"The reason that we have not been Loving our neighbor as ourselves is because we have been doing it backwards. We were taught to judge and feel ashamed of ourselves. We were taught to hate ourselves for being human."

"If I am feeling like a "failure" and giving power to the "critical parent" voice within that is telling me that I am a failure - then I can get stuck in a very painful place where I am shaming myself for being me. In this dynamic I am being the victim of myself and also being my own perpetrator - and the next step is to rescue myself by using one of the old tools to go unconscious (food, alcohol, sex, etc.) Thus the disease has me running around in a squirrel cage of suffering and shame, a dance of pain, blame, and self-abuse."

Codependence: The Dance of Wounded Souls

Codependence is insidious because it is so pervasive. The core emotional belief that there is something wrong with who we are as beings affects all of the relationships in our life and keeps us from learning how to Truly Love. In a Codependent society value is assigned in comparison (richer than, prettier than, more spiritual than, healthier than, etc.) so that the only way to feel good about self is the judge and look down on others. Comparison serves the belief in separation which makes violence, homelessness, pollution, and billionaires possible. Love is about feeling connected in the scheme of things not separate.

Codependence is vicious because it causes us to hate and abuse ourselves. We were taught to judge and shame ourselves for being human. At the core of our relationship with ourselves is the feeling that we are somehow not worthy and not lovable.

My father was trained that he was supposed to be perfect and that anger was the only permissible male emotion. As a result, that little boy that made mistakes and got yelled at felt like he was flawed and unlovable.

My mother told me how much she loved me, how important and valuable I was, and how I could be anything that I wanted to be. But my mother had no self-esteem and no boundaries so she emotionally incested me. I felt responsible for her emotional well-being and felt great shame that I couldn't protect her from father's raging or the pain of life. This was proof that I was so flawed that, though a woman might think I was lovable, eventually the truth of my unworthiness would be exposed by my inability to protect her and insure her happiness.

The church I was raised in taught me that I was born sinful and unworthy, and that I should be grateful and adoring because God loved me in spite of my unworthiness. And, even though God loved me, if I allowed my unworthiness to surface by acting on (or even thinking about) the shameful human weaknesses that I was born with - then God would be forced, with great sadness and reluctance, to cast me into hell to burn forever.

Is it any wonder that at my core I felt unworthy and unlovable? Is it any wonder that as an adult I got trapped in a continual cycle of shame, blame, and self-abuse?

The pain of being unworthy and shameful was so great that I had to learn ways to go unconscious and disconnect from my feelings. The ways in which I learned to protect myself from that pain and nurture myself when I was hurting so badly were with things like drugs and alcohol, food and cigarettes, relationships and work, obsession and rumination.

The way it works in practice is like this: I am feeling fat; I judge myself for being fat; I shame myself for being fat; I beat myself for being fat; then I am hurting so badly that I have to relieve some of the pain; so to nurture myself I eat a pizza; then I judge myself for eating the pizza, etc. etc.

To the disease, this is a functional cycle. The shame begets the self-abuse which begets the shame which serves the purpose of the disease which is to keep us separate so the we don't set ourselves up to fail by believing that we are worthy and lovable.

Obviously, this is a dysfunctional cycle if our purpose is to be happy and enjoy being alive. The way to stop this cycle is two-fold and simple in theory but extremely hard to implement on a moment-to-moment, day-to day basis in our lives. The first part has to do with removing the shame from our inner process. This is a complicated and multi-leveled process that involves changing the belief systems that are dictating our reactions to life (this include everything from positive affirmations to grief/emotional energy release work, to support groups, to meditation and prayer, to inner child work, etc.) so that we can change our relationship with ourselves at the core and start treating ourselves in healthier ways.

The second part is simpler and usually harder. It involves taking 'the action.' ('the action' refers to the specific behavior. We have to take action to do all of the things listed in the first part as well.) Changing the behavior that is giving us a reason for the shame. Just saying 'no' - or 'yes' if the behavior in question is something like not eating or isolating or not exercising. And even though it may sometime work in the short run to use shame and judgment to get ourselves to change a behavior, in the long term - in alignment with our goal of having a more Loving relationship with ourselves so that we can be happy - it is much more powerful to take that action in a Loving way.

This involves setting a boundary for the little child inside of us, who wants instant gratification and instant relief, out of the Loving adult in us who understands the concept of delayed gratification. (If I exercise every day I will feel much better in the long run.) True pride comes from action taken. It is false pride to feel good about ourselves in comparison because of looks, talent, intelligence or for being forced to become spiritual, healthy, or sober. Those are gifts. True pride is taking credit for the action we have taken to foster, nurture, and maintain those gifts.

The way to break the self-destructive cycle, to stop the dance of shame, suffering, and self-abuse, is to set Loving boundaries for ourselves in the moment of that desperate need for immediate gratification and to know that - though it is not shameful if we can't do it perfectly or all the time - we need to 'just do it.' We need to stand up for our True Self to our wounded self in order to Love ourselves.

next: The Codependency Recovery Process, Mental, Emotional, Spiritual

Learn about the different types of alternative medicine including Chinese medicine, Ayurvedic medicine, naturopathy, homeopathy.

On this page

• Introduction
• Traditional Chinese Medicine
• Ayurvedic Medicine
• Naturopathy
• Homeopathy
• Summary
• For More Information
• References

Introduction

Whole medical systems involve complete systems of theory and practice that have evolved independently from or parallel to allopathic (conventional) medicine. Many are traditional systems of medicine that are practiced by individual cultures throughout the world. Major Eastern whole medical systems include traditional Chinese medicine (TCM) and Ayurvedic medicine, one of India's traditional systems of medicine. Major Western whole medical systems include homeopathy and naturopathy. Other systems have been developed by Native American, African, Middle Eastern, Tibetan, and Central and South American cultures.

Traditional Chinese Medicine

TCM is a complete system of healing that dates back to 200 B.C. in written form. Korea, Japan, and Vietnam have all developed their own unique versions of traditional medicine based on practices originating in China. In the TCM view, the body is a delicate balance of two opposing and inseparable forces: yin and yang. Yin represents the cold, slow, or passive principle, while yang represents the hot, excited, or active principle. Among the major assumptions in TCM are that health is achieved by maintaining the body in a "balanced state" and that disease is due to an internal imbalance of yin and yang. This imbalance leads to blockage in the flow of qi (or vital energy) and of blood along pathways known as meridians. TCM practitioners typically use herbs, acupuncture, and massage to help unblock qi and blood in patients in an attempt to bring the body back into harmony and wellness.

Treatments in TCM are typically tailored to the subtle patterns of disharmony in each patient and are based on an individualized diagnosis. The diagnostic tools differ from those of conventional medicine. There are three main therapeutic modalities:

1. Acupuncture and moxibustion (moxibustion is the application of heat from the burning of the herb moxa at the acupuncture point)
2. Chinese Materia Medica (the catalogue of natural products used in TCM)
3. Massage and manipulation

Although TCM proposes that natural products catalogued in Chinese Materia Medica or acupuncture can be used alone to treat virtually any illness, quite often they are used together and sometimes in combination with other modalities (e.g., massage, moxibustion, diet changes, or exercise).

The scientific evidence on selected modalities from TCM is discussed below.

Acupuncture: The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 states that acupuncture is being "widely" practiced--by thousands of acupuncturists, physicians, dentists, and other practitioners--for relief or prevention of pain and for various other health conditions.¹ In terms of the evidence at that time, acupuncture was considered to have potential clinical value for nausea/vomiting and dental pain, and limited evidence suggested its potential in the treatment of other pain disorders, paralysis and numbness, movement disorders, depression, insomnia, breathlessness, and asthma.

Preclinical studies have documented acupuncture's effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine.

It is proposed that acupuncture produces its effects by the conduction of electromagnetic signals at a greater-than-normal rate, thus aiding the activity of pain-killing biochemicals, such as endorphins and immune system cells at specific sites in the body. In addition, studies have shown that acupuncture may alter brain chemistry by changing the release of neurotransmitters and neurohormones and affecting the parts of the central nervous system related to sensation and involuntary body functions, such as immune reactions and processes whereby a person's blood pressure, blood flow, and body temperature are regulated.^2,3

References

Chinese Materia Medica
Chinese Materia Medica is a standard reference book of information on medicinal substances that are used in Chinese herbal medicine.4 Herbs or botanicals usually contain dozens of bioactive compounds. Many factors--such as geographic location, harvest season, post-harvest processing, and storage--could have a significant impact on the concentration of bioactive compounds. In many cases, it is not clear which of these compounds underlie an herb's medical use. Moreover, multiple herbs are usually used in combinations called formulas in TCM, which makes the standardization of herbal preparations very difficult. Further complicating research on TCM herbs, herbal compositions and the quantity of individual herbs in a classic formula are usually adjusted in TCM practice according to individualized diagnoses.

In the past decades, major efforts have been made to study the effects and effectiveness of single herbs and of combinations of herbs used in classic TCM formulas. The following are examples of such work:

• Artemisia annua. Ancient Chinese physicians identified that this herb controls fevers. In the 1970s, scientists extracted the chemical artemisinin from Artemisia annua. Artemisinin is the starting material for the semi-synthetic artemisinins that are proven to treat malaria and are widely used.⁵

• Tripterygium wilfordii Hook F (Chinese Thunder God vine). Thunder God vine has been used in TCM for the treatment of autoimmune and inflammatory diseases. The first small randomized, placebo-controlled trial of a Thunder God vine extract in the United States showed a significant dose-dependent response in patients with rheumatoid arthritis.6 In larger, uncontrolled studies, however, renal, cardiac, hematopoietic, and reproductive toxicities of Thunder God vine extracts have been observed.

