Recovery during a war on depression

 There has never been an easy time for people with severe mental illness (yes, I am calling it that) to get the help they need to recover, but at the present time it seems harder than it has at some other times in my life. The terrible impact of austerity on the provision of mental health care, combined with the redefining of ‘recovery’ as being capable of economic activity has discriminated against those who are disabled. The results have led too many people to take their own lives.

I have experienced episodes of depression throughout my adult life but I acknowledge that I am fortunate to have been able to retire from work, and to embark on what David Karp the sociologist describes as defining depression as a condition that one can get past. When I am well, as I have been for the last few months apart from a blip before Christmas (work related), I find it hard to remember just how awful I felt the last time I was severely ill. But what I’ve been working at over the last couple of years is trying to reclaim recovery for what I always originally understood it to be. Not 50% reduction in my scores on the PHQ-9, or my ability to work, but re(dis)covering the life I’ve glimpsed at times but never managed to reclaim- because I’ve learned how depression cruelly deceives you by whispering that there is nothing left in life for you. It’s so much more than unhappiness. It’s a way of being.

The current discourse about ‘depression’ hasn’t helped. I’ve spoken on social media about how there seems at times to be a war on antidepressants, but actually I think it’s more than that. I think it’s a war on what I, and many others experience as depression. There is a real sense of denial of experience- of the phenomenon (it’s really ‘misery’ and ‘unhappiness’); of the cause (it’s all about power, threat and meaning– the body doesn’t come into it- despite the fact that depression is undoubtedly experienced in the mind and the body); and the treatment (antidepressants don’t work- and anyway they aren’t antidepressant- they just numb and sedate you); and actually work is good for your mental health. Any work (no it isn’t).

Therapy has become aligned in some places with employment services and in Five Years Forward, ‘depression’ is subsumed under Improving Access to Psychological therapies only. The fact that it can have psychotic features in this setting is sometimes missed by those not trained to recognise this.

What I have learned is that first and foremost you need someone who may not agree with your view of the world, but believes you when you say this is how it is, to be there to guide you through. You have to be able to trust them. Many people find that difficult because of what they have been through in life, but so many health professionals seem to fail to understand the role they must play in engaging you.

Getting access to the right treatment for you is essential. I don’t think depression is homogenous. In my experience the part played by physical, psychological and social factors in its aetiology can change between episodes and over a lifetime. And treatment needs to be similarly tailored. When I was younger I benefited from dynamic psychotherapy in helping me to make sense of my difficult early life. Later, CBT helped me to cope with every day living. And I needed medication- and still do.

At the moment we are still in the midst of a debate between those who say there is incontrovertible evidence that antidepressants work- and those who still say that it’s mostly a placebo effect. I believe they work- for many people – but not for others. I guess one of the problems is that if you accept that medication works on depression then there must be some physical process at work in the brain- at least for some people some of the time. As I’ve said above- I think there is- but many will never be willing to consider that.

Some people experience problems with antidepressants- they can make you feel worse- I experienced awful agitation on fluoxetine. You can also have major difficulties withdrawing from them but I don’t think we yet know the true extent of this. Anecdotal evidence or internet surveys with their inherent bias, are not enough. But I believe that people experience this, and I don’t think my profession has, in the past, taken it seriously enough.

And we need better treatment for those who do not respond to antidepressants. I’ve no doubt from my own experience that people with adverse childhood experiences are less likely to respond to medication and need access to sufficient good quality therapy. The kind I had access to, longer term one-to-one, is now rarely accessible without payment. Yet I cannot see how recovery can be possible, with brief interventions only, for people who need time to build up trust because of what has happened to them in early relationships.

Beyond treatment you have to be able to rediscover living again. For me, that’s the part of the process that feels like healing. I’m still learning from the therapy I had in the past. I am rebuilding a life and finding meaning in existence again.

