Dorothy Rowe

A Whirlpool in a Stream

This was a talk by Dorothy Rowe at the BACP's conference on Counselling Children and Young People in November 2006, which was subsequently published in the CCYP Journal (March 2007)

'Man is the same in Pall Mall as in the wilderness of New South Wales.'

These were the words of Captain-Lieutenant Watkin Tench, one of the officers of the First Fleet sent to Botany Bay to found a penal settlement. Two hundred years later the Australian biologist Tim Flannery wrote,

The two peoples who met on that day in 1788 - the Aborigines and the Europeans - had been separated from each other for longer than any other human cultures on our planet. For 60,000 years - perhaps half the span of our species' tenure on earth - they had been cut off from each other, living on isolated and very different land masses at opposite ends of the globe. They had developed separate languages and cultures, different skin colour, gene frequencies and facial features. But despite it all, recognition and understanding were immediate, for so strong is our common bond that 60,000 years of separation melted away in a moment. A smile was a smile. An uncertain glance, an act of friendship, a shout of hostility or fear, a sexual overture - all were instantly comprehended.[i] 

Across the gap of time, language and culture, gestures and facial expressions are comprehended because they are based on the basic needs which all human beings strive to fulfil. Every individual has a sense of being a person. We need other people to recognise us as such. We need to feel that our life has significance. We need to have satisfactory relationships with other people. We need to have a place in our society.

All these needs develop from our sense of being a person who makes decisions and acts on the world. This sense of being a person comes into being very early in our life. Some psychologists argue that self-consciousness does not develop until a child is in his fourth year, but it is impossible to look at the photographic studies which the developmental psychologist Colwyn Trevarthen has made of the conversations between infants and their mothers without being convinced that small babies and toddlers have a sense of being a person who derives pleasure from acting effectively upon the world, who responds warmly to affection, sadly to rejection, and is confused and then despairing when persistently ignored.

What is this sense of being a person? Throughout history people have believed that our body is inhabited by a soul or spirit which continues on after the body dies. Yet, though scientists have discovered many extraordinary things about the brain, they have not found the seat of the soul. You think and feel, but there is no little you sitting in your brain thinking and feeling. Nevertheless, each of us has a strong sense of being a person. How can this be explained?

There is an on-going argument between the scientists who study Artificial Intelligence (AI) and philosophers such as John Searle who believe that, in order for thinking to happen, there must be a thinking agent. The computer scientist Marvin Minsky calls Searle's way of thinking 'prescientific'. AI scientists insist that 'thought does not need a unitary agent who thinks.'[ii] 

It seems to me that both the AI scientists and the philosophers are right. Our sense of being a person is a unit, but this unit is part of a process which is in constant movement and change. This process is the means by which we live in the world, interact with the world, and try to make sense of the world. It is the process of creating meaning which is what human beings are engaged in all the time. The process could be likened to a swiftly flowing stream of water with its constant movement and change. As the stream flows it forms a whirlpool. We can see the whirlpool and talk about it as if it is a thing. We can say to someone, 'Look, there is a whirlpool.' However, we can't bend down and lift the whirlpool out of the stream because the whirlpool and the stream are one. If a large rock is thrown into the stream or the stream dries up, the whirlpool disappears. In a similar way the process of living in the world, acting on the world and trying to make sense of the world, which begins to develop at some as yet unknown time after conception, is in constant movement and change. At some point early in life the process develops its own whirlpool which becomes the individual's sense of being a person. This sense includes but is far more than consciousness because it includes the memory which is an essential part of our sense of being a person. Memory shows us to be in constant change yet it gives a sense of being a person passing through time.

Like the whirlpool, our sense of being a person is a construction which is in constant change. (The Buddha knew this and called the sense of being a person a fiction. Knowing and accepting this is an essential part of becoming enlightened.) Moreover, just as a whirlpool can be destroyed by a rock being thrown into it, so the sense of being a person can be threatened with destruction by events in the environment. Since the process is the process of living, and the purpose of life is to live, the process strives to maintain the integrity of the sense of being a person by constantly monitoring its degree of safety from external assault by aspects of the environment. This monitoring is a stream of interpretations by the process of what is happening. It is a stream of messages along the lines of 'safe, safe, danger, DANGER, safe, danger, safe' and so on. We don't hear the process sending us these messages. What we experience is the creation of those interpretations which we call emotions.

Alll emotions relate to our sense of being a person. Emotions are the meanings we create which concern the degree of safety or danger to our sense of being a person. The positive emotions relate to safety: the negative emotions relate to danger. Feeling happy is the interpretation 'Right now everything is the way I want it to be.' Feeling angry is the interpretation 'How dare everything not be the way I want it to be.' The neural basis of the primary emotions of fear and anger develops very early in a baby's life, while the more complex emotions like jealousy ('How dare that person have something which is rightly mine') require a fully functioning cortex.

List the positive and negative emotions and it is immediately apparent that there are many more negative emotions than positive ones. Danger is seen and recognised in all its various possibilities. The sense of being a person is fragile and needs to be protected at all times. We do this because we know how terrible it is when our sense of being a person falls apart.

This happens to all of us when we are small children. We don't understand what is happening around us, and so our predictions of what will happen can be seriously wrong. For fortunate children these are simply occasions when a desire is left unfulfilled by an adult or tiredness makes trying to hold everything together just too hard to do. For unfortunate children these are major disasters. They find themselves in situations which are beyond their comprehension and in which they are being punished, neglected or abandoned. When their developing sense of being a person falls apart, the intense fear experienced and the difficulty in putting themselves together again leaves them with an expectation of more disasters coupled with a sense of inadequacy and helplessness in meeting such a disaster again. These feelings of fear, inadequacy and helplessness can remain with them for the rest of their lives.

When people talk about their experiences of being annihilated as a person they describe it in one of two ways, as being shattered or as disappearing. In her lecture Margot Sunderland showed a photograph of an arrangement which a young boy had created in a sandtray. It was a skeleton, not intact, but with the various bones separated by random gaps with parts of toys scattered around the bones. The boy had explained, 'When Mummy died I was in bits.' In her book the Best of Times, the Worst of Times, a book about her battle to survive manic depression, Penelope Rowe described growing up in a family where she was subjected to constant cruel criticism and rejection. She wrote, 'Sometimes we would be gathered in the sitting room and the sound of voices or a whimpering baby or the cricket commentary or the ABC news seemed to fade away into an indistinct murmur and I would feel myself fading away as well. I was no longer with them. I was somehow on the mantelpiece above the fireplace or atop the bookshelves or floating on the ceiling, disembodied, weightless, invisible.'[iii]

The fact that we can report the shattering and disappearing means that our sense of being a person does not disintegrate entirely. Just as a whirlpool consists of water so a sense of being a person consists of interpretations or meanings created as the individual interacts with the environment. These meanings are guesses or theories about what is going on around us. From these interpretations we create predictions about what will happen. When these predictions prove to be relatively accurate we feel safe. Even when we predict doom and disaster and these occur just as we predicted we enjoy a certain sense of satisfaction in knowing that we were right. But when our predictions prove to be wrong we feel in danger.

