch and a half long, if that, and rather less than an inch round. As I wrapped it, I found myself thinking about how small it was, that it was about the same size, maybe, as a liquorice torpedo. Then I had a mental image of the penguin in my mouth, followed by another of my giving in to an urge to swallow it, failing, and choking to death. Almost simultaneously, I had an impulse to put the penguin in my mouth right then, right there, and try to swallow it, just to prove to myself, because I needed to, that this wouldn’t necessarily kill me . . . Terrified, I smothered the innocent little penguin in newspaper, as quickly as I could, and shoved it down into the very bottom of the box I was packing. Even though I’d buried the penguin, the thought of it kept bobbing to the surface of my mind, again and again and again. When we unpacked at the new house, I made sure that Chris, not I, unpacked the penguin, and then insisted that he put it on the highest shelf he could find. I laughed about it at the time, but all the same that penguin scared me shitless. I almost named this book after it.
Early in September, one of the clinical psychologists in the department of cognitive and behavioural psychotherapies wrote to my GP to thank him for referring me. She mentioned that I was currently taking a break for a few months from my PhD, and commented that:
She obviously has very high standards, which she is well aware of. A lot of her thoughts centre around ‘should’ statements, in that she always feels that she should be doing more than she is. She also tends to compare herself to others a lot, although she tries not to. At times, when she is down she spends a lot of time crying. She is able to recognise the pattern of her thoughts and that they tend to centre around a fear of failure. Although she can look at these rationally at times, she told me that she has more belief in her negative thoughts.
It’s a very long letter, reminding me of how comprehensively I’d jabbered my heart out in the session. We were both very tired at the end of it.
Going back to the letter, the psychologist agrees that ‘she certainly does seem to have had episodes of depression in the past and that she is a generally anxious person, with a lot of her anxieties centred around a fear of death’. She describes me as ‘somewhat hypervigilant of dangers in her life’ and recommends cognitive behavioural therapy as a treatment which would provide ‘some strategies to help her break the cycle of rumination that she engages in’. She mentions that, although I have had ‘numerous treatments’ in the past, I have not yet had CBT, and that she believes this would provide ‘a very different treatment approach than she has previously experienced’, as it would focus on the ‘here and now’, rather than on my childhood and family history. Straight away, she offered me a different perspective on my mental health: it seemed to her, she said, that my primary problem was not depression as such, but anxiety.
That really threw me. I had so long thought of myself as ‘a depressive’: I’d read the books, written the poetry, listened to The Cure and bought the black T-shirt. I’d identified willingly with Sylvia Plath and Spike Milligan and Franz Kafka and all those other clever, gifted people whose depression had somehow seemed an integral part of their giftedness. As the doctor had said in his referral letter, I believed that ‘some of [my] talent might come from adversity’. You could make depression sound like a valid philosophical position if you chose – hadn’t Camus written of The Logic of Suicide? Depression even had that beautiful and noble-sounding synonym, melancholy. No, I’m not a bit down, I’m melancholy; I languish; alone in my brown study, I palely loiter. Coleridge, Shelley and Keats wrote odes to it. Every word on the ‘Meat is Murder’ lyric sheet justified it.
I understood depression to be an affliction, or at least as a state which lay outside the norm, but I had trouble seeing anxiety in those terms. From both my psychoanalytic and common-sense perspectives, anxiety was a normal, everyday human feeling; looked at from the perspective of common sense alone, it was trivial, and to be so bothered by such a trivial thing that I asked for treatment meant that I must be making a fuss about nothing. That I took the diagnosis as a put-down was partly the result of a certain intellectual – or maybe diagnostic – snobbery on my part, but I think it also had something to do with the poverty of our language when it comes to mental states, which means that we use the same word for both the mild, temporary tension you feel when you need to get back to work in ten minutes and you’re trying to get to the front of a checkout queue, and for that other kind of tension which, if not always with you, is never far away and makes you wonder if a person’s chest muscles really could squeeze her ribs so hard that they cave in and squelch her lungs into fishpaste. There’s something in the very phonology of the word ‘anxiety’ that’s too quiet, too polite to describe what that other kind of tension feels like: it’s a third-person word, a clinician’s word. The Unbearable Feeling is a much better term. That, or ‘terror’.
Let’s say I was suffering from a ‘melancholy/terror thing’: it’s so much more aesthetically appealing. Or feel free to stick with ‘depression’ and ‘anxiety’, if that’s what you prefer. Whatever you choose to call them, you’ll usually find them together.
The psychologist placed me on the waiting list for CBT. It was over a year long. She encouraged me to complain about it if I wanted to, and gave me a list of local private practitioners I might see in the meantime. I couldn’t face a year’s wait, and I had a little inheritance money left, so I phoned one of the people on the list, and by early September I was in his office, ready to start.
