Tag: anxiety

Antidepressants are a feminist issue

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It’s 35 years now since I first took antidepressants, and I’ve been on them continuously for 31, the last 25 years or so on an SNRI (Serotonin and Noradrenaline Reuptake Inhibitor). So, it can be more than a little disturbing to reflect that just like my mother (who took Ativan and Valium long-term) I’ve ended up on psychotropic medication for much of my life. Particularly when I read an article Are antidepressants a feminist issue? published 3 years ago by Halima Jibril in Dazed Magazine, which cites NHS data from 2021/2 that 5.5 million women in England and Wales were prescribed antidepressants compared to 2.8 million men. That’s twice as many. Its woman who are much more likely to be taking them. 

Women are more likely to get diagnosed with depression than men, but there are several reasons for this, many of which I’ve discussed in a previous blog. Jibril also mentions the issue of over-medicalisation of distress, which has been a key theme in feminist critiques of psychiatry over the decades. It’s been suggested that not only are women’s emotions pathologized, but also that medication is used as a tool of control. Both have been true in the past, and in some places they still are. My profession has yet to acknowledge the full extent of its past and continuing poor treatment of women. However, if you are a person who believes there is no such thing as ‘depression’, as many do, it seems logical you are unlikely to believe there is a place in the world for antidepressants. 

I recognise depression to be real and very disabling in its severe forms. I’ve suffered from it much of my life and I’ve met and tried to help many other women, patients and friends, who have too. So, I’ve no doubt we have been the key market for antidepressants, just as we were in the past with benzodiazepines: 

Jan, ‘single and psychoneurotic’ because ‘she had never found a man to match up to her father,’ as the ideal candidate for Valium. [from an advert Archives of General Psychiatry 1970]

My mother didn’t fit this description, but she suffered with chronic anxiety. Something I inherited.

Many of us have benefited from antidepressants. I wouldn’t have been able to engage with some of the psychotherapy I received unless I had recovered sufficiently first by taking the pills. Nice recommends a combination of therapy and medication for severe depression. However, we do know much more now about antidepressants than when I began to use them in the early 90s. We’ve learned about the problems they can cause – particularly difficulties in withdrawing which can be severe for some people and also sexual dysfunction – including PSSD (Post SSRI sexual dysfunction). 

Women respond better to SSRIs than they did to the older Tricyclic Antidepressants (which I took at first), and younger women respond better than postmenopausal women. Hormonal fluctuations affect how our bodies metabolise them.  However, women have also been found to experience more severe sexual side effects from some antidepressants than men do. I’d like to know much more about sex/gender differences in both how we respond to and experience withdrawal from antidepressants, given that they are taken much more commonly by women. 

We still don’t know enough either about the impact on younger women of beginning and continuing on medication for long periods in their lives. Having started pills at 35 after the failure of therapy to prevent a severe relapse, I know how difficult it is for me to answer the question, ‘Who am I really?’ The person I was before I took the medication, whose mood fluctuated sometimes to extremes, or the person I am now, calmer, more level, able to focus (I’ve never experienced emotional blunting although I know some people do) but also not quite the person I was. Is this me or is it the medication? I’ve managed to cut my duloxetine dose in half without too many problems (I am well familiar with brain zaps) but what would happen if I tried to cut further given the length of time that I’ve taken them? I share Awais Aftab’s measured opinion on what we know, and don’t yet know, about withdrawal. We cannot be complacent. 

However neither can we be complacent about how many women are being prescribed antidepressants. It isn’t a decision women take lightly but I know from my own time in practice how antidepressants are prescribed when therapy, if it were available, would be effective. I also know that some, like me, would benefit from medication when therapy and other options, just don’t work. They were far from my first choice in my early life. However, alternative treatments – including any kind of therapy without waiting for months – but particularly, longer-term psychodynamic therapy for women who have experienced early trauma and therapy for depression associated with PTSD related to domestic violence, are all difficult to access quickly if at all in the UK unless you pay. The specific issues facing women who experience depression, either in terms of better access to care other than pills, or politically in the multiple problems in our misogynistic society that make women more likely to get depressed, are not being adequately addressed.

                  Depression is real. As women we need to campaign not only for changes in society to help prevent it, but demand access to more effective and a wider range of treatments for it, when it happens, than simply a prescription. 

