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Fear of flying

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Last week I had one of the most frightening journeys I’ve ever experienced in my life. I flew back into Orkney in the middle of the ‘weather bomb’ that hit Northern Scotland. Despite the forecast, it was surprising calm as the Loganair flight left Aberdeen, but after we had been served the customary tea and Tunnock’s caramel wafer I always look forward to, the wind began to buffet the plane violently, not only from side to side but also up and down. As we came out of the clouds towards the islands we turned on dipped wing into a curve that I soon recognised as the familiar holding pattern.

“Sorry about this,” came the calm voice of the female co-pilot, “there’s a snowstorm at the airport in Kirkwall so it’s going to be a little while before we can land.”

For the next fifteen minutes or so, it may have been longer I lost track of time, we jerked through troughs and peaks of stormy shades of grey, occasionally illuminated by a flash of lightning. My hands, cold and clammy by now, gripped the armrests. My stomach rose up into my throat as I shared false smiles with a woman seated across the aisle. Behind me, another passenger lost the contents of her stomach. As I caught occasional glimpses of the flinty sea just below I began to have those familiar thoughts: ‘is this where it will end, after all?’

A few days before I had been working with fear of a different kind as novice therapists I was teaching about suicide talked about the anxiety which comes with not knowing how to cope when you, as a mental health worker, are faced with someone who might want to end their life.

From my early days in psychiatry I had to try and learn how to cope with uncertainty. I often meet doctors, nurses and other health professionals who quiz me about what is the ‘right’ thing to say or do in a particular situation; as though we can always be prepared for whatever we have to face in a consultation, and handle it ‘properly’. As if, by some magic, we can always find out exactly what the chances are of a person seriously harming themselves by asking them the ‘right’ questions, and manage any situation by being ‘ready’ with the ‘correct’ words and interventions. So that they will be safe…and we will of course not be criticised.

The problem is that it simply isn’t possible for any of us, therapists, doctors, patients or service users, to be sufficiently primed to deal with everything in work (or life) beforehand. There are too many different permutations possible. You have to learn how to use the knowledge, skills and particular talents you have and the information you can glean at that particular moment, to do the best you can to help someone in the time available. In talking to a patient, a mental health worker has to work hard to gain a person’s trust so that the answers to his or her questions will be at the very least some reliable refection of how they are feeling. In order to achieve this the worker has to be able to contain their own anxieties; about their own performance, the safety of the patient, what might or might not happen, in order to help the patient contain theirs. If the worker is struggling to deal with their own fears, such as being simply overwhelmed by the enormity of the person’s problems, the person seeking help will not feel safe enough at that moment to share how they feel- and the worker probably will not obtain an emotionally accurate sense of what is happening for them.

Its not only novice mental health workers who find it hard to manage uncertainty. I meet some quite experienced professionals who are still very obviously struggling to cope with their own fears. For me, it indicates they need a time and place to share their worries about the job. Supervision is still sorely lacking for many workers. As a consultant psychiatrist I regularly shared my concerns with my closest colleagues but I had no formal arrangement for support and supervision. But I have seen how, if we don’t learn to cope successfully with the uncertainty and fear we face in our work, we manage it in other ways. By detaching ourselves from the pain and becoming less empathic; by trying to dissolve it in alcohol and other substances; or just trying to exert an even greater control over the world, searching for answers to those unanswerable questions I get asked at the end of lectures which always raise an uncomfortable laugh from the audience. Our fear is palpable to our colleagues as well as patients.

If we can acknowledge the limits of certainty we have a least a good chance of reaching out and helping a person to tolerate the fear they are experiencing when they begin to tell us about something awful- like their thoughts about dying or the abuse they faced in childhood. Then we can begin to give them some hope. The first step in this must be staying calm, and showing we can take it.

I used to be very afraid of flying. I suppose I’ve undergone a prolonged course of desensitization over the years, but my palms still sweat at every take off and landing. Last week they were wringing wet.

After one run at the airfield which was aborted because of a ‘build up of traffic waiting to get in’ we eventually landed at Kirkwall. I was emotionally drained and almost tearful. But I know that what helped me to contain my fear of dying in the storm was the reassuring commentary of the co-pilot. Her calm professionalism helped. There could have been panic in the cockpit. But it didn’t show.

“Ladies and gentlemen, I know it’s been a difficult flight but you’ll be pleased to know they have just checked the runway; it’s safe and we’ll have you on the ground in a few minutes now.”

I wanted to thank and hug her, but I didn’t…being British of course. So I just said ‘goodbye’ with a teary smile, and stepped onwards into the rain. Happy to still be alive.

Work

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I’m going to write about a topic I know nothing about, at least not from the viewpoint of an expert in the published research, but as that doesn’t generally stop many other people I don’t see why it should inhibit me. I have after all worked for most of my life so I’ve plenty of lived experience; and I’ve treated many people who have been struggling to get back into work, or suffering ill-health as a consequence of the toxic environment in which they work. Its eighteen months now since I retired from the University, and a year since I gave up my clinical work and drastically reduced my workload. I’ve been told that work is something that is good for our mental health, so I can only tell you that I feel better physically and mentally overall than I have for several years. People tell me I look younger. I regularly apologise for having thrown in the towel; but it has been something of a fight- to get to the point where I could be done with the job before it did for me.

