The morals of Mindfulness

‘I don’t know what it is exactly- no one does- but even my GP tells me I’d benefit from it.’ (The Spectator 17/7/2017)

If you mention  you are seeking help for depression its odds-on somebody will mention mindfulness. It has reached a point where it feels like the thing those of us with anxiety and depression should be doing- the self-evidently right thing to do to get ourselves ‘mentally fit’ (whatever that means), booking in to do a few exercises in the mind gym.

Last week I tweeted:

Untitled

The responses were interesting. Several who felt the same way. A couple suggesting I might approach it in a different way (I’m not going to say that they thought I was doing it wrong, because that would be unkind) and one entrepreneur trying to sell me his latest product.

I’ve been interested in meditation for many years. I don’t want this to sound facetious- but I fear it will- I have often thought that I would like to learn more about Buddhism- if it didn’t require so much effort. One of the most fascinating days of my life was spent in a Zen monastery in Japan. There have been times when I’ve meditated every day, and others when I’ve not. Since retirement I have started again- a little more regularly. I’ve found it helps me to feel more centred and calm. Wanting to learn more about Mindfulness, and having benefited somewhat from learning in the past some ways to cope with ruminations using techniques based on it, I started doing a recommended on-line course. My itinerant lifestyle precludes attending a weekly group, although I think this might have been much better.

At first it was helpful, but then my mood began to dip- related to uncertainties in the world- and the guided mindfulness exercises seemed to make things worse.  The ‘thought clouds’ burst and rained their contents down on me. Being asked to think about the painful things in my life with compassion for myself reduced me to tears, while having to think compassionately about others evoked anger. Haven’t I spent most of my life worrying about everyone else? Isn’t that the problem? I found myself saying. I can’t take this. It was no good. I had to stop.

I have heard of professionals telling clients that Mindfulness will put drug companies out of business. This kind of ridiculous promotion goes on in more muted forms across the media- some of it from researchers who should know better. What we can say is:

  • People respond differently to Mindfulness. We know there are potential adverse effects. Recalling traumatic events, increasing your level of anxiety or depression, depersonalization and even psychosis.
  • Mindfulness is suggested to people who are in the throes of depression (never mind full blown crisis)- but the evidence for its effectiveness during a current episode isn’t great– and there is none at all for Mindfulness Based Stress Reduction (MBSR- trademarked by Jon Kabat-Zinn). Mindfulness Based Cognitive Therapy has been shown to prevent recurrence when you’ve had 3 or more episodes and to be as effective as drugs for preventing relapse of depression (reported as ‘Mindfulness is as effective as drugs for treating depression.’) that’s what NICE recommends it for.

There are good reasons why it might not work when you are very depressed. You are preoccupied with anxiety, worries and ruminations. You start to focus on the very things that make you feel worse- your negative thoughts (even though you are only supposed to ‘be aware’- try telling me that when I’m not in control of my thoughts- I find it hard to even pay attention). And anyway you have to motivate yourself to get going.

The other moral objection to mindfulness comes from those who see the promotion of ‘McMindfulness’ as contrary to the values with which meditation is associated in Buddhism. It has become:

  • A personal path to ‘self-fulfillment’ removed from the intention of promoting compassion for others as well as yourself.

And/or

  • A corporate tool with for helping employees work more efficiently- with greater ‘resilience’ in toxic environments- thus putting the burden of responsibility back onto the individual to learn how to cope. I took pills for many years to do that- but it was my choice to- It wasn’t suggested to me by the boss.

Neither seem to be in harmony with the ethics and morals of Buddhist belief.

Indeed the moral imperative to ‘improve yourself’ by practicing mindfulness has something of the Protestant work ethic about it-  I’m only too familiar with that.

We must dust some of the celebrity stardust off Mindfulness and see it for what it is. Another useful tool that will help some but not others. Those of us attracted to meditation will find it helpful- but not when we are acutely depressed. I’m meditating again now- and finding it helpful. I know I have work to do on why ‘self-compassion’ is so hard but I can recognise that,  and I find reading Paul Gilbert’ books on compassion and mindfulness helpful. Others using self-help materials without support might find it much more distressing. Its one of the reasons we need to be alert as to how such tools as mindfulness are being disseminated in the community- and by whom.

We ought not to  promote a therapeutic milieu where people feel they ‘must’ learn to meditate or are told ‘it doesn’t work for you because you aren’t doing it right’ or ‘do this- its better than pills’.

Please.

Damage

‘Mentally ill young woman killed herself hours after NHS staff called her a ‘f**king waste of space’

Sometimes a few words that catch your eye in a newspaper keep coming back to you. This  was from the Mirror a couple of weeks ago. I’m not going to say anything about the details of this particular case, but it set me thinking about the damage that is done to people in the name of care, often by the very people they are told to trust.

Many of you will say, quite rightly, that mental health care has been damaging people for years. I remember a patient of mine who had survived a leucotomy and the half-life he had lived in a long stay ward ever since. I’ve known many who have experienced awful after effects of ECT and medication and I bear responsibility for some of this myself- I was trying to help and sometimes I was successful- but not always. I have given tablets to people, which resulted in them feeling worse than they felt before they started them. But, just like we are now beginning to realize with psychological therapies too, treatments can do good but they can sometimes do harm. But how can verbal abuse by any definition of the word ever be justified as ‘treatment?’

