Thoughts / depression

The decision making "golden rule"

One of my least good skills in life is decision-making.

I really admire people who seem capable of picking between options quickly. Those truly admirable people who can decide on a Sunday evening what they will eat for the entire week. How do they possibly know what they will feel like? Those amazing men and women who throw their clothes away if they haven’t worn them in six months. What if they need them later? What about the astonishing individuals who can spontaneously pick up a can of tomatoes from an entire shelf at the supermarket? Without even thinking twice about the other options?

This may sound a bit pedantic, but if we look at the root meanings of the word from the Latin verb it means ‘to cut’ or ‘to kill’. That’s right ‘decision’ shares this root with words like ‘incision’ and ‘homicide’. This makes perfect horrific sense to me. Making a decision often feels like I am going in for the kill.

I’ve always had a tendency to agonise over decisions. And at the moment, it’s not even all that bad. I’m actually pretty impressed with how it’s going. Whilst painful, its way less bloody then it was.

My anxious and depressive and obsessional nature has really made decision making one challenging experience for me.

Indecision can often stem from anxiety. Fear of making the wrong decision and suffering consequences or remorse can inhibit some of us. Worry about making a mistake and feeling guilty, remiss, exposed or ignorant is common. Sometimes we can be paralysed by a fear of hurting or alienating another.

My decision making capacity really hit the skids during my bouts of depression. It is in fact one of the cognitive symptoms that can accompany the feelings of helplessness and hopelessness and anhedonia (inability to experience pleasure) and lethargy and listlessness. The fog of depression often includes not being able to make even small, everyday decisions — much less big ones — because every option seems wrong, and we can feel paralysed. I found that following an episode of depression, indecisiveness was one of the symptoms that lingered longest. Possibly its persistence set up a self-perpetuating downward spiral. My perception was so skewed that I had been prevented from seeing clearly or taking action for so long that it felt impossible to take any positive action at all which only led to more inaction.

The other thing that can happen during recovery is that EVERYONE can constantly remind you of the golden decision making rule. The rule is - Never, ever make a major decision while you’re depressed.

This wasn’t all that difficult for me to follow. I was happy to let someone else decide what to have for dinner. I’d managed to avoid and deflect my way out of any conversations about the future for the past ten years. As a result, I do not have any assets.

However, I’ve known people who have made life-changing decisions because they think that the problem is related to something else. They’ve changed jobs, changed careers or even gone back to school.  They’ve left their relationships, marriages or started new ones. They figure that the reason they’re feeling so shit balls is that they’re in the wrong career or in the wrong field, or have the wrong partner.

Here’s the main problem with acting on this type of thinking when you’re depressed: depression can distort your reality. It affects our ability to perceive our life in any kind of positive light. It’s the opposite of rose-colored glasses or beer goggles, which make things look better and more attractive than they actually are. Everything that’s viewed through the distortion of depression is negatively affected by it and seems to be worse than it really is. Jobs aren’t satisfying; relationships are unworkable. Depression distortion can even send older people into nursing homes sooner, since they perceive their health as worsening more quickly than it really is.

What happens when you act on this dissatisfaction? Well, unless you’ve recovered from depression, all that happens is you find another career or partner, and sure as the sun rises in the east, eventually you’ll realize that you’re still unhappy. You’ve changed your situation, but chances are that the situation was not the problem; your depression is.

But I did have to make one pretty major decision. It didn’t feel like a single decision at the time, it felt more like I was giving in, or surrendering or accepting something as it was.

When I began to recover some years ago, I started with a single decision. It was really the decision to stop fighting. To stop fighting against my illness. To surrender to it. To accept that I was really unwell and that I couldn’t get better on my own and I had to listen to what other people were saying. It was more than a survival instinct, or fear of where I was headed if I didn’t stop fighting against it. I had to push hard against the current that was forcing me in the wrong direction, and suddenly the strength and purpose were there. I felt in my bones that I did have a choice, and I’d better make the right one.