The sense of being in danger can be as mild as the anxiety we feel when we can't find our house keys which we were sure were on the kitchen table. When we discover the keys hiding in our bag, our anxiety abates. However, when we discover that one of our most dearly held ideas, an idea on which the structure of our life depends, is wrong, the fear of being annihilated as a person becomes overwhelming. When Penelope Rowe was a first year student at Sydney University she was forced by a markedly unjust and unbending university Senate to repeat the year in all her subjects, even though she had passed brilliantly in all her subjects except one. She wrote,

This sudden thump that brought me rudely and crassly down to earth precipitated a depression that was to last for the next three years at university. I had experienced one of life's great lessons - I had foolishly believed until then that life was supposed to be fair. I felt I had nothing to live for. I did not have the maturity to accept that decisions can be taken that are profoundly unjust and can affect a person's whole life, and you cannot do anything about it. There is no guarantee that after bad luck will come good luck. There is just luck.[iv] 

The discovery that the world is not a Just World where goodness is invariably rewarded and badness punished is, in my experience, the most common disaster which serves to precipitate a person into depression. The people who become depressed have spent their lives striving to be good. To achieve their goal they have sacrificed much, but because they believe in a Just World, they have been able to comfort themselves with the certainty that they will be rewarded for their goodness. People will love and admire them: their hopes of a happy life will be fulfilled. When events reveal that the world is not merely unjust, it is indifferent to our wishes, they fall apart and are overwhelmed by terror.

When we discover that we have made a serious error of judgement and that reality is not what we thought it was, we have a choice of how to deal with the consequences of our error. If we know that all we know are our ideas, and that our ideas are no more than guesses, we can say to ourselves, 'I got it wrong.' Then we need to have the courage to endure a period of uncertainty until we can construct another set of ideas which we hope is a closer match to reality. It took Penelope Rowe many years to understand that no amount of goodness prevents disaster. The fact that she continues to experience periods of depression and mania suggests that she has been unable to relinquish the hope that one day she will be rewarded for her goodness.

Many people gain the wisdom which allows them to change their ideas but others refuse to do this because they feel that they cannot cope with the uncertainty while their sense of being a person reconstructs itself. They refuse to change their ideas, and so spend the rest of their life trying to force the world to be what they want it to be. Some of these people develop a way of behaving which psychiatrists call a mental disorder. All mental disorders are both a defence aimed at holding the person together in the face of the fear of annihilation and a weapon aimed at forcing the world to be what the person wants it to be. For instance depression can be seen as a refusal to mourn the loss that the person has suffered. The person may be denying that the loss has occurred, or may be claiming that through the person's suffering that which is lost will be restored. It is a kind of action replay of, 'If I get really upset Mummy will give me what I want.'

An alternative to developing a mental disorder in order to bend reality to your wishes is to become very powerful, and, through your power, make the world be what you want it to be. History is full of such people. George Bush wants to force the world to be what he wants it to be, irrespective of what suffering this causes other people.

 Whenever we see a person behaving in bizarre ways, or in ways which cause the person and/or other people great suffering, we are witnessing that person trying to defend himself against the fear of annihilation as a person. No matter how great the differences in time, place, language and culture, the greatest fear of all human beings is the fear of being annihilated as a person. We are the process, and the process needs to keep whole the fragile structure of the sense of being a person. This is not easy to do, and it is even more difficult for children than for adults. Children can be overwhelmed by events which seem ordinary to adults. An adult has learned what to expect while shopping in a supermarket, a toddler has not. Children find it harder than adults to put themselves together after they have fallen apart. An adult can learn from experience and be able to say, 'I've put myself together before and I'll manage to do so again', but a child can be confronting a completely new experience. Adults have had more time to learn how to regulate the expression of their emotions than children have had, although there are many adults who have never had the faintest desire to master this task. Confronted by a disaster, an adult has more choices than a powerless child in the care of adults who have not prevented or may have even created the disaster which has overtaken the child.

If we see the child's behaviour as the child defending himself against the annihilation of his fragile sense of being a person, how we should act becomes obvious. We need to help the child hold himself together, and encourage him to build up his own self-confidence by discovering ways of acting effectively on the world. Children are not some aboriginal species which evolves into another species - adults - once they turn twenty. They are fellow human being just like us.

Depression

Published in The Sunday Times, 28 January 2007

Depression is a prison whose foundation stone is the unquestioned belief that you are intrinsically unacceptable to yourself and other people, and that you have to spend your life trying to be good in the way that you define 'good'. Setting yourself impossibly high standards, you become an expert in feeling guilty. When a personal disaster befalls you, your ideas about yourself and your life no longer fit reality. This feels like your very self is falling apart and being annihilated. You are gripped by terror. You try to hold yourself together by blaming yourself for the disaster. Now you see yourself as being unforgivably wicked. Immediately you cut yourself off from other people because they will reject you, from your past where lies the evidence of your wickedness, from your hopeless future, and from society and nature. Thus, unintentionally, you create your prison of depression. The more you hate yourself, the worse your prison becomes.

The key to the prison of depression is to decide to act as if you value and accept yourself. You do something nice for yourself, something as simple as going for a daily walk. You talk things over with a friend or perhaps a therapist. You decide whether you'll take some anti-depresssants to mitigate your pain (anti-depressants are pain-killers, not cures for depression) or whether you'll use the pain to motivate you to change how you live your life. Gradually and imperceptively you come to value, accept and love yourself.

Thus you discover the recipe for happiness. You learn to see yourself as being humanly fallible like everyone else. Now you work out what proportion of a disaster is your responsibility, what proportion other people's, and what happened by chance. You no longer claim to be responsible for everything in the universe, and, instead of sinking into self-absorbed guilt, you endeavour to right what can be righted. You no longer see the world as governed by a grand design of immutable laws of reward and punishment, but see it as operating as an interplay of chance and human intention, and thus a world where you can enjoy hope and freedom. You can accept that life will always bring crises and disasters because you know that you'll meet them with courage and optimism.

No longer enmeshed in your concerns about yourself, you discover how immensely interesting and rewarding the world and other people are. Involved in all this, it might cross your mind one day that you are happy.

Depression: The Way Out of Your Prison 3^rd edition Routledge

READERS' DIGEST GREAT BOOKS

Published in Australia January 2007

Edmund Gosse's book about his relationship with his father, Philip Gosse changed the art of biography forever. Published in 1907, it caused a scandal. Until then all authors of an autobiography had to be mindful of the Fifth Commandment, 'Honour thy father and mother so that thy days be long in the land.' Criticise your parents and you're dead. Consequently, parents were spoken of only in terms of the greatest respect. For a son to write about his parents in terms of their strengths and weaknesses, and not merely chronicle but carefully analyse how an unbridgeable gap developed between a father and son, was exceedingly shocking.

Philip Gosse was a geologist and naturalist and, as a devout Plymouth Brethren, tried to reconcile the Brethren's literal reading of the Book of Genesis with the increasing evidence, to which he had contributed, of evolution. The publication of Darwin's On the Origin of the Species was to him a terrible blow. Although the Gosse family lived in great poverty and the parents demanded much of their son, Edmund Gosse did not write a 'misery memoir' of the kind much in vogue at present. Rather the book is the work of someone who looked with both an adult's and a child's eye at the events of his childhood. Edmund Gosse remembered how he had interpreted these events when he was a child and contrasted this with his interpretation of those events when he became an adult. By looking at our past in this way we can discover who we are, and why. All of this Edmund Gosse set down in clear, simple and beautiful prose.

When I began working on my book about sibling relationships I blessed Edmund Gosse for showing how we ought to write about our childhoods. Because sibling relationships are so complex and various psychologists have had little to say about them. So I had to turn to those biographies which were written with the same truth and clarity as Father and Son. Without that book to set the standard of biography I could not have written My Dearest Enemy, My Dangerous Friend.

Edmund Gosse Father and Son (my copy Nonsuch Books, Stroud, Gloucestershire, UK, 2005)

Dorothy Rowe My Dearest Enemy, My Dangerous Friend Routledge, London, 2007, distributed in Australia by Palgrave Macmillan.

