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“It comes over me in waves. Squalls of rolling nausea, shudders of heartbeat in the chest; heart like a hamster, forehead tighter than a walnut in a vice. This is life. This is every day. This is twenty-two years pissed away, twenty-two years lost locked in battle with meaningless minutae, a battle that will ultimately be neither lost nor won, but waged until the end of time, the biblical battle between good and evil, right and wrong, everything and everything else. I won’t really be free of this. Not ever. I realize that now. Like diabetes. Like herpes. A cancer of the brain. A living death. A fucking cliche. I’m a fucking cliche.
I’m a living death.”
- August 2005
It started when I was six; watching Pamela Martin blink under the bright lights of the newsroom, I became so fixated on that unconscious process that, for three hours, I couldn’t concentrate on anything else. By the time I was nine, it had transformed into a continuing irritation that usually struck before bedtime; windows had to be checked and rechecked, thermostats repeatedly consulted to ensure they were in the off position. The simple task of saying goodnight to my parents had to be executed in a perfect, routine fashion, or I’d be driven from my bed ten minutes later by an anxiety too pervasive and formless to grasp, to say it all over again. Two months before my nineteenth birthday, it went full-blown, and, by 2005, I hadn’t had a single moment free from physical anxiety or intrusive thoughts in four years. While my peers were concerned with going to school, traveling, getting drunk, and chasing girls, my days were spent doing nothing but clawing for the shallowest, most desperate breaths, dreaming of one day being able to catch one -just one, free of the crushing panic that pressed down on my chest from the second I woke up until the second I went to sleep.
Medically, it’s known as Obsessive-Compulsive Disorder. The DSM IV (the diagnostic manual for Mental Disorders) defines it, in the driest possible terms, as “recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress,” combined with “repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly”.
“Recurrent and persistent thoughts” meant four years of desperate subsistence. Four years of missed job opportunities and squandered friendships, of lying to every person I knew about how I was doing, hoping each night that the next morning would bring deliverance. A return to normal. “Marked anxiety or distress” meant years of feelings that churned my stomach and left me wrapped around the toilet, retching until my guts burned.
Every day, I’d tell myself to toughen up. Figure it out. Get on with my life. And as I told myself this, I watched everything around me fall apart. By the summer of 2005, a four-year relationship had fractured. My job was suspicious of all of my sick-days. I had to move back in with my parents. It was around that time I first thought about ending it all. Not in the clumsy, cry-for-help fashion, and not out of any sort of angst or existential despair. It was a practical decision, or so I thought; after four years, I’d stopped seeing the point. “This is life,” my journal read. “This is every day.” And, whether it was cowardice, intelligence, or stupidity that kept me from doing it, I couldn’t tell you. But the shock of considering suicide led me to wonder, for the first time, whether something might be wrong. And still, I dreamt of one day catching that single stupid breath. Thought about it with the same enthusiasm I’d once reserved for fantasies of lottery wins and celebrity hookups.
One day it could happen, couldn’t it?
One breath, I thought. Just one.
Close to a million British Columbians are directly affected by mental illness each year. That’s 20% of the province. That’s three times as many people as suffer from diabetes. Four times as many as suffer from cancer.
In a single year, more people in British Columbia are dealing with mental illness than live with heart disease, cancer, Alzheimer’s, dementia, AIDS, stroke, and diabetes. Combined. And, while BC’s mental health care programs were once among the most integrated and effective in the world, they are now in need of a desperate overhaul.
“In the nineties,” explains Darrell Burnham, Executive Director of Coast Mental Health, “people used to come to Vancouver to visit, and they would see basically the best, most integrated mental health system in the world, and, it had area-specific mental health teams, they had a common philosophy, they had good psychiatric services out of the local hospitals, they had access to longer-term treatment options at Riverview Hospital, they had an array of community-based services like Coast, they had supported housing. I mean, they had wait-lists for supported housing, but they weren’t miles long. [...] They had some really innovative elements. And since the mid-nineties, the demand has increased, and supply of those types of services has been static.”
B.C. currently devotes 8% percent of its provincial health care budget to the treatment of Mental Health and Addictions. That’s the highest in the country. However, Canada itself ranks close to the bottom of the list of first-world countries when it comes to mental health spending; below the UK, Germany, the Netherlands, Ireland, Australia, and even the United States. And, though the burden of untreated mental illness on the economy and health care system is estimated in the tens of billions, and, despite dozens of recommendations from provincially-commissioned studies, supreme court judges, the United Nations and the WHO, and even in spite of an admission by former premier Gordon Campbell himself that the deinstitutionalization of Riverview has been a complete failure, there don’t appear to be any significant policy changes in the making on the Federal, Provincial, or Municipal level anytime in the foreseeable future. The result is a province-wide system that is as uneven as it is fractured, with heavy support for certain disorders, and virtually none for others.
