Lacking motivation

A common reason, in my experience, why people don’t get taken on for therapy  (or are discharged prematurely) when they are referred to a therapist is that they are deemed to be ‘lacking in motivation’. The concept of ‘being motivated’ is something I’ve thought quite a lot about because when I’m depressed I have very little motivation to get out of bed. So what is meant when people who are depressed are lacking in motivation to undertake therapy? Why should we think more about it?

To get taken on for a talking therapy, you have to jump through quite a few different hoops, several of which you may not realize are actually there:

  • First you have to recognize that you might actually need some help. That’s a pretty major step. Stigma in our community makes it difficult for many people to come forwards and identify themselves as having a mental health problem. In some minority communities, simply doing this can damage your sister or brother’s marriage prospects.
  • Then you need to be able to access the system, through your GP or by self-referral. That assumes that you can leave your house (many people with disabilities cannot) and negotiate the various other barriers to getting a referral including feeling able to talk to your GP, or using the telephone to refer yourself. All these can be doubly difficult if you don’t speak English. Information about services isn’t always available in other languages. Talking to people on the telephone can be difficult if you are very anxious.
  • •Next you have to understand what it is that you are being referred to. You many have no idea that you are expected to turn up at the same time every week for several weeks. You may be a single parent, who lacks reliable childcare. If out of hours appointments aren’t available you may have to tell your boss you need the time off and why. Not everyone has control over how they spend their day like most professionals do.
  • You may have a great deal of emotional turmoil in your life- relationships in crisis, money problems, ill-health in your family. You are not sure how you can commit to something you don’t really understand and how this can be a priority. No-one may yet have explained how therapy is supposed to help you.
  • A letter arrives. It takes you a while to open it because you haven’t been opening the post. It’s all bills anyway, and seeing them just gets you more upset. You’ve been finding it harder and harder to get going in the morning. The letter says you have to ‘opt in’ to therapy, by a certain date. You tear off the slip and send it back. Just in time.
  • When the assessment appointment finally comes after several weeks or months, you have to cancel because your child is seriously ill. The service tells you that you can only cancel twice then you will go to the bottom of the waiting list again. You try and leave another message but only get the answering machine. Repeatedly. You begin to lose hope. Things are getting worse and you seem to have even less energy than before. You have started to feel that life isn’t worth living anyway.
  • You finally get to see the therapist who asks quite a few questions, but you still aren’t entirely sure what you are supposed to do, or how this is supposed to help you. You tell her that you are taking tablets, which have helped a bit, but your doctor hasn’t reviewed them because he is waiting to hear what the therapist thinks. She tells you that this is nothing to do with her but a question for your doctor. She asks to see you again before making a decision. She says there will be six-month wait anyway to see somebody. You start to think ‘what’s the point?’ you are feeling increasingly hopeless.
  • The evening before you are due to see her, your husband comes home to say he has been made redundant and the two of you spend the evening wondering how you are ever going to cope. The therapist has sent a text to remind you of your appointment but it’s the furthest thing from your mind at the moment. You forget to go.
  • Two weeks later you get a letter offering you one more appointment. If you don’t attend you will be discharged and they will assume you no longer want to come. That last part of the sentence worries you, because you know you really need help now. You are losing weight, you have no energy any more and the future looks bleak. You put the letter in the bin.

The therapist writes to your doctor and says you don’t seem motivated to attend at the moment, and sends you a copy.

There are many things that can contribute to a perceived ‘lack of motivation’. Not being willing to attend regularly (because of what that means in terms of who you have to tell and negotiate with); not able to understand what therapy is about and your role in it (because no-one has still really explained it); not prioritizing therapy because your life is in turmoil (a difficult ask for people who live life on the edge of an economic abyss) or simply feeling so hopeless and lacking in energy that you don’t manage to get there ( symptoms of severe depression).

The responsibility has been put back onto you. The therapist didn’t seem to want to talk about the problems you were facing in your life and your money difficulties. Only what you thought and felt about them. They didn’t address how ambivalent you feel about the whole enterprise or try to really engage you in a way you could respond to. They didn’t seem to understand how difficult you found it to make any decisions at all, never mind commit to ‘therapy’ and when you talked about how you had begun to think of harming yourself they did seem concerned but didn’t seem to know what to say.

You may think this tale is an exaggeration, but it is simply a reflection of what service users have told me many times about their experiences.

