The dark, downward spiral | Malcolm Tortell

Let’s talk about depression. Not perhaps the jolliest topic for a midsummer afternoon on a beach, I’ll admit. But an important one, for very often it is precisely our own fear of depression that may prevent us from detecting warning signs which may otherwise conceivably save lives.

That, at any rate, is what psychotherapist Malcolm Tortell has just finished explaining to me at his Naxxar clinic. In a curious reversal of roles he tells me this from the patient’s couch, while I sit in the therapist’s chair: an arrangement that has more to do with the photographer’s lighting requirements [and with me having a surface on which to take notes] than with any sudden career change on my part.

But it is a useful illusion to maintain for a while, if we are to take a look at depression from a clinical perspective.

This week we were all in a sense forced to do this because of the very public death of US actor and comedian Robin Williams, who committed suicide at 63.

Williams had evidently made a deep impression on the millions around the world who followed his career from their infancy. I myself found the news strangely saddening, and Malcolm Tortell felt the same way. He admits his own reaction took him by surprise.

“My first reaction was, oh, wait, it’s another hoax. But then [when it was confirmed] I really felt it. I thought of all the times I’d seen his movies… Good Morning Vietnam, Dead Poets’ Society… so it felt almost as if I had a personal connection with this guy …”

At the same time, there was a poignant irony in his death. The same Robin Williams who made us all laugh had also struggled for years with depression: a revelation which elicited mixed reactions the world over. Some made public observations of the link that seems to exist between comic mania and depression; others interpreted his suicide as a symptom of the jaded lifestyle of the impossibly rich and famous.

Yet none of us (us lay people, I mean) have very much real knowledge about what depression is and what it does. Let’s start with reactions such as: what did Robin Williams have to be depressed about, anyway? He was wealthy, successful, loved by millions…What does this sort of reaction tell us about our knowledge of depression?

“I think that’s a very superficial view,” Tortell begins. “Just because someone is wealthy, has a lot of fans, just because someone is admired and respected by millions – literally, in this case – it doesn’t automatically mean they are happy. Otherwise, what we’d be saying is that people who don’t have a certain amount of wealth should be depressed. Is that what we’re saying? You have to see the flipside… and I think people would react strongly against that…”

Malcolm Tortell points out that clinical depression is not ‘just a frame of mind’, nor even a reflection of one’s circumstances: it is a medical condition that has a basis in biology.

“This is more a case of: his mental health was such that it led him to this act. It’s not a question that the guy could wake up, look around him and say: oh, I have all these fans, I have these movies…” Tortell shakes his head. “It doesn’t hit home. Another thing is that: would we say that someone who is wealthy should not suffer from diabetes? Or schizophrenia, or a host of other diseases? There is a very strong biological component to depression. It’s not the whole story: I wouldn’t say that depression is just a 100% biological illness. But it makes no sense to say that because you have a certain income you’re suddenly immune…”

So what is a depression, anyway? Tortell starts out by explaining what it is not: and the first misconception to be tackled is the interchangeable use of ‘depression’ with ‘sadness’.

“We need to distinguish between a clinical and a reactive depression. A reactive depression is when you’re in that state for a reason: loss of a loved one, for instance…”

This, he adds, is not a medical condition at all: it is in fact normal.

Clinical depression, on the other hand, concerns cases where the external factors are no longer the only cause.

“In a nutshell, the brain is a mixture of electrical and chemical processes. There are certain chemicals – like serotonin, dopamine, etc. – whose levels are going to affect our mood. It is a two-way process. In other words, if you go out and do something pleasurable, like have a nice meal with friends, it’s going to increase the levels of certain chemicals which lead to a feeling of pleasure.

“So there’s a feedback loop. But if the brain, for some reason, cannot produce the right amount of chemicals, then the person is going to go into a dark mood. In other words, if it were possible for me to ‘inject’ someone with a certain chemical, it could affect their mood. And this we know from the use of even alcohol and other drugs…”

In the case of depression, the chemicals in one’s brain would be out of balance, so one’s mood can no longer be stabilised by external circumstances.

“Clinical depression is not brought about by ‘thinking about life’, either. You cannot think yourself into a depression, because the chemical imbalance in itself will be interfering with your thinking process…”

Nor is it a case of extreme despondency, as the word is so often used to mean.

“These people would experience feelings of emptiness, of darkness… depression is a very heavy, dark experience. It’s not a feeling of sadness, really. It’s more of a feeling of nothingness. And this is the difficulty in working with it. How do you work with nothing…?”

One way is through medication. There are no drugs to change life circumstances, but anti-depressants can directly address the imbalance (i.e., biological) component. “What the medication does is that it resets the chemical levels in the brain, so that the mood can start to lift.”

Anti-depressants are successful in treating acute depression; but the Robin Williams case also illustrated that individual circumstances are very often more complex than they at first appear.  

“In this case there were also addictions. It can happen that one gets into a depressed state, and starts to self-medicate: using alcohol, drugs, whatever makes them feel better. Then the addiction itself starts becoming a problem. Then these people start to feel bad and ashamed because they’re self-medicating, and the whole thing spirals…”

There are also non-biological considerations to consider. Robin Williams was best known as a comic actor, which is in itself an illusion – a role that he played for the outside world. The same basic principle – i.e., that of ‘playing roles’ in which one projects oneself as how one would like to be seen – is applicable to more or less everyone.