Other than that, I’ve managed to stick to the golden decision-making rule. I definitely didn’t make any life changing decisions during my episodes of mental illness. In actual fact, I’ve made hardly any during my recovery too.

My short-term and smaller decisions have progressed. I’m no longer deliberating for hours over what to wear of a morning. This is good news. It means that I’ve started re-wiring my brain.

A depressed brain is stuck in habitual brain circuits loops that don’t help the person get any better. Deciding engages the prefrontal cortex and helps it to override unconscious habit loops. The more you use particular brain pathways, the stronger they get, and deciding beefs up the part of the brain that lets you modulate habits and impulses and work towards goals.

Your prefrontal cortex is responsible for goal directed behavior which means it controls which goals you pursue and how you get there. The first step in successfully achieving goals is making decisions. Once a decision is made, your brain releases dopamine to keep you motivated with every step and achievement along the way. Research shows that reaching the final goal is often less important to happiness than setting the goal in the first place. - Alex Korb.

So over the past couple of years every time I’ve made a decision about what to wear or what to watch on television I’ve been strengthening the decision making circuit in my brain starting a positive cycle making it easier to activate in the future. Similarly, every time that I begin to worry about not investing in the property market, act impulsively at the department store, or procrastinate about longer term decisions, I’m strengthening those capabilities in my brain. It’s like the muscles in my body. My cross-stitching muscles are in fine form, my running muscles less so.

The other night I caught myself telling my friend – How about I make the decision to make that decision next year? It appears my longer term decisions might still need a bit of work.

Two years into recovery, I might be taking the golden rule a bit too far

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When Mental Illness and Comedy AND Irritable Bowels Meet for Laughs: Felicity Ward

Some evenings seem like the most perfect meeting of worlds. Take for example, this evening. I wanted to see Felicity Ward - comedy AND mental health humour guru. And the best person to invite? Well, my delightful friend with Crohn's Disease, of course. Anxiety and poo. Ticks all round!

I reached out to a few comedians, this Melbourne Comedy Festival, to chat about the use of mental health as a topic in stand up. Felicity was super busy, but took the time to email me her apologies, and this evening I got to go along to her show, What if there is no toilet? to get all the answers I was looking for anyway. 

Felicity's current show is very much centred on her multiple diagnoses - generalised anxiety, evolving depression and irritable bowel syndrome (IBS) - or as Felicity acknowledges, the "triple threat" - and her experiences as they evolve over the last couple of years.

Diagnosed with IBS in childhood, the show reveals the development of other diagnoses, and the connectedness of these toilet related anxieties with her own mental health. And shit (excuse the pun), it's not hard to believe it. We hear about that ongoing battle between the geographical locations of toilets. And paying to use toilets. And weird bathroom attendants in UK nightclub toilets. And sensor lights in toilets. We hear about 'Beryl' - the anxious voice that presents herself to Felicity in all kinds of situations. We hear those common thoughts that all too often run through people's minds - "I'm just tired. I'm just 1 sleep away from being great. Just 1 sleep, and this 15 years of tired will all be gone". And it's not surprising. It sounds exhausting. 

Felicity talks really candidly about so many things about her experience with mental illness. Having sat down with a few comedians this month, I get that a lot of professional comedians often believe it easier to reveal significant stories to strangers rather than loved ones. And Felicity really does nail this. She speaks a lot about failing to see her own safety behaviours and symptoms, and avoiding speaking out with loved ones. Even about playing down the symptoms when she eventually sought out professional help. But she also notes, that at some point there is the realisation that in fact mental health issues don't simply plateau when nothing is done about them, they actually keep deteriorating. (Literally, I'm quoting Felicity's therapist here when I say "Avoidance is the maintenance of every problem"). 

Felicity had me on so many levels during this gig. She took the piss out of people wearing ugg boots outside. She educated the audience on appropriately using the smiling poo emoji. She sang. She swore. She wore a dress my sister would've really got a kick out of. She even made an analogy between those people caring for loved ones with a mental health issue with Danni Minogue - coz they just keep sticking around.