Ayurvedic Medicine

Ayurveda, which literally means "the science of life," is a natural healing system developed in India. Ayurvedic texts claim that the sages who developed India's original systems of meditation and yoga developed the foundations of this medical system. It is a comprehensive system of medicine that places equal emphasis on the body, mind, and spirit, and strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. In India, Ayurvedic treatments have been developed for various diseases (e.g., diabetes, cardiovascular conditions, and neurological disorders). However, a survey of the Indian medical literature indicates that the quality of the published clinical trials generally falls short of contemporary methodological standards with regard to criteria for randomization, sample size, and adequate controls.⁷

Naturopathy

Naturopathy is a system of healing, originating from Europe, that views disease as a manifestation of alterations in the processes by which the body naturally heals itself. It emphasizes health restoration as well as disease treatment. The term "naturopathy" literally translates as "nature disease." Today naturopathy, or naturopathic medicine, is practiced throughout Europe, Australia, New Zealand, Canada, and the United States. There are six principles that form the basis of naturopathic practice in North America (not all are unique to naturopathy):

1. The healing power of nature
2. Identification and treatment of the cause of disease
3. The concept of "first do no harm"
4. The doctor as teacher
5. Treatment of the whole person
6. Prevention

The core modalities supporting these principles include diet modification and nutritional supplements, herbal medicine, acupuncture and Chinese medicine, hydrotherapy, massage and joint manipulation, and lifestyle counseling. Treatment protocols combine what the practitioner deems to be the most suitable therapies for the individual patient.⁸

As of this writing, virtually no research studies on naturopathy as a complete system of medicine have been published. A limited number of studies on botanicals in the context of use as naturopathic treatments have been published. For example, in a study of 524 children, echinacea did not prove effective in treating colds.⁹ In contrast, a smaller, double-blind trial of an herbal extract solution containing echinacea, propolis (a resinous product collected from beehives), and vitamin C for ear pain in 171 children concluded that the extract may be beneficial for ear pain associated with acute otitis media.¹⁰ A naturopathic extract known as Otikon Otic Solution (containing Allium sativum, Verbascum thapsus, Calendula flores, and Hypericum perforatum in olive oil) was found as effective as anesthetic ear drops and was proven appropriate for the management of acute otitis media-associated ear pain.¹¹ Another study looked at the clinical effectiveness and cost-effectiveness of naturopathic cranberry tablets--versus cranberry juice and versus a placebo--as prophylaxis against urinary tract infections (UTIs). Compared with the placebo, both cranberry juice and cranberry tablets decreased the number of UTIs. Cranberry tablets proved to be the most cost-effective prevention for UTIs.¹²

References

Homeopathy

Homeopathy is a complete system of medical theory and practice. Its founder, German physician Samuel Christian Hahnemann (1755-1843), hypothesized that one can select therapies on the basis of how closely symptoms produced by a remedy match the symptoms of the patient's disease. He called this the "principle of similars." Hahnemann proceeded to give repeated doses of many common remedies to healthy volunteers and carefully record the symptoms they produced. This procedure is called a "proving" or, in modern homeopathy, a "human pathogenic trial." As a result of this experience, Hahnemann developed his treatments for sick patients by matching the symptoms produced by a drug to symptoms in sick patients.¹³ Hahnemann emphasized from the beginning carefully examining all aspects of a person's health status, including emotional and mental states, and tiny idiosyncratic characteristics.

Since homeopathy is administered in minute or potentially nonexistent material dosages, there is an a priori skepticism in the scientific community about its efficacy. Nonetheless, the medical literature provides evidence of ongoing research in the field. Studies of homeopathy's effectiveness involve three areas of research:

1. Comparisons of homeopathic remedies and placebos
2. Studies of homeopathy's effectiveness for particular clinical conditions
3. Studies of the biological effects of potencies, especially ultra-high dilutions

Five systematic reviews and meta-analyses evaluated clinical trials of the effectiveness of homeopathic remedies as compared with placebo. The reviews found that, overall, the quality of clinical research in homeopathy is low. But when high-quality studies were selected for analysis, a surprising number showed positive results.^13-17

Overall, clinical trial results are contradictory, and systematic reviews and meta-analyses have not found homeopathy to be a definitively proven treatment for any medical condition.

Summary

While whole medical systems differ in their philosophical approaches to the prevention and treatment of disease, they share a number of common elements. These systems are based on the belief that one's body has the power to heal itself. Healing often involves marshalling multiple techniques that involve the mind, body, and spirit. Treatment is often individualized and dependent on the presenting symptoms. To date, NCCAM's research efforts have focused on individual therapies with adequate experimental rationale and not on evaluating whole systems of medicine as they are commonly practiced.

For More Information

NCCAM Clearinghouse

The NCCAM Clearinghouse provides information on CAM and on NCCAM, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

NCCAM Clearinghouse

Toll-free in the U.S.: 1-888-644-6226
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E-mail: info@nccam.nih.gov
Web site: www.nccam.nih.gov

About This Series

"Biologically Based Practices: An Overview" is one of five background reports on the major areas of complementary and alternative medicine (CAM).

• Biologically Based Practices: An Overview

• Energy Medicine: An Overview

• Manipulative and Body-Based Practices: An Overview

• Mind-Body Medicine: An Overview

• Whole Medical Systems: An Overview

The series was prepared as part of the National Center for Complementary and Alternative Medicine's (NCCAM's) strategic planning efforts for the years 2005 to 2009. These brief reports should not be viewed as comprehensive or definitive reviews. Rather, they are intended to provide a sense of the overarching research challenges and opportunities in particular CAM approaches. For further information on any of the therapies in this report, contact the NCCAM Clearinghouse.

NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM.

next: Alternative Approaches to Mental Health Care

References

1. National Institutes of Health Consensus Panel. Acupuncture: National Institutes of Health Consensus Development Statement. National Center for Complementary and Alternative Medicine Web site. Accessed at odp.od.nih.gov/consensus/cons/107/107_statement.htm on April 30, 2004.
2. Takeshige C. Mechanism of acupuncture analgesia based on animal experiments. In: Scientific Bases of Acupuncture. Berlin, Germany: Springer-Verlag; 1989.
3. Lee BY, LaRiccia PJ, Newberg AB. Acupuncture in theory and practice. Hospital Physician. 2004;40:11-18.
4. Bensky D, Gamble A. Chinese Herbal Medicine: Materia Medica. Rev ed. Seattle, WA: Eastland Press; 1993.
5. Klayman DL. Qinghaosu (artemisinin): an antimalarial drug from China. Science. 1985;228(4703):1049-1055.
6. Tao X, Younger J, Fan FZ, et al. Benefit of an extract of Tripterygium Wilfordii Hook F in patients with rheumatoid arthritis: a double-blind, placebo-controlled study. Arthritis and Rheumatism. 2002;46(7):1735-1743.
7. Hardy ML. Research in Ayurveda: where do we go from here? Alternative Therapies in Health and Medicine. 2001;7(2):34-35.
8. Smith MJ, Logan AC. Naturopathy. Medical Clinics of North America. 2002;86(1):173-184.
9. Taylor JA, Weber W, Standish L, et al. Efficacy and safety of echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. Journal of the American Medical Association. 2003;290(21):2824-2830.
10. Sarrell EM, Cohen HA, Kahan E. Naturopathic treatment for ear pain in children. Pediatrics. 2003;111(5):e574-e579.
11. Sarrell EM, Mandelberg A, Cohen HA. Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media. Archives of Pediatric & Adolescent Medicine. 2001;155(7):796-799.
12. Stothers L. A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women. Canadian Journal of Urology. 2002;9(3):1558-1562.
13. Jonas WB, Kaptchuk TJ, Linde K. A critical overview of homeopathy. Annals of Internal Medicine. 2003;138(5):393-399.
14. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet. 1997;350(9081):834-843.
15. Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homeopathy. British Medical Journal. 1991;302(6772):316-323.
16. Mathie RT. The research evidence base for homeopathy: a fresh assessment of the literature. Homeopathy. 2003;92(2):84-91.
17. Cucherat M, Haugh MC, Gooch M, et al. Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials. HMRAG. Homeopathic Medicines Research Advisory Group. European Journal of Clinical Pharmacology. 2000;56(1):27-33.

next: Alternative Approaches to Mental Health Care

Do alternative therapies such as chiropractic manipulation, massage therapy, reflexology or rolfing really improve your mental health? Here's what the science says.

On this page

• Introduction
• Scope of the Research
• Summary of the Major Threads of Evidence
• Definitions
• For More Information
• References

Introduction

Under the umbrella of manipulative and body-based practices is a heterogeneous group of CAM interventions and therapies. These include chiropractic and osteopathic manipulation, massage therapy, Tui Na, reflexology, rolfing, Bowen technique, Trager bodywork, Alexander technique, Feldenkrais method, and a host of others (a list of definitions is given at the end of this report). Surveys of the U.S. population suggest that between 3 percent and 16 percent of adults receive chiropractic manipulation in a given year, while between 2 percent and 14 percent receive some form of massage therapy.^1-5 In 1997, U.S. adults made an estimated 192 million visits to chiropractors and 114 million visits to massage therapists. Visits to chiropractors and massage therapists combined represented 50 percent of all visits to CAM practitioners.² Data on the remaining manipulative and body-based practices are sparser, but it can be estimated that they are collectively used by less than 7 percent of the adult population.

Manipulative and body-based practices focus primarily on the structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems. Some practices were derived from traditional systems of medicine, such as those from China, India, or Egypt, while others were developed within the last 150 years (e.g., chiropractic and osteopathic manipulation). Although many providers have formal training in the anatomy and physiology of humans, there is considerable variation in the training and the approaches of these providers both across and within modalities. For example, osteopathic and chiropractic practitioners, who use primarily manipulations that involve rapid movements, may have a very different treatment approach than massage therapists, whose techniques involve slower applications of force, or than craniosacral therapists. Despite this heterogeneity, manipulative and body-based practices share some common characteristics, such as the principles that the human body is self-regulating and has the ability to heal itself and that the parts of the human body are interdependent. Practitioners in all these therapies also tend to tailor their treatments to the specific needs of each patient.