Please don’t get me wrong, I always enjoyed the interactions with patients and service users, and if I miss anything, it’s the feeling of making a difference in a person’s life; connecting with them and helping them to achieve some change. However I do know that if I had stayed in the NHS rather than being able to move into an academic post quite early in my career I would have been forced into taking even earlier retirement many years ago. I didn’t find the health service to be a sympathetic employer, either in the face of my own episodic periods of depression, which sometimes required time off work, or that of my patients who worked in the system- doctors, nurses and allied professionals. Not only was the macho style of management one of the factors that made it difficult for people to return to work with some degree of flexibility, it was sometimes a key factor in a person becoming depressed or severely anxious in the first place. I personally experienced bullying on more than one occasion, which contributed to several months off work. I know I’m less resilient than I sometimes appear to be.

My patients in the private sector had very mixed experiences. I remember one man who was criticised at work for needing to take breaks to ensure he ate at regular times- he had type 1 diabetes. When he got depressed they sacked him. Another patient with longer-term mental health problems was a poster-girl for a supported back to work scheme. The supermarket who took her on were very keen to be involved, but after a few months, after the support had been withdrawn and a ‘success story’ publicised, expected her to ‘work like everyone else’. Her voices returned as she became increasingly stressed and paranoid. She lost the job. In contrast, a person who worked for a large multinational company was allowed to return to work gradually over an extended period of time, and the occupational health department regularly consulted with all of us to ensure we were all agreed with the plan. They viewed my patient as a valued employee with expertise and experience they did not want to lose. I wish I could say that the NHS generally responded in a similar way. But it didn’t.

So where does this take me? Well, now the end goal of Recovery seems to be to get into paid work. Indeed attendance at Recovery Colleges has been sanctioned in order to apparently assist people with mental health problems to do so. Aside from the fact that, if Recovery were so straightforward all we needed to do was attend a course in it (and I don’t believe it is for many people), I’m very concerned about what we are sending many people back into. Not everyone is an academic who can work flexibly and take time off without risking their employment, I know that. However many more people do jobs from which they gain little sense of self-worth or value beyond simply earning a living. I’m a working-class girl. My parents both clocked in at 7.30 every morning and neither of them would have described their jobs as particularly fulfilling. What they did get was company, an opportunity to use some of their skills at least and a pay-packet. As a student I worked on supermarket checkouts, served in a bar and waited on tables for employers who varied considerably in their attitudes to ill-health. I wouldn’t have coped with those jobs at all if I had been depressed- nor would I have been in any great hurry to return. I personally know people who would never be able to cope with the stresses of regular employment again, yet they are repeatedly reassessed with the constant threat of losing their benefits. This just acts as a further stressor- we all know its cruel and has led to suicide.

So I have doubts about paid employment being the right goal for everyone. Surely it isn’t just about ‘work’ but how we spend our day? Yes, I know we have to bring in an income, but I’ve personally met very few people who really didn’t want to work. What they wanted was a supportive plan to help them move towards employment. A plan which might also involve volunteering and further study or training to gradually help them rediscover a sense of who they were, where they were going, and what goals they could realistically achieve. Not a simple ‘course’ but a journey, which might end in a regular job, but might not if that wasn’t right or possible. A much more humane solution than we are presented with now.

So don’t tell me that work is always good for me, because I know it isn’t. If it was, I wouldn’t be sitting here, feeling quite relaxed, writing this blog. I’d be on call. Or writing another grant proposal.

Whew!

‘Misery’, moods and madness

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I find I learn what I think about something as I write about it. Composing words on a screen (I stopped writing by hand when I gave up clinical work- I have a writing corn from years of scribbling in notes) helps me to formulate what exactly it is that is troubling me. But for a few weeks I’ve had difficulty writing anything very creative other than a single blog. I’m well aware I’ve been grieving for my beloved cat; I was feeling very sad but I began to feel a little better again. Then I had a visit from a family member, which stirred up unwanted thoughts (and dreams) about the past.  I began to ruminate again about all sorts of other ‘stresses’ in my life although I’m still not sure how really threatening they actually are, and, for a couple of weeks, my mood plummeted downwards.

 

It’s become fashionable in some circles not to use the word ‘depression’ but to refer to ‘misery’ instead. ‘Depression’ is a contested concept and there is a powerful view that it is primarily a state that is socially determined, a natural response to life events that will respond to social and/or psychological intervention without the need for anything more. Particularly medication.

 

While I wholeheartedly agree that the DSM concept of a unitary ‘depression’ is simplistic and that there are, as the founder of the Black Dog Institute in Australia, Gordon Parker, has suggested, many different ‘depressions’, I really must draw the line at the increasing use of the word ‘misery’. To be described as ‘miserable’ not only means being constantly unhappy but also has connotations of wretchedness and being an awful burden to others. ‘Misery’ as an idea I can just about tolerate, but to be described as miserable because you feel down feels like yet another form of stigmatization of the ‘undeserving poor’ who are unable, or cannot be bothered, to help themselves.

