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

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

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

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

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

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

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

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

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

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

Moods

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

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

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

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

When something really seems to shift in my mood, it is as though some unseen being in my brain pulls a lever.  Usually this happens in response to a build up of life events (yes, social factors play a key part), and when these events are of a particular kind that holds an inherent threat to my sense of who I am (the psychological part), then my mood is much more likely to shift, and quite rapidly too. When I was working full time I could move from feeling anxious, but keeping my head above water, to quite a different state of mind, within a day. When I am there I feel quite different. I don’t only feel sad, I feel physically ‘changed’; heavy of limb, tired, unable to sleep yet also very agitated. I ruminate about things that at other times I would be able to cope with easily. I am full of fear as the negative thoughts I have about myself the world and the future come flooding back.

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

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

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

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

Do self-help books work?

 

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

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

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

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

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

The books that really trouble me suggest:

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

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

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

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

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

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

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

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

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

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

The morals of medication

Is taking medication for depression the ‘easy option?’ I come across this viewpoint regularly on social media. Usually there is a suggestion alongside that therapy, which I completely agree is hard work, is somehow a purer way to recover. The right way.

The history of psychiatry is rich in references to morality. Is a person ‘mad’ or ‘bad’? Is there really something wrong in the brains of those society labels as bad? Is addiction an illness or simply a behaviour choice? Are we excusing bad behaviour by medicalising it?

Many people who consider medication for depression will find themselves wondering whether it is a ‘good’ thing to take it. When you are depressed it can be very difficult to decide what is the best thing to do, and decisions are taken not only on the basis of discussion with health professionals- moral judgments also play an important part.

  • How does taking antidepressants affect how I feel about me? Does it mean that I am weak?
  • Is it the easy option?
  • Shouldn’t I be able to sort myself out without them?
  • What will other people think- my family- my friends…will it change how they see me?

Alice Malpass and her colleagues identified two parallel journeys that the depressed person embarks on. The ‘medical’ journey goes something like this:

  • I have a duty to be well. Other people need me to be well.
  • If I recover then there won’t be any risk of being seen as ‘mentally ill’.
  • I can get back to my old self and be in charge of my life again.

I’m sure I’ve used some of these arguments in conversation with patients. Any doctor who says they haven’t is not telling the truth- but to consider these are the only things of concern about medication is inherently simplistic and paternal, and reminds me of the cartoon of a couple walking along a beach, smiling and carefree, who say they feel so good they must be in a pharma advert.

In parallel the person is perhaps also on another journey- the ‘moral’ one.

  • I feel awful because I have to ask for help.
  • I feel even worse because I need to take tablets.
  • Is this person the real, authentic me? Am I now my old self or someone else? Or am I only this person because I am on tablets?
  • Am I hooked on these now?

Damien Ridge, who has analysed many interviews with people who are depressed talks not only about the lack of legitimacy for tablets, but also for what they are being prescribed for.

  • Is ‘depression’ real?
  • Shouldn’t I just ‘pull myself together’? Isn’t that what everyone else thinks?

There is a great deal of literature on whether ‘depression’ is ‘real’ or simply no more than unhappiness. And if it isn’t real, then the treatment for it cannot be legitimate either, little better than using street drugs- as one person in Ridge’s paper calls his tablets: ‘My dirty little habit’. I’ve spent my career arguing that to use the term depression is not simply medicalising misery but giving a name to a particular experience and quality of suffering which is not just unhappiness but a deep, dark, hopeless, despair. It has many causes, and it isn’t a single ‘phenomenon’ whatever DSM tells us. But it’s a state of mind that many people with different stories share in common. I experience it too. I have asked all of these questions of myself. I have watched colleagues who work in mental health look a little embarrassed when I get out the tablets at breakfast. Perhaps I do that simply to show I am not ashamed- but I do wish I could have lived my life without them.

All of the above supposes that antidepressants do actually work. Many people think they don’t, and others think they can do harm. You can find my views on these points elsewhere on this blog. I take them myself and they keep me reasonably well, but I have friends and colleagues for whom they have not worked- the medical journey is inherently optimistic- just like the pharma ads, but in reality life is far more complicated. And they are never sufficient on their own.

If doctors, and sometimes friends and family, try and influence you to focus on the ‘medical journey’ then others will try to steer your moral journey. It is really hard to focus on what is right for you when you cannot think clearly. When you are depressed, you are already struggling with guilt and shame and sometimes that can tragically end with the decision that the world is better off without you- that this is the right thing to do.