Scope of the Research

Range of Studies
The majority of research on manipulative and body-based practices has been clinical in nature, encompassing case reports, mechanistic studies, biomechanical studies, and clinical trials. A cursory search in PubMed for research published in the last 10 years identified 537 clinical trials, of which 422 were randomized and controlled. Similarly, 526 trials were identified in the Cochrane database of clinical trials. PubMed also contains 314 case reports or series, 122 biomechanical studies, 26 health services studies, and 248 listings for all other types of clinical research published in the last 10 years. On the other hand, for this same time period, there have been only 33 published articles of research involving in vitro assays or employing animal models.

Primary Challenges
Different challenges face investigators studying mechanisms of action than those studying efficacy and safety. The primary challenges that have impeded research on the underlying biology of manual therapies include the following:

• Lack of appropriate animal models
• Lack of cross-disciplinary collaborations
• Lack of research tradition and infrastructure at schools that teach manual therapies
• Inadequate use of state-of-the-art scientific technologies

References

Clinical trials of CAM manual therapies face the same general challenges as trials of procedure-based interventions such as surgery, psychotherapy, or more conventional physical manipulative techniques (e.g., physical therapy). These include:

• Identifying an appropriate, reproducible intervention, including dose and frequency. This may be more difficult than in standard drug trials, given the variability in practice patterns and training of practitioners.

• Identifying an appropriate control group(s). In this regard, the development of valid sham manipulation techniques has proven difficult.

• Randomizing subjects to treatment groups in an unbiased manner. Randomization may prove more difficult than in a drug trial, because manual therapies are already available to the public; thus, it is more likely that participants will have a preexisting preference for a given therapy.

• Maintaining investigator and subject compliance to the protocol. Group contamination (which occurs when patients in a clinical study seek additional treatments outside the study, usually without telling the investigators; this will affect the accuracy of the study results) may be more problematic than in standard drug trials, because subjects have easy access to manual therapy providers.

• Reducing bias by blinding subjects and investigators to group assignment. Blinding of subjects and investigators may prove difficult or impossible for certain types of manual therapies. However, the person collecting the outcome data should always be blinded.

• Identifying and employing appropriate validated, standardized outcome measures.

• Employing appropriate analyses, including the intent-to-treat paradigm

Summary of the Major Threads of Evidence

Preclinical Studies
The most abundant data regarding the possible mechanisms underlying chiropractic manipulation have been derived from studies in animals, especially studies on the ways in which manipulation may affect the nervous system.⁶ For example, it has been shown, by means of standard neurophysiological techniques, that spinal manipulation evokes changes in the activity of proprioceptive primary afferent neurons in paraspinal tissues. Sensory input from these tissues has the capacity to reflexively alter the neural outflow to the autonomic nervous system. Studies are under way to determine whether input from the paraspinal tissue also modulates pain processing in the spinal cord.

Animal models have also been used to study the mechanisms of massage-like stimulation.⁷ It has been found that antinociceptive and cardiovascular effects of massage may be mediated by endogenous opioids and oxytocin at the level of the midbrain. However, it is not clear that the massage-like stimulation is equivalent to massage therapy.

Although animal models of chiropractic manipulation and massage have been established, no such models exist for other body-based practices. Such models could be critical if researchers are to evaluate the underlying anatomical and physiological changes accompanying these therapies.

Clinical Studies: Mechanisms
Biomechanical studies have characterized the force applied by a practitioner during chiropractic manipulation, as well as the force transferred to the vertebral column, both in cadavers and in normal volunteers.⁸ In most cases, however, a single practitioner provided the manipulation, limiting generalizability. Additional work is required to examine interpractitioner variability, patient characteristics, and their relation to clinical outcomes.

Studies using magnetic resonance imaging (MRI) have suggested that spinal manipulation has a direct effect on the structure of spinal joints; it remains to be seen if this structural change relates to clinical efficacy.

Clinical studies of selected physiological parameters suggest that massage therapy can alter various neurochemical, hormonal, and immune markers, such as substance P in patients who have chronic pain, serotonin levels in women who have breast cancer, cortisol levels in patients who have rheumatoid arthritis, and natural killer (NK) cell numbers and CD4+ T-cell counts in patients who are HIV-positive.⁹ However, most of these studies have come from one research group, so replication at independent sites is necessary. It is also important to determine the mechanisms by which these changes are elicited.

Despite these many interesting experimental observations, the underlying mechanisms of manipulative and body-based practices are poorly understood. Little is known from a quantitative perspective. Important gaps in the field, as revealed by a review of the relevant scientific literature, include the following:

• Lack of biomechanical characterization from both practitioner and participant perspectives

• Little use of state-of-the-art imaging techniques

• Few data on the physiological, anatomical, and biomechanical changes that occur with treatment

• Inadequate data on the effects of these therapies at the biochemical and cellular levels

• Only preliminary data on the physiological mediators involved with the clinical outcomes

References

Clinical Studies: Trials
Forty-three clinical trials have been conducted on the use of spinal manipulation for low-back pain, and there are numerous systematic reviews and meta-analyses of the efficacy of spinal manipulation for both acute and chronic low-back pain.^10-14 These trials employed a variety of manipulative techniques. Overall, manipulation studies of varying quality show minimal to moderate evidence of short-term relief of back pain. Information on cost-effectiveness, dosing, and long-term benefit is scant. Although clinical trials have found no evidence that spinal manipulation is an effective treatment for asthma,¹⁵ hypertension,¹⁶ or dysmenorrhea,¹⁷ spinal manipulation may be as effective as some medications for both migraine and tension headaches¹⁸ and may offer short-term benefits to those suffering from neck pain.¹⁹ Studies have not compared the relative effectiveness of different manipulative techniques.

Although there have been numerous published reports of clinical trials evaluating the effects of various types of massage for a variety of medical conditions (most with positive results), these trials were almost all small, poorly designed, inadequately controlled, or lacking adequate statistical analyses.²⁰ For example, many trials included co-interventions that made it impossible to evaluate the specific effects of massage, while others evaluated massage delivered by individuals who were not fully trained massage therapists or followed treatment protocols that did not reflect common (or adequate) massage practice.

There have been very few well-designed controlled clinical trials evaluating the effectiveness of massage for any condition, and only three randomized controlled trials have specifically evaluated massage for the condition most frequently treated with massage--back pain.²¹ All three trials found massage to be effective, but two of these trials were very small. More evidence is needed.

Risks
There are some risks associated with manipulation of the spine, but most reported side effects have been mild and of short duration. Although rare, incidents of stroke and vertebral artery dissection have been reported following manipulation of the cervical spine.²² Despite the fact that some forms of massage involve substantial force, massage is generally considered to have few adverse effects. Contraindications for massage include deep vein thrombosis, burns, skin infections, eczema, open wounds, bone fractures, and advanced osteoporosis.^21,23

Utilization/Integration
In the United States, manipulative therapy is practiced primarily by doctors of chiropractic, some osteopathic physicians, physical therapists, and physiatrists. Doctors of chiropractic perform more than 90 percent of the spinal manipulations in the United States, and the vast majority of the studies that have examined the cost and utilization of spinal manipulation have focused on chiropractic.

Individual provider experience, traditional use, or arbitrary payer capitation decisions--rather than the results of controlled clinical trials--determine many patient care decisions involving spinal manipulation. More than 75 percent of private payers and 50 percent of managed care organizations provide at least some reimbursement for chiropractic care.²⁴ Congress has mandated that the Department of Defense (DOD) and the Department of Veterans Affairs provide chiropractic services to their beneficiaries, and there are DOD medical clinics offering manipulative services by osteopathic physicians and physical therapists. The State of Washington has mandated coverage of CAM services for medical conditions normally covered by insurance. The integration of manipulative services into health care has reached this level despite a dearth of evidence about long-term effects, appropriate dosing, and cost-effectiveness.

Although the numbers of Americans using chiropractic and massage are similar,^1-5 massage therapists are licensed in fewer than 40 states, and massage is much less likely than chiropractic to be covered by health insurance.² Like spinal manipulation, massage is most commonly used for musculoskeletal problems. However, a significant fraction of patients seek massage care for relaxation and stress relief.²⁵

Cost
A number of observational studies have looked at the costs associated with chiropractic spinal manipulation in comparison with the costs of conventional medical care, with conflicting results. Smith and Stano found that overall health care expenditures were lower for patients who received chiropractic treatment than for those who received medical care in a fee-for-service environment.²⁶ Carey and colleagues found chiropractic spinal manipulation to be more expensive than primary medical care, but less expensive than specialty medical care.²⁷ Two randomized trials comparing the costs of chiropractic care with the costs of physical therapy failed to find evidence of cost savings through chiropractic treatment.^28,29 The only study of massage that measured costs found that the costs for subsequent back care following massage were 40 percent lower than those following acupuncture or self care, but these differences were not statistically significant.³⁰

Patient Satisfaction
Although there are no studies of patient satisfaction with manipulation in general, numerous investigators have looked at patient satisfaction with chiropractic care. Patients report very high levels of satisfaction with chiropractic care.^27,28,31 Satisfaction with massage treatment has also been found to be very high.³⁰

References

Definitions

Alexander technique: Patient education/guidance in ways to improve posture and movement, and to use muscles efficiently.

Bowen technique: Gentle massage of muscles and tendons over acupuncture and reflex points.

Chiropractic manipulation: Adjustments of the joints of the spine, as well as other joints and muscles.

Craniosacral therapy: Form of massage using gentle pressure on the plates of the patient's skull.

Feldenkrais method: Group classes and hands-on lessons designed to improve the coordination of the whole person in comfortable, effective, and intelligent movement.