 

And the question is should all experiences of depression now be lumped together as a result of social causes? This is as simplistic to me as suggesting its all down to incorrect or ‘faulty’ thinking or something wrong with the level of monoamines in the synapse. All of these are, for me, similarly discredited ideas. Surely our brains (and our experiences) are worthy of more complex theories than these?

 

What I’ve learned is that there are times when something really seems to shift in my mood, as though some unseen worker in my brain pulls a lever.  Usually this happens in response to a build up of life events (yes, social factors play a key part), and when these events are of a particular kind that holds an inherent threat to my sense of who I am (the psychological part), then my mood is much more likely to shift, and quite rapidly too. When I was working full time I could move from feeling anxious, but keeping my head above water, to quite a different state of mind, within a day. When I am there I feel quite different. I don’t only feel sad, I feel physically ‘changed’; heavy of limb, tired, unable to sleep yet also very agitated. I ruminate about things that at other times I would be able to cope with easily and I am full of ‘fear’. When I look in the mirror I am quite sure I can see it in my eyes. There are times when my fear can shift into frankly paranoid thoughts and feelings of wanting to end my life. It’s terrifying and yet oddly familiar at the same time. I’ve been there many times, and I’ve just been there, albeit fairly briefly this time, again.

 

I’m fortunate that I haven’t had depression severe enough to warrant admission to hospital but I’ve had several episodes in my life. Why does this happen to me, but not to so many others who seem to be much more resilient? If I’m just ‘miserable’ perhaps it’s because I’m just inherently weak? For me, this is the obvious conclusion I must draw.

 

What I do believe is that ‘depression’ is a complex, multidimensional experience incorporating everything from profound and painful unhappiness to suicidal thoughts and psychotic degrees of despair. As I’ve said before, ‘depression’ and ‘anxiety’ are also very closely linked to the degree that I don’t find the idea of diagnostic co-morbidity useful at all.

 

The only way I can explain why only some of us seem to become depressed in response to life events is by drawing on the concept of vulnerability. A combination of genetic factors, early life experiences and unremitting life stresses such as lack of support and long-term physical illness add to our vulnerability. Such that, when a torrent of life events come along, those of us who have the greatest vulnerability and lowest threshold for becoming depressed, will get washed away by the waves while those who are fortunately more resilient seem to remain standing.

 

I don’t find it difficult to identify all of those factors in my own life. I’ve used biological (medication), psychological (therapy) and social (retirement from a stressful job) strategies to overcome them. Most of the time now, it works for me.  But there are still likely to be times when my mood just seems to switch gear again and I begin to see an image of the world distorted through a glass, darkly. I’ve never been clinically high, but when I begin to feel better I do sometimes feel an odd surge of well-being to be back in tune with life again.

Just please don’t call me ‘miserable’.

Grief

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With so many people experiencing loss and hardship at the moment its not easy to admit the depth of grief I have been experiencing over the last month.  I’m sure I’ve glibly told many people over the years how ‘grief is a normal human experience,’ but that doesn’t make it any easier to bear. It may simply be an everyday kind of emotional pain, but it washes over me in waves of acute sadness and despair. One moment I’m fine, the next I’m in tears; and it hurts physically too. There is a pain my chest right above my heart. But this grief is not for a human being, but for an animal companion, my cat Sophie.

 

I’ve seen that wry smile on a colleague’s face when I tell them how it feels to lose a pet . Not that Soph was a ‘pet’, she was a fiercely beautiful but barely tamed Maine Coon cat who viewed the human race if not quite the enemy, certainly as all potential vivisectionists. But those who don’t understand how attached you can become to an animal are simply embarrassed by our tears; they don’t know what to say. Statements like ‘well you can always get another one can’t you?’ are unhelpful. Yes, I have another cat, but he isn’t her. He is different. I will probably have a few more in my life (or rather they will have me) but each one I have lost has left a unique shaped space behind in my heart that another will eventually fill- but not in quite the same way. Some colleagues of mine have written about the important part that animals play in providing support for people with long-term conditions. But we live in a society where older (and younger) people with mental health problems are regularly separated from their companions when they have to move into new rented accommodation due to the desperate state of our housing policy. I cannot imagine the pain of having to give up my companion animal. Perhaps I will have to one day.

 

Grief is something I know about. I treated many people in my career who were failing to grieve for someone, or something they had lost. It doesn’t have to be a person, it can be a career, a person, your health, or even your hopes for the future. The list is endless. The process IS normal but it can be frightening if you have never felt it before. It isn’t the same as depression although if a person fails to grieve properly depression may follow, and in the vulnerable, loss may trigger it. But it should not be medicalised as it has been in DSM-5 where two weeks of depressed mood following loss is taken to indicate depression. Two weeks? That’s crazy. Grief can take years, a lifetime to resolve. The key thing is the trajectory of the process and the severity of the symptoms. Is it gradually getting easier over time or unchanged in intensity? How low are you feeling? Have you had thoughts of suicide or wanting to join the dead person?  I failed to grieve successfully once when I lost someone very important.  I didn’t talk about it. I tried to work my way out of it at the hospital rather than go through it.  You cannot shut it out. You have to talk, remember …and weep.