Once upon a time you had to be ‘Young, Attractive, Verbal, Intelligent and Successful’ to get into therapy. Now, above all, you have to be motivated. Have things changed?

My new book: ‘The Other Side of Silence: A Psychiatrist’s Memoir of Depression,’ is available now, and describes my own experiences of therapy.

Two units under

According to my other half, I am one of those people who are permanently short of two units of alcohol. I’m undoubtedly better company when slightly I’m under the influence- I’m more sociable and relaxed. I can engage in conversation without feeling self-conscious when I’m with people I don’t know well, or haven’t seen for a while. Life just flows more easily. Two units a day, you say, that isn’t very much, its 14 a week, that’s just on the ‘safe limit’ for women. So why have I been trying to reduce the amount that I drink?

Since my early 20s I’ve been aware that I have an ambivalent relationship with alcohol. Most of the time we remain on reasonably good terms, but when my mood is low, or I’m under stress the booze likes to get one up on me. Like many people, when I was working full-time, I began to rely a little too much on my liquid friend. Days began to be measured on a new scale of severity- the number of bottles of Stella Artois I needed to feel relaxed after a weekday in the real world. One bottle (330ml 2 units) was a normal dosage, two bottles (4 units) for a tough day and 3 bottles (6 units- thankfully not very often) for a bloody awful day, plus a very strong Martini on Friday night to decompress and sometimes again on a Saturday, and wine (3-4 glasses) over the weekend. Mostly I drank just about up to the limit. Sometimes, and increasingly so as time went by, I exceeded it.

Okay, I can hear you saying, ‘what are you worried about, I know loads of people who drink a lot more than that!’ You may even do so yourself. I’m not asking you to consider it that is of course your choice. But it’s not only the amount you consume (although most diseases related to alcohol haven’t been informed there are ‘safe’ limits, the risk just gets greater the more you drink) it’s the nature of the relationship you have with booze. It’s addressing why you sometimes feel the need to rely on a friend whose apparent affability, social and legal acceptability masks the risk it poses for those of us who have the potential to depend on it, not just emotionally but physically too if we drink long and hard enough. Earlier this year, when I was experiencing, for a while, the most severe physical symptoms of anxiety I have ever known, when my chest was permanently tight and my hands shaking, there was only one substance easily accessible that took those symptoms away, and it usually took one of my husband’s martinis which is a fairly lethal combination of gin and vodka (plus Lillet Blanc and a twist of lemon if you are interested) to help me feel anything like calm. Mindfulness exercises didn’t touch it. Exercise was difficult as I felt exhausted most of the time and too anxious to venture out much. I’m quite sure diazepam would have worked too, but I’ve spent so many years trying to help people withdraw from it I wouldn’t wish to take it. I remember one of my patients who was depressed and couldn’t sleep said to me. ‘I didn’t want to take any pills, so I just decided to try alcohol, it’s a natural remedy isn’t it? Well no, it’s about as natural as anything that’s been processed by a brewery or distillery can be I suppose. And the Distiller’s Company also gave us thalidomide too. Not that I am any way comparing alcohol with that particular drug, but we know it also can cause terrible damage to the unborn. Alcohol is acceptable, available and costs comparatively less than it used to when you buy it in bulk at the supermarket or in Happy Hour.

When I worked as a consultant in a substance misuse service I saw so many young men whose problems with alcohol had begun in their teens, when they drank to self-medicate for social anxiety, unable to approach a member of the opposite sex when completely sober. The problem is alcohol doesn’t only relax you, it lowers your inhibitions in other ways. You are more likely to put yourself at risk, for example by having unsafe sex or walking home in the snow with insufficient clothing after a night out risking hypothermia, when you are drunk. Alcohol has a curious relationship with mood disorders that mental health services in the UK (but not in Australia) still don’t pay enough attention to. People with bipolar disorder can drink excessively when they are high and when they are low. Those of us with depression use alcohol to numb the pain of being alive, but the side effect is that we then feel much less inhibited about trying to harm ourselves or end our lives. When I was a student I discovered the advantages and disadvantages of drinking to oblivion. I was in danger of becoming the person we all remember who seemed to go that little bit further than everyone else, and we much later heard was not only emotionally but physically dependent on booze and on their way to destroying their career. Medicine is noted for its relationship with alcohol. There even used to be a bar in the doctors residence in Manchester when I was a junior doctor. I’ve glibly asked students at interview what they do to relax, because ‘medicine is an emotionally taxing profession’, and heard them list all their sporting and musical activities knowing full well how many of us fall back on the nightly Stella because it’s the easy, instant option.

