April 20, 2014

Choosing Happiness

The following document is a sermon written by a recent Telos parent regarding her family’s healing process. It was presented at a Church service in her community. Enjoy.

One day last spring, I saw an accident happen on Museum Road. A teen-age boy on a bicycle came across the road just as a car was making a turn, and the car hit the bicycle and—a few cars back—I saw the boy fly in the air like a tennis ball, up and over the street and the cars until he disappeared. I was suddenly faint, my heart racing, my skin clammy with fear.

This happened in the midst of a much more protracted horror at home—our 17-year-old son’s depression. The boy on Museum Road stood up after a minute, shaken, surely, but just a little bloody. Our experience lasted several months, but it turned out all right, too. We learned we learned a lot, including some things I hope to share with you today.

It’s hard to say when Sam’s depression started. Just a year ago? Or two? Or did it start in 3rd grade when his teacher was so mean, or kindergarten, where the teacher said he seemed to be “elsewhere?” Was it early childhood? Or conception, perhaps, with the mingling of genes from two families with long histories of depression? Was it someone’s fault? Or just the cards he’d been dealt?

When Sam came home from school in the afternoon of March 13, about a month before the bike accident, he was in a pretty bad mood, disappointed with how he’d done in a tennis match. Within three days, he was nauseous and exhausted, like with the flu. He never went back to school. For three months, he could not function. This was not the first time he had been depressed, but it was the worst. The doctors called it Major Depressive Disorder, Severe, known by the diagnostic code 296.23.

He said he was doing a lot of deep thinking, and took copious, indecipherable notes, but he couldn’t explain what it was about. He ate like a zombie, whole minutes lapsing while the spoon was raised. He would wake us up at 2am to say that he wanted to smash his head open like a watermelon and watch it explode in red, wet pieces. He said that if he had a gun he would shoot me and then shoot himself, and then he cried and said he was sorry. The doctor called this suicidal ideation. He woke us at 1, and at 3 and 4 and 5. I would make tea and sit with him, and then I’d turn off the lights and lie on the floor until he fell asleep. Toward the end, he stayed awake all night, his weight on small of his back while his tailbone draped over the edge of the chair and his neck bent against the back, only his thumbs engaged at the controls of his PS2. He’d play a game in which his character would be killed and miraculously restored by a little diamond thing floating above his head, over and over again. The doctor asked him if he knew the difference between what is real and what isn’t, this being the hallmark of psychosis. He’d say, “Yeah?”

By Memorial Day, my son had lost 20 pounds and a quarter of his junior year. He had been through hundreds of cups of tea, six therapists, four medications, and the better part of a set of golf clubs, which lay in pieces on the floor of his room along with a broken lamp, broken chair, broken table, and fragments of wood from his bed, which he had smashed so violently it had to be junked. He slumped in a chair, crying in anguish, his face covered in snot, his mouth contorted from hyperventilation, his throat and chest bleeding where he had clawed himself with his fingernails. The scratches showed above his T-shirt the next day when said good-bye to him at a residential treatment center 2,000 miles from home.

We were lucky.

  • Suicide is the third leading cause of death for young Americans 15 to 24 years old.
  • In the U.S., about 15 million children ages 9 through 17 have a serious mental or addictive disorder such as depression, anxiety, attention deficit hyperactivity disorder, eating disorders, early onset schizophrenia or bipolar disorder.
  • Roughly three percent of all Americans suffer from chronic depression, and 10 percent experience clinical depression at some point in their lives.

It is hard for people who haven’t experienced it firsthand to understand, but depression is not essentially about being sad, or down, or blue. William Styron, author of Sophie’s Choice, calls it “a disorder of mood so mysteriously painful and elusive as to verge close to being beyond description.” Like a lot of sufferers, he complains about the inadequacy of the word depression itself.

“Melancholia”—which appears in English as early as 1303—would still appear to be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a dreadful and raging disease.”

“The first thing that goes is happiness,” explains Andrew Solomon, author of The Noonday Demon, who says the opposite of depression is not happiness but vitality. “You cannot gain pleasure from anything. That’s famously the cardinal symptom of major depression. But soon other emotions follow happiness into oblivion: sadness as you had known it, the sadness that seemed to have led you there; your sense of humor; your belief in and capacity for love. Your mind is leached until you seem dim-witted even to yourself. You lose the ability to trust anyone, to be touched, to grieve. Eventually, you are simply absent from yourself.”