I am very lucky to be able to do this. It would be wonderful if those who espouse those simple absolutes about what depression is and what recovery involves might reflect on what it is like when no-one will listen to how awful you feel, and people just tell you what you should be believing and doing (what they fervently believe themselves or is economically expedient)- when that seems impossible and intolerable to you.

This is not mental health care- and if it were all I had received I would not be recovering from depression now.

Diagnosis, power and suffering

I was very fortunate in my psychotherapists. None of them tried to impose an interpretation on my experiences in a way that didn’t feel right for me. They suggested them from time to time, but they always allowed me the choice to find my own way forward. Two of them didn’t discuss diagnosis at all. However the cognitive therapist, who said that my use of antidepressants was ‘between me and my psychiatrist’ worked from the basis that I had recurrent major depression- what it says at the top of every letter from my psychiatrist to my GP- and the therapy I received was rooted in research evidence.

So it has been interesting, and worrying too, this week to watch people on social media arguing about the Power-Threat-Meaning (PTM) framework just published by the British Psychological Society. Some of its supporters have somewhat grandiosely claimed that it will ultimately replace diagnosis and that this is an ‘all encompassing’ framework. Its authors have denied this although, as widely noted, this is not what it says in the overview, where it states that continuing use of diagnosis is ‘unethical’. Nevertheless those of us, professionals and service users alike, for whom diagnosis has continuing validity, have been concerned and sometimes moved to anger by the conversation.

In my own career, I was particularly influenced by feminist approaches to therapy (especially after a memorable weekend at the Women’s Therapy Centre in the 1980s)- but my longest period of supervision was from a wonderful psychodynamic therapist who skillfully challenged me when my strongly held beliefs interfered with my ability to listen to and empathise with my patient. I can think of people I have seen in the clinic who would have found the PTM framework liberating and potentially empowering, particularly those who had experienced complex trauma in early life and had received the diagnostic label of ‘personality disorder’. But I can also think of others who would have found the idea of their problems being rooted in a response to ‘power’ difficult to understand or use in a way that made sense to them.

I didn’t experience anything like the trauma many of my patients did, but I was shamed and criticized, physically punished and experienced a degree of emotional neglect and absent parenting. The PTM framework doesn’t help me personally to make sense of that, although a therapist with a strong allegiance to it might think differently and want to try and convince me so. Neither does it help me to understand why my brother, alone amongst the members of our family, developed obsessive-compulsive disorder at the tender age of 7. I have spent my life, since my very helpful therapy ended, coming to terms with my grief for the childhood that I did not have- something which Alice Miller wrote about decades ago. I would have found the PTM framework helpful in understanding my battles with power in the NHS, and paradoxically perhaps with managers of psychological therapy services in particular when trying to increase access to therapy. But it still doesn’t explain why I amongst my colleagues was the one who got severely depressed. For that I would still argue a ‘biopsychosocial’ framework is still needed.

For me there are several principles that need to be considered:

  • All mental health professionals need to be able to work flexibly across different models in order to find what is most helpful for this person at this time in their life to understand and overcome this problem. If a therapist has too much allegiance to a particular model this can be detrimental- but I know from what people tell me that they have experienced this. Models may change over time and it may be necessary to draw from several in making sense of a problem and planning treatment.
  • Psychiatrists have power in their ability to diagnose and detain people under the Mental Health Act, but other therapists exercise direct power in the consulting room too. And we all have less power than many might imagine in the face of NHS management. It’s essential we work together effectively in teams alongside patients and service users, not in conflict with each other.
  • Diagnoses are not ‘things’ but concepts. As Robert Kendell, with whom I was a medical student in psychiatry, wrote:

‘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.’