A few days later I read the article about a well know TV presenter and his daughter who is recovering from anorexia. The original is here, (sadly behind a paywall) but it was picked up elsewhere too. He tells how she had felt suicidal after a regime, which

included an expensive regime of forced feeding, no exercise, accompanied lavatory visits to prevent them throwing up the food consumed, and monitored sleep to make sure they didn’t exercise while in bed”.

His daughter resisted and threatened to kill herself.

What I hated most about my job was treating a person against their will. It changed the nature of our relationship, sometimes (but not always) damaging it irreparably. The power inherent in my ability to engage with and forge a therapeutic relationship with a person was, for me, one of the most important and personally satisfying parts of my work. I wanted to work with a person, not against them.

In my years as a consultant I cared for quite a few young and older women with a diagnosis of anorexia and they told me what life was like in the units they had been treated in. Some experienced the style of care they were provided with as ‘punishment’, and for others I have no doubt that is what it was. What I’ve heard recently from people I’ve spoken to who went through some of those strict behavioural regimes (now strongly advised against by NICE) has confirmed that.

So what has this got to do with ‘damage’? Well I think we really do need to consider the long term harm that is inflicted every day when people are told they are ‘dependent’ because a service can only offer short term care, when what we know from attachment theory is that for a person who has never experienced secure, loving relationships, another rejection is the last thing they need. We need to consider how, when young people are sent to beds a very long way from home, this must seem like endless punishment for something they have done wrong but no-one will tell them what it is. We need to think about therapy that ‘does’ to people rather than ‘with’ them (in my experience that doesn’t work either). We need to think how it feels to be asking for help because you feel life is too awful to carry on with, but you are simply told to go away and have a warm bath. When the trauma you went through in childhood or later is simply confirmed by the way in which people treat you now. You are told ‘we have nothing for you,’ or ‘you pose too high a risk for us to manage’ or even ‘You are a f**king waste of space.’

Articles about designing our mental health services utilizing what we know from attachment theory – that the things that have happened to people early in life will affect how they behave and ‘attach’ in adult relationships, have begun to appear. Penelope Campling has talked about the need for ‘intelligent kindness’ from those working in healthcare. Yes, this costs money, and it is much harder to do it when money is short and the system is under such pressure. But some of us have long memories. Attitudes and training of staff were not necessarily so much different when the finances were healthier. Money may help but it wont solve the problem of the how the way care is provided can sometimes do much more harm than good- and the cost may be even greater than doing it differently.

I wonder what happened now to the many young women who ‘resisted’ treatment in the wards where I visited one of my most severely ill patients with anorexia. Who is caring for them now? What long term impact did a rigid unforgiving approach doing things to them rather than with them have on them? I hope that many have recovered but I cannot help wondering if some have been diagnosed with personality disorder for being ‘difficult’ and/or rejected from the system. Resistance in therapy is something to work through with a person, not punish them for.

At the end of the article the TV presenter’s daughter talks about how she was eventually helped to recover, in an NHS day care programme. Her words have stayed with me this month.

‘I had a key nurse who really understood me and saw the Maddy without the demons. She made me realize that inside me was still laughter and joy. I was lucky, but mental-health treatment should not be a lottery. The kind of unit that eventually helped me is all too rare. I feel desperately that things need to change and now is the time for action. Otherwise it will be too late’.

Maybe I am too idealistic. But I’ve resisted being damaged by the system too.

Going North- the problems of trying to lead a disciplined life.

It is high Summer in Orkney, and I am back again in Scotland once more.

When things are difficult in my life I’ve always headed North. I don’t mean the North of England. That’s pretty much where I come from now. I’ve lived and worked there long enough to be a real ‘Northerner’. When I go South to London I like to broaden my accent a bit for the hell of it. But for most of my life the real North has only existed somewhere in my imagination- a magical place that never seems entirely real until I arrive there- and when I do it isn’t because I’ve reached some point on the map. Its more than that, it’s the sense of peace that infuses first my limbs and then seeps through my body. My heart rate slows down. I can feel the blood pressure in my arteries falling as the valves that constantly drip adrenaline into my system and contribute to my persistent feeling of anxiety are closed down one by one. Not by medication, but by nature. I can stop moving. My skin begins to tingle and itch as the wounds beneath, the invisible ones I’ve carried around most of my life, begin to heal.

Recovery isn’t just about absence of symptoms. Researchers who deal in the currency of symptoms talk about how in depression we pass from ‘normalcy’ (whatever that is) to the experience of ‘disorder’ followed hopefully by ‘response’ to the treatment, ‘remission’ of symptoms (in which they lessen or disappear) and then ‘recovery’, but many of us have ‘residual’ symptoms which wax and wane over time. Similarly psychological therapies are not designed to achieve a ‘cure’ in medical terms. We have to find ways of living with from day to day with our symptoms, problems and unresolved psychological conflicts. Health professionals rarely ask ‘How do you get through the day?’ yet that is such an important question. Every morning when you finally get out of bed, you have to face several hours of being, doing, feeling and interacting before you can get back under the duvet. For me, how to survive this daily experience is central to the process of recovery.

But I’ve never been very disciplined and in many ways I am still a rebellious child. I dislike going to bed. Without my husband to get me up to bed I can sit lost in my thoughts, reading, surfing the net or watching the TV for hours. I can lie in bed half the morning like a teenager.