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is available now.

What is happening to the mental health of young women?

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Society seems to have great difficulty in talking about the mental health of women just now. That’s problematic when the latest figures show the gender gap between men and women remains and is especially stark for young girls and women. The proportion of all those aged 16-24 with a common mental health condition rose from 17.5% in 2007 to 25.8% in 2023-4. However, the proportion of young women reporting a mental health condition is now the highest on record, at 36.1% in comparison with 16.3% of men. This news went almost unregistered by the media in Britain at the end of June.

It’s just girls isn’t it?

The authors of the latest iteration of the Adult Psychiatric Morbidity Survey (2023-4) say in their Conversation article, ‘Mental health in England really is getting worse. One in five adults are struggling.’ They also challenge the claim of overdiagnosis. “The APMS has been conducted with consistent methods over decades, using the same robust mental health assessments with large, random samples of the population. This means the results are largely not affected by changes in levels of mental health awareness or stigma, and changes in levels of diagnosis or service contact.”  These data are epidemiological estimates based on official criteria. (Helpfully the survey also shows self – diagnosis rates too for comparison, and these are higher).

So what is happening for young women? And why do we seem to find it so hard to discuss it? 

We know this is a worldwide phenomenon and in many countries suicide rates are increasing more rapidly in young women than in men. A recent Australian study reported an annual prevalence of nearly 50% for mental disorder in young women. Socioeconomic factors play a significant part in why both men and women develop mental health conditions – debt, unemployment, chronic ill-health, homelessness – but women are more likely than men to be in precarious work, to be reliant on benefits to survive, be single-parents and unpaid carers. Poverty matters, and if you add in intersectional factors such as being from an ethnic minority and/or LGBTQA+ risks to mental health multiply. Women are also more likely to have faced early traumas such as sexual abuse and then must deal with sexual harassment and gender-based violence in their everyday lives.  If in doubt, look at the pages of Everyone’s Invited which spells out the experiences of many young women very clearly. We have rising levels of misogyny, which is rightly leading us to question what is happening to young men and what needs to change for them. But this fails to take into account what happens to those who experience and survive the damage caused by the behaviour of boys and men, and the harm this is causing to the psychosocial development of young women. Gender based violence and abuse alongside being in poverty creates a web of adversity and mental ill-health in women’s lives.

Growing up now as a girl is very different from how it was for me in the 1960s and 70s. The pressures in terms of getting an education, feeling good about your body image, navigating sex and relationships and discovering and developing an identity are considerable and amplified by social media, which I’m so relieved I never had to contend with. 

Women are more often seeking help for anxiety, depression, eating disorders and self-harm but their mental health issues are not being considered through a gender specific lens. The menstrual cycle plays an important part in the mental health and well-being of young women but has been largely disregarded in the past in mental health care. We still need to know, for example, much more about the interactions between ovarian hormones and early life trauma in women. The APMS reveals that more men are getting access to care than they previously did. However, waiting times for psychological therapy remain long, the majority on those lists are women and the therapy provided will most likely not be tailored to the specific needs of women who have experienced trauma and violence. It is all too easy, as a young woman, to receive a diagnosis of Borderline Personality Disorder when you have been subject to repeated abuse and trauma.

 Is it surprising that new claimants for disability benefits in the UK are more likely to be younger, for mental health related problems and to be women? Limiting access to those benefits will increase poverty and continue the cycle of despair and adversity. Instead, we must rethink the way we support women and girls. Many will need access to a tailored, person-centred, biopsychosocial assessment, designed around their needs and preferences but its most definitely not a problem to be solved with more medication. To stem the increasing problems young women are facing demands that society recognises it, talks about it and has the political will to address the serious challenges young women currently face such as gender-based violence and misogyny. As women we are expected to not complain too much, ‘put up and shut up’ and if we do need help, ask for it ‘appropriately’ which doesn’t include harming ourselves, even though our needs often go unnoticed anyway. We often are accused of exaggerating or faking it. There is a continuing pattern of raising concerns about women’s mental health and society failing to act.

Isn’t it time we listened to young women, believed what they are telling us about their lives and talked about it rather than just let each new report drift by and disappear into the ether?

Then let’s get together and do something about it. 