 

Sophie was killed by a fox one night in August. She loved going out at night to hunt. She began her life as a pedigree puss and then heard the call of the wild. She escaped when she got very frightened as were taking her to a cattery and wriggled out of her harness. She would never travel in a cage. I missed her terribly but I always hoped she come back to us, and she did. She spent two years living rough before she finally trusted a lady enough to accept help, and was returned to us (due to her microchip) by the RSPCA. She would sit next to me on the sofa and purr loudly, demanding her share of my love. Her coat was soft and silky before she disappeared, but woolly and thick when she returned after two winters outside in Yorkshire. But she knew she was home and she embraced it with enthusiasm. She was a happy, healthy cat and she was only seven years old. It’s really hard to accept she could have survived so long on her own and then die now. But I couldn’t have kept her inside. That would have been unbelievably cruel.  Yet I still feel I should have been there to protect her. Grief isn’t just about sadness, but guilt and anger. And remembering.

I have some of her fur, and a library of pictures to remember her by. I can look at them now. It was very painful at first.

It’s getting a little easier each day.  That I’ve been able to write this is a sign I’m coming through it.

But I’ll always miss her.

 

Reassessing ‘assessment’

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One of the side effects of having more time than I used to is that I begin to brood over the meaning of the words I once used without a second thought. It particularly happens on long walks without the running commentary of the radio. In a recent bIog I talked about ‘recovery’. Now I’ve started to think about a word I would never have given much more than a second thought too as a working psychiatrist- ‘assessment’.

The problem with many words in mental health is that they can begin to assume alternate meanings. Use of the ‘active’ and ‘passive’ tense can be important too in conveying a sense of who has the power. There is something very passive about being ‘counseled’ and the act of counseling has itself taken on various meanings from receiving counseling as ‘therapy’, wise counsel as ‘advice’ and being ‘counseled’ as a form of disciplinary act.

I don’t remember as a psychiatric trainee being specifically trained to carry out a ‘psychiatric assessment’. I was taught how to master a psychiatric interview, which considered of ‘taking the history’ (which can sound and feel rather like a rather one-sided action on the part of the doctor, removing something from the patient) and carrying out a mental state examination. I soon learned that for the interview to be effective I had to spend as long actively engaging the patient in thinking I was a person with whom they would be willing to share their experiences, as asking all the questions that psychiatrists are (in)famous for. Later on, I began to research how both GPs and psychiatrists approach the ‘consultation’ as the meeting between professional and patient is commonly known in primary care. Indeed actively ‘consulting’ the doctor conveys more power to the patient than being interviewed or assessed by them. I spent hours, days and weeks observing interactions for my research. I remember the patient who, when asked by the psychiatrist whether he knew if he had had a traumatic birth quite reasonably replied ‘well the Battle of Britain was on at the time doctor’.

Somewhere along the line, the psychiatric interview or consultation became the ‘assessment’ with a list of questions to ask the patient. Changes in the examination system of doctors reinforced this, with the shorter structured OSCEs (Observed Structured Clinical Examinations) with role-played patients, that are probably fairer to the candidates, but reward marks for asking the ‘right questions’ when ‘assessing depression’, ‘suicide risk’ or ‘hallucinations’. I’m as guilty of this as anyone. I teach suicide risk assessment skills. The blurb for my latest book on depression mentions assessment too.

So what’s the problem I have with assessment? Well, when a person assesses another they are implicitly making a judgment about their suitability for something or their ability to achieve particular goals. As a patient I have been assessed for therapy. That’s fair enough perhaps when there are indications as to whether or not a person might benefit rom that intervention. Psychologists regularly carry out assessments perfectly reasonably as not everyone will benefit from their specialist expertise. But how often is this mutual assessment? Are you a person I could talk to?

And so often now I see mental health assessment as a tool to exclude rather than seek to help a person find the help they might benefit from. Its more ‘this person isn’t psychotic or actively suicidal so there is nothing we can offer them’ rather than, ‘this person is consulting me. They are extremely distressed. They don’t understand what is happening to them. How can I help them?’ In our increasingly fragmented health care system everyone is carrying out assessment according to their particular ‘criteria’ while the service user understandably feels they have been ‘assessed to death- when is someone going to help me?’

Can we move away, in mental health care, from this culture of assessment back to one of a consultation, which David Tuckett and his colleagues first described many years ago as the ‘Meeting Between Experts’?

I am the expert in what I am experiencing. You are the expert in what might be effective. In consulting you and providing you with all this very sensitive information about my inner life, I’m an trusting that you as a professional will be able not only to say if you will be able to help me personally, but also that you will do your best to help me access what I need.

I really need your assistance now to navigate this increasingly hostile system of care. I am asking for your help.