I have this intention every time I come up here that this time I am going to get myself into some kind of healthy daily regime. There is so much information about the kind of lifestyle I should lead if I am going to learn how to manage my recurrent downswings in mood and loss of energy, which are the first signs that I might be becoming more severely depressed again. I know there are some things I can do to stay well. The list is endless and I know there is some evidence for all of these things: taking regular exercise, getting sufficient sleep for my age, avoiding alcohol and other ‘substances’ and eating a “Mediterranean diet” (not always easy in Scotland- never mind if you are on a low income). I also know that, given my propensity for relapses I should stay on the medication I have taken, in one form or another for more than 20 years, as well as the other tablets I have for my physical health problems. Keeping my mind on track is essential here as I am alone most of the time. It’s a great place to practice the skill of allowing the boxes containing ‘difficult thoughts’ to pass across on the horizon of my mind without having to unpack them. I know there is a lot of rubbish in them that really needs to be thrown out. If I allow a worry to take over my mind here its quite difficult to elude it. My mood soon begins to spiral downwards. These are the skills, based on Mindfulness I began to learn in the Cognitive Therapy I underwent a few years ago, to help manage ruminative thoughts.

I must get to bed before midnight and up before 8. Eat healthy meals that I have cooked myself. Take some exercise every day. There is a voice inside me saying ‘if you do these things you will not only be well, but you will be good’. But why do I have to be good? I find it impossible to be good all the time. Can anyone truthfully manage that?

So I cannot tell you a satisfying tale of how I did all of these things that I know should help me and they did. I can only say that when I am able to do them, they do.

I am gradually learning to forgive myself for failing to always live up to the targets I set myself for each day. I made them, so I can break them. I don’t have to spend every hour doing something useful- where does that idea come from? I have a choice. It doesn’t really matter if I don’t get any cleaning done until just before I return to Yorkshire. The North is a place where I find it easier to be me because it reflects something about what is inside me- I can see myself reflected in the lochs, the moorland and hills- a little chilly at times and not to everybody’s taste, but perhaps worth discovering. We all have to find a place where we feel we can be ourselves. I need to learn how to carry the essence of it back South with me. The longer I am here, with each visit, the easier it is becoming.

My latest book’The Other Sides of Silence- A psychiatrist’s memoir of depression is out now and also just published in  USA

Moods

Not everyone who gets depressed recognizes the experience of simply ‘feeling low’. The pain of emotional suffering comes in many different forms. The agony of heartache; the exhausted feeling of weariness with the world; the anguish and torment of ruminative thoughts of guilt and despair; the perception, which can develop into a terrible sensation of being beyond any feeling at all, that all of the joy has simply gone out of being alive. A sense that the world has gone from being a place where there is still a potential for happiness, to one which seems empty, hopeless or even dead.

But each day I am aware of something I call my mood. I have more time now to reflect on my life from moment to moment than when I was working. Rushing around all day meant that I was probably less acutely aware of it and yet my mood is a key part, for me, of my experience of ‘being in the world’. It’s the lens through which I see what is happening around me- and its qualities on any particular day colour, clarify or even completely distort the different ways I am able to think about myself, the world around me and what will happen in the future- just as when I was a child, the Hall of Mirrors in the fairground warped my reflection: sometimes I was amused by the altered image that was reflected back to me. Other times it horrified me.

Mood is more than simply ‘feelings’ or ‘emotions’- it’s a longer lasting state of mind and it encompasses everything you are thinking about- it can transform how you view events around you and change something which yesterday you thought was a great opportunity into tomorrow’s disaster in the making. We aren’t always aware of our mood but the people around us often are. My mood is not only the spectacles I wear but the overcoat I show to the outside world.

My mood is both me and yet not me, simultaneously. I cannot manage without my glasses. I know, rationally, when I feel down that if I could will myself in some way to change them to a different pair, the world wouldn’t look as bad as it does to me at that moment, but those are the only ones I possess. Tomorrow, or even tonight things may appear differently though them, brighter, sparkling and full of hope. My mood has never been ‘high’ –However I do have periods of irritation and agitation when I can get very angry with people around me when I don’t think they are doing what I think is the ‘right’ thing. But what I perceive as ‘right’ can also change with my mood. When I’m feeling positive even the things I find most boring can seem worth doing. At times my mood seems to be balanced on a knife edge- it can change within the space of a few hours. But then it can remain stable for months.

When something really seems to shift in my mood, it is as though some unseen being 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. I am full of fear as the negative thoughts I have about myself the world and the future come flooding back.

If I am going to manage my moods more effectively I know that I need to work harder at challenging my familiar, but hard to live up to, rules about how to live in this world that I identified in therapy. But I mustn’t beat myself about the head if I am not able to do it every time. Making another rule for living that I cannot keep is not the answer. I fantasize about being the kind of disciplined person that meditates every morning, exercises every afternoon and eats a healthy supper in the evening, doing everything that I know is ‘good’ for mental health.

I want to be able to keep the awful low periods and those hopeless suicidal thoughts at bay if I can, but if I don’t succeed I have to remind myself that, with time and care, the way I see the world usually changes once more.

The first rule we often have to challenge in life is that it is unacceptable to fail.

My memoir: The Other Side of Silence: A psychiatrists’s memoir of depression is available now.

Do self-help books work?

 

Having just returned from the USA where all bookshops have extensive sections on ‘self improvement’, and ‘self-help’ is big business, I couldn’t help thinking Bridget Jones had the right idea when she tossed them all into the bin. As a lifelong cynic I find the wilder claims made by some authors completely beyond the pale. I simply don’t believe that reading a book by a well know hypnotist can make me rich, thin or universally loved, but I do know that selling this promise has certainly made him wealthy.