My latest book: Out of Her Mind: how we are failing women’s mental health and what must change, is on sale now.

Addendum to ‘Three times more common in women.’

lindagask2 Comments

I promised I would reply to the comments on this blog which were posted on X, mostly by psychotherapists working in the USA, so, after a holiday and an intensive week of public events (conducted from my desk in Orkney whilst wearing my slippers) here we are.

In response to Mark Ruffalo’s comments about the ‘Borderline Wars’ which prompted the discussion I can only say that debate does continue, as does research and psychiatric science is always evolving and modifying our views of the world – as it should do.  My views have changed over my career in response to listening to the stories of many, many women who have received the diagnosis, but I still found the observations and insights provided by reading the great psychoanalytic researchers in the field very helpful in my work. Although I disagree with Peter Tyrer’s view that diagnosis of personality disorder should be broadened – in fact I’d much prefer to limit it very considerably – his work on ICD-11 brought together world experts in the field and they arrived at somewhat of a compromise to still include the ‘borderline pattern specifier’. He notes in a recent review in World Psychiatry:

‘The features of borderline personality disorder are not traits, but symptoms and fluctuating behaviours, and – like many symptomatic conditions – improve steadily over time. When borderline symptoms are examined in factor analytic studies, they are scattered over a range of both personality and other mental disturbance and have no specificity’. All attempts to find a borderline trait have failed. While borderline symptoms appear coherent when examined in isolation, they disappear into a general personality disorder factor when modelled alongside other personality disorder symptoms.’

            I’d recommend this open access article to anyone interested in a different perspective on ‘borderline’. I realise it contrasts with that held by many therapists, especially in the USA (hence the inclusion of the ‘borderline pattern specifier’).

            I’ve questioned why the diagnosis is more common in women. I certainly agree that more men get diagnosed with anti-social personality disorder, and many of them are indeed in prison. But I suspect some men are also more likely to get diagnosed with cPTSD instead? Do we know? Women with the diagnosis of BPD are also overrepresented in the prison population too, (including some that are frankly misdiagnosed – which is certainly a major problem as I’ve discussed in the blog). Women are more likely to seek help for mental health problems, but I do think we need to consider, (as someone commented but I can no longer find their post!) how much the criteria used to diagnose BPD reflect emotions and behaviours that are more associated with women in extreme distress.  I also really appreciated the comments about the menstrual cycle, which affects and colours just about all mental health problems that women experience, not just those given a diagnosis of BPD.

It’s very difficult for me to know how different care is for those diagnosed with Borderline Personality Disorder across the Atlantic. Reading Laura Delano’s book Unshrunk includes a description of her care under John Gunderson at McLean Hospital and has been fascinating in many ways (review to come). Such residential care with intensive therapy has, as far as I’m aware, pretty much disappeared now from the UK, but I’d be interested to hear whether this is true.

 Awais Aftab, in his review of Out of Her Mind, has said, in response to my views about BPD that:

 ‘In a system where such attitudes are pervasive, it is easy to see how one would conclude that misogyny is baked into the very concept of BPD. Working as a psychiatric clinician in an entirely different health care system in a different country with a different patient population whose experiences with the diagnosis are more favorable, I can afford to say in return that it is more complicated than that.’

I really appreciate his different perspective but would like to know what happens to those in the USA given this diagnosis, especially women, without access to the kind of expertise that families or good health insurance can purchase. And elsewhere around the world too.  What do they think of the care that they receive?  

Listening to women’s experiences has been key for me, which is why why Out of Her Mind is so full of women’s stories.

Three times more common in women

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Women are three times more likely to be diagnosed with borderline personality disorder (BPD) than men. That fact alone should give you pause for thought. 

Yet when I read the endless academic papers and discussions about the proposed causes of and treatment for BPD, (sometimes still called emotionally unstable personality disorder or EUPD), especially those from the psychoanalytic community in the USA, the question ‘why?’ never seems to arise. It is a ‘complex interplay of genetics, biological factors, trauma, abuse, neglect and pathology of attachment’. But isn’t that true, more or less, for many of us with mental health problems? I say this as someone who has in the past been told I have ‘borderline traits’ (by someone who was reviewing my first book, The Other Side of Silence, on Amazon).  My personality has certainly been influenced by all of these factors, as have those of a great many of us. That doesn’t mean I think we all have personality disorders (which is the direction that ICD-11 has taken us in). Rather like if ‘everything is trauma’ then it follows that nothing probably is, for me the same is true of personality disorder. We are all complex individuals and some of us are far more capable of managing interpersonal relationships than others, depending on many things but particularly the interplay between our early experiences, temperament (which is inherited) and (sometimes traumatic) life events. But that shouldn’t make us ‘disordered’.