Strategies for Living

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In the last few weeks, while I’ve been largely alone in Orkney, I’ve been aware of having to cope with my mood and thoughts from day to day and reading about how people with mental health problems cope on Twitter and support each other.

I’ve also been reminded of something I read many years ago.

At the turn of the millennium, the Mental Health Foundation carried out some service user research and produced a report called ‘Strategies for Living.’ Over 400 people had completed Knowing our own Minds – a user-led survey of alternative and complementary treatments and therapies in mental health and Strategies for Living reported the findings from interviewing 71 people with experience of mental health problems in depth. This was a really positive piece of work, which highlighted the particular activities and experiences which people with mental health problems found helpful in coping with their everyday lives: from on-going survival strategies, such as the need for financial security to crisis strategies such as making contact with friends or professionals, ways of controlling symptoms such as taking medication, having therapy, taking exercise or using a Walkman (yes it is a few years old) to distract from hearing voices, to ‘healing strategies’ through religion and spiritual beliefs to complementary therapies.

Relationships with others were key. Several common themes could be identified:

• Acceptance
• Shared experience… shared identity
• Emotional support… ‘being there’
• A reason for living
• Finding meaning… and purpose
• Peace of mind… and relaxation
• Taking control… having choices
• Security… and safety
• Pleasure

Mental health services were largely absent from the accounts that people offered although some individual professionals clearly offered a great deal of valued support

Why am I reminded of this now?

How we cope from day to day is a very personal phenomenon. There are of course some common strategies that people find helpful and these were the ones reported in Strategies for Living.

However there are also some other ways of coping that were not reported in here. The strategies that people do not always want to admit to. I know some of these intimately. Despite growing up in a household of heavy smokers, I’ve never tried a cigarette, but I watched my father consume 40 a day as his own personal way of keeping life at bay. Excessive drinking is something I’ve always suspected I could sink into and I’ve consciously tried to cut down in recent months. It isn’t always easy. I spent some of my career working in alcohol services and I know how hard it can be to withdraw from alcohol and other substances. But there are other ways too that we cope with how we feel: eating, or not, over exercising, self-harm and self-injury , spending every night out on the town or shutting ourselves away completely from the world to the point that we feel completely isolated and ultimately brooding about strategies for dying rather than living. Suicidal thoughts are themselves a coping strategy. Knowing there is a way out when it all gets just too much.

My concern with much of the self-help literature, some of which sits on my own bookshelf unopened, is that it makes various assumptions:

  • We actually want to change, and stop using the sometimes self-destructive ways of coping we find helpful in day to day survival.
  • We can find the resources to be able to do that.
  • We have the material resources and social capital to be able to adopt some of the positive strategies people suggest to us, such as time, money and a place to live to start off with.

Its difficult to adopt new ways of coping until you have acknowledged what you will lose in giving up the other strategies, the ones health professionals would prefer you to unquestionably ditch. Such positive ways of coping cannot be prescribed (such as in the advice to ‘go home and have a warm bath and a cup of tea’ that currently seems beloved of some crisis support teams- actually I didn’t  see these even mentioned in Strategies for Living either). Health professionals need to start from where we are at now. What have we found helpful in the past? What do we do now to cope? What is difficult about changing ? And avoid being judgmental if they want us to be honest.

The problem with feeling depressed is that it involves rumination. Indeed in some cultures it is considered to be a problem of ‘thinking too much’. We become aware of our thoughts, and struggle to cope with them minute by minute. I certainly have some obsessional features to my thinking, and I’m aware that if the day doesn’t go ‘right’ in some often hard to clarify way, I can feel as though everything has gone ‘very wrong’. I have to mentally restart the day in some way. These thoughts can be painful and repetitive and I seek ways to avoid them. Distraction is probably the most effective way I’ve found and I deeply resent that some psychologists I’ve met seek to denigrate such an effective coping strategy as a ‘safety behaviour’ in CBT speak. Hell- give me a break- it’s what I find helpful!

There are many different strategies for living and quite a few for dying.
Help me to find the ones that fit me best to help me survive.
Don’t advise, lecture or proselytize.

Solitude

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Winter sunshine, Orkney

I’m back in Orkney after six weeks away. I’ve been busy, teaching and working, as far afield as Bangladesh. I’ve also found it impossible to sit down and write even when I’ve not been occupied.

One of the things I’ve had to learn as an adult is how ‘be’ with myself. When I was a child, I was often very solitary. I enjoyed reading and spending time alone. I’m one of those introverted people who needs to recover from a stressful day, with people who never seem to stop talking, by being on my own; rather than, as some people relax, by heading out to a noisy party. Extended time interacting with others without a break is for me a peculiar form of torture, although I strangely never experienced this much in the company of my patients and closest colleagues.