So when I got home to Yorkshire I scanned my bookshelves to see how many I could find. There were a few more than I suspected, including two celebrity endorsed books on nutrition and fitness, a book for the ‘highly sensitive person’ (how to thrive when the world overwhelms you); a guide to help people who live with a person diagnosed with borderline personality disorder (I’ve absolutely no idea why I bought that- but perhaps it was a present for my other half). Similarly there was an aging copy of ‘Do I Have to Give Up Me to be Loved by You?’ with a photograph of the idyllically happy couple who authored it on the back. Where and when did I get that? Under one of the piles on my study floor I later found a copy of ‘Organising for the Creative Person’ … clearly ineffective.

However, to be serious, I can understand why self-help books are so popular:

  • A book is cheaper than therapy- and easier to obtain.
  • A book provides not only information, but hope, inspiration and things that you can practically do to solve my problems.
  • There is a vast choice of different books on offer. When one doesn’t work you can always try another.
  • The answer to your problems- all in one book?

I didn’t write my memoir as a ‘self-help’ book, but I’ve heard from readers who have found it helpful in explaining what depression is and how it can be treated. I hoped my story would provide some insight and hope for others living with depression, but it doesn’t contain much direct advice or strategies for coping. I just don’t have a simple, straightforward solution that will fit everyone who gets depressed. My explanation is more complicated… that everyone has their own experience of depression, and the parts played by psychological, biological or social factors not only differ between us, but change throughout our lives. Nevertheless some bookshops include my book in the ‘personal development’ section and maybe that is one place it fits.

The books that really trouble me suggest:

  • There is a single, simple answer to your problem
  • What has happened to you is essentially your own fault and there are things you should do to overcome this.
  • Strategies that may actually be harmful- such as stopping all prescribed medication because the author hasn’t personally found it helpful- and failing to tell you to discuss it first with your doctor, or get some informed advice about how to withdraw gradually.

And if you cannot get any benefit from the strategies that are suggested then this can lead you to blame yourself (if you are not doing that already) and feel even worse. Many of the things that cause us problems are not under our control, so we might feel even more helpless because we cannot change them.

But can they really help? There is remarkably limited research into this question. Self-help books really do seem to be effective for some people, but most of the published evidence is from those that apply ideas taken from cognitive behaviour therapy. ‘Guided’ self-help where the book is used in conjunction with brief sessions from a therapist, in which you can discuss what you have read, ask questions and generally be supported through the process of change, is more effective than simply reading a book on its own. Information alone isn’t enough- support is also important in helping people to help themselves.

Self-help is also more likely to work if you are highly motivated to seek help, and positively choose it, not have it prescribed to you- which was clearly found to be a problem in the recent study of computerised CBT prescribed to people with depression, in which I played a minor part. And a person with more severe depression simply may not have the drive and energy to find that motivation- which is one of the reasons I find the exhortation to ‘Climb Out of Your Prison’ (the title of a bestseller in the genre) so problematic, even though this idea clearly has currency for some. I’ve previously written on this blog about the crass insensitivity of handing information and leaflets out to people with severe mental health problems and those who are in crisis.

What one person will find a helpful idea will be an anathema to others. The social scientist Bergsma, writing in the Journal of Happiness Studies (yes, it exists) suggests that self-help books ‘offer a strong antidote against learned helplessness… but perhaps for readers that do not suffer from it.’ And current health policy supports the idea that we should all be responsible for ourselves, however unwell we happen to be, rather than dependent on the state.

Books can provide information and inspiration, but they can only point to possible directions in which to travel. According to Susan Krauss Whitborne, writing in Psychology Today the prospective reader might do 5 things:

  • Check out the author’s credentials- who are they? How are they qualified to write on the topic- and that doesn’t mean they have to an academic reputation or be famous.
  • Think of the book as your therapist: work done by Rachel Richardson and her colleagues at the University of York suggests that a successful self-help book establishes a relationship with you, gives you hope, confidence and anticipates you will find it difficult to keep going at times. Just like a good therapist.
  • Look critically at the quality of the writing. Is it going to ‘engage you, enrage you or just bore you to tears?’
  • Decide if the book will motivate you.
  • Don’t be afraid to give it a critical reading.

I have just remembered there are several more bookshelves in Scotland – and that’s where the latest ones are…on mindfulness.

If you ever hear that I am writing a self-help book, please remind me to re-read this blog.

My memoir ‘The Other Side of Silence: A Psychiatrist’s Memoir of Depression’ is available now.

Authenticity

Oxford dictionary: Authentic – adjective: ‘relating to or denoting an emotionally appropriate, significant, purposive, and responsible mode of human life’.

My 60th birthday has come and gone. My body is beginning to fall apart but I still feel 16 inside. Life is a ‘work in progress’, or at least that is how it has always seemed for me. I get depressed from time to time and it’s such a truly awful experience that it’s hard to believe there can be any positives from suffering it, even if evolutionary biologists suggest there might be. But I recognise that its impact on my life has enabled me to begin to see more clearly what is really important : my relationships and my writing.

When you are someone with mental health problems it can be difficult to work out who is the real ‘authentic’ version of you. Even if people aren’t really talking about me, am I the oversensitive person who will always think they are? Or maybe that is one side of me, amongst many different faces. There are times still when I wonder whether the medicated me I’ve been for so long is the ‘real’ me, or are these tablets simply suppressing the person I truly am? When I worked in addictions people would ask me the same kind of questions.