Forty years ago when I was training in psychiatry, and hoping to become a psychoanalytic psychotherapist, I was first introduced to the ideas of the great American psychoanalytic thinkers, Heinz Kohut, Otto Kernberg and John Gunderson. I do appreciate their massive contribution to understanding and working with people who have great difficulty in relating functionally to themselves and others. I listened to the legendary British psychotherapist Anthony Ryle in the spring sunshine in garden at a society for psychotherapy research meeting in Ravenscar sometime in the late eighties as he diagrammatically reformulated borderline personality disorder, with his ‘broken egg’ diagram and realised how I had felt many times as though I was stuck between the sharp edges of the egg shell not only as a therapist, but also as a person and a patient. Because I was in therapy too over several years, trying to manage my own difficulties with a persistent depression that was undoubtedly influenced by that complex biopsychosocial morass of factors that both moulded my personality, and resulted in my problems with my mood and my relationships.  For decades I was professionally and personally aware of the overlap between ‘borderline’ symptoms and many other diagnoses, particularly mood disorders. If aspects of our personality contribute to us both experiencing and having difficulty recovering, we need psychotherapy and should be able to get this without being diagnosed with personality disorder. Something I wrote to the NICE guideline committee about with no success.

But, even though later, as a clinical academic general psychiatrist (I decided against becoming a psychotherapist and went into academia) I wrote and taught about personality disorder, I was aware that ‘borderline’ was diagnosis that I almost never personally used. In later years I’ve found the words of George Vaillant the veteran American psychiatrist particularly cogent, ‘The beginning of wisdom is never calling a patient borderline.’ In his paper Vaillant, who followed people up over many years for his research into personality, talks about ways to help those who use problematic defence mechanisms to cope. People who had experienced difficult lives. He calls their defences ‘immature’ but they are very common ways of coping, and I have met them often in my work in mental health, amongst my colleagues as well as my patients. Vaillant says: ‘I believe that almost always the diagnosis “borderline” is a reflection more of therapists’ affective rather than their intellectual response to their personality-disordered patients’, the powerful impact of the countertransference – that the patient has on the therapist. He also talks, as do others such Peter Tyrer, of the considerable symptom overlap with other diagnoses. In British psychiatry “Borderline’ has become an insult applied to many women too often without any adequate assessment of what their problems might be. This now applies to the umbrella term ‘complex emotional needs’ which Hat Porter and their colleagues rightly call a new pseudo-diagnosis that ‘risks further legitimising the personality disorder construct and broadens its scope, therefore widening the prejudice, discrimination and neglect associated with the label.’

I’ve spoken to some who find the diagnosis useful to understand their way of relating to the world, and sadly to obtain therapy (accepting it seems to be required by some therapists). But I have met so many others in the world, during my research for Out of Her Mind, and on Mad Twitter who have not, and have suffered terribly – even been excluded from care altogether.

            But why is it so commonly applied to women? First of all, I’ve no doubt that many women given this label are misdiagnosed and may have PTSD, bipolar disorder, Premenstrual Dysphoric Disorder or be neurodivergent, but have simply not been listened to. Secondly, people who get the label BPD are overwhelming likely to have experienced complex trauma and have experienced childhood adversity which we know is more common in women. How many women who are subject to repeated sexual violence end up with this label? And, as Jay Watts say in her recent paper ‘who gets to be a victim’ determines whether the cPTSD (complex posttraumatic stress disorder) diagnosis is given (which I’ve witnessed in practice), or BPD. Sometimes it’s even both. cPTSD was intended as a kinder label but “Paradoxically, the introduction of cPTSD has reinforced the seeming validity of BPD, as direct comparison often does.” Helping someone doesn’t require acceptance of the label. Therapies researched for BPD do work for cPTSD and perhaps it’s time we took a transdiagnostic approach, working in collaboration with the patient to consider with them what is needed to help them, be it help with emotional dysregulation, mentalisation, processing trauma, or other ways of coming to terms with living in the world. I benefited greatly from psychodynamic therapy so I am biased, but I do know that the sense that my therapist believed in me, and didn’t see me only as a ‘difficult woman’ was crucial.