“If you get diagnosed with cancer in B.C., you’re likely to be treated within five days,” Burnham laments. “You’re likely to be plugged into the treatment recovery process in five days, and you’ll be layered with the best support to get that disease under control, treated, cured. If you get diagnosed with a mental illness – first of all, how long will it take to get diagnosed? And then, how long will it take for you to get the best resources to actually help you recover? It’s a huge gap. If you go to the hospital with a heart attack, you get the best care. You go into the hospital because of a psychotic experience because of mental illness, you go to VGH, and you end up in the worst ward in the hospital. You get treatment, but you often get discharged before you’re well, with no follow-up component. The parallels are terrible.”
Obsessive-Compulsive Disorder is a disease of nagging doubts: A housewife hits a bump in the road, and spends the next hour circling the block to make absolutely certain she didn’t hit anyone. A straight college student glimpses his roommate in his underwear, and suddenly needs to prove to himself that he didn’t feel even the tiniest glimmer of arousal. A middle-aged man uses a public restroom, and, for the rest of the day, washes his hands over and over, because, damn it, they just don’t feel clean. Intrusive thoughts tend to fall into specific categories (known as “spike themes”), with the majority being about germs, violence, or sexuality. The thoughts themselves are often quite common; we’ve all looked at someone we’re not necessarily attracted to, and had a random sexual thought. We’ve all stood at the top of a tall building and imagined what it would feel like to jump. The mind is an idea machine, constantly generating thoughts and impulses; some of them we agree with, others, we find ridiculous, unusual, or repulsive. And, while you might consider those things for a second, a minute, an hour, I couldn’t stop thinking about them for four straight years. Where the average person can dismiss an idea they don’t understand, a person suffering from OCD can’t. These thoughts become trapped in a feedback loop in the brain, with the response being anxiety, and a fanatical need for certainty. In the mind of the sufferer, certainty equals relief; if they can just make absolutely sure that they aren’t gay, aren’t infected with HIV, aren’t secretly planning to smother their newborn in their crib, then their fear will vanish.
My own spike themes sat most often in the region of Sexuality and Relationships – consistent, pervasive fears that I might secretly be gay, and worries that the love I felt for my girlfriend at the time wasn’t entirely sincere. As Dr. Steven Phillipson explains in his revelatory article, “I Think It Moved”, this form of obsessional doubt is extraordinarily common (in fact, it’s just as likely that a gay OCD sufferer will be tormented by fears that he’s secretly straight), and is, in his words, one of “society’s favourite spikes to enable.”
“With the vast majority of OCD spike themes the unreasonable and irrational nature of the spike is generally obvious,” Phillipson explains. “The major difference is that with these two spike themes one does not generally think of OCD as an initial consideration. As a result, most persons with these spike themes generally have a long and painful history of seeking and obtaining fruitless guidance from others in a effort to bring a reasonable resolution to these seemingly legitimate issues.”
Why my spikes revolved around Sexuality and Relationships is something I’ve never totally understood. But, as I later learned, it doesn’t really matter. Because ultimately, it’s not actually about sexuality. It’s not about violence. It’s not about cleanliness. It’s about certainty. It’s about a need to prove the unprovable. The mechanics of obsession are identical no matter what the content is. The thoughts themselves could actually be about anything.
“The predominant distinguishing variable,” Phillipson continues, “which can help determine the difference between a legitimate conflict and an OCD sufferer’s torment, is the felt need and anxiety experienced by the sufferer to gain an immediate, definite, and conclusive resolution to the question.”
It didn’t stop there. Sometimes, I became so fixated on the physical sensation of anxiety that I’d drive myself straight to a panic attack. Once, I spent four days reassuring myself that I hadn’t been possessed by the devil. I knew I was acting in this ridiculous way, but I couldn’t stop it. It was like spending years in the first four stages of grieving, without ever reaching stage five: Anger, denial, bargaining, depression. Repeat.
As far as I knew, the only way to find relief was through Absolute Certainty.
I just couldn’t find it.
“Mr. Donaldson reported a long history of obsessive thoughts and compulsive behaviours dating back to his childhood. He explained that when he was younger, he engaged in numerous checking behaviours (eg. checking the heater of windows a certain number of times before going to bed) and superstitious behaviours (eg, he would have to say goodnight to his parents in a certain way and if he did not do it correctly, he would have to do it again. His OCD symptoms decreased through his adolescence, but flared up in November 2000, and have gotten more severe since. [...]