So, of late, I’ve been considering this relationship much more honestly than I have in the past. I’m aware I have within me the potential to spend far too much time with this erstwhile friend and be lead seriously astray, but I’m still ambivalent. l so love the feeling of being intoxicated, at least until I wake in the early hours next morning. But I rarely allow things to go that far now. I’ve been staying alcohol free for longer and longer, particularly when I’m in Scotland. I don’t drink alone in the house, and I can no longer have anything at all when I’m out due to the new drink driving laws. I hope they are having an effect on the overall amount people consume, but we still need legislation on minimum pricing. I learned as a medical student that national consumption was governed by cost and availability. Why is more research required?

I still enjoy the occasional drink but I’m beginning to know, and like, my persona who is always two units under a little better and helping her find other ways to manage her anxiety. It’s a healthier option for me, in the longer term, giving alcohol the brush off.

Relapse and rewind

It’s fortunate that my other half and I share the same acerbic sense of humour.

‘When you aren’t well you start to talk all the time, and about 80% of it is rubbish, ’ he told me, ‘and you’re doing that now.’

It was at this point that I was finally able to admit that my mood, up and down since last autumn, had taken a major nosedive since New Year. The problem is that when I’m going down, I don’t generally recognise it until quite late, and I’m not always willing to listen to advice to ‘slow down’. This time, along with the usual symptoms of depression I’m so familiar with, I experienced the worst constant physical symptoms of anxiety I have ever felt; resulting in panic when I lost my bearing in Manchester’s Arndale Centre and I couldn’t immediately find the way out. This time, nothing would relieve the anxiety apart from alcohol. What my other half was referring to was the emotional and verbal expression of my anxiety. The constant seeking of reassurance and ruminating out loud about life problems, in a way that probably drives those around me crazy too.

However given my history of recurrent depression, it’s no surprise really that I’ve had another relapse. I had hoped that since retirement I somehow wouldn’t experience the same stresses I used to. And I’d been pretty well for a couple of years at least. But I was wrong. Losing my animal companion and several major family and health stresses I won’t go into here were enough to tip the balance again. It was back.

It’s the beginning of March now. For a while I panicked when I simply switched on the desktop computer. Now I can write again. I burst into tears in the middle of my last blog but I forced myself to get it finished. I have this feeling that if I can’t write then somehow I couldn’t live. Maybe it isn’t right, but I kind of believe that. For the last couple of weeks I’ve gradually been feeling better and the constant anxiety is subsiding to its usual level. I don’t feel like something awful is going to happen imminently and I’ve stopped thinking about death (I was having passive thoughts that life wasn’t worth living again). I heard birdsong the other day as I walked up the garden path and I realised I hadn’t taken any notice of the birds in the garden or their choruses or the bulbs shooting up for…well I’m not sure; because depression creeps up insidiously.

Why is my mood lifting?

Perhaps it just would do anyway. Spring is on the way. I’m bound to feel better…except for me it doesn’t happen that way. Even after the events that precipitate it are all past, my downturn goes on and on, thought not as low or for as long as when I was off medication altogether.

I can only make sense of it as a combination of the following and as you might expect from me, it’s a biopsychsocial combination of remedies:

  • I found a way to talk about my worries and fears about the future with my partner. It wasn’t easy but we managed to resolve some practical things I was concerned about.
  • I was able to utilise some of the practical coping skills for managing my rumination I learned from cognitive therapy and I started to use the guided mindfulness CD I had always been ‘too busy’ to listen to. I tried to stop myself from fighting against my mood, and simply accept that I was feeling terrible: bleak sad and empty. Paradoxically once I do that, I’ve learned, it is always a little easier to move forwards.
  • I forced myself to keep going out even though I wanted to shut myself in the house and never come out again. I’ve met many people in my career who have done just that. I had to ‘feel the fear and do it anyway.’
  • I was able, too with support, to put aside some of the impossible self-imposed deadlines I place on myself. I have to remember that my ‘Rules for Living’ are nigh impossible to live up to. Instead I set myself somewhat simpler goals like going out for a walk, and doing some washing. Small achievements which then helped me to move forwards.
  • I agreed to a change of medication. I wasn’t happy about it. I’m now on multiple tablets for my various conditions, but at the point I was at, it was worth a try. I cannot bear the thought of being sedated by medication and fully understood all my patients who refused to take medication that numbed their thinking. My mind has to be clear but when I’m very low I can’t frame the words and sentences either. I try to get to somewhere in the middle. I just cannot do it without pharmaceutical aid.
  • I sought and accepted the support of friends, real life and on line.