Hippocrates considered depression an illness of the brain. But in the Dark and Middle ages it was seen as a sign of God’s disfavor, and it still carries a whiff of this stigma. When I was struggling with how to help Sam, no one outside of this church and my closest circle of friends spoke to me about it. I was really hurt, but I came to realize that it was awkward and sort of shameful, and they didn’t know what to say. The Renaissance romanticized depression and gave us the paradigm of the melancholic genius whose dejection was insight—and we still have that notion, too, that artists, and especially writers, are the hardest hit, although that may be because writers are the ones who write about it—Virginia Woolf, Sylvia Plath, Rick Moody, Anne Sexton. Today, our understanding is shaped by the psychoanalytic model, although neuroscience, very recently, is giving us some fantastically exciting new ideas about the brain and how it works—among other things, that we are literally wired to connect with other people—and that positive thinking and nourishing relationships quite literally have a beneficial impact on our health.

Someday we’ll understand all this and have specially targeted medicines, but last spring I was alone in the house with a very sick boy, and it was hard to know what to do. Some people said that depression was the very essence of adolescence, and perfectly normal. In fact, depression is often missed in adolescents because their extreme emotions and disproportionate suffering look so much like depression anyway. People said, “Don’t worry, they all talk about suicide.”

But we did worry, and I think we were right to.
Let me say again that we were lucky—among other reasons, because we live in a place and time where mental illness is recognized at least by some people as an authentic issue; you don’t get killed for witchcraft, or told (too often) to suck it up. We were lucky because my husband earns a living wage and his employer shares the burden of health insurance with us, and because I could drop everything else and devote myself to watching over Sam, to reading everything I could lay my hands on and making hundreds of phone calls. Depression reaches across all social classes, but treatment is available only to those with the resources to find it and pay for it. We were lucky because we didn’t have other big issues to deal with at the time, no hurricanes, or drug addictions, or crippling family belief systems such as shame and guilt. We were lucky, most of all, because we didn’t lose him.

Sam did have a psychiatrist, and in this, I didn’t realize how lucky we were. Only about 7,500 child psychiatrists are currently practicing in the US, and every single one of them has a waiting list. Only 300 new child and adolescent psychiatrists complete training each year, which adds up to a pretty severe labor shortage. But we still needed someone for Sam to talk to. It turns out that Reading Pediatrics has child and adolescent psychologists on staff, but honestly, it never crossed my mind. I just started asking about psychologists in town. It’s a wonder I didn’t go off the deep end myself.

Some of those who came highly recommended couldn’t see us for six months. We would agree to see someone in the practice who was, shall we say, less popular, and then we would find out why. Some seemed depressed themselves. Others were obnoxious. One fellow actually slapped me on the back in a crowded waiting room and said, “So! How’s the kid today?”

It could have been worse. Andrew Solomon tells of a therapist who had covered all her furniture with Saran Wrap to protect it from her yapping dogs; he left when one of the dogs peed on his shoe.

Doubtless there are competent adolescent psychologists in Berks County, but it takes more than competence to make a good match. We ended up talking to at least half a dozen therapists, which is a lot of people to tell your whole life story to, and discouraging if from the moment you walk in, you know it’s not going to work. We also met some nice people, but rapport is the most important factor in a patient-psychologist relationship, and rapport we did not find.

You’re not supposed to do this, by the way; you’re supposed to take what you can get and shut up. At one point in our search, Sam’s psychiatrist said, “Hear this? (bang, bang) That’s the sound of me beating my head against the wall.” I found a wonderful therapist, finally, but not before we were turned away three times by his office—he doesn’t see adolescents, he’s not taking new patients, he’s out of the country. He and the psychiatrist both told me later I was right to persevere.

There are a lot of ways to get bogged down when you’re trying to help someone with depression, and one way is to spend a lot of time thinking about why it happened, when the important thing is to take action. Another way to get bogged down is to spend a lot of time trying to choose between the so-called talking therapies or medication. This is often posed as a moral conflict. If it’s “chemical,” then it isn’t your fault, and it’s OK to take medicine—but then wellness still associated not with achieving control of the problem, but with discontinuation of medication. People say, “I’m glad you’re feeling better, but I sure hope you can get off those pills soon.” If it isn’t chemical, then it’s your fault, or so the faulty thinking goes. The important thing is treatment.

“No one has yet taken Prozac for eighty years,” says John Greden, director of the Mental Health Research Institute at the University of Michigan. “But I know the effects of non-medication, or of going on and off medication, or of trying to reduce appropriate doses to inappropriate levels—and those effects are brain damage.”

In other words, depression, particularly repeated episodes, ravages our neuronal tissue. Early intervention can be a life-saver. Like snowflakes, every depression is unique, but for most people, including Sam, what worked best was an integrated approach involving relief of symptoms and the learning of new behaviors to keep you out of trouble. It took our family a long time to figure all this out. In the meantime, Sam was in bad enough shape that a weekly session with a therapist and a few pills wasn’t cutting it. Hospitalization would have been an option for only a couple of weeks, thanks to insurance, and there was reason to think it might make things worse. With the help of a very expensive consultant, we finally found a residential treatment program—in Utah.