What if there isn't a toilet? talks mental health, and talks about it without bullshit. Early in the piece, Felicity does call out that, yes, this show is about mental health, and it isn't to be taken too seriously. This is proven pretty obviously when - half way through - Felicity wears a moustache made of toilet paper, whilst she tells her story about an incredibly (incredibly) short run of self harm, just to make it seem less serious. And she even calls out the audience for the quiet that sets in when she goes into it.

Felicity acknowledges that there are few places that people with mental health issues (and we do a rough audience tally during) can laugh at themselves and their experiences. Comedy has got to be at least one of them.

I like to think that one day, we won't need our comedians to provide disclaimers such as 'Show may contain traces of mental health', and that our conversations with mental illness will be awesome everywhere. But in the meantime, I'm happy for Felicity to introduce us to such conversations, and I look forward to one day passing the toilet paper.

We're nearing the end of the Comedy Festival, but Felicity Ward's What if there is no toilet has 4 more shows up until Sun 17 April, before taking it to Sydney April 23 & 24. Don't miss out.

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A new depression card and another man's dogs

You may not be able to immediately tell, but this brand new card comes from dogs.

Pretty much everyone has heard of Pavlov. And his dogs. But there’s another important psychologist who had dogs too. And he didn’t treat them all that well.

In 1965 Martin Seligman began electrically shocking dogs in an attempt to expand on the research of Pavlov - the genius who could make dogs salivate when they heard a bell ring. For nerds, he was the brains behind ‘classical conditioning’.

Seligman’s study involved fear and learning. To condition the dogs when Seligman rang his bell, instead of providing the animals with food, he zapped them with electricity. And to keep them still, he restrained them in a harness. It was predicted that the dog would learn to associate the bell with the shock and then in the future (when released from the harness) the dog would feel fear when it heard the bell. And that fear would cause the dog to run away or show some other signs of mild panic when the bell toned.

Following the conditioning/bell-electric-zapping-time, the dogs were put back into a box with a small fence dividing it into two halves. It was expected that when the bell rang, the dog would jump over the fence to escape it. It didn’t. The dog just sat there and copped it. When they shocked the conditioned dog without the bell, nothing happened. Again, the dog simply lay down and took it. Interestingly, when the researchers put a normal dog into the same box contraption, when zapped it immediately jumped over the fence to the other side to escape it.

Unfortunately for some people who experience depression they are just like Seligman’s dogs. I know I was.

Like the conditioned dogs, who had learned more than the connection between the bell and the shock, some people with depression may believe that escape from possible shocks is futile. In other words they have somehow learned to be helpless. According to Seligman, people experiencing depression may feel that whatever they do will be futile and that they have no control over their environments. This is called ‘learned helplessness’.

Seligman proposed that individuals who - over the course of their lives - had experienced defeat or abuse or loss of control, learned over time that there was no escape. To the point that if an escape was offered, it wouldn’t be acted upon. Initially this theory didn’t really explain how people who hadn’t experienced negative life events ended up going on to experience depression, so Seligman added in some important cognitive or thinking style components.

Studies of people with depression reveal that when these people fail they often will give up and stop trying. Whilst most people will look for external reasons and factors to explain failures, people experiencing depression will hold much stronger views – “It’s my fault”.” I’m stupid.”

Imagine having to carry these thoughts around with you – constantly - whilst feeling – constantly - shit and sad. It’s not then hard to imagine that an extended period of these feelings and thoughts could lead you to giving in to despair and accepting this as reality. Learned helplessness is very closely linked to a loss of feeling in control.

In 1976 Langer and Rodin found that in nursing homes where conformity and passivity is encouraged and where every patients need is attended too, the health and wellbeing of patients’ declines rapidly. In contrast, the patients in nursing homes who were given choices and responsibilities remained healthy and active. This research was repeated in prisons, finding that if inmates were able to move furniture around and control the television this kept them from developing health problems.