He reported that he spent considerable time focused on his obsessions, resulting in severe interference in his life. Although he tried to resist the obsessions, he had little control over them.[...]
Given Mr. Donaldson’s openness to psychological interventions, previous successful experience with cognitive behavioral techniques for managing his OCD symptoms, motivations for treatment, good insight, and lack of comorbid psychological conditions, prognosis is cautiously optimistic.”
- Intake Evaluation, from an interview conducted by Rami Nader, Ph.D, on October 24, 2005
In the fall of 2005, my parents sensed that something was wrong and scheduled an appointment with my GP. As a result, I was given a referral to the UBC Anxiety Disorders Clinic, the only government-funded treatment option in the province.
I waited three weeks to hear from them.
At the end of the second month, I made a phone call, and was told that the facility had a wait list in excess of five years. There was also the chance that I’d be unable to receive treatment at all. The woman on the phone used the phrase “no guarantees”. Shortly thereafter, the clinic closed its doors forever, to be replaced by the Operational Stress Institute, a publicly-funded program which deals with instances of Post-Traumatic Stress Disorder in Canadian Police and Military Officers. Currently, there isn’t a single provincially-funded option available within the City of Vancouver specifically for individuals with anxiety-spectrum disorders. And, considering that, of the 900,000 individuals affected by mental illness provincewide, 400,000 of them are suffering from an anxiety disorder, this leaves few real options: either take one’s chances with a VGH Outpatient Team, explore a few group-based options run by non-medical personnel, or pay $160 per session for psychotherapy at a fee-for-service clinic.
“The [UBC] clinic doesn’t exist anymore, because UBC decided that we don’t have anxiety disorders in BC,” explains Dr. Charles Brasfield, his voice layered with sarcasm. Brasfield is the former consultant to the UBC Anxiety Clinic, as well as former Clinical Associate Professor in UBC’s Department of Psychiatry, and the province’s only psychologist/psychiatrist. “VGH had a pretty good outpatient program for difficult anxiety disorders and personality disorders; a dialectical behaviour therapy program,” he continues. “It was discontinued last year. The DBT program now at UBC is entirely private. You can access it, if you have, you know, $3,000.”
Brasfield is also the founder of the North Shore Stress and Anxiety Clinic, the only cognitive-behavioural option in the province for individuals with anxiety-spectrum disorders. The operation employs two psychiatrists, 16 psychologists, two nurses, and takes in close to one million dollars per year. Brasfield is an affable, intelligent, soft-spoken fellow, who divides his time between the North Shore, and remote First Nations communities in BC’s North, where he is involved in outreach work. Brasfield’s expertise is formidable, and, according to him, while the treatment of anxiety disorders is never easy, the process is less mystical than many would believe.
“Panic Disorders, we can deal with in half-a-dozen sessions,” Brasfield explains. “Specific phobias, about the same. They’re simple for us- we’ve all done this for years. We know how it works. We know what the pitfalls are, and what actually helps. Chronic anxiety disorders -PTSD, they’re all about 8 months or so.”
My own psychotherapy program lasted 6 months. The clinic’s approach involves a combination of medication and cognitive-behavioural therapy (CBT), which, as the name suggests, deals with treatment on two fronts. On the cognitive side are number of homework assignments called Thought Experiments, meant to challenge faulty ways of thinking (known as Cognitive Errors), and shine some light into the quiet, private, muffled hell you’ve created for yourself. To contest the assumption that every thought is true and meaningful, a patient is made to record everything that passes through their brain for thirty minutes, and afterward rate its importance. As a challenge to the superhuman amounts of harm you’re afraid of causing, (the harm I imagined causing my girlfriend, for example, was near-catastrophic) you’re made to imagine and document the worst-case scenario of your fears on a chart.
It all leads toward the understanding of a single idea: that thought you had? The one that disgusts and terrifies you? That one you’ve spent days, weeks, years avoiding, or explaining away, or neutralising through compulsions?
It could be true. And there’s no way you’ll ever be sure.
The first day I uttered those words – the first day I wrote them up on my laptop, printed them, and posted them prominently on my bedroom door – was the first day in four years that my life made any sort of sense. Granted, it was a perverse and horrifying kind of sense, but it was something.
It could be true. And there’s no way to be sure.
There’s no cop-out, there’s no brush-off, there’s no attempt to soften the blow.
It’s called Acceptance, and it’s stage five.