  • The need for diagnosis is not going to disappear whatever the most evangelical adherents of new models might think. Diagnosis is used worldwide, for clinical work, epidemiology and research because it has utility. Psychiatrists are the first to admit that the current systems are problematic. I was involved in the ICD-11 for primary care, and met some of those working on DSM5 firsthand. I’ve seen how unsatisfactory the process can be. But across the world the vast majority of people with mental health problems don’t receive any mental health care at all, and if they do it is not from a highly qualified psychological therapist, but in a primary care setting. In helping doctors in many different countries to recognise the commonly occurring experience we call ‘depression’ (which exists the world over) I’ve tried to do my part to promote better care, and I certainly don’t think that is unethical- indeed quite the opposite.
  • It would be foolish to think that ‘good’ ideas don’t have unintended consequences. The libertarian wing of antipsychiatry described by Peter Sedgwick in Psychopolitics was perfectly in tune with the Thatcherite reduction in spending on mental health care in the 1980s. We must beware that statements that ‘mental illness doesn’t exist’ are not taken up by those seeking to further persecute people who are suffering terribly in the current social and politic climate. Because people are suffering.
  • And people who are suffering have a right to be ‘ill’. Cassell (1998) talks about the importance of understanding the nature of ‘suffering’. Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. It is crucial that we respond empathically to address that suffering whatever we call it. To call it ‘illness’ does not necessarily suggest a biomedical aetiology. The ‘sick role’ has its benefits and it allows us time out of life and additional support and help in order to recover,  and if everyone’s response is ‘normal’ then why do some suffer so much more than others do?

Because there are undoubtedly those amongst us in our society who are more vulnerable and need our help.

According to those who are at the front line in the fight for social justice for people with mental illness in our community,  diagnoses are required (regardless of what it says in the PTM framework) along with deficit based descriptions which fit mental health problems with every day tasks such as difficulty in eating, bathing and dressing. Follow this link for more guidance. Med_Evidence_WCP_Guidance_final_14dec

 

We have plenty to do together to work for better mental health care. The PTM framework will be enormously helpful for some, but not for others.

Please lets not not forget how we all came to be here- to try and work together to improve the lives of service users and patients.

 

Why I’m fed up with being positive

So many people in the world now seem to be in pursuit of happiness. Worryingly that seems to be perceived to be something that primarily requires us to rework our ‘self’ with all of those self-help books I’ve complained about before; or achieve with very short-term therapy in which you don’t, God forbid, have the opportunity to get dependent on your therapist, even though every one of us, therapists included, are dependent on someone or something. And if you don’t achieve happiness I suspect the conclusion will not be anything to do with the difficulties that you have faced in your life- the traumas of childhood, the struggles of poverty, the lack of meaningful employment or the stigma that you face for being ‘depressed’. No, I am beginning to fear that in this age of relentless positivity the conclusion will be that you simply haven’t been smiling hard enough.

If there is a truly positive place in the world it is America. People serving you in shops and restaurants (mostly) smile at you and wish to ‘have a nice day’ (although the young man in the fish shop in Orkney wished me that today too- sadly). For those of us more cynical Brits who spend time in the USA (like Ruth Whippman in in her recent book ‘The Pursuit of Happiness’) it can be difficult to come to terms with a place where everyone seems to be so determined to find happiness by one means or another. In my favourite bookshop, the Elliott Bay Book Company on the top of Capitol Hill in Seattle, which by the way has a marvelous ice cream shop nearby, I found that the personal development shelves where people go to seek instruction in happiness, have now been relabeled simply as ‘self’. On the top of this section there is now label which simply said ‘self overstock’ which may or may not be intended to be ironic. I didn’t purchase anything, though I did buy a large vanilla cone from next door, which provided some relatively short-lived but exquisite pleasure.

I find the current vogue for dishonestly reframing everything in a positive way really irritating. We are not allowed to have problems any more only strengths.

Well that’s fine. I know I am a resourceful and resilient individual thank you very much with an excellent standing in the community. But can you help me with the fact that my electricity’s been cut off. That’s a problem not a bloody strength. And since I lost my job I’ve been feeling really down and I’ve had no money for 6 weeks while they sort out my benefits. I don’t mind you saying they are problems, because its true, they are, and I need some help.