‘Who will I be without the alcohol? Will I be able to live with myself? Will other people?’

‘Why am I so different when I’m drinking heavily? Yet sometimes that feels like the real me- the one who is trying to get out and cause havoc?’

One of my patients used to give me brutal feedback about the colour of my nail polish (I had a gothic period- which on reflection I’m still passing through) when she was going high. When she was well she would insist on apologizing when she really didn’t have to- she was just expressing another, very perceptive, part of herself that was usually kept in check.

When my mood is irritable and agitated, I can come out with the kind of comments that would be much better left unsaid- and certainly not shouted. From psychodynamic therapy I learned about the parts of me I was repressing, but they don’t have the best of social graces. In cognitive therapy I found ways to manage the way I ruminate about being me in this world. It’s far from a perfect fit, but who is to judge what is perfect?

Damien Ridge highlighted 4 different aspects of recovering from depression after talking to people who were, or had experienced it. (I am talking here about recovery in its original meaning as a personal journey not a service driven imperative).

  • Preventing depression from occurring in the first place
  • Limiting the impact of actual episodes of depression
  • Recovering from the effects of depression in the short and long term
  • Re-working the self so that is more functional or authentically felt

I haven’t succeeded in preventing episodes and, as one reviewer commented about my book, perhaps it would be fair to say my story illustrates well the limits of medicine. Neither talking nor tablets, separately or together, have provided a complete answer. My current doctor thinks I would have been in hospital over the last few years without the treatment I’ve had, and I think he is probably right. I can limit the impact of episodes now, and I’ve been able to live and work while experiencing bouts of depression.

I cannot always remember what the ‘depressed me’ is like until she wholly inhabits me once more. I can only say that being ‘her’ is not a good feeling in any way, it means feeling cut off from the rest of the world, unable to communicate, as though there is a thick ground glass screen between me and the rest of life. I can hear and see something of what is going on but I don’t feel any part of it, and it fills me with fear. I don’t want to be her, and so far I’ve managed to get away from her much of the time in the last 20 years, but has that been the right thing to do?

The writer Will Self, who is fiercely against taking tablets for depression has said that ‘from the stand point of the 20th century, to be melancholic is good mental health’. He has been able to employ his own personal experience of it to gain insights into extraordinary ways of viewing the world. Would I have had a different perspective on life if I had persisted in trying to cope in a different way? For instance by writing, painting my way out of depression or seriously learning how to meditate – or even, dare I say it, attempting to rediscover the faith I had as a teenager?

The problem I have is that it’s been nigh on impossible to open a book when I’ve been severely low, never mind sit down at a laptop and type. I would love to have been able to write my way out of depression, but it’s not possible for me. I can only work when I’m ‘well’ and I cannot help but see the world through the lenses of the treatment I have had- the ideas I have taken on board from therapy, and in particular the medication I still swallow every morning and evening. They certainly seem to alter my perception of the world in some way to make it a less hostile place.

For thirty years my major role in life was being a doctor. It both satisfied me and punished me. The thought that I might ever have to return to work again as a doctor fills me with anxiety, but I’m still registered with the General Medical Council. The alternative was being ‘erased’ which sounded like I had done something wrong, when I hadn’t. The act of giving up my work as a health professional stands in the way of what I’ve felt was my raison d’etre – helping other people.

Last month, more than 2 years after retiring, I shredded all the paperwork relating to my annual appraisals over the last 15 years (or whenever they began). There is no going back even though I miss that sense of being part of the ‘real’ world on the front line of health care. Now I have time to find out more about the person I really am and what I want to do next. There is some important unfinished business with my ‘self’.

“The privilege of a lifetime is to become who you truly are.” C.G Jung

My memoir on depression and psychiatry: The Other Side of Silence- A psychiatrist’s memoir of depression, is available now.

 

 

The problem with resilience

‘Resilience’ is one of those words its hard to avoid at the moment. No one seems to be quite sure what it means, but one suggestion has been that it refers to a person’s ability to maintain or regain a state of mental health in the face of significant adversity or death; in which case it is a quality in which I am undoubtedly lacking. I am very sensitive to the ups and downs of life especially loss. I get anxious and depressed; I’ve had periods off work. I may have successfully survived a lifetime of work as a psychiatrist and an academic, but I’ve also had to use mental health services to keep afloat. Life in the NHS is challenging and I’ve not got through my career without some serious wounds to show for it.

Before the word ‘resilience’ achieved common usage, and its current prominent space on the buzz word bingo board of healthcare, I understood it broadly to be inversely related to the degree of vulnerability conferred by a combination of genetic heritage (see Goldberg & Goodyer)- which influences our temperament, personality and susceptibility to some types of mental health problems, early life experiences and social learning in childhood. If a group of people are exposed to the same degree and type of stresses most will cope, they will demonstrate resilience, but a minority will not. We all have differing degrees of it. Some will develop common mental health problems like depression and anxiety in response to traumatic events, and others less common ones, such as psychosis, but many others will get through relatively unscathed.