My other half did his part by being there for me, as he always is, even if I am talking rubbish, and arriving home one evening with a present of Lindt chocolate bunnies. Chocolate has antidepressant properties too, I tell myself as I bite the head off one of them. He tells me he knows I am getting better because I’ve started to talk about it all in the past again now. I think I’m getting better too, but I wont really know until I can look back and recognise how much I’ve improved.

That’s the nature of the beast.

A diagnosis of anxiety

On one of those occasions when I peep around the screen at what my GP is typing I see a diagnosis of ‘anxiety with depression’ at the top of the screen. I’m not sure how I feel about that. I suppose I’ve always thought about my problems as being more to do with depression than anxiety. But regardless of the idiosyncrasies of the recording system that GPs use (for the uninitiated, the Reed codes used in British General Practice don’t much conform to DSM or ICD), I think it’s probably right. In my life, low mood comes and goes, while anxiety has been pretty pervasive at the times when it hasn’t progressed to frank agitation.

This all comes to mind recently because the National Institute for Health and Care Excellence (NICE) just published its quality standard for anxiety disorders. It has information on all the different disorders neatly laid out- with specific pathways for Generalised Anxiety disorder, Panic disorder, Obsessive Compulsive Disorder, Post-traumatic Stress Disorder etc. At the same time there has been the usual and continuing debate about the validity of diagnosis in psychiatry in the twitter sphere, in which I occasionally participate.

My problem with NICE guidance is that there are so many different pathways for the different diagnostic categories of what are called Common Mental Health Disorders– which consist of all the anxiety disorders plus depression. Some mental health professionals disparaging call these ‘minor’ mental health problems and the people who suffer with them the ‘worried well’. I’ve unfortunately heard psychiatric trainees use those terms.

Warning: don’t ever use these terms in my presence, I can’t be responsible for the consequences.

If you add in the other common mental health problems in the community, use of drugs and alcohol which many use to self-medicate for these ‘minor’ problems, you have a complex bundle of guidelines for a large section of the community (around 15%) who mostly get their mental health care from primary care. In common with the main classification systems, NICE treat all these as distinct diagnoses. If only life were so simple.

The problem is that in the real world they all overlap, co-occur and change around over time much in the way that my own symptoms have done since adolescence. ‘Anxiety and depression’ is the commonest mental health problem that GPs see. Mixed in with that may be some phobic symptoms, panic attacks, obsessional symptoms along with other features which suggest post-traumatic stress such as hypervigilance. Add to this the common ‘co-morbidity’ with drugs and alcohol, and the difficulty some people with these problems additionally have in social relationships which equates to some degree of personality difficulty, we have the potential to label a person with multiple diagnoses. At the other extreme we could say, these ‘disorders’ are all part of the same problem. You are suffering from something called ‘life’.

My view is somewhere in the middle, but I struggle with it. I’m a supporter of the need for psychiatric diagnosis and anyone who doubts the need for it should first read Robert Kendell’s classic book The Role of Diagnosis in Psychiatry. But to say that doesn’t mean we’ve got it right, or that the same system is appropriate in all settings. In my work with WHO, I’ve helped towards developing the ICD-11 system for primary care, which is a good deal simpler than anything DSM can ever think up. However what is key for me is that a diagnosis is only a construct,

as Kendell puts it:

‘thoughtful clinicians are aware that diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organising and explaining the complexity of clinical experience in order to provide predictions about outcome and to guide decisions about treatment.’

Clinically I have found the NICE stepped care model useful: severity of symptoms is the key to what intervention is likely to be helpful. But my approach to helping people has been to start with their life, their problems and hopes and concerns and help them to work out goals for how they would like it to be different. To work towards this by both finding out exactly what they are experiencing, and have been through, and then use a range of therapeutic tools from medication, psychological and social interventions in an essentially transdiagnostic way according to what is likely to help, both from the evidence base and their own past experience and preferences. This has been how I’ve supervised step 2 workers in Improving Access to Psychological Therapy (IAPT) in Salford where I worked for several years, to deliver care for people who might have ‘anxiety and depression’ in some kind of admixture, but had complex life problems. I’ve utilised a very simple set of ‘working’ diagnoses which can easily change over time.

