Hitting the Wall

Metaphors from the Canyon for Mental Health
by Norm Hanson

The run through the rapids felt like a ride on edge of chaos.
Giant waves, holes, skimming along the base of an awesome cliff.
I wondered aloud how it was that we did not hit the wall.
The Guide said, “…try to think like the river.”

There is a familiar adage about how Science excels in dissecting the natural world, whereas Poets (and an occasional River Guide!) may excel in putting the pieces back together. Sometimes, only a metaphor or work of art has sufficient power to comprehend and integrate the countless relationships and events which comprise a whole experience. In like manner, the concept of mental health is something more than a listing of parts, and certainly more than just the absence of disease. Mental health is experienced by each of us in our own way, and for most people it is a prized possession. It molds our experience of who we are, shaping relationships with our loves and fears, with our strengths and handicaps, with our commitments and careers, with our communities of family and friends, and even our relationship with the larger natural world. Perhaps most often it is experienced as a sense of well-being.…..of being in-tune and effectively connected with our internal (inside the head) and external (outside the head) environments.

The state of health of the River Community is self-selected in several ways by the high level of physical and mental demands of the work and the environment. Those who cannot meet these demands are less likely to come, or to stay for very long. Nevertheless, it is a human community with human vulnerabilities. The Whale Foundation arose on realization that problems of health do occur with some frequency for which there were scarce resources of assistance relevant to the unique setting and needs of the River Community. Examples of conditions of mental health which come to the attention of the Health Services Committee include depression, addictions, family strife, reactions and adjustments to crises occurring on the river, situations where mutual respect has been violated in relationships (aka harassment), and problems arising in the transition of careers. Each of these in their own ways can become an example of mental health hitting the wall, with distortion or loss of ability to stay effectively connected or in tune with the things that matter in our physical, mental, social and natural worlds of function. The following comments pertain chiefly to depression.

Depression is fundamentally a problem of regulating emotion. Brief depressive moods and grievings occur in the course of life of most everyone. Major depression is different. It is defined by its intensity, duration, recurrences. It can dominate or constrict function at any or all levels of living, which may include severe dampening of physical and emotional energies, constriction of range and flexibility of thinking and feeling, and inability to sustain open relationships with people and events which occur outside of ourselves. It tends to cluster in families. It is one of the most common conditions, along with substance abuse and schizophrenia associated with thinking about suicide, and with deaths by suicide.

Neuroscience models of brain function, emotion and behavior, have greatly expanded in recent years. The models for depression are no longer confined to simple notions such as chemical imbalance. The regulation of mood and emotion has roots deep in the structure of the brain, and deep in the evolutionary history of animals. Long before the appearance of human computer-like intellect and memory, mood and emotion were the most important means for adaptation and interaction with life’s conditions. Intellect and reason of course expand greatly the choices, but they still operate only in partnership and with the energy provided by emotion.

Genes are the substrate from which all life forms develop; but in a larger sense our heritage also includes the natural and human environment. Genes function only in the context of an environment which can nurture and interact; and each influences the life and function of the other. Major depression tends to cluster in families. Studies now indicate that within those affected families, the direct influence of genes on risk for depression is approximately 30% for men, and 40% for women (For comparison, risk for depression in the general unselected population ranges from 5 to 10%.) To put this another way, even if a person is well endowed with “depressive genes,” there is still a 60 to 70% environmental effect upon whether or not a depression will actually occur. Some aspects of this interaction have been demonstrated in studies of specific genes which regulate brain circuits of emotion, and which have been observed to turn-on and turn-off during interaction with environmental events. These events include exposure to chemicals and drugs, physical trauma and neglect, and even modes of thinking and expectations (which in turn may be representations of culture and social environments). These studies are early and small, but certainly suggest a very complex and holistic model of relationships for understanding mental health.

A geologist friend, veteran of many river trips,
Tells of her deep sense of humility every time she comes here.
No one owns the canyon. We are all visitors;
But the canyon gives and gives,….usually something big
For everyone.

Hitting the wall of familiarity and security of usual experience invites a person to think outside the box. A force for reordering the usual ways we think and believe and act in relationship with our natural worlds. We often respond with fear and seek to restore security of the old order. The Greek roots of the word Crisis mean “a time to decide,” forcing a choice between denial and defensiveness on one hand, or on the other hand acceptance, with an expectation that it will be possible to explore novel ways of adapting to change. Acceptance seems to require at least a small dose of humility.

Anyone who has experienced serious depression will say, “Easier said than done”. Depression can lock- down ability to recognize another way. The first line of response to the crisis may naturally consist of trying harder in doing the things that we know best. The intellectual tries to out-think it. The person oriented to action may try to work it off. The athlete trains with even more intensity. Transient relief through substance use becomes substance abuse, further impairing the capacity to adapt. When these efforts fail, exhaustion and hopelessness are amplified. The terms of survival are increasingly perceived as being all or none.

Feet stuck in red muck
Knees quivering creeping along the ledge.
“I don’t think I would have made it without a Helping Hand.”.
No pushing or pulling, nor barking directions
Steady and quiet, it led me through

The essence of effective therapy, regardless of form, might well be described as a helping hand. Counseling or psychotherapy with a professional may focus on new ways of thinking about problems, and of dealing with emotions and relationships. Medical therapy may consist of taking an antidepressant medication to aid the brain in reregulating mood to a more flexible state. There is some evidence that psychological and medical therapies may complement each other, i.e. Stabilization of brain mood-circuits aids ability to think, and changing a pattern of thinking aids in stabilizing the brain’s circuits for regulating mood. How well do these methods work? And, are there not serious risks?

Repeated studies demonstrate certain degrees of effectiveness of either one or both of these approaches, with approximately 70% of persons reporting significant lessening of depressive symptoms and improvements in conducting their lives. A smaller proportion, approximately 30%, report complete resolution of symptoms within a 6 month period. Clearly, therapies are not cure-alls, but most often do provide some wiggle-room, allowing a person to renegotiate “the edge of the ledge,” to then hopefully continue to build from there. Response to treatment is almost always gradual, over a period of several weeks to months. Someone observed that changing the course of depression was similar to changing the direction and temperament of a legislature: Complex systems seem universally stubborn and entrenched!

All helping hands come with some risks and potential side effects, whether psychological or medical. The act of accepting help opens a window of vulnerability to the potential power of another person, or power of medication over which we initially may not have much control. There is risk that a helper could be misguided, and vulnerability could be abused. The training and standards of the professional therapist strive to prevent this: The safety of the patient comes first. Medication side effects vary greatly person to person: from nothing at all, to benign annoyance, to being intolerable. Some of these sensitivities appear related to presence or absence of certain genes, to dosage of the medicine, and to other contributing physical conditions. Competitive athletes often are endowed with an exquisite sensitive sense of their physical well-being, they never stop tuning it up. Side effects of medication, added on top of physical and motivational problems of depression, can be especially difficult burden for them to tolerate. There have been concerns that antidepressants could increase the risk suicide, at least early in course of treatment. The most recent large statistical follow-up surveys of adults and adolescents do not support this concern. The largest number of suicide attempts occurred during the week prior to starting treatment with an antidepressant, and gradually decreased over the weeks that followed. Again, the effects of therapy take time.

Mark Twain took Huck Finn and Jim down the Mississippi, a journey
that Huck wished would never have to end. It became an American
classic about the “rivers of life”. Metaphors help keep us whole and real.
There are some fortunate people, who have opportunity to live the metaphor, day to day. Keep them coming!

Norm Hanson