This persistent and problematic level of positivity seems to have entered almost every aspect of mental health care. I suspect it wouldn’t bother me so much if it was balanced with an acknowledgement that people have real life difficulties that for which they do really need the help of others, especially mental health and social care services. And I have a suspicion that its all really about people becoming more ‘self-sustaining’ and cheaper to run.

The current wave of positivity began with the rise of the Positive Psychology movement almost two decades ago, led by the American psychologist Martin Seligman, previously better known for having come up with the term ‘learned helplessness’ to describe what happens when people feel powerless to change their lives for the better- and proposed as one of the psychological theories for how we get depressed. In her wonderful book Smile or Die: How positive thinking fooled America and the world the journalist Barbara Ehrenreich ably convinces the reader that the ‘positive thinking’ movement has not only pervaded almost every aspect of our world in the 21st century through the influence it has had on business and economic theories, but that it has also done a considerable amount of harm. We have been encouraged to believe that by thinking in ways akin to making magical wishes, we can improve our lot. That by the repetitive act of reading daily ‘affirmations’ and writing gratitude letters to express how we feel about what is positive in our lives we can increase our sense of ‘wellbeing’. Even that by thinking positively we can avoid death from cancer.

Even though the evidence for positive psychology remains weak  when viewed against what we know about other kinds of psychological treatments (and in the case of beating cancer, non-existent), it has consumed all in its path- perhaps supported by the extraordinarily powerful marketing that has accompanied it. Those who have developed it have become gurus and then very successful business people. As Ruth Whippman points out, their expertise is now being purchased to bully the unemployed into feeling better about their job prospects. And positive psychology has found its natural bedfellow in the Recovery movement where there is a similar degree of evangelical positivity about the future prospects of a person struggling with mental health problems. In the recent book Wellbeing, Recovery and Mental Health’  which ‘brings together two bodies of knowledge on wellbeing and recovery’ the authors describe a type of positive psychotherapy for people with severe mental health problems including such strategies as ‘savouring’ (I’m not sure what that means), gratitude letters, and recognizing your signature strengths; once again without providing much good evidence of its effectiveness  other than those who took part had very positive views of the programme. I do hope that was enough for them.

I’m finding all this unwarranted and dishonest positivity quite depressing. Am I alone? Or is this just another instance of my unfortunate learned helplessness?

Talking values

Our values are the principles by which we make judgments about what is important in life. We often make the assumption that because we consider ourselves to be ‘reasonable’ people, share a professional title or have similar political views we must feel basically the same way about everything- but we don’t.

I was reminded of this at a recent conference when I was talking (as I sometimes get asked to) about the importance of and ways of helping people with common mental health problems in primary care. One member of the audience expressed concern that directing resources to people with anxiety and depression was being promoted at the expense of people diagnosed with ‘real’ mental illness and told us that a member of a team working in primary care had complained to him that there was ‘nothing wrong’ with people they were being asked to see. Another asked the panel how we might help people to stop asking for help with such problems and be more ‘resilient’ instead.

If you know me at all you will be able to imagine my reaction. I’m one of those people who get help with a ‘non-psychotic’ illness, although what has been of great benefit to me is so much harder to access these days, not easier. I was also thinking of the depressed colleagues of these professionals who would find it quite difficult to admit they needed help in the face of people around them expressing these values and beliefs. I objected passionately to the use of the word ‘resilience’, as I always do and probably alienated the young woman who asked the question rather than convinced her with my reply- she disappeared soon afterwards.