So I would only ask those who make even subtle comparisons between the easy way to ‘block out the pain’ with meds and the hard way of suffering through therapy to think before they write. It is only human to want to alleviate pain, and sometimes the tablets are the only thing that will do it. To infer that a person needs to suffer in order to be blessed is one of the ultimate moral judgments- and can be found in most religions.

Depressed or not, clinician or service user, expert or lay person-none of us have the right to sit in judgment over others.

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

 

 

 

 

Borderline Traits

A recent reviewer of my memoir about depression and psychiatry has noted that in describing the emotional mess of my early adult years and on-going struggles with low mood, I ‘courageously come close to defining traits of Borderline Personality Disorder’.

I really don’t mind her saying that- indeed part of me is actually surprised that she is the first person to do so. I purposefully included a description of my difficulty in relationships, mood swings and problems in trusting others alongside a description of similar problems in one of my own patients. I wanted to show not only the variety of ways that people can experience what we commonly call ‘depression’, but also how my own problems mirrored those of my patients, such that there was very little distance between us.

By this time, in my early thirties, I had already had quite a long period of psychodynamic therapy but was still having problems:

 I didn’t know how to begin to contain these frightening feelings when they took hold of me. There were times when I felt low in mood and physically exhausted, as though there was a weight bearing down on my chest, which prevented me from moving. On other occasions, it seemed as though anything and everything was possible. At those times I did seem to lose control and retreat from reality. It was then that the suicidal thoughts would return, although by then usually only fleetingly.

Nevertheless, I recognised only too well the persistent state of emotional chaos that Elizabeth Wurtzel described in her book, Prozac Nation. I particularly empathised with her when she talked about wanting a therapist who could help her to learn to be a grown-up and to show her how to live in a world where the phone company didn’t care that you were too depressed to pay the phone bill.   (From The Other Side Of Silence: A psychiatrist’s memoir of depression)

 I’m well aware that there are features of my personality and behaviour that could well be called ‘borderline traits’ and it’s interesting that no one else has mentioned this. Is it because I am a Professor of Psychiatry? Is this the kind of thing one shouldn’t  say to me?  Most people have been incredibly supportive about my honesty, but others- including one or two mental health professional colleagues, have seemed a little embarrassed by my openness. Some will have been on the receiving end of some of my irritability and anger in the past- which is always much worse when my mood is going down. If so, I can only offer my apologies, but might add that in my experience some mental health services can be less than sufficiently understanding of the emotional problems of those whom they employ.

As time goes by my views are changing, despite having written on the topic of Personality Disorder in the BMJ; and this largely because of my anger at the lack of access to appropriate therapy for people who need and deserve help, rather than abuse. I’ve always been aware that people like me who perhaps have ‘difficult’ personalities (I prefer to think there are also times when I can be very warm, creative and caring too) are often dealt a bad deal by mental health services, when they get depressed. Our difficulties with early attachments both make relationships difficult to cope with, and predispose us to longer periods of more severe depression and anxiety as well. I have considerable sympathy with the view put forward by Peter Tyrer that Borderline Personality Disorder is ‘neither borderline nor a personality disorder’. People given this label describe ‘symptoms’ for which they desperately seek help, and don’t demonstrate persistent and inflexible ‘traits’. Their problems are not necessarily lifelong (which I understand personality traits as being), and they can be helped to change over time.

My mood is still unstable at times, but not to degree it was before I had the right kind of therapy to help me comes to terms both my past with how to survive in the world. I also need medication to stop me from plunging down into prolonged despair- with all the associated physical symptoms of anxiety and depression.

People who have problems with their mood don’t fit into neat boxes. As I’ve argued before, diagnoses have their place in terms of research and predicting likely response to treatment, but they should be used alongside a plan that addresses their main presenting life problems, range of symptoms and underlying aetiological factors that may be maintaining the status quo. Some will call this a formulation, but it’s not simply a psychological one- it addresses all three of the key areas- biological, psychological and social.

We need to design the treatment around the person- looking at what they need, not excluding on the basis of a diagnosis that has become for many, a term of abuse. I know many will still want to use the term ‘borderline’ because it can help get access to the right kind of therapy; but we need to acknowledge that the difficulties some of us have with managing certain aspects of everyday life (without, for me, a little drama on occasions) are simply degrees of the extraordinary diversity of humanity- differences that we should learn to celebrate not abjure.