Unfortunately the world is full of extroverts who cannot understand the needs of someone like me. As Anneli Rufus commented in her book Party of One: The Loner’s Manifesto, its not easy to be a loner in a world obsessed with ‘team-building’; in a society where the very word ‘loner’ has connotations of being odd, crazy, secretive and strange.
However, being alone brings it’s own challenges. Living inside your own head is all very well if it’s fairly pleasant in there. But if it’s rather a mess and full of the rubbish left over from past relationships and conflicts, it’s not a peaceful place to be. Its tempting to spend more time in the company of others, not necessarily because you want to be with them, but in order to drown out your troublesome inner dialogue.

It is true that spending time on your own can be a way of escaping from dealing with things you have to tackle in the ‘real world’, but its really important not to assume that is always the case. I’ve seen too many people forced out of their protective shell by extroverts who think they should ‘socialise’ more. It happens in mental health because of the belief that those who are on their own mustn’t feel lonely. Some people need time alone to feel safe.

Looking back over my adult life, I’ve spent hours, days and weeks in the company of others trying to avoid feelings of loneliness and unworthiness, while at the same time resenting the time I’ve wasted not doing all the things I wanted to be able to spend time on. Something changed for me in adolescence. I started to hear the self-critical voices in my head (and my mother too- a born extrovert) telling me to ‘get out and mix more’. Its also hard to meet a partner too if you never leave the house, though social media is changing the way we view dating and our other interactions with the world to a degree that mental health workers haven’t quite caught up with yet. The on-line world can seem more real to you than the jungle out there…and can be just as threatening.

I find it difficult to be creative in the company of others, or when there is too much ‘going on’ in my life. Virginia Wolff was so right about needing a Room of Your Own. I’m on an island. As Anthony Storr wrote in his now classic text Solitude we need time and space to discover what we are capable of achieving. Being alone is a necessary step to learning about your self. The difficulty of course is that you may not like what you find. There may be a great deal of ‘stuff’ reverberating around your head. Being alone forces you to begin to sort out the packed store cupboards of your mind and throw out the junk. When I am on my own with my thoughts I have to find ways of dealing with them, e.g.by going out for a walk or having a sleep. Not by seeking out others who will then make more demands on ‘me’. It sounds a little selfish as I write about it. But its self-care.

An increasing number of people live alone, including many who are depressed. Loneliness is viewed as a growing problem in our society, yet there remains a real stigma to being on your own, which I suspect prevents some people from embracing their solitude and learning to live with it as they fear becoming even more lonely. I can see now that I felt lonelier in a failing marriage, making meaningless conversation at corporate parties, than I did when I really began to come to terms with being on my own on a prolonged stay in a remote Scottish cottage.

I am not completely alone now. I have a husband to whom I speak to every day, but from whom I spend quite long periods away. He is a person who needs his own space too. Each of us needs to find, what is for us, the right balance of intimacy of aloneness to be able to function.

There now….I’ve started writing this blog again.

Defining recovery

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Some years ago I was told off by a mental health worker for using the word ‘chronic’ in a presentation I was giving on the Chronic Care Model, an approach to organising care widely used in long term physical health conditions. It’s been used in improving care for depression and I wanted people to think of applying the same principles to improving care for people with severe mental health problems.
‘You shouldn’t talk about ‘chronic’, we emphasise recovery now,’ she told me.
I remember feeling a little bruised by the encounter. I certainly hadn’t wanted to suggest recovery wasn’t possible. I know it is but of course it depends how ‘recovery’ is defined.

I’ve seen people with all kinds of mental health problems, from psychosis to depression to substance misuse, manage to reclaim their lives and get back to something they would consider to be a ‘normal’ life- if there is such a thing. When we asked people in the community who had experienced depression for up to several years how they defined ‘recovery’ many of them didn’t understand what we meant. The ‘recovery’ literature has not penetrated much beyond mental health care. When we asked how they defined ‘getting better’ they talked about:

…not feeling tired, achy, sad… So feeling normal is getting up in the morning going, “Oh, right, yes, new day.” Get ready, have a shower, brush your teeth, clean up quick so you can get out.” (Makin and Gask 2012)

In other words not having to think much about the minutiae of everyday survival.

What has become clear to me is that recovery is a very personal experience. It is not about symptoms, but more to do with a sense of being able to live life with a sense of fulfillment. It’s not static, but a dynamic phenomenon- your perception of it changes over time. When I have been very low, my perception of my own state of ‘recovery’ has been quite different from how I view myself looking back in time- when I can appreciate I may have been much less’ recovered’ than I thought I was. We all approach it at our own pace. It cannot be externally defined. Some addicts call themselves ‘recovering’ in perpetuity. I understand what they mean. I have met many people who have had great difficulty in achieving it, but I’ve tried hard to help them lead the best quality of life they could, given the problems they faced. I don’t know if they would have called this ‘recovery’. I didn’t ask. But I didn’t give up hope for them getting what they wanted from life.