March 3, 2001

The Fifth Commandment

The Fifth Commandment does not simply direct us to honour our parents but contains a threat. 'Honour thy father and mother so that thy days will be long in the land.' Criticise your parents and you're dead. In an authoritarian society children had to be taught to respect a person in a position of authority because that person was in that position and irrespective of the attributes of that person. An abusive parent merited the same respect as a kind, loving parent.

The Fifth Commandment has made a major contribution to human misery. If you believe that to review critically and dispassionately certain events in your childhood which involved your parents you prevent yourself from discovering that some of the conclusions you drew from those events were wrong. When your mother told you that fire would burn you, you soon discovered that she was right. When she told you that you were wicked and useless, you decided that this must also be true, and so you grew up believing that you were intrinsically bad and unacceptable. In adult life you cannot enjoy good relationships with other people because you fear that they will discover just how bad and unacceptable you are.

Most parents want to do the best for their children, but they might not understand that what determines a child's behaviour is not what parents do, but how the child interprets what they do. Thus the parents do not achieve what they wished to achieve. Some parents see their children not individuals in their own right but as objects which they own and which they can use and abuse. A man in his forties told me that it was only recently that he had realised how he was ruining his relationships by the way he responded to another person's ill-temper. He said, 'If anyone was angry I always thought it was my fault.' His mother, as I knew personally, had never accepted responsibility for anything she did. If life was not what she wanted it to be, her son was to blame, even when he was a little boy.

As a therapist I found that many people felt that uttering anything remotely critical of their parents would bring death and damnation. They would say nothing about their parents, or they would construct a form of words to ward off the danger. Often my clients would preface any remark about a parent with, 'Don't get me wrong, Dorothy, my mother's a wonderful woman.'

Human suffering would have been much diminished had the Fifth Commandment been:

Value your parents for their virtues and pity them for their vices for they are like all of us, fallible human beings.'

Dorothy Rowe

Dorothy Rowe Friends and Enemies HarperCollins

February 13, 2001

DEPRESSION TWO

Alice wrote to me to tell me how much she had been helped by counselling and by my books, but she added, 'I understand now why I get depressed, and I've really tried to change, but I can't make myself feel good about myself. I tell myself I'm valuable and all that, but deep down I know I'm not. What can I do?'

Believing that you are, in essence, bad and unacceptable is absolutely central to depression. If this is how you feel about yourself then, when you suffer a disaster, you blame yourself and think that you are even more wicked and unacceptable than you had realised. Doing this you cut yourself off from other people, from society and nature, from your past and your future, and thus, inadvertently, create the prison of depression. The key to this prison is to come to see yourself as valuable and acceptable, but many people have great difficulty is finding this key. No matter how much they suffer, they cannot bring themselves to believe that they are, in essence, valuable and acceptable.

So, to find the key to the prison of depression you might need some help.

The help most often offered to someone who is depressed is antidepressant drugs. When in the 1960s antidepressant drugs were first used many people believed that depression would disappear, just as many infectious diseases had disappeared with the discovery of antibiotics, but instead the incidence of depression continued to rise. Different kinds of antidepressants were created, first the tricyclics, then the monoamine oxidase inhibitors (MAOIs), and more recently the Selective Serotonin Reuptake Inhibitors (SSRIs), of which Prozac is one, but none of these has the magic ingredient to change how a person feels about himself. Antidepressant drugs, like alcohol, nicotine and the illegal drugs, can lift our mood and make us feel happy with ourselves for a little while, but none of these drugs can change the ideas and beliefs which are integral to how we see ourselves as a person. No drug will change you from hating yourself to loving yourself.

The public is given a great deal of misinformation about antidepressant drugs. While Prozac has been greatly hyped, research shows that no single antidepressant has any greater effect on depression than any other antidepressant. The talk about depression being a chemical imbalance in the brain and about the SSRIs working on the serotonin in the synapses of the brain is quite misleading. All antidepressants work unspecifically on the whole brain, and just what they do is not understood. Doctors often insist that there are no withdrawal reactions when a patient stops taking an antidepressant, yet the evidence is that coming off any of these drugs at all abruptly can leave the person feeling ill, shaky, unable to sleep and anxious. This reaction is often interpreted by the doctor, and sometimes by the patient, as evidence that the patient is still depressed, and so the antidepressant is again prescribed.

In the report on the 1994 International Conference on Moods Disorders Joseph Mendels MD wrote, 'There is now clear evidence that, for a substantial proportion of the millions who suffer from major depressive disorder, the condition is often chronic or recurrent. Many of our patients require long-term maintenance treatment.' By 1999 David Nutt, the Professor of Pharmacology at Bristol University, was writing, 'Of those who have suffered one episode of depression 50-85% will have a subsequent episode, while of those who have had two episodes 80-90% will develop a third. With each recurrence a further recurrence becomes more likely and the period in remission tends to become shorter.' Many psychiatrists now prescribe a maintenance dose of an antidepressant which the patient is required to take for the rest of his life, but research shows that between 20 and 70 percent of patients on maintenance doses relapse.

All these research results concern depressed people who were treated only with medication. Research studies where the treatment combined medication and some form of therapy produce much more encouraging results. When medication and therapy are combined the medication can lift the person's mood, and then the person can feel that he has enough energy and enthusiasm to do something for himself. He might join a yoga class, or start exercising regularly, or, if he feels particularly low in winter (Seasonal Affective Disorder as it is now called), he gets a bright light and thus has a pleasant break each day sitting in front of it. Or he might find a therapist.

The effectiveness of therapy depends on the quality of the relationship between therapist and patient. You might have to try two or three therapists before you find someone who you feel is right for you. However, before you start looking for a therapist, you need to know a little about what different kinds of therapy are on offer.

If you are an NHS patient the kind of therapist you are most likely to encounter is a cognitive therapist. Many clinical psychologists work in this way and there are also a number of nurses in psychiatric units and in the community who have trained as cognitive therapists. A great deal of research has been carried out on the effectiveness of cognitive therapy, and all this shows that it is much more effective than medication and that its effects are long-lasting. People don't relapse, or, if they start to feel themselves going down the slippery slope into depression, they use the techniques they have learned to stop this happening. Cognitive therapists begin by getting you to listen to the way you talk to yourself. If you don't value and accept yourself then all the time you're putting yourself down. You tell yourself you're unattractive, you're sure to fail, no one likes you, you deserve to be punished, and so on day after day. The cognitive therapist shows you how to monitor your self-talk and how to develop ways of talking to yourself in encouraging, supportive ways. If you talk to yourself as your best friend rather than as your worst enemy you'll soon discover that you're valuable and acceptable.

Researchers in the effectiveness of therapy divide all the therapies into two groups, prescriptive and exploratory. Cognitive therapy is a prescriptive therapy. The therapist will begin by finding out about your background, but this exploration soon gets turned into the prescribing of exercises for you to practise. Some cognitive therapists find that this way of working can be too limiting and not totally appropriate for different clients, and so they combine prescriptive therapy with exploratory therapy.

There are many different kinds of exploratory therapy - Freudian and Jungian psychoanalysis, humanistic therapy, existential therapy, cognitive analytic therapy, psychodynamic therapy, and so on - but all are concerned with exploring, not simply the person's past experience, but how the person interpreted those experiences. If you hate yourself then there have certainly been events in your childhood which you interpreted at the time as evidence that you were bad and unacceptable. Perhaps your father deserted your family, or perhaps your mother died, or perhaps someone sexually assaulted you, and you said to yourself, 'If I'd been really good this wouldn't have happened.' Exploratory therapy lets you look at these events and see them again with an adult eye, and thus realise that, though that was how you saw these matters when you were a child, now you're an adult you can see these matters differently and realise that you weren't to blame for what happened to you.