Some time ago there was a push towards ‘values based practice in mental health’. According to the Oxford psychiatrist and philosopher Bill Fulford ‘Values-Based Practice’ is the theory and skills for effective health care decision making where different (and hence potentially conflicting) values are at play. Not only do health professionals hold many different values from patients and service users, they often differ considerably between each other- both between and within their respective groups. Discussion of all of our respective values is essential in those difficult areas such as the role of diagnosis, how to make care more patient-centred in the face of feeling ‘hit over the head with evidence’ (as someone said recently on twitter) and ethical dilemmas such as involuntary treatment. It is never so simple as something being ‘right’ or ‘wrong’. All of these require time to reflect, on how and why we hold particular values of our own and why completely different ones may be so important to another person- and being able to admit honestly ‘maybe I don’t have all the answers’.

On social media there is little opportunity for reflection and arguments about value-laden topics can quickly become abusive. I do think its crucial to remember how many people with mental health problems look to social media for support, and abrupt questioning by mental health professionals of the personal values they hold on topics, such as being given a diagnosis and treatment that they believe has helped them, should be viewed as ethically unacceptable by their membership organisations- just as it would be in a direct clinical encounter. Values based practice is not simply about educating a person about what is wrong with their beliefs, but starting from where that person is at and trying to understand and make sense of their values and beliefs. Neither of you is ‘right’.

I should try to understand how and why fellow professionals come to hold the views they have about people with common mental health problems. Telling them they are wrong isn’t the right way to approach the problem- I know that- but sometimes, as with all of us, emotions get in the way.  And, as I’ve witnessed in so many meetings, we can assume we are all ‘on the same page’ (or hope we are to avoid conflict) but attempted execution of the task at hand soon reveals that we all do it entirely differently because we never wanted to have those difficult discussions about our basic values. The national roll out of services- such as implementing stepped care services for depression, and IAPT, were good examples of this- approached very differently depending on the values and beliefs of those leading the process in each place, and varying considerably in effectiveness. If we do have time and place for both self-refection and conversations with fellow professionals and service users we often find we have much more in common that we imagine. We can even agree to disagree on certain topics but still work together if there is mutual respect.

I have much more time now to talk and think about those powerful emotional responses, so influenced by my personal experience and those of friends who have felt unable to disclose their problems- and how these have affected my decision-making. Can we please have more opportunities in the training of mental health professionals not just to talk with people who reinforce our values- but those who might challenge them? and I don’t mean in the setting of a conference presentation where discussion is limited and things can easily degenerate into a shouting match too. A first step, according to Gwen Adshead,  might be to ‘respect’- to be mindful of another persons differing beliefs and values. To care about their experience as much as your own. The people I have disagreed with will have arrived at their position perhaps because of particular experiences they have had- just like I have. How and why?

All of practice- not only psychiatry, is influenced by values- but insufficient attention is paid to not only what is best for the patient from the viewpoint of the doctor or therapist, but what is right for that person, at that point in their life given the situation in which they find themselves. A professional cannot and should not assume that they always have the ‘right’ values or the correct answer.

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.

Therapy

I know many people have enormous difficulty accessing therapy for depression- but as someone who has benefited for it, provided it, and supervised others, I realize how fortunate I’ve been, and how important it has been personally for me. Antidepressants have helped me with many of the symptoms of depression, but I still needed to sort out the conflicts and problems in my life that had contributed to the emotional mess in which I found myself. We keep hearing how there will be medication tailored to suit each individual some day, but I don’t think there will ever be a tablet labeled ‘take two a day to come to terms with how you feel about your mother.’

Over a period of about 12 years, during my twenties and thirties I underwent psychodynamic therapy, something in which I had also had some training – with 3 different therapists. Two of them helped me but there was one with whom I simply could not ‘gel’. Finding a therapist with whom you can make some kind of emotional connection is essential. I was able to learn how the problems in my childhood and the dysfunctional relationships I had with both of my parents were still affecting my adult life. I’m quite sure that, at the time, that was the best type of therapy for me. There were some major unresolved issues from my childhood and adolescence that  interfered with my ability to make stable, trusting relationships. I had also spectacularly failed to grieve for my father, who died when I had just qualified as a doctor. There was a period of a few years in my late twenties when my emotional life can only be described as chaotic. With therapy I was able to access the parts of my personality that I had been desperately trying to keep under control, but sometimes the new and more assertive me who emerged from the chrysalis of therapy was more of  an abrupt and outspoken moth still seeking the light of day, than a perfectly finished social butterfly. Nevertheless talking therapy helped me to address some of the difficulties that I had in the major relationships in my life and embark on what has been a successful second marriage.