So I am deeply disturbed to observe just how the term ‘recovery’ has been turned into something that many people with mental health problems now feel is an imperative. Something to be enforced upon them. Even more worryingly a state which can be achieved, even by people with severe mental health problems, through use of the kind of often simplistic self-help materials for which the evidence isn’t particularly strong even for common mental health problems. To provide a person in a suicidal crisis with an information leaflet suggesting they might get benefit from a cup of tea, and that they should immediately be writing their ‘wellness and recovery plan’ is not only crass. It is cruelly denying the reality of the depth of that person’s suffering. It is suggesting that it is simply their lack of knowledge of the healing power of caffeine that is responsible for them seeking your help. That once you’ve provided them with the piece of paper with the bullet pointed recovery aid-memoire, this is all they need to know to feel better. They will just be able to get on with it. If this were the case we could do away with skilled workers providing face-to-face care and replace mental health clinics with leaflets and a drinks machine- which is indeed the direction in which we are going.

But we cannot pretend that people do not need a great deal of help to recover. Recovery is a collaborative process. It is a goal to be negotiated between a service user and mental health worker in the often very difficult process of changing how we see ourselves, the world in which we live and the future. It may involve coming to terms with terrible trauma from the past, and the discrimination, stigma and social inequalities of the present.

We cannot force a person to recover. Our politicians, instead of aiding personal recovery, have redefined what recovery is. It means getting back to work and being economically active. The personal has become political in the most disturbing way.

I don’t know if I am recovered. I prefer to think of myself as ‘recovering’ from depression. I’m still on a full dose of meds and I have given up work. I’m achieving my own personal goals. That’s enough.

In response to the criticism of my approach to ‘Chronic Care’ I wrote a paper with the late Helen Lester on the importance of a collaborative approach to care of people with long term mental health problems, who need high quality, person-centred care plans, jointly negotiated with well trained and supervised mental health professionals, to help them achieve their own personal goals.

As long as we do it, I don’t care what you call it.

Taking the tablets

lindagask7 Comments

I’ve been putting off writing about this topic. Even though I know it is something I really should talk about. I’ve used the excuse of the failure of British Telecom to sort out my intermittent broadband connection, which can be real a problem living alone on an island. But I cannot avoid it any more. So I am going to say what I think about antidepressants.

In the spirit of presenters at the American Psychiatric Association currently taking place in New York, let me begin my presentation with a few disclosures, so that you are fully aware where I am coming from:

I am a psychiatrist.

I don’t practice now, I’ve retired, but throughout my entire professional life I prescribed antidepressants regularly.

 

I have spoken at meetings funded by pharmaceutical companies and they have funded a couple of small research projects for me over the last two decades.

Neither my talks, nor my research have been promotional. I’ve never been involved in any research trial of a medication. At meetings I’ve generally been the acceptable psychosocial meat in the biological sandwich- squashed between presenters talking about the latest research into the biology of depression, much of which I’ve had a great deal of difficulty really understanding, even as an academic.

Last, but not least, I’ve taken antidepressants for most of the last 25 years. I’ve been continuously on them for 20.

My treatment record reads a bit like a history of the pharmacology of depression- and the promotion of antidepressants. Tricyclics (dosulepin), SSRIs (paroxetine and fluoxetine), SNRIs (venlafaxine and duloxetine) and adjunctive therapy (Lithium) with some antipsychotics thrown in.

So those are my disclosures.

What can I say about the rights and wrongs of taking medication?

First of all, just that: It is neither right nor wrong. I number among my friends people who will not take medication, and others who do. I don’t try and impose my view on them. Neither do they try and do that to me. It’s a matter of personal choice. But I hope it’s a fully informed choice when you make it.

Secondly: I dislike a great deal of what is written in the press about medication, because it often diminishes my experience of both having personally benefited from it and of seeing many of my most severely depressed patients do so too. Suggestions I would be harmed by it (which I haven’t been, though I’ve certainly experienced a great many side effects and had to withdraw from Seroxat- so I know about withdrawal symptoms) have proved incorrect. Some of the items in the media of late diminish the whole experience of severe depression by telling me everything can be solved by my going out for a run (radio 4 today) or taking up gardening.

Thirdly: Just because I’ve taken medication it doesn’t mean I haven’t had episodes of depression, but they haven’t been as severe as they were before I went on it. They are certainly not ‘happy pills’. I wear black most of the time and my friends will tell you I am not known to be pathologically over-cheerful. My mood dips, usually in response to how I cope with life events, and when I’m on medication it rights itself a little faster, but at least it bounces back. It used to take a lot longer, and I would get much lower, when I wasn’t.

Fourthly: Even Skeptics will acknowledge there is some evidence for antidepressant medication in severe depression. My approach clinically was always to work through the advantages and disadvantages of particular treatments and add my own opinion. As an expert, my patients expected me to have one. But the choice was theirs. If they were severely depressed, I’d ask that they not completely dismiss medication as an option, but to hold it in reserve for a while. I would do all I could to help them with their preferred option first. But if that didn’t work could we re-evaluate the decision at a later date?

Fifthly: Medication has its risks as well as its benefits. There are no easy options when your mood is very low. Side effects can be awful, and there are situations in which antidepressants should be used with extreme caution. Especially in younger and older people. A combination of venlafaxine and lithium gave me a prolonged Q-T interval in my ECG, which in lay terms means I had a greater than average chance of dropping down dead. I recovered on it, but it had to be stopped.