Of the talking therapies, a system called Cognitive-Behavioral Therapy, or CBT, is one of the most successful. It was developed by Aaron Beck at the University of Pennsylvania, and is now in used throughout the US and most of Western Europe. Its tenants have been among the most important things my family and I have learned this year.

Very, very simply put, CBT suggests that one’s thoughts about oneself are frequently destructive, and that by forcing the mind to think in certain ways one can actually change one’s reality—some call this “learned optimism.” David Burns has done a lot to popularize CBT as a self-help technique with his books, Feeling Good and the Feeling Good Handbook. At $20 for the 732-page handbook, it is certainly the cheapest form of therapy you can find, and it seems to be working for thousands of people.

You can attribute blue moods to hormones or body chemistry, or blame childhood events, or say that it’s realistic to feel bad because you’ve experienced a loss, or because the world sucks. Burns points out that all these claims are based on the notion that our feelings are beyond our control. If you say “I just can’t help the way I feel,” you will only make yourself a victim of your misery—and you’ll be fooling yourself, because you can change the way you feel.

CBT teaches that even though you might be convinced that they are valid, most of your negative thoughts are distorted and unrealistic. All-or-nothing thinking is a prime example, where if something isn’t perfect, we think it’s a total failure. Obviously this technique is no cure-all, and would not be the first tool to bring out in response to a truly crippling depression. It’s just one tool in the box, but it’s an amazingly effective one. It underlies the philosophy of the residential treatment program my husband and I chose for our son.

We arrived at Telos on Wednesday, May 31st. It’s a funny looking brick house on a busy street, about 45 minutes south of Salt Lake City, but on the horizon, in every direction, are mountains that in May were still covered with snow. There were three of us—Sam, my husband Bill and me—and none of us had had a lick of sleep in at least 36 hours. We were a wreck, but had no real alternative than to trust in a handful of people we had never met and in the strength and resiliency of our son.

There are thousands of residential treatment centers in the U.S. ranging widely in quality, size, focus, approach, and length of stay. They are all expensive. Telos—which is Greek for “ultimate potential”—cares for 24 boys aged 13-17 whose primary diagnosis is anxiety and/or depression. There are boys there with drug and alcohol problems, and boys who cut themselves, but not sexual predators or violent offenders, although every once in a while someone gets mad and punches out a window. It happens. The average length of stay is 9 months.

My first question was, “is this place religious?” because there was no way I was going to turn my son over to a bunch of Mormons. The answer was no, and while it is true that Telos does not preach or judge by Mormon rules, most of the leadership is Mormon—or LDS, as I learned to say, for Latter Day Saints. A couple of boys came to my door just the other evening—two earnest 19-year-olds in white shirts. They were radiant, and they said to me, “Aren’t you curious about what gives us such joy?” and I had to admit, that yes, I was. I’m still not willing to be a subscriber, but in the eight months since I met the folks at Telos, I have learned to love and respect them, especially Tony Mosier, the clinical director and Sam’s principle therapist, and to appreciate the inner strength he gets from his faith.

In the Telos philosophy, the cornerstones of genuine change are love, family, spirituality, principled living, and insightful choices.

  • By love, they mean the truly radical therapeutic idea that the ability to give and receive love is as important as food, water and air. They love the boys. They don’t try not to.
  • Family means that change within the family is needed to accommodate and support lasting individual change.
  • By spirituality, Telos means a person’s ability to connect to a purpose greater than themself. I could definitely go along with this definition.
  • Principled living. Not surprisingly, Telos does not have an “anything goes” philosophy. They believe that certain fundamental truths govern life and support health and happiness, and the program helps kids and families identify and live by those principles. I tend to get a bit squirmy when people talk about fundamental truths, but I really got into this.
  • Finally, by insightful living, they mean the most fundamental human freedom—to choose your attitude. To think clearly, and to make choices about how to live one’s life.

The first thing each of us had to do—not just Sam, but Bill and I, too—was to make a list of at least 10 personal life-principles or values. We had to define them, put them in priority order, and write an essay on why our principles were important to us—and whether or not our actions match them. [In the order of service, behind the announcements, you’ll find the list they gave us to choose from, and I invite you to do the exercise yourself.] It was revealing process for us, and very meaningful. Bill and I were stunned by the beauty and eloquence of Sam’s choices, even just a day or two into the program, and I was reminded all over again of why I chose Bill as my life partner.