Later, when undertaking a course of cognitive behaviour therapy (CBT), I found ways to begin to manage the way I ruminate about being me in this world and to cope more effectively with people in day-to-day life. Therapy was anchored in the present, not the past and I began to learn much more about how my mind actually worked. I could identify my previously unspoken, but very difficult to live up to,‘Rules for Living’ from David Burn’s book the ‘Feeling Good Handbook’, and I began to understand how attempting to live up to my internal very high but often conflicting standards, led to experiencing anxiety in everyday life. It is six years now since I completed that last course of therapy and I am beginning to realize just how long it can take for it to work. I still continue to have new insights into why I am the way I am, and what triggers and sustains those periods of anxiety and low mood, as life goes by. Life is a ‘work in progress’, or at least that is how it has seemed for me.

What most people get offered now in the first instance now is brief therapy, mostly based on CBT principles. For many people that will be very helpful- and when I was supervising a primary care based team of therapists, I saw how effective it could be- particularly if the behavioural aspect of CBT – behavioural activation- was employed first. CBT is very much about ‘doing’ things to feel better. Like setting goals for activities that you may have stopped doing. Or actively trying to address the depressive automatic thoughts that can both trigger and maintain depressed mood- both with the aim of getting you out of the shadow of depression to which you retreated when you lost the energy to fight anymore. In some ways the conceptual basis of brief CBT based therapy isn’t all that different from medication- in that both seek to ‘activate’ either your mind or your body. You get going and take up your life again. You are ‘fixed’ at least for the present as your deficit, of either serotonin or self-esteem ,has been addressed, as Alain Ehrenberg in his book on the sociology of depression, ‘The Weariness of the Self’, clearly describes. And in today’s climate you must of course take responsibility for helping yourself to get fixed- through self-help or presenting yourself at the doctor’s office.

CBT helped me when I was struggling with  my depressive ruminations and it was the right therapy at the right time. But when I was younger, and I couldn’t make sense of who I was or wanted to be, I needed time to build up trust in a therapist, and work on the complex problems from my past that actually interfered with me engaging in therapy in the first place. As I wrote recently, the simple ‘fix’ doesn’t work for a significant number of people who are depressed- particularly those dealing with painful conflicts and the impact of trauma- and we realistically should not expect it to. They need what I was fortunate enough to receive, but it is less available than ever- not only because of cuts, but the prevailing view that depression in primary care is something that can be ‘fixed’. Some people need time to engage, to trust and to work out how to discover who they are and learn how to forgive themselves for even being alive. Some who don’t respond to the simple fix are labeled as having borderline personality disorder- and their anguish is downgraded to ‘distress’ but they too are experiencing something that is only one aspect of the many faceted but hard to define experience that we call ‘depression’. I can assure you that it is real and those who suffer from it kill themselves.

Those who need more than the quick fix are  just as deserving of our attention- and our help.

 

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.

 

 

Learning from Goldilocks

I’ve hesitated in writing about this topic, because I know things are extremely difficult in mental health services at the moment in this country. I don’t want to sound as though I think it is easy to do things differently. When teams are being cut it is very hard, and I am also retired now from clinical care so I am not in the firing line any more.