Massage therapy: Assortment of techniques involving manipulation of the soft tissues of the body through pressure and movement.

Osteopathic manipulation: Manipulation of the joints combined with physical therapy and instruction in proper posture.

Reflexology: Method of foot (and sometimes hand) massage in which pressure is applied to "reflex" zones mapped out on the feet (or hands).

Rolfing: Deep tissue massage (also called structural integration).

Trager bodywork: Slight rocking and shaking of the patient's trunk and limbs in a rhythmic fashion.

Tui Na: Application of pressure with the fingers and thumb, and manipulation of specific points on the body (acupoints).

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About This Series

"Biologically Based Practices: An Overview" is one of five background reports on the major areas of complementary and alternative medicine (CAM).

• Biologically Based Practices: An Overview

• Energy Medicine: An Overview

• Manipulative and Body-Based Practices: An Overview

• Mind-Body Medicine: An Overview

• Whole Medical Systems: An Overview

The series was prepared as part of the National Center for Complementary and Alternative Medicine's (NCCAM's) strategic planning efforts for the years 2005 to 2009. These brief reports should not be viewed as comprehensive or definitive reviews. Rather, they are intended to provide a sense of the overarching research challenges and opportunities in particular CAM approaches. For further information on any of the therapies in this report, contact the NCCAM Clearinghouse.

NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM.

References

next: Mind-Body Medicine: An Overview

References

1. Astin JA. Why patients use alternative medicine: results of a national study. Journal of the American Medical Association. 1998;279(19):1548-1553.
2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Journal of the American Medical Association. 1998;280(18):1569-1575.
3. Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. Journal of the American Medical Association. 1999;282(7):651-656.
4. Ni H, Simile C, Hardy AM. Utilization of complementary and alternative medicine by United States adults: results from the 1999 National Health Interview Survey. Medical Care. 2002;40(4):353-358.
5. Barnes P, Powell-Griner E, McFann K, Nahin R. Complementary and alternative medicine use among adults: United States, 2002. CDC Advance Data Report #343. 2004.
6. Pickar JG. Neurophysiological effects of spinal manipulation. Spine Journal. 2002;2(5):357-371.
7. Lund I, Yu LC, Uvnas-Moberg K, et al. Repeated massage-like stimulation induces long-term effects on nociception: contribution of oxytocinergic mechanisms. European Journal of Neuroscience. 2002;16(2):330-338.
8. Swenson R, Haldeman S. Spinal manipulative therapy for low back pain. Journal of the American Academy of Orthopaedic Surgeons. 2003;11(4):228-237.
9. Field T. Massage therapy. Medical Clinics of North America. 2002;86(1):163-171.

1. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Annals of Internal Medicine. 2002;136(3):216-227.
2. Koes BW, Assendelft WJ, van der Heijden GJ, et al. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine. 1996;21(24):2860-2871.
3. Bronfort G. Spinal manipulation: current state of research and its indications. Neurologic Clinics. 1999;17(1):91-111.
4. Ernst E, Harkness E. Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials. Journal of Pain and Symptom Management. 2001;22(4):879-889.
5. Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine. 2003;138(11):871-881.
6. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database of Systematic Reviews. 2004;(2):CD001002. Accessed at www.cochrane.org on April 30, 2004.
7. Goertz CH, Grimm RH, Svendsen K, et al. Treatment of Hypertension with Alternative Therapies (THAT) Study: a randomized clinical trial. Journal of Hypertension. 2002;20(10):2063-2068.
8. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database of Systematic Reviews. 2004;(2):CD002119. Accessed at www.cochrane.org on April 30, 2004.
9. Astin JA, Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Cephalalgia. 2002;22(8):617-623.
10. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine. 1996;21(15):1746-1759.
11. Field TM. Massage therapy effects. American Psychologist. 1998;53(12):1270-1281.
12. Cherkin DC, Sherman KJ, Deyo RA, et al. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine. 2003;138(11):898-906.
13. Ernst E. Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001. Medical Journal of Australia. 2002;176(8):376-380.
14. Ernst E, ed. The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach. Edinburgh, UK: Mosby; 2001.
15. Jensen GA, Roychoudhury C, Cherkin DC. Employer-sponsored health insurance for chiropractic services. Medical Care. 1998;36(4):544-553.
16. Cherkin DC, Deyo RA, Sherman KJ, et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Journal of the American Board of Family Practice. 2002;15(6):463-472.
17. Smith M, Stano M. Costs and recurrences of chiropractic and medical episodes of low-back care. Journal of Manipulative and Physiological Therapeutics. 1997;20(1):5-12.
18. Carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. New England Journal of Medicine. 1995;333(14):913-917.
19. Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine. 1998;339(15):1021-1029.
20. Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Subgroup analysis, recurrence, and additional health care utilization. Spine. 1998;23(17):1875-1883.
21. Cherkin DC, Eisenberg D, Sherman KJ, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Archives of Internal Medicine. 2001;161(8):1081-1088.
22. Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. Western Journal of Medicine. 1989;150(3):351-355.

next: Mind-Body Medicine: An Overview

"Perspective is a key to Recovery. I had to change and enlarge my perspectives of myself and my own emotions, of other people, of God and of this life business. Our perspective of life dictates our relationship with life. We have a dysfunctional relationship with life because we were taught to have a dysfunctional perspective of this life business, dysfunctional definitions of who we are and why we are here.

It is kind of like the old joke about three blind men describing an elephant by touch. Each one of them is telling his own Truth, they just have a lousy perspective. Codependence is all about having a lousy relationship with life, with being human, because we have a lousy perspective on life as a human."

(All quotes are quotes from Codependence: The Dance of Wounded Souls)

The path to empowerment and freedom from the past lies in owning that we have choices about our belief systems. Our mental attitudes, beliefs, and definitions dictate our emotional reactions and control our relationships. If we are living our life in reaction to the past, in reaction to our childhood wounds, then we are not making choices - we are not free.

This is true rather we are trying to conform to the old tapes or rather we are rebelling against them. Either way, we are giving the past power over how we live our lives today.

One of the most vital prerequisites of healing and recovery, of being open to growth, is a willingness to be open to looking at anything, and everything, from a different perspective. As long as we are stuck in a rigid perspective on any issue, we are like the blind man who thinks the elephant is a snake because all he can feel is the trunk.

The reason that we have rigid perspectives is because we are reacting to emotional wounds. When I was first introduced to twelve step recovery, I thought the people were a bunch of religious fanatics because they talked about god. I did not want anything to do with god because of the shame based religion I grew up in. I had been tremendously wounded by that religion and rejected the concept of god because the one I was taught about was an abusive father.

"We were taught a reversed, backwards concept of god. We were taught about a god who is a small, petty, angry, jealous, judgmental, male being. We were taught about a god who is an abusive father.

If you choose to believe in a punishing, judgmental, male god, that is your total right and privilege. If that works for you, great. It does not work for me."

When I got into twelve step recovery, I was emotionally beaten and bloody - I was wishing for, and courting, death because life was so painful. I had to choose to be open to some new ideas in order to change my life. Owning that I had a choice to change was what opened up a whole new life for me.

What I have discovered in recovery is that I need to be willing to look at any attitude or belief in order to keep growing. Any issue that I am not willing to look at is tied to emotional wounds that I have not healed. And anytime I am allowing old wounds and old tapes to dictate my life, I am not capable of making informed choices - which sets me up to be the victim of my own blindness.

When I am in reaction, then I am not capable of discernment. Then I am not able to pick the baby out of the dirty bath water - I either accept it all or throw it all out.

"The teachings of all the Master Teachers, of all the world's religions, contain some Truth along with a lot of distortions and lies. Discerning Truth is often like recovering treasure from shipwrecks that have been sitting on the ocean floor for hundreds of years - the grains of Truth, the nuggets of gold, have become encrusted with garbage over the years."

Blindly accepting religious teaching and blindly rejecting any kind of a concept of a Higher Power are the same thing - a reaction to old wounds and old tapes.

Each and every one of us has the absolute right to make our own choices in regards to what we believe to be Truth. No one has a right to dictate to anyone else that their concept is the only one that is right.

Our concepts of the meaning and purpose of life, of who we are and why we are here, are what dictate the quality of our relationship with life. Each and every one of us needs to find a concept of the meaning and purpose of life that works for us individually. You have an absolute right to believe that life has no meaning or purpose - or that the purpose of life is suffering and penance for some mythical sin of mankind - whatever you choose to believe.

But if we reject even looking at any alternative perspectives, then what we are empowering is ignorance. The person we hurt the most in doing this is our self. In blindly rejecting other perspectives without even considering the possibility that there might be some grains of Truth in them, in being rigid and choosing to be blind to alternative points of view, we are limiting ourselves. By closing our minds to any new input, we are giving power to the past - we are letting old wounds and old tapes dictate how we live our life today.

Paradigm shifts are very important for growth and learning. Paradigm shifts occur when we change our perspective, when we modify our attitudes, definitions, and beliefs. What I am doing in this article is sharing some different perspectives on the concept of spirituality for you to consider. If you can find the willingness to be open to some alternative views, perhaps something that is shared here can be a catalyst for a paradigm shift for you.

I would just ask that you be open to seeing if any of it resonates with you.

"There is a principle which is a bar against all information, which is proof against all arguments, and which cannot fail to keep a man in everlasting ignorance - that principle is contempt prior to investigation."
~ Herbert Spencer

next: Spirituality As Relationship

Chapter 15 of Adam Khan's new book Self-Help Stuff That Works

I WAS JUST READING A TRUE STORY about a Norwegian soldier who had been put out of action by frostbite and was confined to a small sled in the middle of the Arctic wilderness. Some friends were hiding him from the German soldiers who were occupying Norway. He was alone for twenty-seven days except for a short visit by someone about every three or four days. He had a book with him, but he didn't read much of it during those twenty-seven days. He "never seemed to have the time."