Yet, mental health professionals seem to find it a label they want to continue to apply especially to ‘difficult’ women, including those who fail to recover from depression or eating disorders as fast as they ‘ought’ to do and especially those who self-harm. I have sympathy with the feminist view that the ‘symptoms’ of BPD are remarkably like the way that women simply cope with extreme emotions. That it is inherently misogynist.  In some ways ‘complex emotional needs’ echoes this – how many women have been told they are ‘too needy?’ I was, many times, in my younger days. 

We must begin to consider in greater depth how women with serious mental health problems which are not ‘psychotic’ (which tends to be the focus of care) are being assessed, diagnosed and helped, or not in mental health systems. Just because ‘this is how we’ve always done it’ or ‘we have specialist units set up for excellence in BPD’ are not good enough reasons to avoid change (except of course for accountants). 

Read about my latest book: Out of Her Mind: How we are failing women’s health and what must change

Why aren’t we talking about what’s happening to women in mental health care?

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It was utterly shocking to read Scout Tzofiya Bolton’s description in the Guardian a week ago of how she was re-diagnosed from having bipolar disorder to having a diagnosis of emotionally unstable personality disorder (EUPD), and, excluded from care then ended up in prison.

                  And yet, sadly, wasn’t. 

Because many women and girls have told me similar stories during my research for Out of Her Mind. 

We know it’s remarkably easy to be given this diagnosis. Women are three times more likely to be given it, and some are very clear about how easy it is to receive it. Challenging a doctor’s views, as Scout did, is one way. 

When I was training in psychiatry ‘borderline’ or ‘EUPD’ wasn’t a recognised diagnosis but difficult women were usually labelled as having ‘hysterical personality disorder’ until they received sufficient time and care to be able to tell their story to someone who would really listen. It can take years to get a diagnosis of bipolar disorder, especially if you are a woman perceived as behaving ‘outrageously,’ and you can be rediagnosed easily too, as Scout’s story demonstrates.

 However, we don’t seem to be any better now than we were 40 years ago at listening to women with complex problems and finding out what is needed to help them. Now we have the diagnosis of borderline personality disorder and undoubtedly, as clinical psychologist Jay Watts says, some with this diagnosis are suffering from missed bipolar disorder, are autistic or have premenstrual dysphoric disorder. The vast majority have experienced trauma, if not before they came into mental health care, certainly afterwards. I’ll discuss the issue of complex post traumatic stress disorder cPTSD versus BPD in another blog, but I’ve made no secret of my desire to put ‘borderline’ in the bin – and that is a change of opinion from my experiences of listening to women.

What we do know is that a  majority of those with this diagnosis who take their lives when under mental health care are women.  Not only are they unlikely to get an adequate assessment but they have great difficulty accessing appropriate psychological therapy. We hear about them quite frequently now at inquests and/or there are investigations into the quality of their care, after which we are told that ‘lessons will be learned.’  

Surely, in mental health care, and society too, we should be paying more attention to this? Yet when I recently shared my views in a psychiatry teaching session, several (male) colleagues told me I was mistaken. It was a helpful diagnosis – for them. And I felt like I was once more being a ‘difficult’ woman. That’s familiar.

We also know that women are regularly victims of  sexual violence in mental health care, though without the fact that the majority of victims are women being mentioned. 

Many women who end up in in-patient care have already experienced trauma of one form of another.  In mental health care, be it from the lack of respect, kindness and compassion from staff that women described to me (and was clearly visible in the BBC Panorama report) or the risk of sexual violence, women are being retraumatised every day.

                  All-in-all its not so very different now for women in hospital from what I described in The Other Side of Silence of my experience as a new consultant in an old asylum in 1990. I didn’t name the hospital, but everyone who knows me can guess where it was. We closed those places, but the culture sadly hasn’t changed.

In the focus on men’s mental health in the last decade, we have failed to pay attention to what’s been happening to women in the mental health system. I know that many of these problems happen for men too, but being ‘gender neutral’ is not helping to address the very specific problems that women are facing.