When someone is experiencing depression, there’s a strong possibility that feelings of helplessness might begin to occur and may become totally overwhelming. Making small choices and achieving daily tasks, like getting dressed or having a shower, are the things that can hold someone back from the crushingness of learned helplessness. And for someone with depression these tasks are not just tasks, they are massive fucking achievements. When you can succeed at something small, harder tasks might feel more possible. But if you don’t notice what you’re achieving, everything will seem too bloody difficult and useless.

Remind your loved one that you can unlearn learned helplessness. Don’t let them give in to it yet. Celebrate ALL the achievements.

You can find the card here.

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Why the 'hope' in Hope Street Cards?

I’m going to be entirely honest here. It wasn’t brilliant genius that led me to the name of this little card business. It was a bike ride home on a miserably cold Canberra evening. The idea for Hope Street Cards had been with me for some time, however I had been struggling with finding a name that wasn’t naff, lame or tacky. I mean, my sister’s hipster reputation was at stake here! I remember having a very negative internal dialogue with myself that evening regarding the state of the weather and catching myself attempting to disrupt these thought patterns as I cycled into my street. Thinking ‘Oh well, at least I get to live on a street called ‘Hope Street’’. Full disclosure. I got the name from my address at the time.

The more I thought about it though, the more totally appropriate it was. Because there really is not much more important a thing than hope.

I find it really difficult to concretely define or describe hope with the poetic justice that I feel it deserves. The dictionary says that ‘hope is an optimistic attitude of mind based on an expectation of positive outcomes related to events and circumstances in one’s life or the world at large’. Thanks dictionary. The psychologist Charles Snyder associated hope to the existence of a goal, combined with a determined plan for reaching that goal. Thus an essential ingredient for future planning, motivation and change. But it just feels like so much more than that.

Viktor Frankl, Austrian neurologist and psychologist, chronicled his experiences as a concentration camp inmate in his book ‘Man’s Search for Meaning’ (1963). Frankl’s observations and writings led him to discover the importance of finding meaning in all forms of existence, even in Auschwitz, which create a reason to continue living. He stated “It’s a peculiarity of man that he can only live by looking to the future” (p. 115). He warned that “the sudden loss of hope and courage can have a deadly effect” (p. 120) and observed that “the prisoner who had lost his faith in the future – his future – was doomed” (p. 117). Prisoners who Frankl observed as having lost hope reportedly died within a short time. That’s pretty massive.

And more recent, empirically-validated research backs the importance of hope up. Hopeful individuals have been found to make healthier lifestyle choices in areas such as exercise, eating and drinking (Peterson, 1988). They recover from illness and injury more effectively (Snyder, Rand & Sigmon, 2005) and have increased life expectancies (Maruta, Colligan, Malinchoc, Offord, 2000). They manifest less depression and anxiety symptoms (Cheavens, Feldman, Gum, Michael & Snyder, 2006) and experience increased positive mental health, personal adjustment, life satisfaction (Gilman, Dooley & Florell, 2006; Kwon, 2002) and sense of meaning in life (Feldman & Snyder, 2005). Obviously the benefits of possessing a hopeful approach to life are numerous and noteworthy.

During my first year of clinical psychology training, the importance of ‘instilling a sense of hope’ in conjunction with the client was taught as one of the key ingredients for providing successful psychotherapy. Some consider hope as one of the four most significant common factors in good therapy outcome (Hubble, Duncan & Miller, 1999). Irvin Yalom a guru in the world of psychotherapy teachings identified the instillation of hope as the first curative factor in effective group psychotherapy. Esso Lette observed: “Hope is crucial to recovery, for our despair disables us more than our disease ever could”.

During my very early training this knowledge made me feel slightly relieved. Being overwhelmed by anxiety at providing psychological treatment whilst feeling entirely inadequate, underprepared and paranoid I would end up ruining someone’s life, I thought, ‘well at the very least I think I can help someone feel hopeful’. And for the most part I could. There was one time though, when that sense of hope was so incredibly difficult to cultivate. Where the empathic response I had to a client’s traumatic past and current internal experiences left me feeling devoid of hope. I too felt hopeless. And it was gut-wrenching. And terrifying. And so incredibly sad.