The General Medical Council (GMC) with whom I am still registered, although I no longer practice psychiatry, has recently decided that the current generation of doctors is less resilient than those in the past and students need to undergo resilience training in order to be tough enough for the job. I have a number of problems with this view:

  • As an excellent review of the topic by Balme and her colleagues in BMJ Careers recently stated ‘there are no consistent definitions, no standardized, valid or reliable measurements; and no robust studies into what resilience is, what the predictors of resilience are, and whether resilience is related to better patient care.’
  • So if you intend to screen for it please check out this first. If I were starting medical school now (and I still dream I haven’t yet passed my finals) I would want to know, as will others, exactly what it is I am lacking in (given that I tend to get depressed I will likely feel guilty and even more insecure) and whether being without it is going to be of harm to anyone but myself. We don’t screen out people with diabetes from being health professionals. Why should we even consider doing that with people who might be vulnerable to depression.
  • Because in an increasingly hostile working environment the reality is health care professionals are going to experience more mental health problems. They are human beings like the rest of us, although they are not encouraged to admit they need help, for fear of appearing weak. The culture is tough enough already.
  • Please don’t dress up this quality called ‘resilience’ as something for which they must take full responsibility (I have a problem because I lack resilience) rather than the NHS (I’m not very well because I do not work in a supportive and caring workplace). As Balme et al. point out resilience is always contextual – it’s a complex interplay between the person and their environment.
  • Please don’t assume that attending a few short workshops would increase my resilience much either. The evidence for the effectiveness of resilience training is patchy at best, and though there is a suggestion of some positive outcomes, these are mainly from self-report in studies lacking rigorous methodology. It might be more effective to address these problems I have in relating to the world and coping with stress much earlier in life before any thought of being a health professional is even a twinkle on the horizon.
  • What I would need is help to identify coping strategies like problem-solving. There is evidence that this works for people with depression, and those who self-harm in response to life stresses. I wish someone had taught this to me in childhood, it might have helped me earlier. I would need things I can rehearse to put into action at times when life gets tough. But I’m also going to need to be encouraged not feel too ashamed to ask for support and how to identify I might need it earlier rather than later, as so many health professionals who have consulted me have been unable to do. Fast and confidential access to help and support too, not having no choice but to consult a service that I work in, which happens to so many people now in mental health services in the UK.
  • And finally, please don’t assume that just because I’m not as tough as the GMC would perhaps like me to be, I would not be a good doctor. Since my book was published a month ago, I’ve heard from medical students who have feared for their future because they have experienced mental health problems at medical school, worried that they will not be strong enough to cope. Yet these very young people, who have experienced what its like to be a patient can bring a very special dimension to their work. Like me, they know what its like to be on the other side.

We all differ in our ability to deal with traumatic events and the stress of work, yet within that spectrum of abilities lies the potential for us to learn to listen, support and care for each other: as friends, colleagues, some managers and a insightful and proactive occupational health service did for me; supporting me through my sometimes difficult career.

My memoir about experiencing depression during my career in psychiatry is out now: The Other Side of Silence: A Psychiatrist’s Memoir of Depression ‘published by Summersdale.

I’m a psychiatrist and I live with depression

I am a psychiatrist, and I’ve had depression on and off for most of my adult life. I’m now retired from practice. I’ve written about depression in a book, and people are saying how brave I am to ‘come out’ and say it. Yet if I had written about having arthritis, or some other physical condition, no one would have described my ‘coming out’ in such terms. Why should it be such a surprise that a a person who worked as a consultant psychiatrist for almost 25 years, and has spent her life researching and teaching the subject, should have first hand experience of it herself? Probably because, in the health professions, the last thing we usually want anyone to know, particularly our colleagues, is that we too are vulnerable to exactly the same stresses and problems as our patients. We like to see ourselves as strong; indeed maintaining our position on the career ladder often seems to depend on that. There is stigma related to having depression, even though mental health workers profess that they are always ‘fighting’ it. Depression is something that others suffer from, not us.

It is exactly this ‘us’ and ‘them’ attitude that I set out to challenge in the book. It started off as a memoir of my own fairly extensive treatments for depression, both with medication and psychotherapy. However as I began to write it, the close parallels between my own experiences, and those of the people I had tried to help throughout my professional life just became more and more obvious to me. There certainly wasn’t a clear boundary between my own experiences and those of my former patients. We all had complex lives- experienced loss, grieved for those who have gone from our lives, felt lonely, wanted to be loved, and sometimes felt compelled to self medicate with alcohol to ease our distress. Some of us made the same mistakes in our relationships over and over again. Many of us wanted or even tried to end our lives. The stories I tell in the book are taken from my own work as a psychiatrist but have been extensively altered and merged to create people who are true to life, but not ‘real’ case histories. However my own story is very real indeed. It wouldn’t have been appropriate to have been so open when I was still practising- when people came to see me the focus was rightly on their problems not mine. When I was unwell I withdrew from seeing patients until I was recovered. I’ve never tried to hide my illness from colleagues. I’ve just never been quite so public about it.

So far, I’ve had some interesting reactions. As I mentioned above, I’ve been described as brave by some, but others are still clearly unsure what to say to me. When I’ve talked in the past about treatment, in particular the fact that I’ve taken antidepressants now for the last 20 years, I’ve certainly picked up from some of my colleagues that ‘this isn’t the sort of thing one talks about’. Why not? Isn’t this exactly what mental health professionals talk about every day? How can we challenge stigma in society if we cannot face up to our own tendency to stigmatise both our colleagues and, even now, our patients?