I think we do underestimate the importance of anxiety, but it’s not just that we fail to recognise anxiety disorders. Anxiety pervades all of the common mental health problems except for in those people who experience depression without it. There is a significant genetic component which I can easily identify in my own family. Anxious symptoms in the presence of both bipolar and unipolar depression tend to make the outlook worse and suicide more likely.

Recently, since I gave up the day job, I’ve been feeling much less anxious. This was (unhelpfully) commented on by a colleague whom I hadn’t seen for a while who decided to mime how agitated I used to be at times. I have to admit that I was (strangely) usually worse when in his company. However this coming week I have to have more investigations for my physical health and the familiar churning stomach, sweating and tension have returned once more. Hopefully, after tomorrow, I will be able to return to the combination of exercise and mindfulness which I have recently found helpful in managing my ‘anxiety’.

Fingers crossed.

The healing power of the sea

I’m on the coast of North Yorkshire this week weathering a storm. I can hear the waves lashing the sea wall below my window. It’s different from the storm I would be facing if I were still at work, having to face the reality of providing care for people with mental health problems when services are being so constrained. While I listen to the windows rattling and watch the water rising up the slipway at high tide I find myself dipping into twitter every now and then. I can sense my blood pressure rising as I follow the debate about whether it is actually possible to achieve parity of esteem with physical care for people with mental health problems when everything is being cut. In some ways I miss work, particularly for the sense of being able to make a difference and for the contact with my patients. In other ways, for the constant anxiety it evoked in me for so many years, I don’t miss it at all. I’m still writing, and involved in research and teaching but I have control over what I do each day. That sense of having control over your life is important when you experience depression.

The sea can be both a source of fear, and of great comfort. I grew up next to it, and it evokes powerful memories of my childhood. My father was an excellent swimmer, but however hard he tried he never succeeded in teaching me. I was simply too anxious to take my feet off the bottom. I didn’t entirely trust he would not let go of me, yet now those times when I sat on the beach and watched him powerfully crawling through the waves off the Lincolnshire coast are some of the fondest memories I have of him.  I was born a couple of years after the great flood, which devastated the East of England. Since then I’ve travelled all over the world but have always felt the need to dip my toes in the water of whatever ocean I find myself beside. It’s like touching base with the past.

I cannot begin to imagine what it is like to be swept away in a tsunami, have your home battered by tidal waves or lose your husband when a fishing boat goes down with all hands. I’ve stood in the waves on Copacabana beach in Rio, and felt the warm tropical current try and drag me down into the depths. I’ve been unable to go into the shallows in Queensland for fear of being attacked by box jellyfish and sharks. The ocean is immense, merciless and can be so destructive, and yet it connects us all together. It has a power over which we can have no control; we have to accept it.

When times are bad the sea has a way of helping me to get my problems into perspective. I came here once, to the place I am now in Yorkshire, when an intense relationship that meant everything to me had broken down. Listening to the sound of the waves pounding the walls below as I lay in bed, with only the moonlight shining through the curtains illuminating the room, both resonated with my mood and helped me to understand how life goes on whatever happens.

Some years ago when I was on a beach in the Pacific Rim Park on Vancouver Island in Canada, I saw a woman meditating whilst sitting on a driftwood log next to the ocean. Since then, I’ve always taken the opportunity to use the sound of the waves to help me to clear my mind and relax whenever I am in earshot of the sea.  Next time you are there, whatever the weather happens to be, find somewhere to stand or sit awhile that is sheltered from the wind (or rain). Focus on your breathing as you would in any kind of meditative practice, but listen intently, with your eyes closed, to the sound of the waves ebbing and flowing and crashing to the shore. Try and carry on for at least ten minutes or longer if you can. When I make time to do this, it gives me a wonderful sense of wellbeing. For me it’s a kind of meditation in which I connect directly with nature. I suspect it’s a similar feeling to that achieved by mindfulness practice, but I am only just making time now to learn more about that. I will write more on that topic soon. In the meantime I am returning home with the sound of the sea, not in a shell in my pocket as I did as a child, but in my soul instead.