That experience really affected me, because the guiding principle of recovery from a mental illness is hope – the belief that it is possible for someone to regain a meaningful life despite a serious mental health condition. And that recovery is not a linear process. Or an end result. It’s a process, ongoing adventure, one step at a time, that sometimes looks and feels like one big mess and is completely different for everyone. And it’s really, really, really hard work. Because there’s so many things you have to do that you often just don’t want to do (e.g., get adequate sleep, exercise, challenge unhelpful thinking patterns). And you have to do these things with no absolute certainty that doing these things will make you feel better. You need courage and commitment and a bucketload of hope.

But for someone who is experiencing a mental health condition there can be an overwhelming sense of hopelessness, so where can that foundation for recovery come from? At the launch of Hope Street Cards, Clinical Psychologist Jo beautifully described the benefits of having someone else “hold on” to that hope for you, when you yourself can’t. And I totally agree. At my darkest times my therapist – let’s call him Dr M – has held the hope for me. I’m not even sure he knows he’s doing it. But he will refuse to engage with me in any particularly ridiculous notions of my self-worth I might have. He does this very subtly and tenderly, but it is a gentle reminder that he doesn’t believe in such thoughts, he believes in me. And at times this has been enough.

At other times it’s been my family and my friends who have carried that hope for me. Just by being there they provided the gift of faith that I might be able to live well again. And what does that gift feel like? I think Emily Dickenson may have described hope best: “Hope is the thing with feathers”. And those feathers tickle your heart a little.

 

Smart things I quoted:

Frankl, V. E. (1963). Man’s search for meaning. New York: Pocket Books.

Yalom, I. (1985). The theory and practice of group psychotherapy. New York: Basic Books, Inc.

Peterson, C. (1988). Explanatory style as a risk factor for illness. Cognitive Therapy and Research, 12, 117-130.

Snyder, C. R., Rand, K. L., & Sigmon,D. R. (2005). Hope theory: A member of the positive psychology family. In Snyder, C. R. and Lopez, S. J. (Eds.). Handbok of positive psychology. (pp. 257 -267). New York: Oxford University Press.

Maruta, T., Colligan, R. C., Malinchoc, M., & Offord, K. P. (2000). Optimists vs. pessimists: Survival rate among medical patients over a 30-year period. Mayo Clinic Proceedings, 75, 140-143.

Cheavens, J. S., Feldman, D. B., Gum, A., Michael, S. T., & Snyder, C. R. (2006). Hope therapy in a community sample: A pilot investigation. Social Indicators Research, 77, 61-78.

Gilman, R., Dooley, J., & Florell, D. (2006). Relative levels of hope and their relationship with academic and psychological indicators among adolescents. Journal of Social and Clinical Psychology, 25, 166-178.

Feldman, D. B. & Snyder, C. R. (2005). Hope and the meaningful life. Theoretical and empirical associations between goal directed thinking and life meaning. Journal of Social and Clinical Psychology, 24, 401-421.

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Why Hope Street Cards?

I have always loved to send a card. When I moved out of home, over 15 years ago to attend Uni, my sister – Trudy – and I began the ‘card game’. The premise is pretty simple. Send each other really, really good cards as frequently as possible. We’ve been playing it ever since. It’s a fabulous game for so many reasons. Firstly, it involves surprise mail in the post. Breaking up the monotony of the bank statements and electricity bills. Secondly, it is hilarious. The range of quirky, funny and downright ridiculous cards that are available for sale is incredible. And thirdly, it will ALWAYS make you feel a little bit better than however you were feeling just moments before. Always.

cards
Card sources: Popsy Greeting Cards, An April Idea, La La Land and Able and Game 

As a result, we both have an excellent working knowledge of the current Australian greeting card market. And for your make-you-feel-better-in-the-general-sense card, it’s really pretty good.