It's hard to draw a clear line between therapists and counsellors, and indeed the British Association of Counselling has now changed its name to the British Association of Counselling and Psychotherapy (BACP). Some 50% of GP practices now have access to a counsellor. Professor Michael King led a large study comparing the effectiveness of counselling with that of GP care and with cognitive therapy and found that patients found counselling much more helpful than medication or cognitive therapy. Having someone who is on your side and who sees you as valuable and acceptable can be of immense help in changing your view of yourself.

Many depressed people endure not just the isolation of the prison of depression but the loneliness of knowing few people or living in a family where people hurt them, or ignore them, or treat them as doormats. Joining a self-help group for depression can make a great deal of difference. Two organisations, Depression Alliance and The Fellowship of Depressives Anonymous, have groups across the UK. Andrea, a member of Depression Alliance, wrote in their journal A Single Step, 'A self-help group can be the first step to integrate oneself back into society. It gives you some confidence to see that you can cope with this group of unknown people and enjoy their company.'

In a self-help group you'll meet people who know what it is to be depressed. They'll understand what you're going through and not despise you. The only drawback of self-help groups, in my experience, is that you're likely to encounter people who have made being depressed their whole identity. They speak of being 'a depressive' and they have no intention of changing.

However, a self-help group can be extremely helpful in learning to value and accept yourself. Andrea wrote, 'Listening to other members of the group I always think that all these people are really nice; none of them is ugly and horrible. How can they possibly have a low opinion of themselves? Then I think that maybe the others feel the same about me; perhaps I am not this horrible and worthless person I am convinced I am.'

Whatever kind of therapy you choose, if you go into therapy expecting that the therapist will take your pain away but you won't have to do anything or change in any way, then the therapy will certainly fail. You need to go into therapy being prepared to change even though neither you nor your therapist can predict what will be the outcome of these changes. How you feel about yourself is central to your identity. If you change from hating yourself to valuing and accepting yourself then everything about you and your life will change. I have seen many people make this change and all of them went on to lead lives - happy lives - very different from the life they led when they were depressed.

How you feel about yourself is central to every decision you make. If you value yourself and you're buying something for your dinner you'll choose something simply because you fancy it, but, if you believe you're worthless, you'll think, 'I don't deserve something nice,' and you'll buy something dreary and perhaps not very good for you. Seeing yourself as wicked and every disaster a punishment you deserve, you'll be too terrified to take a holiday anywhere interesting, but, valuing yourself, you'll choose to jet off all around the world. Most importantly, when you don't value yourself you'll let people hurt you and use you, but when you value yourself you'll defend yourself against those who would bring you down.

Moreover, as you come to value yourself, you find yourself in situations where you have to learn new skills. Hating yourself, you kept people at arms' length, but, now that you like yourself and so expect other people to like you, you have to learn how to really get to know people and let them get close to you. Feeling inadequate, you never put yourself in any competitive situation, but now, sure of your worth, you have to learn how to compete and how to risk losing.

Indeed, to value and accept yourself you have to accept that life is full of risk and chance. The great advantage of being depressed is the security of the prison of depression where you can make sure that every day is the same and that you'll be correct in expecting that everything will turn out badly. It is the fear of change that keeps a person locked in the prison of depression. To get out of that prison you have to ask yourself, 'Am I prepared to change?' The best answer to this question is 'Yes.'

Dorothy Rowe

Dorothy Rowe Breaking the Bonds: Understanding Depression and Finding Freedom HarperCollins £8.99

Dorothy Rowe Depression: the Way Out of Your Prison Routledge, £10.99

UK Council of Psychotherapists and the British Confederation of Psychotherapists each publish a register of psychotherapists accredited to each organisation. These registers are available in public libraries.

The British Association of Counselling and Psychotherapy's new phone number is 0870 443 5252

Depression Alliance can be contacted on - London 020 7633 9929, Scotland 0131 467 3050, Wales 01222 521774

Fellowship of Depressives Anonymous 01702 43 38 38

February 12, 2001

DEPRESSION ONE

Lewis Wolpert, the scientist who wrote about his own depression in his book Maligant Sadness, and I were taking part in a television discussion about depression. The producer had hoped that Lewis and I would disagree, but when I began talking about how being depressed is far, far worse than having a physical illness Lewis nodded his head furiously and said, 'Yes, yes, absolutely.' Lewis had had more than his share of physical illnesses, but he was in doubt that being depressed was his worst experience.

The fact that being depressed is so terrible makes the news about increasing rates of depression so very serious. Depression is certainly better diagnosed than it was in past years, and more people, especially men, are prepared to admit that they are depressed, but the increasing numbers of adults and children who describe themselves as being stressed at work and at school suggest that there is a real increase in the incidence of depression. We can turn stress very easily into depression by blaming ourselves for our misery.

A World Health Organisation report in 1999 showed that in Europe and America depression is the second greatest cause of death after heart disease. An earlier WHO report looked worldwide at the number of years lost through sickness and death by people aged between 15 and 44 who were suffering from various diseases or injuries. The people who had suffered by far the greatest loss of healthy years were those people suffering from depression. It has been known for some time that stress reduces the effective functioning of the immune system, and so can lead to physical illness. Depression, the greatest stress, is now seen as one of the possible factors leading to influenza, pneumonia, cancer and heart disease.

Suicide rates in young people have increased steadily since 1946. Of recent years rates for young women have levelled out, but rates for young men have continued to climb. Studies of which groups of people become depressed have always shown that the group most prone to depression is married women, but it is now clear that the group which is next most likely to become depressed is single men. Married men and single women fare best. It seems that marriage suits men but not women.

There are two competing theories about the nature and causes of depression. One is the medical theory which says that depression is a physical illness which is caused by a chemical imbalance in the brain and which has a genetic origin. The other is the psychological theory which says that depression is our response to our upbringing, the present circumstances of our life and our sense of being vulnerable and of little self-worth. The first theory is supported by most psychiatrists and by those people who prefer to explain human behaviour in terms of physiology. The second theory is supported by psychologists and psychotherapists and by those people who prefer to explain human behaviour in terms of personal experience.

Like everything in life, these two theories have advantages and disadvantages. The first theory has the advantage that, if you are depressed, you don't have to feel responsible for your depression, but it has the disadvantage that if your treatment is simply medication designed to attempt to re-establish the chemical balance in the brain (though no one knows just what a chemically balanced brain actually is) then, while the treatment might seem to be effective in the short term, depression is likely to recur. Psychiatrists who believe in this theory don't talk of curing depression but of managing the depressed patient. The second theory has the disadvantage that you have to take responsibility for your depression, but it has the advantage that you can change and end depression forever (though the best way of making this change is far from clear).

In all the years when I worked closely with depressed people I often wished for a magic pill which would take away their suffering, but I have seen the evidence steadily mount that depression is something that arises out of the way we see ourselves and our world, and that we are capable of changing how we see ourselves and our world so that depression never again becomes part of our experience.

Discussions about depression are often confused because the words 'depressed' and 'depression' are used incorrectly. People will say that they are depressed when what they mean is that they're disappointed or dispirited. They'll say , 'I'm depressed that my son didn't pass his exams,' or 'I find this weather really depressing.' The word 'sad' is used to denigrate a person, as in, 'He's a sad guy', when in fact being sad or being unhappy is the appropriate response to loss or disappointment.