We need a women’s mental health policy. 

And if that’s at the risk of offending men, well so be it. Something has to change.

My book: Out of Her Mind: How we are failing women’s mental health care and what must change, is out now.

On writing a book about women’s mental health

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For the last 5 years I’ve been working on a new book about women, mental health and feminism, addressing two big questions – how are we failing women’s mental health? and what needs to change?

                  Over the last decade, we’ve been rightly concerned about men’s mental health. Men continue to take their own lives at 3 times the rate of women. However, women are suffering too, and the size and nature of the mental health problems and illness they experience seems to get lost beyond that desperate headline. Just as women’s physical health is much more than about our reproductive system, the mental health crisis we currently face is much more than about perinatal mental illness. Girls and women are twice as likely to experience depression and anxiety, ‘common’ mental health problems and intersectional factors such as race, LGBTQ+ and disability, along with poverty, simply magnify this difference further. Girls and women are much more likely to self-harm than boys and men, experience 2 to 3 times more post-traumatic stress disorder, more commonly have eating disorders and are 3 times more likely to be given the diagnosis of borderline personality disorder, a diagnosis that I argue (controversially still for some) should be finally consigned to the bin. Young women are presenting with more anxiety and depression than ever before and since the pandemic there has been a considerable increase in their distress and requests for help from services than have been unable to cope. Some of those who have been failed by ‘mental health care’ in our hospitals and community services are tragically dying too.

                  Why is this happening to women?

                  Has feminism failed?

I have no doubt that what happens to women in our society plays a huge part. Women not only experience more sexual abuse in childhood, but they are also subject to greater intimate partner violence as adults than are men. There is an epidemic of male violence towards women in our society and it is happening too within our mental health services. Misogyny and sexual harassment are rife. Women are more likely to be single parents, working in low paid, precarious jobs, and be forced to live on benefits.  And it is clear that when women who experience trauma cannot get the understanding and help they need, they alone can become the problem, rather than helping to address the circumstances that contributed.

Women who discovered during the pandemic that their jobs were considered of less value than those of men, so they could return to full-time childcare, certainly felt failed by feminism. The silenced women in the street of Afghanistan must surely feel the same too.

In the 1980s when I started training in psychiatry there was a real resurgence in feminist interest in mental health. In ‘Out of Her Mind’ I’ve explored what has changed since then. Most recently some feminist writers have denied the reality of ‘depression’ and accused psychiatrists of simply labelling the impact that trauma has on women as mental illness. In my view that denies the reality of what many women are experiencing and can be perceived as another form of gaslighting. Instead of repeating the mantras of the past about the evils of psychiatry, even though I can and do acknowledge horrendous things have happened and still do, to women in mental health care, we must also focus down on the experiences of individual women, here and now. What needs to change?

Listening to this woman’s story has always been my starting point. What has happened to her? What is she experiencing? What does she need now to help her move forwards? 

As a psychiatrist I work from a biopsychosocial perspective, and looking through biological, social and psychological lenses, identify what increased her vulnerability to mental illness, and what has stresses in her life have caused it to occur right now. However, we must add a fourth lens to these three, the political. What part does her status as a woman in this society, particularly if she is also subject to intersectional inequalities, play in her experience of emotional distress and mental illness? 

What can all this tell us both about what might help her? 

                  I began to write this book while not only researching but most of all listening to many stories from women not only in the UK but elsewhere too, as well as interviewing expert commentators. Those stories add to the many I have collected in my own mental filling cabinet during the years when I was working as a psychiatrist. The book is framed as a narrative of how I returned to my own feminist roots as a doctor who spent so much of working life both working with and trying to help women. Everyone whose story and/or opinion is included in the book gave permission and had the opportunity to comment on/make changes to text that was finally included – over 120 people. I’m immensely grateful to those who gave me their time. 

You can purchase the book here its called ‘Out of Her mind’

A final note I’ve donated a large proportion of the advance I received from the publisher, Cambridge, to three charities: WISH, Self-Injury Support and Southall Black Sisters. They continue to help, daily, those who are facing sometimes incredibly challenging problems.

Therapy

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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.

 

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

lindagask7 Comments

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

lindagask1 Comment

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?

lindagask2 Comments

 

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.