When I read that last line, it jolted me awake and has been bugging me ever since. Do you understand why? Here was a man who couldn't walk, who was confined to a sleeping bag in the middle of a silent, snow-covered, completely uninhabited area in the Arctic, and he was too busy to read. What's wrong with this picture?

What's wrong is the same thing that's wrong with you and me. We're too busy. You are, aren't you? Yeah, so am I. Short of time. More things to do than you have time to do. Always trying to catch up.

But what has been dawning on me with a certain degree of irony and ridiculousness is that my lack of time is completely created by me.

There is no shortage of time. There is only the greedy effort to get more from our days than we can, while at the same time greedily wanting to also spend some of that time in leisure.

It's silly. And it's tragic. It costs us the experience of living. Time seems to fly by. Wow, where did those last ten years go? Were we so busy getting things done we forgot to enjoy our own lives?

Let's just relax, shall we? Let's quit trying to do so much. We don't have to get all that stuff done. We don't have to be perfect parents kids have been raised by imperfect parents for a long time and still turned out okay. We don't have to be perfect at anything. We don't have to do it all. And we don't have to be happier. But when we realize we don't have to cram so much into our days, we will be.

If your own greed is making you discontent, quit cramming so much into your days.

If you really need a little more organization in your life, here is the most fundamental principle in the time-management field:
Time Management Made Simple

Where did our rushing, high-pressure culture come from? And what can you do to create peace of mind in your own life? Read more about it in:
We've Been Duped

next: Think Positively Positively

Chapter 84 of the book Self-Help Stuff That Works

by Adam Khan:

WE'VE ALL FELT IT. You don't know what to say or what to do. You feel too aware of yourself and how you're standing, how you're looking, what you sound like. If you have teenagers, you know they feel it intensely. And some of the things teens do that seem so incomprehensible to parents stem from a simple desire to avoid feeling socially awkward.

Although it's very natural to feel awkward around people you don't know very well, it isn't pleasant or productive. Here are two practical things anyone can do to feel more socially comfortable:

1. Relax your muscles. This makes you calmer. Most people don't have any problem at all being social around people when they're relaxed. That's why social gatherings have traditionally served alcoholic beverages: It relaxes people. Find a muscle in your body that feels a little tense and consciously relax that muscle. You will instantly feel more at ease.
2. Make it your mission to help the other person feel more comfortable. Make conversation easy for the other person by asking questions she'll enjoy answering. Find out the person's name, whether she's from this area, or if she's not, where she's from. Her answers will probably stimulate other questions and conversation. How about her family: Do they live in this area? Big family? Brothers and sisters? What do they do? How about work? What does she do for a living? Does she like it? What got her into it? How about travel? What parts of the world has she seen? Any hobbies? Listen with interest. Let her know you like what she's saying. Help her feel comfortable.

That is basically six areas to talk about: name, home, family, work, travel, hobbies. Memorize that list of six topics, and when the time comes, the questions will come to mind easily, keeping the conversation lively and smooth. A smooth and lively conversation will put the other person at ease which will make you feel more comfortable.

You'll probably never get to all six of the topics because as the other person starts talking, you'll find points of interest you'll want to know more about, and the two of you will start talking about that, and off you'll go into Conversation Land.

You'll get to know the person and have a wonderful time and you'll just forget to feel awkward because you can only feel awkward when you're self-conscious. As you become increasingly conscious of the other person, you become less conscious of yourself and your awkwardness disappears.

Relieve your social awkwardness by relaxing and concerning yourself with helping the other person feel comfortable. People will love you for it.

Relax your muscles and make it your mission to help the other person feel more comfortable.

Learn more about gaining confidence and getting rid of self-consciousness and feelings of insecurity:
Insecurity

Would you like to learn more about the fine art of positive thinking? Would you like to behold the power of positive thinking? How about the power of anti-negative thinking? Check this out:
Positive Thinking: The Next Generation

How can you take the insights from cognitive science and make your life have less negative emotion in it? Here's another article on the same subject but with a different angle:
Argue With Yourself and Win!

next: Your Inner Guide to Self-Esteem

The Rewards of Depression

Do you really want to shake off your depression? Don't answer too fast, and don't be too sure. It is quite common that people get enough benefits from their depressions so that they prefer remaining depressed--despite all its unpleasantness--to being undepressed. So they stay depressed.

At first this assertion seems nonsensical. Doesn't everyone want to be happy rather than sad? But the word "want" is a tricky one, because a person can have more than one "want" at a given moment. By analogy, consider that you may "want" a piece of chocolate, but you may also "want" not to ingest additional calories or get fat. The resultant of these two forces may be that you do not eat the cake even though you "want" it, or you may eat it even though you want not to get fat.

There are two kinds of conflicting wants that may be involved in depression: other wants which conflict with being free of depress, and the wish to stay depressed for its own sake. Here are a few examples of "wants" that may keep you depressed: (1)

1) You may know that overwork causes you to be depressed, but you may want the fruits of the work sufficiently badly so that you overwork anyway. This is little different than the situation of the person who risks heart attack by working too hard.

2) You may have the "magical" belief that if you punish yourself for your misdeeds by being sad, an authority (which may be God) will take note of your self-punishment and therefore refrain from punishing you further. We see this in children who, following misbehavior, put on a sad and apologetic face and thereby effectively avoid punishment. This connection may continue to exist within the adult's mind, even though it no longer works. A person who violates a legal or moral code may punish himself with sadness in the hope that the law or his peers or God will thereby be foreclosed from punishing him in an even worse manner. Hence he chooses to remain depressed.

3) "Experienced" depressives -- that is, people who suffer depression from time to time -- sometimes use depression as an excuse not to meet demands and do unpleasant chores.

4) An important "benefit" of depression is that you can feel sorry for yourself because you are so miserable. Self-pity and depression are almost inseparable, wrapped up with each other like climbing vines. Some writers have even believed that self- pity is the origin of depression.

At the root of the adult depression of a child whose parents die may lie this mechanism involving self-pity: At the time of the death, other members of the family express their sorrow and pity for the child, together with their love for the child. This is relatively pleasant for the bereaved child, and it is the best substitute for the parent's love. It would be logical for a child to extend the period of seeming depressed in order to continue eliciting this expressed pity and love by others. And this pattern of depression to elicit pity and love may continue through the person's life--perhaps most strongly for a person who does not get enough of this pity and sorrow to surfeit her at the time of bereavement.

Benefits of Self-Pity

Self-pity is a pleasant substitute for pity from others. In turn another person feeling pity for you is pleasant because it is associated with the other person caring about you, and that caring is associated with loving you. Any lack of love of others may be the proximate cause of sadness, because of the close association between lack of parental love and neg-comps. (Notice how a parent expressing love for a child can banish a child's sadness. And a depressed adult is often conscious of the desire that a friend or spouse give comfort in the form of expressing sorrow.)

There is sound inner logic, then, in remaining depressed so that you can give yourself a reasonable substitute for the love of others that you crave. And this may act as a powerful attraction toward depression and a formidable obstacle to forsaking depression for happiness.

In this respect depression is similar to hypochondria, which elicits sympathy from others and provides an excuse not to exert oneself. Just as with hypochondria, the benefits of depression may seem greater than the costs.

The concept of self-comparisons is especially fruitful in analyzing self-pity. Consider these examples of external events upon which people fix their thoughts when they are in a self- pitying frame of mind:

Homely Sally pities herself because she does not have the advantages that come with being better looking; men therefore don't appreciate her other virtues, she tells herself. Unsuccessful poet Paul pities himself because magazines never publish his poetry, though they publish others' poems that are nowhere near as good as those he writes. Five-foot-seven-inch Calvin pities himself because, though he was a hot-shot basketball player in high school, no college would give him a scholarship due to his height, and he therefore never went on with his studies. Mother Tamara pities herself because two of her five children died.

Earlier I said that people enjoy self-pity. They get so much benefit from it that they are unwilling to stop feeling sorry for themselves even if the price of the self-pity is continued depression. But why should this be? What is there so pleasant in the nature of the examples given above that would make the thought desirable? Why would anyone want to go on pitying herself for losing two children to death, or because his poetry doesn't get published? We need an explanation in terms of neg-comps.

The answer to this riddle is that in their self-pity people also make a positive self-comparison which gives them gratification. Poet Paul tells himself, while he is feeling sorry for himself, that he really is a better poet than many of those who do get their poetry published; that self-praise makes him feel good. At the same time, the thought that he is not getting what he deserves -- a negative self-comparison, please notice -- is making him feel sad. He flips back and forth from one thought and feeling to the other, getting pleasure from the self-praise and the positive self-comparison, and then getting sadness from the negative self-comparison.

Tamara tells herself that when her two children died, she got a worse deal from life and God than she deserves, a negative self-comparison which makes her sad. At the same time she reminds herself that she is a virtuous woman who did not deserve the blow, and she gets gratification from thinking of her virtue by comparison to other people.

Calvin gets pleasure from reminding himself what a hot-shot basketball player he was, while pitying himself for the opportunities he did not know. And Sally gets pleasure from thinking about her good mind and her fine character when pitying herself that because of her face men don't like her despite these virtues.

We can now understand how a person gets hooked on the self- pitying mechanism, just the way a person gets hooked on heroin, and why it is so hard to kick this habit. Self-pity exerts a fatal fascination. It is like the situations in experimental psychology called "plus-minus stimuli," stimuli that are neither only positive nor only negative, but rather are both negative and positive. The fatal fascination arises because you cannot obtain the benefits without suffering the costs. Paul cannot think how he is a good poet without also coming to think how his poems do not get published. And he cannot stop thinking about his publishing failure without giving up the pleasure of self-praise of his poetry.