You’ll have heard of cognitive behavioural therapy: it’s very popular with the department of health, because it is, as Wikipedia puts it, ‘cost-effective’ and seen by many as ‘evidence and empiricism based’. It is often recommended, with or without medication, as a treatment for mild-to-moderate depression as well as for a variety of anxiety disorders, including OCD. If you are offered therapy on the NHS, it will most likely be some form of CBT, and most probably a short course of it – somewhere between six and ten sessions. The fact that it is administered, like antibiotics, in a set course means that health authorities can budget for it: we have x number of qualified therapists working y hours per week, and therefore we can provide z courses of therapy in any given financial year. That gives it a certain practical advantage over psychoanalysis and its sister psychodynamic therapies, which by their very nature are open-ended. Another advantage it has, at least from an administrative point of view, is that its effects can be measured with instruments that are regarded as valid and reliable tools for the job. Of the two concepts, validity is the harder to pin down: in this context, it would be reasonable to say that a valid instrument can be sho
wn to have measured what it set out to measure. For example, if excessive lethargy plus tearfulness equals depression, then an instrument that measures the degree of a patient’s lethargy, and of her tearfulness, is a valid tool for the diagnosis of depressive illness. To say that an instrument for psychological assessment is reliable is to state, among other things, that it would produce the same results with the same patient no matter who administered it.
This is in clear contrast to the knowledge a psychoanalyst has – or claims to have – of her patient’s condition, as this knowledge will be grounded in her relationship with her patient, in her experience of that relationship, and in her application of psychoanalytic theory to the insights gained from that experience. This theory, along with the body of recorded clinical knowledge which the analyst may use to inform the treatment, is, in itself, drawn from a hundred years’ experience of these private, unobserved, clinical encounters. I don’t think, myself, that this means that psychoanalytic theory has no explanatory value, or that psychoanalytic psychotherapies have no clinical use, but it does have the consequence that conventionally reliable evidence for psychoanalysis is in rather short supply. It is also worth remembering that the existence of the unconscious – in the psychoanalytic sense of the word – is hypothesized rather than proved. Neither the unconscious nor its workings can be directly observed. That doesn’t help either.
The aim of psychoanalysis, in its classical form, is nothing less than a fundamental rearrangement of the patient’s psyche, which is a tall order. On the other hand, the aim of behavioural therapy, in its classical form, is the modification of particular behaviours. Unlike the primitive processes of the unconscious, behaviour can be directly observed and precisely recorded: you can measure, for example, the number of minutes per hour a patient spends washing her hands, and if the aim of the treatment is to cut this down, you can measure her improvement in terms of minutes cut. Therefore, it’s evidence based, it’s empirically sound, and it’s cost-effective.
It doesn’t stop there, though. CBT is designed to improve mood as well as behaviour. This mood is measured using the valid and reliable instruments I mentioned earlier. The instruments which mainstream psychologists and psychiatrists use for both research and clinical purposes are structured clinical interviews, and self-administered questionnaires, or inventories. These inventories are identical in form to quantitative market research surveys: the patient is handed a list of statements, and is asked to mark the boxes next to them to show whether or not she agrees with them. Some inventories, like some market research surveys, also have a five-point scale next to each statement, so that the patient can indicate to a more precise extent how much she does or doesn’t agree. Each inventory is designed to measure that patient’s condition against a particular scale; when the completed inventory is handed back to the clinician or researcher who is making the assessment, he or she can then follow a set of precise instructions to convert the patient’s answers into a numerical score, check this score against the scale, and thereby get at least an initial sense of whether this patient’s OCD, for example, is absent, mild, moderate or severe.31 The scores are no substitute for clinical intuition and judgement, and most psychologists would not use them as such, but they are useful in so far as they can be measured at the beginning and end of a course of treatment, and the difference noted as a precise number. That’s a demonstrable result.
At my initial consultation with Ben, the CB therapist, I filled in three questionnaires, designed to measure, respectively, anxiety, depression and hopelessness. I came out as moderately anxious, moderately depressed, and moderately hopeless. The letter which Ben sent to my GP following the consultation, like the letter from the hospital psychologists, covers an immense amount of ground, and this time in smaller type. It takes in my hypochondria, my concerns about knives, my physical anxiety symptoms, my worry that I talked too much and said the wrong things when I ‘encountered people situationally’. Behaviourally, he mentions my skin picking, my reassurance seeking, my rumination and my avoidance, terms which are very familiar to me – and boring to you – by now, but which meant very little to me at the time. His impression was that the woman in front of him was ‘showing different symptoms of anxiety, focusing perhaps on mild hypochondriasis with possibly some obsessive compulsive symptoms where she ruminates’. I remember him asking me if I didn’t agree that I was a little bit obsessive. I did agree, but assumed he meant it in the general sense.
In the closing paragraphs, he outlines his plan of treatment.