I have listened to junior members of staff describe people with depression who are not actively suicidal, or psychotic as the ‘worried well’. I’ve been told that depression is not a ‘severe’ mental illness warranting more investment of psychiatric and mental health nursing resources. I’ve read articles written by my colleagues, which describe it as ‘medicalising misery’. Only people who have never experienced the pain, despair and hopelessness could talk about depression in such terms. I’ve spent my life challenging such attitudes. I made it as far as being a Professor of Psychiatry, despite repeated episodes of depression. I know I’ve had better treatment than many people ever receive and my aim has always been to improve access to, and quality of care for depression. I’ve managed to live with depression and found ways of coping with it- though that has been far from easy. That is also what my book is about. I refuse to be ashamed of it.

Nobody should be.

My book, ‘The Other Side of Silence: A Psychiatrist’s Memoir of Depression’ is published this week by Summersdale.

Reclaiming the past

What is it about a song that it suddenly transports you back to another time and place, and evokes all the different emotions associated with it? There are some places in the recesses of my memory that I’ve haven’t visited for a very long time. I’ve not experienced major trauma in my life, unlike some of the people I met when I was a practicing clinician, but I’ve still locked places, events, moments, away in the corners of my mind and every now and then something triggers them back into my consciousness.

I was at a concert the other evening when I heard an old Scottish folk song I hadn’t sung since my childhood. Suddenly I was transported into the past. I hadn’t thought about it in years but I could remember singing it at school, and at home with my mother, who loved singing too. We often sang at home- it was probably the only time my mother and I were ever in harmony.

The feelings stirred up by those ten minutes of music have stayed with me all week. I’ve been dreaming again about my childhood when I’ve not done that for some time. There are some things I want to recall, and others I don’t but my mind seems to want to churn away at those memories until I’ve unlocked a few more dusty cabinets in my brain and rifled though them. It’s at the very least a disconcerting feeling, yet it doesn’t stop me brooding on it.

Repressing memories and the feelings they arouse is something everyone does, but some of us do it more than others. I know why I do it. I’ve managed some difficult times by packing away memories and the people and places associated with them. It’s remarkably easy to do. You simply move on and start again, promising yourself that you will get in touch with the friend who has been bereaved but to whom you find it hard to talk because it evokes too many memories of losing people who have been important to you; go back to the place you lived at a complicated time in your life when both wonderful and awful things happened to you, because you cannot face dealing with those emotions again- so you lose touch with all the people you knew there. It’s just too painful so you avoid it. You don’t go back.

The danger of doing this repeatedly is that you can become almost a person without a past- and that isn’t only a potentially lonely place to be. It also means you cannot always be sure who you really are. You tear up your roots each time you move on leaving little trace behind, either where you have been, or in your conscious memories. Or at least that’s how it’s been for me. Sometimes I find it difficult to make any sense of my life because for many years I almost never returned to anywhere associated with the past. This included my childhood home, place I visited in my youth, even the city where I went to university. For more than two decades I avoided going back to the town in which I spent the first 18 years of my life. What I do know is that it’s not easy to exorcise ghosts, but it is possible. A consequence of psychotherapy was that I was able to do quite a lot of this emotional work, its just not complete yet. I’ve been able to revisit many of these places in recent years, but it still doesn’t feel like I’ve completely reclaimed them, and allowed myself to acknowledge their importance in my past. I’m not entirely sure why.

And the Scottish folk song? It was Charlie is my darling sung by Eddie Reader in concert with the Scottish National Jazz Orchestra, although she performed it with the more racy lyrics written by Robert Burns than the version I remembered. My mother was Scottish, and when I was a child in England I was very conscious, and proud, of being half Scottish and half English. We visited Scotland on holiday, but not the part that I live in now in Orkney, or the tourist routes of Highlands with the views I still associate more with the pictures on tins of shortbread than reality. We went to North Lanarkshire, where my grandfather had been a miner, and my uncle a steelworker at Ravenscraig. I shared a bed with two of my cousins in the overcrowded house in which they lived on the Whitehill estate- which has the dubious reputation of being one of the first places in Britain to impose a youth curfew, to try and get children off the streets at night. It wasn’t pretty, and I was always aware I didn’t fit in somehow. I didn’t speak with the same accent, didn’t have (quite) the same approach to alcohol and I wasn’t at all preoccupied with whether you wore blue or green on a Saturday. I wasn’t used to knowing who was a protestant and who was a catholic in your street like my cousins were. But I am aware that my grandfather, who I never knew, belonged to the local Orange Lodge. He was active in that sectarian tradition of central Scotland that I totally abhor. And when my relationship with my mother deteriorated to the point that we cut off contact, it became somehow harder than ever to feel an affinity with the place of her birth. But if there are Scottish genes in me, that’s where they come from. I still feel a bond with Scotland. I went to university there. I’ve travelled all over it. I was even married to a Scotsman- for a while and I live there some of the time now. But at the same time, it sometimes feels like I can’t really claim an honest connection because that part of my early life that provides a tangible link has been locked away. I haven’t really dealt with it because isn’t ‘me’.

A couple of years ago, I travelled to Glasgow by train for the first time in 30 years to examine a PhD student, and was suddenly and powerfully transported into the past as I walked out through the concourse of Glasgow Central. I remembered going into the city for the day on the train in the 1960s, across areas that were almost derelict and due for demolition. For someone from the rural east of England, it was like travelling through another universe. I’ve driven up the M74 many times, past the exit for Hamilton, and all the signs for the places that remind me of day trips in my childhood. But I’ve never been back to where my family comes from. I’ve lost touch with both family and place and in doing so I’ve cut out another part of my life.