To test this analysis on yourself, inspect your thoughts the next time you are feeling sorry for yourself. Look for both (a) the self-praise for being virtuous and good -- the positive self- comparison between what you are, compared to the benchmark comparison of what you are getting from life; and (b) the negative self-comparison between what you get and what you deserve. You may also test this analysis by listening to what you say to another person when you express pity for him or her. And pure logic also implies this behavior: Unless the gratifying element of the positive self-comparison is present in self-pity, why would anyone not simply kick the habit?

Please notice that you will not expect -- or usually get -- pity unless you deserve better than you got. The rotten mother, the mediocre basketball player, the lazy poet will neither expect nor get pity for child death, non-scholarship, or publication rejection.

This analysis of the benefits of feeling sorry for yourself is described in Mike Royko's satire of the benefits of moaning when suffering from a New Year's day hangover.

The other part of a hangover is physical. It is usually marked by throbbing pain in the head, behind the eyes, back of the neck, and in the stomach. You might also have pain in the arms, legs, knees, elbows, chin, and elsewhere, depending upon how much leaping, careening, flailing and falling you did.

Moaning helps. It doesn't ease the pain, but it lets you know that someone cares, even if it is only you. Moaning also lets you know that you are still alive.

But don't let your wife hear you moan. You should at least have the satisfaction of not letting her have the satisfaction of knowing you are in agony.

If she should overhear you moaning, tell her you are just humming a love song the lady with the prominent cleavage sang in your ear while you danced.

Some people say that moaning gives greater benefits if you moan while sitting on the edge of your bathtub while letting your head hang down between your ankles. Others claim that it is best to go into the living room, slouch in a chair, and moan while holding a hand over your brow and the other over your stomach.(2)

Consider the example of Charley T., an obese depressive. Charley says to himself: "I'm so miserable, and the world has been so terrible to me, that I might as well cheer myself up with a few chocolates. Why shouldn't I? No one else gives me any love or help or pleasure, so at least I can give myself some pleasure!" And there goes the whole box of bon-bons.

If Charley stops feeling depressed, he no longer has a handy excuse to munch chocolates by the handful. And this is an inducement for him to remain depressed. We might label this sort of ailment "candy depression".

The goodies that the rest of us give ourselves when we are depressed--relief from work, self-sympathy in feeling sorry for ourselves, excuses not to do things for others--are not so obvious. Yet they can be just as powerful a barrier to curing our depressions as is Charley's yearning for food. If we are to cure our depressions, we must face up to the fact that we must give up something in exchange. If we won't pay the price, we won't stop being depressed. That may be hard for you to hear, but in many or most cases it is a fact.

Some writers such as Bonime(3) view depression only as a way of obtaining its benefits. To Bonime depression is a "practice...a way of living," that is, a way of manipulating other people. Certainly this may be an element in the depression of some persons, maybe even most depressives, a carryover from childhood sulking that often does produce results. But to view adult depression only as a device to achieve the sympathetic response of other persons simply is far from the facts of the lives of, for example, many depressed recluses who are not even in contact with other persons who might be induced to respond to the depression; the explanation then becomes downright silly.

The question we shall tackle later is how to decide whether you want the pleasures of a) moaning for yourself in combination with depression, versus b) being undepressed.

Breaking the Habit of Self-Pity

As to dealing with the self-pity habit: I said that poet Paul thinks of himself as a "good poet." Perhaps he should ask himself whether his poems are good or bad, and not whether the maker of the poems is a good or bad person. Ellis uses the term "rating" for this tendency to label the person rather than the act, and he argues that reducing the amount of rating is an important way to attack depression. I agree, though noting that such rating is very much bound up with the daily living of most of us, and therefore hard to forswear.

Summary

Strange as it may seem, a person sometimes gets enough benefits from her/his depression so that the person prefers remaining depressed--despite all its unpleasantness--to being undepressed. Possible benefits include a good excuse from work or other demands, the concern of others, or the justification for self-pity. Recognizing that this sort of mechanism may operate can help you face the matter squarely, and decide that the benefits of the depression are not worth the pain of the depression.

next: Good Mood: The New Psychology of Overcoming Depression Chapter 10
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~ depression library articles
~ all articles on depression

• Watch the video on Narcissists and Fame

Question:

Are narcissists addicted to being famous? 

Answer:

You bet. This, by far, is their predominant drive. Being famous encompasses a few important functions: it endows the narcissist with power, provides him with a constant Source of Narcissistic Supply (admiration, adoration, approval, awe), and fulfils important Ego functions.

The image that the narcissist projects is hurled back at him, reflected by those exposed to his celebrity or fame. This way he feels alive, his very existence is affirmed and he acquires a sensation of clear boundaries (where the narcissist ends and the world begins).

There is a set of narcissistic behaviours typical to the pursuit of celebrity. There is almost nothing that the narcissist refrains from doing, almost no borders that he hesitates to cross to achieve renown. To him, there is no such thing as "bad publicity" - what matters is to be in the public eye.

Because the narcissist equally enjoys all types of attention and likes as much to be feared as to be loved, for instance - he doesn't mind if what is published about him is wrong ("as long as they spell my name correctly"). The narcissist's only bad emotional stretches are during periods of lack of attention, publicity, or exposure.

The narcissist then feels empty, hollowed out, negligible, humiliated, wrathful, discriminated against, deprived, neglected, treated unjustly and so on. At first, he tries to obtain attention from ever narrowing groups of reference ("supply scale down"). But the feeling that he is compromising gnaws at his anyhow fragile self-esteem.

Sooner or later, the spring bursts. The narcissist plots, contrives, plans, conspires, thinks, analyses, synthesises and does whatever else is necessary to regain the lost exposure in the public eye. The more he fails to secure the attention of the target group (always the largest) - the more daring, eccentric and outlandish he becomes. Firm decision to become known is transformed into resolute action and then to a panicky pattern of attention seeking behaviours.

The narcissist is not really interested in publicity per se. Narcissists are misleading. The narcissist appears to love himself - and, really, he abhors himself. Similarly, he appears to be interested in becoming a celebrity - and, in reality, he is concerned with the REACTIONS to his fame: people watch him, notice him, talk about him, debate his actions - therefore he exists.

The narcissist goes around "hunting and collecting" the way the expressions on people's faces change when they notice him. He places himself at the centre of attention, or even as a figure of controversy. He constantly and recurrently pesters those nearest and dearest to him in a bid to reassure himself that he is not losing his fame, his magic touch, the attention of his social milieu.

Truly, the narcissist is not choosy. If he can become famous as a writer - he writes, if as a businessman - he conducts business. He switches from one field to the other with ease and without remorse because in all of them he is present without conviction, bar the conviction that he must (and deserves to) get famous.

He grades activities, hobbies and people not according to the pleasure that they give him - but according to their utility: can they or can't they make him known and, if so, to what extent. The narcissist is one-track minded (not to say obsessive). His is a world of black (being unknown and deprived of attention) and white (being famous and celebrated).

Mistreating Celebrities - An Interview

Granted to Superinteressante Magazine in Brazil

Q. Fame and TV shows about celebrities usually have a huge audience. This is understandable: people like to see other successful people. But why people like to see celebrities being humiliated?

A. As far as their fans are concerned, celebrities fulfil two emotional functions: they provide a mythical narrative (a story that the fan can follow and identify with) and they function as blank screens onto which the fans project their dreams, hopes, fears, plans, values, and desires (wish fulfilment). The slightest deviation from these prescribed roles provokes enormous rage and makes us want to punish (humiliate) the "deviant" celebrities.

But why?

When the human foibles, vulnerabilities, and frailties of a celebrity are revealed, the fan feels humiliated, "cheated", hopeless, and "empty". To reassert his self-worth, the fan must establish his or her moral superiority over the erring and "sinful" celebrity. The fan must "teach the celebrity a lesson" and show the celebrity "who's boss". It is a primitive defense mechanism - narcissistic grandiosity. It puts the fan on equal footing with the exposed and "naked" celebrity.

Q. This taste for watching a person being humiliated has something to do with the attraction to catastrophes and tragedies?

A. There is always a sadistic pleasure and a morbid fascination in vicarious suffering. Being spared the pains and tribulations others go through makes the observer feel "chosen", secure, and virtuous. The higher celebrities rise, the harder they fall. There is something gratifying in hubris defied and punished.

Q. Do you believe the audience put themselves in the place of the reporter (when he asks something embarrassing to a celebrity) and become in some way revenged?

A. The reporter "represents" the "bloodthirsty" public. Belittling celebrities or watching their comeuppance is the modern equivalent of the gladiator rink. Gossip used to fulfil the same function and now the mass media broadcast live the slaughtering of fallen gods. There is no question of revenge here - just Schadenfreude, the guilty joy of witnessing your superiors penalized and "cut down to size".

Q. In your country, who are the celebrities people love to hate?

A. Israelis like to watch politicians and wealthy businessmen reduced, demeaned, and slighted. In Macedonia, where I live, all famous people, regardless of their vocation, are subject to intense, proactive, and destructive envy. This love-hate relationship with their idols, this ambivalence, is attributed by psychodynamic theories of personal development to the child's emotions towards his parents. Indeed, we transfer and displace many negative emotions we harbor onto celebrities.

Q. I would never dare asking some questions the reporters from Panico ask the celebrities. What are the characteristics of people like these reporters?

A. Sadistic, ambitious, narcissistic, lacking empathy, self-righteous, pathologically and destructively envious, with a fluctuating sense of self-worth (possibly an inferiority complex).

6. Do you believe the actors and reporters want themselves to be as famous as the celebrities they tease? Because I think this is almost happening...

A. The line is very thin. Newsmakers and newsmen and women are celebrities merely because they are public figures and regardless of their true accomplishments. A celebrity is famous for being famous. Of course, such journalists will likely to fall prey to up and coming colleagues in an endless and self-perpetuating food chain...