There is a very great difference between being depressed and being unhappy, as anyone who has been depressed will know. When we're unhappy, no matter what terrible thing has happened to us, other people can comfort us and we feel warmed and supported. When we're depressed there is a barrier between us and other people. We see them doing comforting things, but nothing gets through the barrier to warm and comfort us. When we're unhappy we can comfort ourselves. We speak to ourselves kindly and look after ourselves. When we're depressed we'll do nothing to comfort and help ourselves. We have turned against ourselves and hate ourselves. We find ourselves alone in a prison where we are both the prisoner and the cruel jailer.

The essence of the experience of depression is that we are alone in a prison. All depressed people have their own individual image of this complete isolation. Some people describe themselves as being in some kind of pit; some of being alone in some vast, desolate, dangerous landscape; some of being some kind of sealed enclosure; some of being wrapped tightly in a cloth or weighed down by something immensely heavy and unmoveable.

Complete isolation for an indefinite period is the torture which will break the most hardened prisoner. All jails and concentration camps use it. It is this sense of utter isolation which makes depression far worse than a physical illness. When we're physically ill, even though we may be in great pain and discomfort, we can for short periods separate ourselves from our suffering body and enjoy a joke or feel close to others, but when we're in the prison of depression there is a barrier as impenetrable as it is invisible between us and the rest of the world and we cannot escape.

Over many years I have been listening to the stories of their lives that depressed people tell. No two stories are the same, but every story has the same theme, just as the theme 'boy meets girl, boy loses girl, boy gets girl' is a theme upon which many millions of stories have been built. Following is the theme which underlies all depression stories.

The story starts with the kind of upbringing that most of us have. All babies come into the world full of unself-conscious self-confidence, but by the time babies have turned into toddlers they have learnt that as they are they're not acceptable to their families. They have to learn to be clean, unselfish, unaggressive, obedient, that is, they have to learn to be good. Being good means that you believe that you are never good enough. Some of us grew up in families where the adults were easy-going, warm and accepting, and so we learned to think of ourselves as being, not perfect, but basically valuable and acceptable. Others of us grew up in families where the adults set us high standards and inflicted harsh punishments when we failed to meet those standards. Our parents might have threatened us with the loss of their love, or told us we would be being sent away if we weren't good, or they made us feel guilty for not being good, or, if we displeased them, they isolated us, or beat us, or, as in sexual abuse, they treated us cruelly and told us that we deserved this. Growing up in such families we learned to think of ourselves as being unacceptable and therefore we had to work very hard to be good.

Most of us grew up in families where we were taught that we lived in a Just World, that is, that ultimately and invariably bad people are punished and good people rewarded. All religions teach this, though they differ in how they define good and bad, rewards and punishments. A Just World is one where nothing happens by chance. If we believe in a Just World we can answer the question, 'Why did this disaster happen to me?' only with 'It was my fault' or 'It was someone else's fault.' We cannot say, 'That happened by chance.'

Most of us grew up in families where the adults told us that the way they saw the world was the right way and, if we saw things differently, we were wrong. Few of us were taught that what determines what we do isn't what happens to us but how we interpret what happens to us, and that we are always free to change our interpretations. Thus most of us grew up believing that what we saw as the world was fixed and real, and how we experienced ourselves was fixed and unchangeable.

If you believe that you are in essence bad and unacceptable, that you live in a Just World, and that everything is exactly as you see it then you have laid the foundations of the prison of depression. All you have to do is wait for a disaster to occur to you.

This disaster might be something which other people can see, or it might be a loss or disappointment which is private to you. Whatever the disaster, you discover that you have made a major error of judgement. The world and your life aren't what you judged them to be. You feel yourself falling apart, and this is utterly terrifying. Depressed people often speak of the panic which preceded the onset of depression, but others, not wanting to remember this terror, say that depression came out of the blue.

In your terror you ask yourself, 'Why has this disaster happened to me?', and, being a good person, you have to answer, 'It was my fault.' Good people, being experts in guilt, can manage to blame themselves for any disaster, however unlikely. Blaming yourself for the disaster brings a kind of calm for you now have an explanation for what has happened, but it is the calm of the prison of depression.

In blaming yourself you turn against yourself and hate yourself. Believing yourself to be wicked you become frightened of other people in case they see how bad you are, and so you cut yourself off from them. (By 'cut yourself of' I am referring to that sense of being connected to other people, to the world, and to our past and future which we experience when we are happy.) You cut yourself off from your past, for all you see there is evidence of your wickedness. You cut yourself off from the future for all that lies there is punishment for your wickedness. You cut yourself off from society and nature for you are too wicked to be part of that. You have cut yourself off from every aspect of your life and thus, inadvertently, you have created the prison of depression.

There is a way out of the prison. Discover that what you see as fixed and real is actually your interpretations and that you are free to change your interpretations. Now you can see yourself as valuable and acceptable. You can see that events can happen by chance and that you don't have to blame yourself for every disaster. As you make these changes to your interpretations the walls of your prison disappear.

However, making these changes isn't always easy. Old habits die hard, and you may need some help.

Dorothy Rowe

Click here for "Depression Two": Treatments and therapy

Dorothy Rowe Breaking the Bonds: Understanding Depression and Finding Freedom HarperCollins £8.99

Dorothy Rowe Depression: The Way Out of Your Prison Routledge, £10.99

Lewis Wolpert Malignant Sadness Faber, £9.99

You: Mail on Sunday

13th September 1998

Women and Depression

Libby Purves is one of the nicest, friendliest, most cheerful, most attractive, most competent and hard working women I know. She combines very successfully the roles of wife, mother, friend, career woman with many outside interests, something that many women nowadays try to do. I'm sure that when she was a little girl everyone must have loved her because she was so nice, friendly, cheerful, pretty and good. However, I didn't know that Libby had been through what so many women - good women - go through, the experience of being depressed.

Libby knew what unhappiness was. She'd encountered loss and disappointment. But depression was quite different. Life had no colours but grey, and she hated herself.

Kate made the same discovery. Like Libby she had good friends she could always turn to. When she and her first boyfriend split up and later when she missed out on a job she wanted she poured her heart out to her friends. They listened and told her she was wonderful and would always be successful, and she felt greatly comforted. But when the doctors told her she could never conceive a child and all attempts at in vitro fertilisation failed she felt an invisible but impenetrable barrier come down between her and the rest of the world. Friends and family offered her comfort, but nothing got through the barrier to warm her and ease her pain. She was in the prison of depression.

This prison is the essence of the experience of depression. Every depressed person can describe this prison, but no two people describe it in exactly the same way. Patricia told me, "I'm curled up like a baby in the corner of a bare, locked room." Janice said, "I'm just a black dot in the middle of an infinitely large, empty space."

Depression isn't an illness. Depression is a defence which we can use when we discover that there's a huge discrepancy between what we thought our life was and what it actually is. When this happens we feel ourselves falling apart and we're terrified. Then we can use the prison of depression to hold ourselves together, but it's a very painful place to be. However, in it we can learn great wisdom and so leave this prison behind us forever.

To understand how this happens we need to know something very important about ourselves, which is that what we do isn't determined by our genes, or our parents or even our stars, but by how we interpret what happens to us. As the ancient Greek philosopher Epictatus once said, "It's not things in themselves which trouble us but our opinions about things." Recently I did some work on a television series about lottery winners. One of these winners was a woman who'd always believed that life should be enjoyed. Another winner was a woman who'd always believed that to be good she had to work hard. Can't you guess what they decided to do with their winnings? The first woman took her friends on holidays, and the second woman bought a large hotel where, she said, "I've never worked so hard in all my life."

