Strategies for Living

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

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.

On not being immortal

When I was a medical student, I remember one ward round when we were gathered around the bed of a patient who was breathless and coughing up blood. She admitted to being a heavy smoker. The surgeon gave her his usual stern ticking off about the dangers of cigarettes, and then we all trooped back to the doctor’s office where he took the patient’s chest x-ray out of the envelope and pushed it up onto the light-box on the wall.

“Look at the mass there he said,” pointing to dense shadow in the left lung, “almost certainly a carcinoma.”

And then he calmly took a packet of Senior Service cigarettes out of the pocket of his white coat and lit one up, puffing away as we discussed the prognosis. You have to understand this was the Stone Age.  People did still smoke in hospitals, even doctors. But some things haven’t changed. I think many doctors still have a peculiar belief in their own immortality. That knowing all about disease not only gives you power over it but makes you immune to it. It begins at medical school. Many medical students aren’t even registered with a GP where they go to university. They alternate between being sure they have every disease they learn about and denial of their own susceptibility. And it carries on. Doctors generally don’t smoke now, but we still abuse ourselves in other ways, notably with alcohol. We are tough and macho, don’t admit to weakness, and rarely follow the advice we give our patients, yet expect them to wholeheartedly agree with us.

Last year I had to come to terms with the fact that I’m not going to be immortal after all. I don’t mean that in the sense of transcendence of my soul.  I’ll keep out of that argument for the moment.  Rather I am not going to live forever, and life might get quite a bit harder for me physically in the future than it is now. To add to the anxiety, depression and hypothyroidism, I was diagnosed with progressive kidney disease.

Okay, so I know I will not live forever. Of course I won’t. Indeed would I really want to? There have been times when I’ve been so depressed that I’ve wanted to end my life somewhat sooner. The thing about depression for me, unlike physical illness, is that it feels like if I were to die from it, it would be because I wanted to. I have control. Even though I know rationally, as a psychiatrist, that what I perceived I wanted would be strongly influenced by my mental state at the time.  But there is, I think, a part of all of us that secretly hopes we can cheat fate and carry on forever (only while enjoying of course the perfect health of youth). When I was a young child, the idea of dying seemed so impossibly far away as to be almost irrelevant to being alive. Then my grandfather died followed by my father, both at ages not so different from where I am now. When people close to you die, death became a real possibility for you too.

People who have chronic illness are more likely to experience depression and anxiety, and the more chronic illnesses you have the greater your risk. In the last research project I worked on in Manchester, we attempted to offer psychological therapy to people with diabetes and/or heart disease who were also depressed. What was striking was how few of these people were actively receiving help despite the fact that all them had been screened for depression on an annual basis as part of the payment incentive system for GPs in the UK. Some of them had never discussed their mood or suicidal ideas with their doctor. They didn’t want to, they were embarrassed or they didn’t see the point, so they suffered in silence. It can feel stigmatizing having chronic illness, and having a mental health problem as well just doubles the stigma.

So it turns out I have a genetic disorder of the kidneys that I’ve had for many years, but didn’t know about before, and which is going to get worse as I get older, at a rate as yet undetermined. There is a good chance I will eventually need to have dialysis. Despite feeling fitter than I have for years, it is as though my body has let me down. Something is happening inside me over which I have no right of determination. Like many people with chronic illness I feel my useful life has now become shorter, so I’m beginning to speed up my rate of travel, picking up again those things I started to do many years ago but dropped because of my career, and aiming to achieve a few of them while I’m still quite healthy. Not quite a bucket list but something similar. It has increased my level of anxiety but I don’t feel depressed about it yet because I’m still in control, trying to keep myself fitter than I have since – well ever.

Or maybe it’s because I’m just being tough…. and I still believe I can win.

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.