7. I think that the fan-celebrity relationship gratifies both sides. What are the advantages the fans get and what are the advantages the celebrities get?

A. There is an implicit contract between a celebrity and his fans. The celebrity is obliged to "act the part", to fulfil the expectations of his admirers, not to deviate from the roles that they impose and he or she accepts. In return the fans shower the celebrity with adulation. They idolize him or her and make him or her feel omnipotent, immortal, "larger than life", omniscient, superior, and sui generis (unique).

What are the fans getting for their trouble?

Above all, the ability to vicariously share the celebrity's fabulous (and, usually, partly confabulated) existence. The celebrity becomes their "representative" in fantasyland, their extension and proxy, the reification and embodiment of their deepest desires and most secret and guilty dreams. Many celebrities are also role models or father/mother figures. Celebrities are proof that there is more to life than drab and routine. That beautiful - nay, perfect - people do exist and that they do lead charmed lives. There's hope yet - this is the celebrity's message to his fans.

The celebrity's inevitable downfall and corruption is the modern-day equivalent of the medieval morality play. This trajectory - from rags to riches and fame and back to rags or worse - proves that order and justice do prevail, that hubris invariably gets punished, and that the celebrity is no better, neither is he superior, to his fans.

8. Why are celebrities narcissists? How is this disorder born?

No one knows if pathological narcissism is the outcome of inherited traits, the sad result of abusive and traumatizing upbringing, or the confluence of both. Often, in the same family, with the same set of parents and an identical emotional environment - some siblings grow to be malignant narcissists, while others are perfectly "normal". Surely, this indicates a genetic predisposition of some people to develop narcissism.

It would seem reasonable to assume - though, at this stage, there is not a shred of proof - that the narcissist is born with a propensity to develop narcissistic defenses. These are triggered by abuse or trauma during the formative years in infancy or during early adolescence. By "abuse" I am referring to a spectrum of behaviors which objectify the child and treat it as an extension of the caregiver (parent) or as a mere instrument of gratification. Dotting and smothering are as abusive as beating and starving. And abuse can be dished out by peers as well as by parents, or by adult role models.

Not all celebrities are narcissists. Still, some of them surely are.

We all search for positive cues from people around us. These cues reinforce in us certain behaviour patterns. There is nothing special in the fact that the narcissist-celebrity does the same. However there are two major differences between the narcissistic and the normal personality.

The first is quantitative. The normal person is likely to welcome a moderate amount of attention - verbal and non-verbal - in the form of affirmation, approval, or admiration. Too much attention, though, is perceived as onerous and is avoided. Destructive and negative criticism is avoided altogether.

The narcissist, in contrast, is the mental equivalent of an alcoholic. He is insatiable. He directs his whole behaviour, in fact his life, to obtain these pleasurable titbits of attention. He embeds them in a coherent, completely biased, picture of himself. He uses them to regulates his labile (fluctuating) sense of self-worth and self-esteem.

To elicit constant interest, the narcissist projects on to others a confabulated, fictitious version of himself, known as the False Self. The False Self is everything the narcissist is not: omniscient, omnipotent, charming, intelligent, rich, or well-connected.

The narcissist then proceeds to harvest reactions to this projected image from family members, friends, co-workers, neighbours, business partners and from colleagues. If these - the adulation, admiration, attention, fear, respect, applause, affirmation - are not forthcoming, the narcissist demands them, or extorts them. Money, compliments, a favourable critique, an appearance in the media, a sexual conquest are all converted into the same currency in the narcissist's mind, into "narcissistic supply".

So, the narcissist is not really interested in publicity per se or in being famous. Truly he is concerned with the REACTIONS to his fame: how people watch him, notice him, talk about him, debate his actions. It "proves" to him that he exists.

The narcissist goes around "hunting and collecting" the way the expressions on people's faces change when they notice him. He places himself at the centre of attention, or even as a figure of controversy. He constantly and recurrently pesters those nearest and dearest to him in a bid to reassure himself that he is not losing his fame, his magic touch, the attention of his social milieu.

next: Narcissism and Trust

• Watch the video on The Homosexual Narcissist

Question:

What is the typical profile of a homosexual narcissist? Why is he always on a lookout for new victims? Is he lying or is he telling the truth when he says that he "wants to get laid" by one and all? If he is not suicidal, is he not afraid of AIDS?

Answer:

I am a heterosexual and thus deprived of an intimate acquaintance with certain psychological processes, which allegedly are unique to homosexuals. I find it hard to believe that there are such processes, to begin with. Research failed to find any substantive difference between the psychological make-up of a narcissist who happens to have homosexual preferences - and a heterosexual narcissist.

They both are predators, devouring Narcissistic Supply Sources as they go. Narcissists look for new victims, the way tigers look for prey - they are hungry. Hungry for adoration, admiration, acceptance, approval, and any other kind of attention. Old sources die easy - once taken for granted, the narcissistic element of conquest vanishes.

Conquest is important because it proves the superiority of the narcissist. The very act of subduing, subjugating, or acquiring the power to influence someone provides the narcissist with Narcissistic Supply. The newly conquered idolise the narcissist and serve as a trophies.

The act of conquering and subordinating is epitomized by the sexual encounter - an objective and atavistic interaction. Making love to someone means that the consenting partner finds the narcissist (or one or more of his traits, such as his intelligence, his physique, even his money) irresistible.

The distinction between passive and active sexual partners is mechanical, false, superfluous and superficial. Penetration does not make one of the parties "the stronger one". To cause someone to have sex with you is a powerful stimulus - and always provokes a sensation of omnipotence. Whether one is physically passive or active - one is always psychosexually active.

Anyone who has unsafe sex is gambling with his life - though the odds are much smaller than public hysteria would have us believe. Reality does not matter, though - it is the perception of reality that matters. Getting this close to (perceived) danger is the equivalent of engaging in self-destruction (suicide). Narcissists are, at times, suicidal and are always self-destructive.

There is, however, one element, which might be unique to homosexuals: the fact that their self-definition hinges on their sexual identity. I know of no heterosexual who would use his sexual preferences to define himself almost fully. Homosexuality has been inflated to the level of a sub-culture, a separate psychology, or a myth. This is typical of persecuted minorities. However, it does have an influence on the individual. Preoccupation with body and sex makes most homosexual narcissists SOMATIC narcissists.

Moreover, the homosexual makes love to a person of the SAME sex - in a way, to his REFLECTION. In this respect, homosexual relations are highly narcissistic and autoerotic affairs.

The somatic narcissist directs his libido at his body (as opposed to the cerebral narcissist, who concentrates upon his intellect). He cultivates it, nourishes and nurtures it, is often an hypochondriac, dedicates an inordinate amount of time to its needs (real and imaginary). It is through his body that this type of narcissist tracks down and captures his Supply Sources.

The supply that the somatic narcissist so badly requires is derived from his form, his shape, his build, his profile, his beauty, his physical attractiveness, his health, his age. He downplays Narcissistic Supply directed at other traits. He uses sex to reaffirm his prowess, his attractiveness, or his youth. Love, to him, is synonymous with sex and he focuses his learning skills on the sexual act, the foreplay and the coital aftermath.

Seduction becomes addictive because it leads to a quick succession of Supply Sources. Naturally, boredom (a form of transmuted aggression) sets in once the going gets routine. Routine is counter-narcissistic by definition because it threatens the narcissist's sense of uniqueness.

An interesting side issue relates to transsexuals.

Philosophically, there is little difference between a narcissist who seeks to avoid his True Self (and positively to become his False Self) - and a transsexual who seeks to discard his true gender. But this similarity, though superficially appealing, is questionable.

People sometimes seek sex reassignment because of advantages and opportunities which, they believe, are enjoyed by the other sex. This rather unrealistic (fantastic) view of the other is faintly narcissistic. It includes elements of idealised over-valuation, of self-preoccupation, and of objectification of one's self. It demonstrates a deficient ability to empathise and some grandiose sense of entitlement ("I deserve to be taken care of") and omnipotence ("I can be whatever I want to be - despite nature/God").

This feeling of entitlement is especially manifest in some gender dysphoric individuals who aggressively pursue hormonal or surgical treatment. They feel that it is their inalienable right to receive it on demand and without any strictures or restrictions. For instance, they oftentimes refuse to undergo psychological evaluation or treatment as a condition for the hormonal or surgical treatment.

It is interesting to note that both narcissism and gender dysphoria are early childhood phenomena. This could be explained by problematic Primary Objects, dysfunctional families, or a common genetic or biochemical problem. It is too early to say which. As yet, there isn't even an agreed typology of gender identity disorders - let alone an in-depth comprehension of their sources.

A radical view, proffered by Ray Blanchard, seems to indicate that pathological narcissism is more likely to be found among non-core, ego-dystonic, autogynephilic transsexulas and among heterosexual transvestites. It is less manifest in core, ego-syntonic, homosexual transsexuals.

Autogynephilic transsexuals are subject to an intense urge to become the opposite sex and, thus, to be rendered the sexual object of their own desire. In other words, they are so sexually attracted to themselves that they wish to become both lovers in the romantic equation - the male and the female. It is the fulfilment of the ultimate narcissistic fantasy with the False Self as a fetish ("narcissistic fetish").

Autogynephilic transsexuals start off as heterosexuals and end up as either bisexual or homosexual. By shifting his/her attentions to men, the male autogynephilic transsexual "proves" to himself that he has finally become a "true" and desirable woman.

next: The Narcissist's Addiction to Fame and Celebrity

Question:

My husband is a narcissist and is constantly depressed. Is there any connection between these two problems?

Answer:

Assuming that these are clinically established facts, there is no necessary connection between them. In other words, there is no proven high correlation between suffering from NPD (or having even a milder form of narcissism) - and enduring bouts of depression.