No two people ever interpret anything in exactly the same way. However, many of us create the kind of interpretations which can lead us into the prison of depression. These aren't strange, way-out interpretations but the kind of interpretations which arise quite commonly in our society. These interpretations go right back to the day we're born.

A baby is born knowing how to create interpretations and is eager to do so. A newborn baby looks around eagerly, working out that the voice she got to know while she was in the womb comes from a face - and babies love faces - that keeps coming back again and again. Little babies can do amazing things, like recognize their mother's photograph from a set of photographs of women who look their mother. However, no newborn baby is busy wondering, "Will people like me?" "Will people approve of me?" Rather, babies enter the world full of unself-conscious self-confidence.

Alas, this soon changes. The baby forms a bond with her mother, and then becomes anxious about losing or angering her mother. Long before she can talk, the sounds of "There's a good girl" and "Don't be naughty" take on a special meaning, and thus the unself-conscious, self-confident baby turns into a self-conscious little girl who is trying to be good. This change comes so early in life that many children grow up believing that they are in their very essence bad and unacceptable, and so they have to spend their lives trying to be good.

Being good means never being good enough and always feeling guilty about not being good enough.

This process of learning to be good is the same for boys as for girls, but the way "good" is defined for boys and for girls means that more women than men become depressed. Even after two decades of feminism, studies show that mothers will tolerate their small sons being quite aggressive, competitive, noisy, selfish and dirty while they expect their little daughters to be unaggressive, co-operative, quiet, unselfish and clean. These are very high standards for little girls to reach, and thus many girls grow up feeling inadequate, lacking in confidence and feeling guilty for not being good enough.

The Duchess of Kent, in an interview last December, talked about the depression she suffered in 1977 after her much wanted baby was stillborn. She said, "I can still be very shy walking into a room full of strangers. I know how to do it, but I have never gained confidence. It is one of the reasons I am always trying to boost other people's self-esteem - because I know what it's like not to have it." She went on, "I don't think I have ever felt extremely confident. It would probably be awful if I did, because I might then do what I was required to do extremely badly."

Here the Duchess reveals why she had never become self-confident, despite all the evidence that she is very competent and very much liked. She believes that to be confident means doing things badly. She can't afford to do things badly because she has set herself impossibly high standards. As she said, "I am a perfectionist."

Whatever interpretations we create they all have implications, often with results which we don't want. If you believe that you are not good enough and have to work hard to be good, and that everything you do must be done perfectly you have ensured that you live a life of hard work with constant self-criticism and much unhappiness.

How you feel about yourself is central to every decision you make, whether it's about buying a new pair of shoes or deciding on a career. It's quite a complex feeling made up of whether you feel affection for yourself, or dislike yourself, even hate yourself, whether you look after yourself or neglect or punish yourself, and how you judge yourself. Do you set yourself reasonable or impossible standards? Many women set themselves the impossible standard of wanting to be perfect in every way - the perfect career woman, the perfect wife, mother, lover, the perfect cook, the perfect friend, and of course being perfectly attractive.

How you feel about yourself develops out of how you interpreted events when you were a child. Kate saw that her father would approve of her only if she were a high achiever. Janice's parents took little interest in her but her teachers praised her for being obedient and working hard. Patricia was close to her mother and wanted to be like her, someone who devoted her life to her family. So they each defined "being good" in their own individual way and they each created a way of living where they could be good in this special way. Kate was a very successful journalist, Janice was a hard working and loyal PA to a senior executive in a large firm, and Patricia became a very good wife and mother.

In childhood we learn how to interpret the world. When we're small children life is very confusing because unexpected things are happening all the time. We're quite pleased when we discover some regularity in some events, even if it's not particularly pleasant. Mother says, "If you're naughty you won't get an ice cream," and we are naughty and we don't get an ice cream. Now we've discover a regularity which we can predict. If I'm bad I get punished, and, along with that, if I'm good I get rewarded.

In some families "bad-punishment, good-reward" is simply a rule for a peaceful family life, but in many families children are encouraged to take this rule and generalise it to the whole world, to believe that we live in a Just World where goodness is rewarded and badness punished. All religions teach this, though they differ in how they define good and bad, reward and punishment. When the Duchess of Kent was explaining why she joined the Catholic Church she said, "I do love guidelines and the Catholic church offers you guidelines. I have always wanted that in my life. I like to know what's expected of me. I like being told: 'You shall go to church on Sunday and if you don't you're in for it!'"

There are many people who don't have a particular religious belief but who still believe in a Just World. Kate told me, "I'm not religious but I do believe that somehow, in the end, there's justice for everyone." Some people don't think about whether there's a justice that's applied to the whole world but they do expect that there will be justice in their lives. Patricia expected that because she devoted herself to her family they in their turn would be devoted to her, just as Janice expected that because she worked so hard and so loyally for her firm she could rely on the firm's loyalty to her.

Believing in some kind of Just World gives a sense of security. You can think to yourself, "If I'm good nothing bad will happen to me or to my loved ones." Usually we don't spend time thinking about a Just World until a disaster happens. Then we ask, "Why?" Many of the messages left on the tributes to Princess Diana were asking the question, "Why in the whole scheme of things did this happen?"

There are only three possible answers to this question - it was someone else's fault, it was my fault, it happened by chance. However, if you believe in a Just World something happening by chance isn't an option. In a Just World nothing happens by chance. It's either someone else's fault or it's your fault. This becomes a great problem if you're a good person and you suffer a terrible disaster.

Kate, Patricia, Janice and the Duchess of Kent all suffered a terrible disaster. For Janice and the Duchess the disaster was sudden. Janice was made redundant by the firm to whom she'd given her life, and the Duchess lost her baby. For Kate and Patricia the disaster came upon them slowly. Each failure to get pregnant Kate saw as her own personal failure. Pat tried to deny every slight and betrayal that her husband and sons inflicted on her until her birthday came and not one of them remembered. She had to recognize that she was to them no more than a useful doormat.

Each of these women discovered that there was a serious discrepancy between what they thought their life was and what it actually was. They had made a serious error of judgement.

Everyone who reads this article is likely to be old enough to have made a serious error of judgement. It might be that some one you trusted betrayed you, or that something you were sure would happen didn't. Then you start to question every judgement you've ever made. You feel very shaky, and then you find yourself crumbling, fragmenting, even disappearing. Janice said, "When my boss sacked me I couldn't speak. It seemed that everything around me had disappeared and I was falling into nothingness."

When something like this happens you can think that you're going mad but you're not. All that is happening is that many of the interpretations you've made are falling apart because they don't fit what's actually happening. You have to find new interpretations and so put yourself together again.

All the while through this confusion and terror you're asking, "Why has this happened?" If you already know that life is a chancy business and that anything can happen at any time you can say, "It's just one of those things. I'll have to make the best of it." But if you believe in the Just World you can't do this. You're left with "It was someone else's fault" or "It was my fault."

If you choose "It was someone else's fault" you'll get angry. However, good people know that it's wrong to blame other people and get angry with them. Good people always blame themselves.

So when Kate, Janice, Patricia and the Duchess faced the terrible disaster that had befallen them they felt themselves falling apart. They were terrified, and asked themselves, "Why has this happened?" Their answer was, "It's my fault."

What they said to themselves was, "If I'd been a really good person this disaster wouldn't have happened. I must be even more wicked that I thought I was." Thus they turned against themselves, felt disgusted with themselves, hated themselves.