But what I’m going to talk about goes way back beyond the present problems- as long as I can remember. When I was younger, it pervaded the decisions I had to make when I saw a person in A&E who was unfortunate enough to live on the wrong side of the red felt pencil line in the on-call copy of the Manchester A to Z. It’s the problem that led one senior psychiatrist a few years ago to respond to me in a research questionnaire that no other speciality defines itself more adamantly by what it does not do than mental health. Its important to also say that I am not here referring to the awful burden staff carry when trying to find a bed for a person who needs admission; when they can spend all night phoning around the country. I know they are trying desperately to help the person who is in immediate need of care. I’m talking about what happens at the front line contact- when a person is referred by their GP, or seeks help- long before their problems have reached the point where admission is indicated.

We talk a great deal about patient and service user centred care in health services, but what we deliver and receive is not always that. The `Goldilocks Principle’, which applies in many areas from climate study to economics, states that something must fall between certain margins, rather than reaching extremes. The earth is a Goldilocks planet as it falls within a planet’s habitable zone. So what does have this to do with health care? Well, in mental health care the situation is often the reverse of the Goldilocks story. Instead of one person and three bowls of porridge, which may or may not be right for them, we have the reverse. Three people and one bowl of porridge. A service often defined by what it will not offer rather than how it might help, with no other options available for the people who do not fit these criteria. The decision not to help the other two people is often accompanied by the statement ‘we are not commissioned to provide X,Y……’ This is not a new phenomenon. It existed beyond the current cuts, but they have made it worse.

Now, there may be so little on offer that even access to that single bowl of porridge is limited or absent. Or a person may be told that their health will have to deteriorate further before the service will accept them. ‘Go away and come back when you are just right, even though we all know that is going to make it even harder to provide the help you need in the long run.’ And I know this is not a new phenomenon in the inner city populations where the lack of opportunity for early, timely intervention means a person may only be offered help, even though their GP has tried and failed to get them care for some weeks, at the point beyond which they no longer believe that they need it. So they then receive it under the Mental Health Act.

But when we do get the opportunity to re-build services- and its difficult to have seen thirty years of changes without hoping that something will change again at some point for the better, we need to try and ensure that what is provided is not simply about matching the person to what is on offer. This is what results in the multiple assessments with different teams which service users find so difficult, demeaning and pointless. This doesn’t have to mean allowing a person to choose exactly what they want, like Goldilocks did. We know that has problems not only of cost-effectiveness but the risk of causing harm. It is about having a dialogue in which all views are considered.

On a personal level -It is about thinking- ‘How can I help this person to get what they need’? If I cannot help them- who can and how can I facilitate them to arrive there. If it isn’t available what can I do?

At a service level it is considering how, if the person doesn’t really require specialist care, how can we support their GP, and/or the third sector to provide that care- and if we are ill equipped to do that, how can we find out.

It is also about ensuring we are not ‘cherry picking’ those people who are easier to help to improve our outcomes but trying to meet the needs of the people we were commissioned to help.

At an organisational level it is not only about developing specialist skilled teams to deliver help for more service users with complex problems, but making sure these teams in turn provide the right support to generalists. This will help to ensure service users who need help for which services have not been clearly commissioned and ‘fall between the cracks’ can be offered appropriate care.

It also means fostering a culture of dialogue, trust, respect and cooperation to ensure that the worker who makes initial contact with a service user is not told that their assessment is of no value because they do not belong to a particular profession or work in a certain team.

At a commissioning level, it is about asking the question ‘what are we not doing?’ ‘what isn’t there that should be?’ and ‘what isn’t working?’ for people with mental health problems- who will be able to tell you very clearly. It may not be possible to provide it, but we still need to talk about it and work out what can be done rather than what cannot.

At the moment it may seem hard to achieve any of these things- but these are not new problems and they will not all be solved by more investment. A person should never be thought of as ‘just right’ for a service. The care that they are offered should be, like Goldilocks’s porridge, ‘just right’ for them. Only unlike in the fairy tale, we should also try and ensure that doesn’t come at the expense of others- the three bears.

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.

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.