Perhaps the real message of the song for me was it’s time for me to revisit the place that evokes those memories, if not the people. It’s far too late for the latter and I doubt I would ever be welcome. But I need to reclaim the past, to reconcile myself a little more with who I am and where I come from- while I still can.

Surviving Christmas

Like many people I’ve never found Christmas easy to bear, yet I still find it strangely odd to admit to that. After all, it is so eagerly anticipated by many, especially the young. I make very little preparation and only do a little shopping at the last minute. I send few cards and hardly receive any now. I try and pretend Christmas day is ‘just like any other day’ except I have to cook a ‘traditional’ dinner, and every other year I cook for my mother in law too, which can be stressful. We watch a lot of television, and then, by halfway through Boxing Day, I simply cannot wait for it to be over. I want normal life just to begin again.

In the out-patient clinic, I would spend quite a bit of time before Christmas discussing with each person what their plans were for Christmas, especially those who were facing it on their own. What was he or she going to spend their time doing? Who could they contact if they needed to talk to anyone for support? What were our plans if there was a crisis? Then in the few days before New Year I would catch up with those people who needed urgent review or support and repeat the task for New Year’s Eve. Sometimes people would ask me if I was looking forward to the holiday and I would usually tell a little white lie, and say that I was, if only for the ‘rest from work and the chance to spend some time at home’.

I guess my problems with Christmas stem from unhappy memories of time spent in close quarters with a family who wanted to be able to enjoy themselves, but somehow, whether due to lack of money or simple intolerance of each other’s failings, never managed to get along. My father would take away the only lifeline we had on a day of enforced closeness by insisting on switching off the television and listening to ‘his’ music (twenties and thirties jazz- which I kind of appreciate now, but didn’t then) on the radiogram with the rest of us keeping him company in silence. I never really understood why he did this. It seemed to be a way of making a point about who was in control of the household, but in retrospect it seemed a peculiarly passive aggressive act. This would trigger an almighty argument between everyone, which generally continued until bedtime. By early afternoon on Boxing Day I was able to excuse myself from the misery without any further ire. By my teenaged years I was in the pub that evening and everything was, to my relief, almost back to normal. I just had to listen to how other people spent their Christmases. As a child you always imagine every else’s family is just like your own. Then you find out they are not. They are just strange in different ways.

The first time I realised I was going to spend Christmas on my own I felt quite ashamed to tell anyone. What does it say about me, I thought, that there was no-one who wanted to spend the ‘happiest’ time of the year with me? (I’m a miserable sod?) Yet I know now I was neither particularly abnormal nor very unusual. I was estranged from my family. The man my mother took up with after my father’s death was even more difficult to spend Christmas with. He would sit beside the fire in silence brooding over his broken marriage. There wasn’t even the relief of Fats Waller singing Aint Misbehavin’. I stopped going home altogether. Then I got divorced…and depressed again. And then I was completely alone.

What I learned was that there are ways to manage Christmas on your own, but you need to be prepared. I refused offers to go to friend’s houses as I didn’t want to be part of someone else’s celebrations, or to accept invitations out of what I, possibly wrongly, perceived as pity. I wanted to have my own special time for me…just for it not to be particularly Christmassy. Apart from a perverse enjoyment in belting out certain Christmas carols I don’t do ‘festive’ at all.

So the first year alone, I took myself to Paris for 4 days, and ate a Parisian Christmas meal alone in a Greek Restaurant on the Left Bank, which was open on Christmas Eve. Finding food on Christmas day was much harder, so it was fresh bread from the bakers, which at least open every day in France, in my little hotel room. One of those with faded wallpaper that goes all the way over the ceiling. I didn’t have any TV in English, but I had the streets of Paris to walk. It was ideal for occupying my mind.

The following year I decided I really must go somewhere where food would be easier to obtain over the holiday so I returned to France, driving all the way there in an old mini. I hadn’t had my licence very long, and it was scary. At one point I found myself trying to negotiate the roundabout at Hyde Park Corner as I didn’t want to go on the M25 to get to Newhaven where I took the ferry to Dieppe; but it was an adventure. I had a puncture and had to seek help at a garage. My schoolgirl French wasn’t really up to the task, and half a dozen men stood around looking at me quizzically. Yet when I said I was from Manchester someone said’ ah Manchester United!’ (apologies to City fans) and my little red car was whisked away and speedily repaired. I ate and drank well, and again walked for miles, this time around the small town of Honfleur, in Normandy. I found the grave of a relative who died just after D-Day and left flowers for him. I sat on the seawall at Deauville looking out to sea, watching Parisians trouping down the boardwalk with their dogs, and felt relieved of the burden of my expectations of Christmas.

I spent three Christmases alone, in succession. I was fortunate I could afford to travel away; it made it easier to bear for me, but many do not have this luxury. I don’t think I could have easily tolerated watching everyone else enjoying Christmas around me while I sat within my four walls. So I was really pleased to see there is recognition that many people, especially those who, like me, were and are estranged from their families of origin, will spend Christmas alone, in their own homes, and that there is advice available to help them cope with it.

I wish I’d had it then. I eventually perfected the art of eating alone in restaurants without drawing attention to myself, feeling conspicuous to the other guests or being openly pitied by either them or the waiting staff.

However that is probably another story.