When we feel at peace with ourselves we feel at one with the world. We feel a bond between ourselves and other people. We remember pleasant events from our past and we look to the future with joyful anticipation. When we turn against ourselves and hate ourselves we immediately become very frightened of other people, lest they see how bad we are and so punish and hurt us. So we cut ourselves off from other people. We cut ourselves off from the past because all that we see there is evidence of our wickedness. We cut ourselves off from the future because all that lies ahead is punishment for our wickedness. We cut ourselves off from the world because we are too wicked to be part of society and nature. We are cut off completely, alone in our prison of depression.

The things that put us in that prison are the same things that can release us. This is the wisdom that many people have learnt in the prison of depression.

First they learn that the feeling of being bad and unacceptable isn't an intrinsic, unchangeable attribute but a set of interpretations which they'd created and so could change. Kate said, "I've learnt that it's okay to fail."

Second, they learn that life isn't controlled by a set of laws about punishment and reward but that things happen by chance and it's best to accept this. Janice said, "I no longer feel I have to control everything. I'm free and it's wonderful."

Of course leaving the prison of depression doesn't mean that you'll be blissful happy forever. You've suffered a loss and you feel sad. But the good thing about sadness is that, unlike depression, it can bring people close together.

STRATEGIES FOR CHANGE

Whenever we go on and on doing something which causes us pain, whether it's smoking, falling in love with unsuitable men or being depressed, there's something in the situation which gives us a reward. When we're depressed it's pride that stops us from changing. We take pride in being good. To leave the prison of depression behind you need to

• 1. Admit that you are depressed.
• 2. Make a list of all the things you take pride in - having extremely high standards, keeping yourself to yourself, working hard, letting others depend on you and so on.
• 3. You are faced with a choice - be a very good proud person and depressed or an ordinary person and happy. Which do you prefer?
• 4. If you'd rather be happy than good decide to act as if you are your own best friend. You don't feel like your own best friend but you are going to pretend that you are. Now you're kind to yourself, you look after yourself, you give yourself treats.
• 5. Make sure that every day without fail you do something nice for yourself - go for a walk, listen to music, make someone else do the ironing, say "No" to someone who wants you to do something you don't want to do.
• 6. Find someone to talk things over with, a friend or a counsellor. Sometimes just telling your story is enough. When you can't give up criticising yourself find a psychologist who uses cognitive therapy. Your GP can refer you to an NHS counsellor or psychologist or you can find a private therapist listed in the National Register of Psychotherapy
• 7. Keep a notebook where you can keep a diary and jot down anything you come across - a poem, a thought - which means something to you.
• 8. Helpful books on depression

Dorothy Rowe Depression: the Way Out of Your Prison Third edition Routledge

Dorothy Rowe Breaking the Bonds Harper Perennial

19th March 1997

Sex Changes

It's ideas, not things, that change the world. The mechanics of sex stay the same, generation after generation, but what changes are the ideas we have about sex.

I was born into a society where the dominant idea about sex was that it was secret. Men might talk privately to one another about sex, but they didn't talk about it to women, and women, that is, good women, didn't talk about sex at all. A really good woman didn't even think about sex. My mother, my aunts and my teachers all behaved as if sex didn't exist, or, if it did exist, it was something no teenage girl needed to know anything about.

This idea governed what we were taught at school. When I was in my final year at the Girls' High School in Newcastle, Australia, one of the set texts for the matriculation exams was Shakespeare's The Tempest. The particular text which my class of very bright sixteen years old girls was given was one from which all unseemly words and actions had been removed. We read the text through in class and our teacher, the English mistress, set us an essay about the relationship between Prospero and his servants Ariel and Caliban. Every one of us wrote an essay about how appalled we were by Prospero's unkind treatment of Caliban. At our next lesson our teacher, extremely embarrassed, had to explain to us that Prospero was harsh with Caliban because Caliban had tried to seduce Prospero's young daughter.

We all sat there is silence as she stumbled through this explanation. No one dared to comment out loud, but I remember being disgusted with the sheer stupidity and deceit of these adults. No wonder I became so sceptical of anyone in a position of power!

Now ideas have changed. I spent February with my son in Sydney and every morning woke to the sound of one of the most popular talk radio stations in Australia. It's fast and funny and, whatever the topic might be under discussion, what's always being discussed is sex. One morning the topic was celibacy. Listeners were invited to phone in if they were leading a celibate life. One man phoned to say that he'd been celibate for six days and he was suffering terribly. This was hilarious. A woman phoned to say she'd been celibate for seven years. This was serious. How could she possibly manage without sex! One of the presenters was worried that she might have forgotten how to do it. The one unchallengeable idea in all of these discussions was that if you're not getting plenty of sex and not talking about the sex you're getting there's something seriously wrong with your life.

Nowadays, to be a real, dinky-di Australian, man or woman, you have to be seen to engage regularly in four activities - mowing your lawn, cleaning your car, taking part in or watching sport, and having and talking about sex. No wonder I live in England! Lawns, cars and sport don't interest me at all, while I have always preferred my sex to be private, and I don't want to hear about you unless, of course, you've got something to tell me that's really funny.

Being private about sex is partly a hangover from my childhood and partly from my belief that the ideas people have about sex are so extreme in one way or another that anything I might say could be misunderstood. I've always been puzzled about why our ideas about sex always go to the extreme. In the seventies when the pill had been accepted and still wasn't seen as a danger and Aids hadn't arrived many of us tried to make sex as ordinary and comfortable as a warm sweater on a cold night, but that didn't work. We still got jealous and felt threatened or inadequate and behaved just as badly as did people when sex was the big secret or when, as now, being sexy is what you need if you are going to be seen as someone to be accepted and admired.

Making sex the badge of honour or the standard by which you pass or fail is just as stupid an idea as making it the big secret. It's the stupidity of over-valuing an idea. Sex is important, but it isn't that important.

Every generation of teenagers think that they discovered sex. Ask the Spice Girls and that's what they'll say, except that what they say will be exactly the same as what my friend Merle said when she used to wow the boys. Merle's sixty now. Every generation, on discovering sex, thinks it's important because the very thought of sex can make you feel that life's worth living. The mistake every generation makes is in thinking that it's only sex that will give their life significance. My mother's generation thought that sex expressed as chastity, faithfulness and secrecy made them distinguished in their virtue. Now the idea is that to be valuable you must be seen to be sexually attractive and sexually active. Both ideas are equally nonsensical.

I saw the pain that sex as secrecy caused my mother's generation and their children, and now I see the pain of those people who measure themselves against the standard of sex and see themselves as failing. I see too, out of both sets of ideas, the terrible waste of human energy and talent that could have been spent as friendship, creativity and discovery. When you enter what could be your last decade neither the thought "I am virtuous" nor the thought "I was a sexual athlete of Olympic standards" can make you feel that your life has significance in the universal scheme of things, whereas your friends, the things you've created, the knowledge and understanding you've acquired can give a sense of immense satisfaction. The thought "I've had a great time in bed" can be very satisfying, but if that's all you've got, you'll die wanting an awful lot more.

Dorothy Rowe

Dorothy Rowe's Guide to Life HarperCollins

By VICTORIA LAMBERT

The death of her mother left Janet Grange devastated. The teacher, who lives in Swanage, Dorset, couldn't stop crying, sleep was impossible and she became anxious about her own health.

Her GP was very helpful; after a quick verbal test, he said she was suffering from depression and prescribed antidepressants.

Janet's experience was far from unique - last year doctors wrote 31 million prescriptions for the drugs - a six per cent rise in two years. Meanwhile, estimates about the numbers affected by depression have also risen, to as many as one in 12 people.

Depression, it seems, has become an - epidemic. Or has it? A new book by two leading psychiatrists suggests that more of us are not depressed, rather that doctors are turning sadness - a normal human emotion - into a disease.