Sixthly: there is no place for the use of medication alone. Most people get depressed because they have problems, and if they don’t have them before they get down, persistent depression will cause them. It’s difficult living with a person with chronically low mood. Our physical health suffers too. We cannot work.

Talking of one form or another is an essential accompaniment to medication; anything on the broad spectrum from an honest and open conversation with a GP who listens to you and provides continuity of care to a longer term psychological therapy to help deal with some of the issues which increased your vulnerability to depression in the first place. Whatever is most appropriate and needed at the time.

Lastly: If the life events and problems which originally contributed to your depression have not resolved, you may benefit from staying on medication. Not everyone is able to make the changes in their lives that are needed to stay well. I’ve spent my life working in places where people lead very tough lives. There is nothing to be ashamed of in staying on medication, and I’ve argued the point with GPs who wanted to ‘wean’ patients off tablets prematurely. (Weaning is such a demeaning and unwarranted term anyway- it suggests a degree of infantilism).

I don’t know what would have happened if I hadn’t taken medication, but I can tell you things were not looking very positive. There are times when engaging in talking therapy is very difficult. When you feel as though there is a weight pressing down on your chest, making it very hard for you to breathe or carry on. The idea of going out for a run….well….need I say more? It feels impossible to be sure of your next breath. Antidepressants helped me to get to a point where I could use psychotherapy effectively. I’ve been able to keep going, write, research and hopefully help others. So I cannot put off honestly saying what I think and hope you will listen.

That’s all I can ask for.

Making a connection

lindagask6 Comments

The young woman, we can call her Mary (let me say now she is not a real person), is sitting in the chair opposite me.
‘What is it like, at home?’ I ask.
‘Difficult, no forget I said that.’
I wait a moment, then take a risk and ask, ‘What’s hard about it?’
Mary picks silently at a scab on her left arm. I can see blood beginning to ooze from beneath the hard carapace as she worries away at it with what remains of her fingernails. On both of her forearms are marks where she has scratched herself repeatedly with a razor blade. The newer injuries are still an angry shade of red. The older ones look like the silvery trails a snail leaves on paving stones. She has told me already how she feels a strange sense of relief when she cuts. She doesn’t want to kill herself, but there are times when she needs to have some relief from her inner pain, and this is something which seems to help, albeit for a short while.
‘Can you tell me a little bit about home…?’ I try again.
‘I can’t say I hate it can I? I mean they care about me, I suppose. But I can’t be what they want me to be.’ She sobs and her tears drip onto the arm of the chair.
I push the box of tissues towards her. ‘Do you have to be what they want?’
‘I don’t want to be…different.’
‘So tell me about being different…what does that mean?
Silence.
‘Maybe…I don’t know… you feel different?’
Silence. No- a shrug. A response.
‘Maybe that’s okay,’ I try again, ‘… to be different. Or maybe it’s not…it can be hard.’
‘Why? Why should it be okay? Not fitting in!’ She sounds angry now.
I find myself backing off a little, ‘I don’t know. Sometimes people just feel different.’
She nods but still looks at her lap.
Encouraged I continue. ‘Sometimes they are, different I mean. That’s OK with me, but how about you?’
Mary looks up. I detect an uncertain, conspiratorial glance and the first flicker of a smile. I sense we have started to make a connection.

Psychological therapy is a topic about which there is a great deal of mystique wrapped up in layers of ever more complex jargon. Each approach comes with its own vocabulary, set of abbreviations and training course. I had some training in my youth in psychodynamic psychotherapy; I’ve been on the receiving end of quite a lot of therapy too. I’ve also spent much of my life trying to help health professionals communicate more effectively with people who are distressed.

From all of this I’ve learned a few lessons:

Asking endless questions about symptoms is not the way to connect with someone.

Being a good listener is essential but not sufficient. You have to show that you are listening, and this means saying or doing things helpful things during the conversation. Not too much, and not too little. You have to be able to pick up on important cues, which may be verbal or visual, and comment on them. These important cues are the ones redolent of emotion.

You cannot fake empathy. If you don’t feel it, don’t pretend.

You have to be ready to hear awful stories about the suffering that people have endured. If you are not ready to do that then you shouldn’t be in a position where a person may need to confide in you.

You need someone to talk to about what you hear. Supervision is essential and many people in the caring professions simply don’t get adequate opportunity to make sense of their experiences with patients and service users with the end result that they emotionally close down and become insensitive to the pain of others.

You don’t have to be trained in psychological therapy to be able to connect with a person, but psychological therapies are useless when no emotional connection is made. Some people who have been trained are still hopeless at connecting.

Having your own experience of emotional distress isn’t enough. It might help you to understand what it feels like, but that won’t necessarily be what this person feels like and your work is to connect with them, not make them connect with you.

Without a connection you won’t feel able to talk about how you feel, develop trust and share your worries. I know this because the professionals who helped me most wanted to find out who I was and made the effort to connect with me. I will never forget them, or those of my patients with whom I was fortunate enough to forge similar bonds.