Depression is a form of aggression. Transformed, this aggression is directed at the depressed person rather than at his environment. This regime of repressed and mutated aggression is a characteristic of both narcissism and depression.

Originally, the narcissist experiences "forbidden" thoughts and urges (sometimes to the point of an obsession). His mind is full of "dirty" words, curses, the remnants of magical thinking ("If I think or wish something it just might happen"), denigrating and malicious thinking concerned with authority figures (mostly parents or teachers).

These are all proscribed by the Superego. This is doubly true if the individual possesses a sadistic, capricious Superego (a result of the wrong kind of parenting). These thoughts and wishes do not fully surface. The individual is only aware of them in passing and vaguely. But they are sufficient to provoke intense guilt feelings and to set in motion a chain of self-flagellation and self-punishment.

Amplified by an abnormally strict, sadistic, and punitive Superego - this results in a constant feeling of imminent threat. This is what we call anxiety. It has no discernible external triggers and, therefore, it is not fear. It is the echo of a battle between one part of the personality, which viciously wishes to destroy the individual through excessive punishment - and the instinct of self-preservation.

Anxiety is not - as some scholars have it - an irrational reaction to internal dynamics involving imaginary threats. Actually, anxiety is more rational than many fears. The powers unleashed by the Superego are so enormous, its intentions so fatal, the self-loathing and self-degradation that it brings with it so intense - that the threat is real.

Overly strict Superegos are usually coupled with weaknesses and vulnerabilities in all other personality structures. Thus, there is no psychic structure able to fight back, to take the side of the depressed person. Small wonder that depressives have constant suicidal ideation (=they toy with ideas of self-mutilation and suicide), or worse, commit such acts.

Confronted with a horrible internal enemy, lacking in defences, falling apart at the seams, depleted by previous attacks, devoid of energy of life - the depressed wishes himself dead. Anxiety is about survival, the alternatives being, usually, self-torture or self-annihilation.

Depression is how such people experience their overflowing reservoirs of aggression. They are a volcano, which is about to explode and bury them under their own ashes. Anxiety is how they experience the war raging inside them. Sadness is the name that they give to the resulting wariness, to the knowledge that the battle is lost and personal doom is at hand.

Depression is the acknowledgement by the depressed individual that something is so fundamentally wrong that there is no way he can win. The individual is depressed because he is fatalistic. As long as he believes that there is a chance - however slim - to better his position, he moves in and out of depressive episodes.

True, anxiety disorders and depression (mood disorders) do not belong in the same diagnostic category. But they are very often comorbid. In many cases, the patient tries to exorcise his depressive demons by adopting ever more bizarre rituals. These are the compulsions, which - by diverting energy and attention away from the "bad" content in more or less symbolic (though totally arbitrary) ways - bring temporary relief and an easing of the anxiety. It is very common to meet all four: a mood disorder, an anxiety disorder, an obsessive-compulsive disorder and a personality disorder in one patient.

Depression is the most varied of all psychological illnesses. It assumes a myriad of guises and disguises. Many people are chronically depressed without even knowing it and without corresponding cognitive or affective contents. Some depressive episodes are part of a cycle of ups and downs (bipolar disorder and a milder form, the cyclothymic disorder).

Other depressions are "built into" the characters and the personalities of the patients (the dysthymic disorder or what used to be known as depressive neurosis). One type of depression is even seasonal and can be cured by photo-therapy (gradual exposure to carefully timed artificial lighting). We all experience "adjustment disorders with depressed mood" (used to be called reactive depression - which occurs after a stressful life event and as a direct and time-limited reaction to it).

These poisoned garden varieties are all-pervasive. Not a single aspect of the human condition escapes them, not one element of human behaviour avoids their grip. It is not wise (has no predictive or explanatory value) to differentiate "good" or "normal" depressions from "pathological" ones. There are no "good" depressions.

Whether provoked by misfortune or endogenously (from the inside), whether during childhood or later in life - it is all one and the same. A depression is a depression is a depression no matter what its precipitating causes are or in which stage in life it appears.

The only valid distinction seems to be phenomenological: some depressives slow down (psychomotor retardation), their appetite, sex life (libido) and sleep (known together as the vegetative) functions are notably perturbed. Behaviour patterns change or disappear altogether. These patients feel dead: they are anhedonic (find pleasure or excitement in nothing) and dysphoric (sad).

The other type of depressive is psychomotorically active (at times, hyperactive). These are the patients that I described above: they report overwhelming guilt feelings, anxiety, even to the point of having delusions (delusional thinking, not grounded in reality but in a thwarted logic of an outlandish world).

The most severe cases (severity is also manifest physiologically, in the worsening of the above-mentioned symptoms) exhibit paranoia (delusions of systematic conspiracies to persecute them), and seriously entertain ideas of self-destruction and the destruction of others (nihilistic delusions).

They hallucinate. Their hallucinations reveal their hidden contents: self-deprecation, the need to be (self) punished, humiliation, "bad" or "cruel" or "permissive" thoughts about authority figures. Depressives are almost never psychotic (psychotic depression does not belong to this family, in my view). Depression does not necessarily entail a marked change in mood. "Masked depression" is, therefore, difficult to diagnose if we stick to the strict definition of depression as a "mood" disorder.

Depression can happen at any age, to anyone, with or without a preceding stressful event. It can set on gradually or erupt dramatically. The earlier it occurs - the more likely it is to recur. This apparently arbitrary and shifting nature of depression only enhances the guilt feelings of the patient. He refuses to accept that the source of his problems is beyond his control (at least as much as his aggression) and could be biological, for instance. The depressive patient always blames himself, or events in his immediate past, or his environment.

This is a vicious and self-fulfilling prophetic cycle. The depressive feels worthless, doubts his future and his abilities, feels guilty. This constant brooding alienates his dearest and nearest. His interpersonal relationships become distorted and disrupted and this, in turn, exacerbates his depression.

The patient finally finds it most convenient and rewarding to avoid human contact altogether. He resigns from his job, shies away from social occasions, sexually abstains, shuts off his few remaining friends and family members. Hostility, avoidance, histrionics all emerge and the existence of personality disorders only make matters worse.

Freud said that the depressive person had lost a love object (was deprived of a properly functioning parent). The psychic trauma suffered early on can be alleviated only by inflicting self-punishment (thus implicitly "punishing" and devaluing the internalised version of the disappointing love object).

The development of the Ego is conditioned upon a successful resolution of the loss of the love objects (a phase all of us have to go through). When the love object fails - the child is furious, revengeful, and aggressive. Unable to direct these negative emotions at the frustrating parent - the child directs them at himself.

Narcissistic identification means that the child prefers to love himself (direct his libido at himself) than to love an unpredictable, abandoning parent (mother, in most cases). Thus, the child becomes his own parent - and directs his aggression at himself (=to the parent that he has become). Throughout this wrenching process, the Ego feels helpless and this is another major source of depression.

When depressed, the patient becomes an artist of sorts. He tars his life, people around him, his experiences, places, and memories with a thick brush of schmaltzy, sentimental, and nostalgic longing. The depressive imbues everything with sadness: a tune, a sight, a colour, another person, a situation, a memory.

In this sense, the depressive is cognitively distorted. He interprets his experiences, evaluates his self and assesses the future totally negatively. He behaves as though constantly disenchanted, disillusioned, and hurting (dysphoric affect) and this helps to sustain the distorted perceptions.

No success, accomplishment, or support can break this cycle because it is so self-contained and self-enhancing. Dysphoric affect supports distorted perceptions, which enhance dysphoria, which encourages self-defeating behaviours, which bring about failure, which justifies depression.

This is a cosy little circle, charmed and emotionally protective because it is unfailingly predictable. Depression is addictive because it is a strong love substitute. Much like drugs, it has its own rituals, language and worldview. It imposes rigid order and behaviour patterns on the depressive. This is learned helplessness - the depressive prefers to avoid situations even if they hold the promise of improvement.

The depressive patient has been conditioned by repeated aversive stimuli to freeze - he does not even have the energy needed to exit this cruel world by committing suicide. The depressive is devoid of the positive reinforcements, which are the building blocks of our self-esteem.

He is filled with negative thinking about his self, his (lack of) goals, his (lack of) achievements, his emptiness and loneliness and so on. And because his cognition and perceptions are deformed - no cognitive or rational input can alter the situation. Everything is immediately reinterpreted to fit the paradigm.

People often mistake depression for emotion. They say about the narcissist: "but he is sad" and they mean: "but he is human", "but he has emotions". This is wrong. True, depression is a big component in the narcissist's emotional make-up. But it mostly has to do with the absence of Narcissistic Supply. It mostly has to do with nostalgia for more plentiful days, full of adoration and attention and applause. It mostly occurs after the narcissist has depleted his secondary Sources of Narcissistic Supply (spouse, mate, girlfriend, colleagues) with his constant demands for for the "re-enactment" of his days of glory. Some narcissists even cry - but they cry exclusively for themselves and for their lost paradise. And they do so conspicuously and publicly - to attract attention.

The narcissist is a human pendulum hanging by the thread of the void that is his False Self. He swings between brutal and vicious abrasiveness - and mellifluous, maudlin, and saccharine sentimentality. It is all a simulacrum. A verisimilitude. A facsimile. Enough to fool the casual observer. Enough to extract the drug - other people's attention, reflection that somehow sustains this house of cards.

But the stronger and more rigid the defences - and nothing is more resilient than pathological narcissism - the greater and deeper the hurt the narcissist aims to compensate for. One's narcissism stands in direct relation to the seething abyss and the devouring vacuum that one harbours in one's True Self.

Perhaps narcissism is, indeed, as many say, a reversible choice. But it is also a rational choice, guaranteeing self-preservation and survival. The paradox is that being a self-loathing narcissist may be the only act of true self-love the narcissist ever commits.

next: Homosexual and Transsexual Narcissists