Furthermore, they argue, sadness is not a 'bad' state that needs treating, but can actually be good for us. The authors - Allan Horwitz, professor of sociology at Rutgers University, and Jerome Wakefield, professor of social work at New York University - argue that while genuine depression undoubtedly needs medical attention, somehow every other sort of normal human gloom has been rolled up into the package marked 'depression'.

They say sadness is a natural state of mind that has existed since time began and is of some use to humanity. It's not something that should be medicated away with a handful of Prozac.

It may seem extraordinary to think of sadness as a positive thing, but evolution may be the key - according to some experts, sadness helps us learn from our mistakes. It also invites sympathy and therefore help from others.

So how has a normal response become a medical condition? The problem, say the authors, is that when

the definitions for mental illness were set out (in the psychiatrists' bible, The Diagnostic And Statistical Manual Of Mental Disorders), there was no reference to the context in which symptoms were experienced.

For instance, in order to be diagnosed with 'major depressive disorder', you need to experience at least five of nine symptoms that include change in appetite and insomnia. However, these are similar to the sort of symptoms a healthy person might develop after a bereavement.

But the psychiatrist's checklist can't take this into account. As a result, what are entirely normal feelings are characterised as a 'disease', and the bereaved ends up with medication.

As a result, many people are diagnosed with depression when they don't have it. The problem is compounded by the test GPs give their patients to diagnose depression. This takes the form of two questions: 'During the past month, have you been bothered by feeling down, depressed or hopeless?' and

'During the past month have you been bothered by having little interest or pleasure in doing things?'

If you answer 'yes' to both questions, as Janet did, you could find yourself on Prozac.

This type of medication is not to be taken lightly. About 25 per cent of patients have problems when they try to stop taking them, and studies have found they can cause a rise in suicidal thoughts and actions.

Patients also report a loss of libido.

Furthermore, two studies have linked the drugs with a drop in bone density, leading to osteoporosis and a dramatic fall in the number of sperm a man can produce.

It's not just doctors who are to blame - culturally, we seem to have given up on the acceptability of sadness. Eminent psychologist Dorothy Rowe blames sociological changes, too.

'The first problem is that "sad" has become a derogatory word,' she says. 'To be seen as sad, is to be despised.' Meanwhile, in the world of psychotherapy, 'happiness' is the new buzz word.

'There is a notion that you can make happiness your aim when, in fact, it is a by-product of what you do,' she explains.

The reality about sadness, explains Dr Rowe, is that it is usually connected to bereavement 48 - due to a job loss, a child leaving home for university, or most commonly the death of a loved one.

'When you lose someone central to your life, you feel like the world is falling apart and that is very frightening. No wonder you feel anxious. What you don't need is a diagnosis of depression and tablets.

'You actually need help talking about your grief and what the loss is. But it is easier to medicate and then pronounce you cured.'

She agrees that sadness can be a positive emotion. 'If you never feel sad, it is because you have never become attached to someone, and that is a very lonely way to be.'

The Loss of Sorrow: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder by Allan V. Horwitz and Jerome C. Wakefield, (Oxford UniversityPress, £17.99). Dorothy Rowe, Depression: The Way Out of Your Prison (Routledge).

Positive Health Magazine
July 2004

Our Best Drug

Dorothy Rowe

Research in psychiatry over the last 50 years has been largely concerned with comparing one drug with another. Pharmaceutical companies have always been well aware that drugs used in psychiatry could produce vast profits, and so there has always been much competition between drug companies to produce the most effective drugs in the treatment of mental disorder. Many different drugs appear in the research literature, but one drug keeps appearing, a simple drug called placebo. It does remarkably well compared with drugs that contain active ingredients but the authors such of research reports have always preferred not to draw too much attention to these findings. How can a drug company make money out of a sugar pill whose effectiveness resides solely in the how the person taking the drug sees it? If the person thinks it will make him well, it will; if he doesn't, it won't.

However, recent research in physical medicine is putting placebo centre stage because researchers are using methods very different from those used in psychiatry. Psychiatric research simply counted the number of people taking a drug and, of these, how many got better. Recent research in physical medicine has looked at aspects of the situations in which a placebo was used, such as the status of the person doing the prescribing, the way in which the drug was given, even the colour of the pill.

Thus a high status prescriber such as a consultant was more likely to be believed than a low status prescriber such as a nurse. A placebo tablet wasn't as an effective as an intramuscular placebo injection. An injection is a more serious matter than swallowing a pill, and doesn't an injection go straight into the blood stream while a pill has to negotiate the complexities of the digestive system? Pinky red placebos were found to be more effective than blue ones, possibly because pinky red suggests health and vitality while blue suggests illness and failure. Machines, as we all know, can do extraordinary things, so if a person we trust tells us that a machine can reduce our pain we believe this and find that our pain is diminished, even though, unbeknownst to us, the machine wasn't switched on. This is what happened when researchers investigated the use of an ultrasound machine in the treatment of post-operative dental pain. Such a result is hardly surprising, given what is now known about pain.

It used to be thought that there was a direct correlation between the severity of an injury and the degree of pain felt. Yet it was well known that in the height of battle a soldier can be unaware that he has received a massive wound, while in a situation where the person is keenly aware of what is actually happening a tiny injury can be extremely painful. In trying to explain why this was so researchers discovered that the pathways which carry pain messages from the site of the injury to the brain have a series of 'gates' which are open or closed according to the mental state of the person. When we're concentrating on something other than our injury or when we're relaxed and happy many of the pain gates are closed, thus blocking or slowing down the message, but when we're stressed and anxious the gates are open and the pain message goes unimpeded to our brain.

Discoveries like this take our understanding of the relationship between mind and body out of the realm of mystery and into the realm of science. Another research area where this is happening is in those studies of brain activity made possible by the invention of techniques for scanning the brain to determine which part of the brain is being used when the person is engaged in different kinds of activities. One of these techniques is quantitative electroencephalography imaging, a measure associated with blood flow in the brain. Psychiatrists at UCLA compared depressed patients treated with placebo and depressed patients treated an antidepressant drug. It was found that the patients who responded well to placebo showed increased activity in the prefrontal cortex, while patients who responded well to medication showed decreased activity in the prefrontal cortex. It had already been established that the prefrontal cortex is involved in the business of making sense of what's going on, for which we need to be able to think, process information, remember recent events, pay attention, and organise what we're doing.

Amongst people who've been prescribed anti-depressants it's common knowledge that these drugs make thinking and feeling very difficult. Such people will say, 'My head's full of cotton wool,' or, 'I watch things happen but I don't feel anything.' It's perhaps not surprising that many of the depressed people treated only with anti-depressants fail to get better or, if they do, they get depressed again.

By contrast, if we're able to think clearly when we've been prescribed a drug which we believe is going to make us better, we're able to feel hopeful and happy and able to plan for a better future. But only if we value and care for ourselves.

Neither active drugs nor placebos work well for people who are convinced beyond doubt that they are incorrigibly bad, unworthy of health and happiness. People who see themselves like this live constantly in a state of stress. Always expecting rejection, they're constantly frightened of other people. Expecting to be punished for their wickedness, they live in constant fear of what is about to happen. Heartache and self-disgust create pain as real as that which follows physical injury. It's not surprising that researchers are now finding that many major and minor illnesses follow stress and depression.

There's nothing magic about a placebo, no matter what form it takes. Placebos work only when we've already got inside us the key to make a placebo work. That key is the best drug of all, and it's simply the belief that we're valuable and acceptable and that life is worth living.