“I get clients who say, oh, because everyone on Facebook is really happy… they’re all on holiday, and there are all these smiley photos. I tell them, listen, that’s an illusion. That is people picking and choosing aspects of their life… there is actually research on this, I recently read a dissertation about it. People create and market an image of themselves. No one posts a photo of the bog standard cereal they have every morning, but if it’s a fancy English breakfast they’ll post a photo. No one posts a photo of themselves in the morning going to work, but if they’re on holiday they do. But people take that as reality, and compare it. So really and truly, I would think the biggest danger is comparing ourselves to others. We’re comparing ourselves to an illusion, to the image a person wants to project…”

Meanwhile, the attention received by celebrity tragedies masks another reality. For every widely reported case, there will be countless others which never make the news. How widespread is depression, anyway, and (tentatively) what percentage of these cases would be considered at high risk of suicide?

“In terms of depression, generally we are talking about roughly one per cent of the population. But that doesn’t shed much light on the risk of suicide. There are other factors that may cause people to take their own life. You can argue that they were depressed at the actual moment, yes, but it wouldn’t have been a direct cause. At the same time, there is another one per cent suffering from schizophrenia. One per cent OCD [obsessive compulsive disorder]; 30% of women have been sexually harassed; 30% of women have been physically abused… by the time you add it all up… and then there are the less visible cases. People suffering from OCD, minor depression, anxiety disorders…”

This latter category appears to be on the increase. “Suicide can be the result of something acute: a panic or anxiety attack. It can be people failing exams, it can be people breaking up a relationship, it can be all sorts of things. What we have to realise is that when you add up all the ‘one per cents’, and the prevalence of abuse in Malta, which a lot of people don’t acknowledge, there are a lot of people suffering. Child protection and domestic violence get one new case a day. Obviously cases vary in how serious they are, but that’s a lot for a country the size of Malta.”

Psychotherapists and social workers are on the front line when it comes to dealing with emergencies. But anyone can conceivably find oneself in that classic Hollywood cliché scene where they have to ‘talk someone off the ledge’.

From a professional perspective, is there an established procedure to handle such emergencies? Is there a “do’s and don’ts” list for potential suicide cases… like there is with people asphyxiating or having an epileptic fit?

There is no specific handbook, it seems, but Malcolm Tortell believes from experience that some approaches tend to work.

“I would say, address it directly. Let’s take it one step back. Let’s say you think someone might be suicidal: a friend or a family member, whatever. Don’t beat about the bush. Ask them: are you thinking about killing yourself? A lot of the issue is our own fear, our own reluctance to address the subject, when that person would actually be crying out for someone to acknowledge it. He might say, yes I am. That in itself can already provide a level of support. To ask the direct question is usually the best way. On the other hand, if someone comes up to us and tells us he’s depressed and thinking of committing suicide, the first thing you need to do is acknowledge the validity of those feelings. You can’t go: oh come on, you’ll get over it… things will get better, and so on and so forth. It’s more a case of: tell me how you’re feeling?”

In most cases, he adds, the answer may surprise you.

“I find it almost insulting to try and empathise with them, and say, oh I know how you feel. We don’t know how someone suicidal feels. So you have to ask. Can I help in any way? Can I do anything?”

As for direct confrontation with a person in the act of attempting suicide, the approach should be based on attitude rather than technique.

“As humans we have a tendency to ‘overcomplicate’ things in our mind. We tend to think, there’s a new technique, there’s a method. The technique is basic human relationships. It’s ‘hi, how are you, what can I do for you?’ That’s it. If you can create a connection… because a person, in that moment, will be feeling very disconnected, very isolated. So we need to approach with an attitude, not with a technique. Believe me, if there were techniques we could say would definitely work, someone would be selling them for 5,000 euros. But there isn’t. It’s an attitude we need to develop.

As far as the “don’ts” are concerned, Tortell advises against being judgmental: an advice he extends to judgmental reactions to suicide cases along the lines that suicide is a ‘selfish’ or ‘irresponsible’ act. 

“We tend to judge people by our own standards: ‘If I were you…’ Well, you’re not. We have to understand that what a person goes through is what he goes through. We can’t sit there and say, ‘oh, I would have done differently.’ First of all, we don’t know this. To give a very brief example: I worked with heroin addicts for a number of years. Sometimes you say, but how can people knowingly go down that road, with all the problems, and so on. But I wasn’t brought up in their circumstances. Had I been let loose on the streets from a housing estate at the age of five or six, maybe I would have become a drug runner, or a drug user. You can’t just point a finger and take the high moral ground.” 

Moreover, this attitude overlooks the mental state of people in such extreme situations.

“I honestly think that when a person gets to that stage, and tries to take his own life… I don’t think that person can be held up to the normal standards of responsibility. I think in that moment, they cannot see any hope, or any reason for it. I don’t think placing a moral judgement on someone who has already suffered so terribly is useful in any way. As a matter of fact I find it quite distasteful. How do they know? How do they know what version of hell that person was living through?”

Though tragic, Robin Williams’ death also illustrated precisely how little we knew about the man behind the mask: and the same applies to the people behind the masks worn by everyone else we know. Is there anything in all this that Malcolm Tortell would consider to be his final ‘Mork Calling Orson’ moment?

“Robin Williams’ death was first and foremost a tragedy for his family and friends. But also we have a man here who reached out to millions, who left an amazing legacy. At the risk of… I don’t know how this will sound, but maybe we can use things like this to bring about more awareness; to let people know that depression can strike anyone… get over this idea of people being ‘immune’. And that would also, I think, be a nice legacy to leave behind, apart from his acting and his comedy and all that.”

The final message, however, comes from his life, not death. “I think it’s a strong message to people who suffer from the same or similar issues: that they can still lead a life full of meaning. Because the guy did a lot. He spread so much. So I think the final message to be taken from his life is that, even if someone is struggling or suffering, they can still make something of it.”