The behavioural component of CBT is pointed toward the same goal, but it’s an altogether different beast. While Thought Experiments address the psychological, subtly forming new neural pathways, Exposure and Response Prevention (ERP) is the therapeutic equivalent of a punch in the guts. Rather than avoiding fears, it forces the sufferer to confront them head-on – not just once, and not just for a second, but for an hour each day, until finally, through the process of habituation, those stimuli no longer provoke an anxiety response
You work with a therapist to create an Exposure Hierarchy: a list of potential triggers, ordered according to their potential for anxiety. Sufferers then subject themselves to these triggers, paying close attention during the process, and noting their body’s anxiety response on a scale of 1-10. Once a stimulus no longer causes anxiety, it is retired.
Although I had to make several (one for each spike theme), mine started off tamely enough: say “I’m Gay” out loud. Watch a television show with a gay main character. Write a breakup letter to your girlfriend. Punctuate it with actual failings or issues. Read some homoerotic literature. Eventually, it moved to soft-core erotica. Naked pictures. Reading my breakup letters out loud. And finally, weeks and weeks of the most explicit gay porn imaginable. Acts that would make legitimate homosexuals blush. Picking the most unattractive photos I could find of my then-girlfriend, and putting them in frames nearby.
Anxiety spikes are sadistic creatures; they grow and change as time passes, evolving to fit the freshest of insecurities. And, as a result, there’s an attitude that begins to develop during the early stages of ERP; an idea equally quiet, and equally sadistic. After so many years of being a slave, you begin to get a sick thrill out of your own suffering. You can watch yourself go through some of the darkest moments of your life, but, as you watch, you begin to, in a small way, relish the pain. Thrive on it. Because you realize that through it comes relief. Recovery. Management. Because, for the first time in your life, you’re not running from your fear. You’re not avoiding it. You’re walking straight toward it. You’re looking it square in the eye, and even though you’re sweating bullets, and even though you want nothing more than to turn and bolt, you don’t even slow your step.
Instead, you open your arms, smile, and say “Bring it On.”
You’ve trained yourself to be so at peace with your own uncertainty that, if someone were to ask you about the content of your obsessions, you’d no longer have a definite answer for them.
If someone asked whether you really loved your girlfriend, you could say “Maybe”.
If someone asked whether you were gay, you could say “I don’t know.”
Funny to think that, after all that time, the ultimate expression of your liberation could be nothing more than a shrug of the shoulders.
Helen Keller once said “Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.”
I left psychotherapy in May of 2006, and, in the five years since, thanks to the tools developed there (not to mention some medication to even out the physiology), my disorder has been more or less managed. Of course, there are still rough days – days where I feel like I spun the wheel in some random genetic lottery, and came out as a colossal fucking loser. But there are also days when I feel nothing but gratitude that I found treatment at all. That I wasn’t born fifty years ago, to be condemned to Riverview for a life of Insulin Shock treatments. That I don’t live in BC’s north, where there is zero support, few services, and the only option is to move away or die. That I had a decent-paying job and supportive parents who could help me come up with the more than $3,600 that private treatment cost. Not everyone is so lucky.
I met a girl recently, through mutual friends. She was the first “fellow” Obsessive-Compulsive I’d ever encountered, and, when we met, she was entering her second decade of symptoms. Naturally, I made mention of medication and CBT, and, though she listened, it wasn’t information she was ready to hear. Instead, she told herself to toughen up. Figure it out. Get on with her life. And as she told herself this, she watched everything around her fall apart. For her, it took a visit to the emergency room to put things into perspective. But, when she picked up the phone to figure out what to do next, I’m honoured that she called me. Thanks to that discussion, she’s now in CBT, and, after more than ten years, on the road to managing her symptoms.
There are close to a million British Columbians affected by mental illness each year. Of that million, 400,000 are affected by anxiety disorders, and 75% of them will never seek treatment of any kind. Some of these people have no options. Either due to addiction, or poverty, or simple circumstance, tens of thousands of people in this province will need assistance, and they won’t get it. Some will have that chance. And those people need to know that there is a future. Need to know that, at the end of the road, with a lot of work and a lot of money, there is recovery. There is relief. There’s a breath. There’s the reality that, one day, you’ll be looking back, and realize you did something that millions of people everywhere have never done: you looked your worst fear square in the eye, and you didn’t back down. You laughed in the face of your tormentor. You faced the single greatest challenge of your life, and you beat it. And, what’s more, you can beat it again. It’s knowing that you have the tools to manage yourself. That you know yourself more intimately than most people you’ve ever met will ever know themselves. That you’ve been to the edge of your fear and come back again, and that, if you’re willing to put in the work, you need never fear a single damn thing ever again.
The only liberation is uncertainty, and the only solution is acceptance.
Or maybe it isn’t.
There’s really no way to know.