But a couple of years ago the son of a close friend of mine attempted suicide. And I didn’t quite know what to do to show my support. As someone who had worked in the mental health sector for a number of years, I knew the right things to ask her about the situation. I asked how she was sleeping. I checked on the level of care and treatment he was being given. I said I was sorry and I asked if there was anything I can do. But as a friend I wanted her to know that I cared and that I was thinking of her. And so I joked with another friend that Hallmark should release a “I’m so sorry your child tried to kill himself” card. But it really wasn’t funny at all. I had never in all my greeting card buying experience come across a card specifically for any type of mental illness and that didn’t seem quite right. And thus the seed for Hope Street Cards was sown.

That same year my Mum was diagnosed with breast cancer. And whilst I was able to visit her on occasion, the 1000 kilometre distance between us made providing support somewhat more difficult. So I took to doing what I do best – sending cards. And I was blown away with the range of cancer-related cards available. From the “Fuck Cancer” card to the “If cancer was a man, I’d kick him in the balls” to the sympathetically appropriate “Sorry about your tit”. And I sent these cards off with delight.

But it was all very interesting. There was a time not that long ago when cancer was taboo. We wouldn’t tell someone we had it, let alone go out of way to support someone with it. But it appears we’re not scared anymore. And that’s great. But why the injustice? When I google mental illness card I get something quite disturbing – a card with a picture of a sticky tape dispenser. And the words – Put yourself back together! How come I can send hilarious, supportive and hopeful cancer cards, but can’t find an appropriate mental illness card. And so now the Hope Street Cards idea had formed and now I was a little angry that mental illness was not only suffering from stigma in the greater community, but also in the business of get well cards.

And then not long after I got sick. Another episode of a recurring mental illness. My third. Off I went to a private psychiatric hospital. Again. And this time I felt another anomaly. Often when I get admitted to hospital I feel the odd one out. A mental health worker becoming the mental health patient. But this time I noticed that I was one of the very few patients in the hospital who had flowers next to their bed. Who regularly received mail. Had visitors attending at all available times. And had cards of support adorning the walls. I was a statistical outlier in this hospital. I had outward displays of social support everywhere. And the research supports this.

Studies have shown that only 1 in 4 people who have experienced a mental health issue will receive a get well card during their illness, despite 80% of these individuals reporting that a card would have been beneficial to their recovery. And social support has been found to have numerous beneficial effects on recovery. Low levels of social support has been found to increase the chances of experiencing a mental illness episode and decreased chance of recovery. Whereas high levels of social support have been correlated with shorter major depressive episodes in women and predict 6-month symptom recovery. Furthermore, studies of individuals who have experienced ‘severe’ mental illnesses (schizophrenia, schizoaffective disorders, bipolar disorder or affective psychosis) found that both social network size and social support were correlated with better recovery and a reduction in symptoms. Despite this, studies have repeatedly shown that psychiatric inpatients receive about half as many cards and gifts when compared to medical inpatients. So I am just incredibly rarer and lucky. The result of having friends and family who didn’t shy away and were willing to show their love and support no matter what. And I gained so very much from this love and support. I had hope. And I knew I was loved. And being stuck in an episode of mental illness, these things were vital for me. I could not be more grateful for the support I received from those around me during this time and it is one of the reasons that I am where I am today.

And so here we are with Hope Street Cards. A very small attempt at making it a little bit easier for a friend or family member to support their loved one with a mental illness. Our dream is that each Hope Street Card enables the donor to learn more about mental illness and to show a loved one they care and will support them through their recovery in a non-judgmental, empathic and hopeful way. Showing someone that you’re thinking of them and that you care can really go a long way.

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Hope Street Cards in Victoria!

The awesome team at the Melbourne Leader had a chat with Trudy this week about our upcoming business launch. Meeting at our creative headquarters in North Fitzroy (aka Trudy's place), the full article can be read here

melbourne leader hope street cards
Photo credit: Martin Reddy (Source: Melbourne Leader)

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