My plan is to help her to understand the link between thinking, affect and behaviour with a view to helping her challenge automatic thinking, as well as using behavioural experiments to explore the risk issues. The more general issues around guilt may be explored through schema focus, which may be done later using Beck’s Early Model. Usual questionnaires will monitor progress.
As the methods of CBT – unlike those of psychoanalysis – are intended to be transparent to the patient, I have a copy of a diagram which, very handily, sets out that cognitive-affective-behaviour link.
To put the model into words, something happens which acts as a TRIGGER for a NEGATIVE AUTOMATIC THOUGHT which gives rise to certain unpleasant EMOTIONS which in turn give rise to correspondingly unpleasant PHYSICAL SYMPTOMS so that these three together – negative thoughts, negative emotions, nasty symptoms – prompt the individual to engage in certain BEHAVIOURS to try to deal with them all. This is expressed as a circle rather than a line, because these behaviours, while providing a certain amount of immediate relief from the cognitive, emotional and physical aspects of anxiety, are in the long run ineffective, as they do not enable the sufferer to do what she really needs to do to escape from the circle, which is to challenge the thoughts in the first place and to modify the behaviour accordingly. The model is probably best explained by example:
TRIGGER: I am waiting to cross a road. I look both ways and see that a car is turning into the road, about a hundred yards away.
NEGATIVE AUTOMATIC THOUGHT: If that speeds up on its way down the road and I’m halfway across and I fall over and can’t get up and the driver is talking on his mobile phone or something and doesn’t see me or is drunk perhaps, he might run me over and kill me.
EMOTIONS: Anxiety, fear.
PHYSICAL SYMPTOMS: Pulse speeds up, butterflies in the stomach, muscles tense.
BEHAVIOURS: I wait until the car has approached and passed, so that the road is completely clear before I cross.
The behaviour is the perfect strategy in the short term, because it lessens my anxiety and ensures that I’m still alive and intact on the other side of the road. It doesn’t help in the long term because I have failed to take the opportunity to cross earlier and to learn through experience, firstly, that I do not need to wait until the road is completely clear in both directions before I can cross it safely and secondly, and more importantly, that I can do something that makes me anxious and bear that anxiety. As I have not taken this opportunity, all those unhelpful thoughts, emotions, physical sensations and behaviours are free to reinforce each other in life as in diagrams.
In behavioural terms, the trigger – the sight of an approaching car – is a ‘stimulus’ to which I have become ‘sensitized’: I am paying it greater attention than it warrants, and as a consequence I am judging it to represent a bigger danger to me than any objective evidence might suggest it to be. This inflated perception of risk makes me anxious, and the anxiety only inflames the situation further. As Ben put it during one of our sessions, ‘The thought only seems true because it gives you anxiety and anxiety makes thoughts seem truer than they really are.’
The CBT approach is, in the first instance, to help the patient understand the nature of the problem, by explaining the cognitive-behavioural model, as I’ve tried to do, and then to work with the patient to figure out what her own problematic triggers, thoughts and behaviours might be. At the first session, Ben asked me to begin keeping a journal in which I
would record my negative automatic – or ‘hot’ – thoughts alongside the situations which had triggered them. When I came back with my first, long list, he began to help me see my habitual reactions in terms of the model, something I’ve tried to do here with the thought CAR – CROSSING – SQUELCH.
Once he was sure that I had understood how the model worked, Ben set me a series of tasks. The aim of these was to breach the vicious circle at its behavioural and cognitive points. On the cognitive side, I was to try to counter each ‘hot’ thought with a ‘fair and realistic thought’. So, if the hot thought were something like, ‘X hasn’t replied to my email because I’ve inadvertently upset her and now she hates me and will never speak to me again,’ I could counter it with, ‘If X hasn’t replied to my email so far, it is most likely nothing to do with me, but because she is away, too busy or too upset for some completely unrelated reason to answer it.’ These thought exercises were recorded on tables with the following headings: ‘Situation’, ‘Hot thought’, ‘Emotions %’, ‘Realistic thought’, ‘Emotions %’. Under the percentage headings I would record what CBT practitioners call ‘SUDs’, with SUD standing for Subjective Unit of Discomfort, a self-administered measurement of the intensity with which an individual feels any given negative emotion. If the thought that I have offended X and she hates me now makes me – by my subjective reckoning – 70 per cent anxious and 80 per cent sad, then the hope would be that, after thinking and writing the realistic thought, I might record myself as feeling merely 30 per cent anxious and 20 per cent sad, which would be, once again, a demonstrable result – or, at any rate, a result expressible as a percentage, which is a start. Personally, I’ve never liked SUDs: whenever I have to use them, I become horribly preoccupied with the question of whether I’m rating the intensity of my emotions accurately enough; it’s a bit of an unwelcome distraction.
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