Further along in the program, we put together a set of family principles. Our family worked together to come up with a set of five, with definitions: Love, Openness, Togetherness, Generosity and Responsibility. I’m pretty proud of our definitions. Eventually, we built on them to form a whole system of family rules and consequences based not on arbitrary decisions but that flow meaningfully from the principles. We don’t always follow the rules, but just having them gives us a clarity we didn’t have before. We have a lot of family meetings.

The Telos program integrates several modalities. They use medication—very carefully. The staff psychiatrist asked us a million questions, and talked often to Sam, and over time found a formulation that works for him. The boys do a LOT of therapy—group therapy every day, individual therapy each week, recreation therapy, and family therapy—mostly on the phone, although we did spend three fairly intense days out there camping with 24 boys and their families. Just learning to get along at Telos is a kind of therapy. They also believe in the power of exercise—especially daily cardio workouts—and it’s clear that exercise at this level has a profoundly stabilizing effect on the emotions. The boys participate in triathlons, and Sam worked out at a gym at least 1.5 hours a day.

Sam worked really, really hard on all of it. He worked so hard he became the first boy to complete the program in three months. To their credit, Telos changed along with him, redesigning the program so that it was right for him.
The rest of us worked pretty hard, too. It was always moving and sometimes painful, but always rich, deep work. Bill and I wrote letters to Sam describing his first week in our lives. We wrote to him about the best and the worst things we had done as teenagers. We described our spirituality. We studied ego defense mechanisms, and communication techniques. We read The Art of Happiness by the Dalai-Lama, Codependent No More, by Melody Beattie, Man’s Search for Meaning by Viktor Frankl, and The Feeling Good Handbook by David Burns.

In family therapy, the person who goes to the doctor is the “identified patient,” with the rest of the family being the unidentified patients, as it were. We’re all part of a system, and we discovered family systems that were not healthy—cycles of unacknowledged depression, codependency, a tendency to make it “too comfortable” to be depressed.

When I came home that day last spring after the bike accident, I burst into tears not just for the boy, of course, but for my own son. Sam wrapped his skinny arms around me and said, “I’ll make you some tea.” It was a beautiful gesture, and I’m thrilled to have a child who can be compassionate even in pain—but at Telos we learned how much Sam felt responsible for me. He felt he had to be strong in our family, and had to take care of people and make them laugh, and of course that’s too much responsibility for anyone.

Sam came home for good on December 23rd. After Telos he went into an affiliated transitional program where he lived in a house with 9 other boys, and went to public school. That presented its own set of challenges, but it served well as a transition from the wrap-around control of an institution to the “real world.” In a couple of weeks, he’ll start the second semester of his senior year at Wyomissing High School, and graduate with the kids he’s been friends with his whole life. Right now, he’s working on his college applications—and we’ll be ready to send him when the time comes. Six months ago we wouldn’t have sent him around the block.

Will he ever get depressed again? Almost certainly. Will he always know what to do? No. Does he understand himself better, and have goals and principles and in general a pretty strong handle on making a good life? Yes.

I could not be prouder of him. Sam is not just the boy he used to be—or even the boy we knew he could be. He has become a more wonderful, more compassionate and wise, more disciplined and thoughtful, more terrific human being than I could have imagined. He still leaves his socks everywhere, and breaks the rules now and then, but hey, he’s 17.

I’d like to close by going back to David Foster Wallace, who I read before the sermon, and the idea of choosing what has meaning and what to worship.

First, I want to make one thing as clear as I can. There are terrible, wretched, crippling depressions—and then there are the little vexations of everyday life. They are not the same, nor can they be treated the same way—and not in a million years would I suggest that a little shift of perspective will help someone who is really, desperately depressed—but I can’t help but thinking they’re part of the same, long mind-body continuum—along which we always have some control. Because we get to decide what has meaning and what to worship.

Everybody worships, says Wallace.
“The only choice we get is what to worship. And an outstanding reason for choosing some sort of God or spiritual-type thing to worship—be it J.C. or Allah, be it Yahweh or the Wiccan mother-goddess or the Four Noble Truths or whatever—is that pretty much anything else you worship will eat you alive.

If you worship money and things, then you will never have enough.
Worship your own body and beauty and sexual allure and you will always feel ugly, and when time and age start showing, you will die a million deaths before they finally plant you.
Worship power, and you will feel week and afraid, and will need ever more power over others to keep the fear at bay.
Worship your intellect, being seen as smart, and you will end up feeling stupid, a fraud, always on the verge of being found out. And so on.

My son Sam says that the most important thing he learned at Telos was to take responsibility for making things the way he wanted them to be. Not to be passive. Not to be a victim. Some of us, and God help us, will suffer from severe depression while others will get away with the blues. But all of us have choices about how we think and what we worship and how we take care of ourselves. May we choose well.

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