PS- my husband proofreads my blogs- and says life with me has always been a bit of a roller coaster at times- but he wouldn’t swap me for anything.

 

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.

 

 

Children and young people first

There are some images from my six months as registrar in child psychiatry that stay with me.

It was the early 1980s and the social worker and I were visiting a young single parent living on the 9th floor of a tower block in Salford 6. She had just moved back to live with her parents after the breakdown of her relationship. As she opened the door we were greeted by her 6 year old daughter, a pretty little girl who danced towards us, twirling around in circles. Only she continued to twirl around, and around, and around the overcrowded space completely absorbed in in own world. According to her mother she spent much of the day performing an unearthly dance between the furniture and screaming loudly every time she was prevented from doing this. She had no words. I could see how much her mother and grandparents loved her, but their faces were lined with desperation. The young mother already had the air, and appearance of someone at least a decade older than her years.
“I’ve been told she’s autistic,” she said, starting to cry, “but I don’t know how to cope with her…I just can’t, and now my husband has left me.”

It wasn’t difficult to see what was needed was some intensive support for the whole family. It was then, as now, in short supply but that didn’t stop us trying to put it in place. In my time at the clinic in the old Royal Manchester Children’s Hospital in Salford (not the shiny new one at the Infirmary) I witnessed over and again the impact of serious mental health problems and difficulties on families already struggling to cope in unsuitable or substandard housing. And it reminded me, sometimes too often, of the impact that the problems of my younger brother, who developed obsessive compulsive disorder at the age of 7, had on my own parents’ physical and mental health.

As my friends will know, I’m not particularly ‘good’ with children (I have none of my own) so when I was on-call over the weekend I struggled to try and strike up conversations with silent teenagers in the paediatric ward, the day after they had taken an overdose. They usually went something like this:
‘Hello, my name is Doctor Gask. And your name is Jenny- is that right?’
Silence…no eye contact…a reluctant nod.
‘I really wanted to find out what happened to you- to see if we can help…is that okay?’
…’I suppose so.’
‘OK. So would you like to tell me what happened yesterday?’
More silence.
I soon learned, by watching the consultant I was attached to, a kind and extraordinarily astute child psychiatrist who was close to retirement, that direct questions were not the way to engage a young person in talking about their problems. If they turned up for a follow up appointment- and that often unfortunately depended on whether their parents saw the need for them to have any help, not only their own willingness to come, he would set about making a young person feel at ease, without actually appearing to make any effort at all. He would smile like a genial grandfather, and simply strike up a chat about things completely unrelated to the events that had brought them into hospital: their favourite pop stars (they were not called ‘bands’ then), hobbies, best friends and gradually build trust before moving onto the thorny question of why they had taken the tablets. After forty minutes or so he would be ready to ask: ‘So how would you like things to be different?’ followed by ‘I wonder how we can help you with that…should we try and look at that together?’

I realized quite soon into my six months working with children and young people that this wasn’t where I wanted to be for the rest of my career. I didn’t have the kind of skills and patience that the consultant had. I found it difficult to work with families where children whose apparently quite normal behavior did not meet the expectations of their parents. In particular I felt angry when parents failed to take up the offer of help because of their perception (perhaps rightly so) that we were suggesting the difficulties their children presented with had a great deal to do with their own life problems and parenting style.

However what I did learn, and has never left me, was the acute awareness of how the people I saw later in their lives with depression and anxiety, in their twenties, thirties and older, had first developed difficulties with their mental health in their youth. This was where their problems had begun.

I returned to work in Salford 20 years later and helped to set up a primary care based mental health team. Our base, at first, was in a building attached to the old Salford Royal Hospital where I had attempted and failed to strike up conversations on a Saturday morning. Only now the building, like many older hospitals, had been converted into luxury flats. As I discussed in supervision, with the Psychological Wellbeing Practitioners, the problems of the people being referred to us, I was acutely aware that the generation we had struggled to help back in the 80’s were the very people now presenting to the mental health services. What happens to us in early life- our relationships, experiences within our own families, continues to have an impact on our mental well-being for the rest of our lives.

Services for children and young people with mental health problems have never been well funded and now in the UK they have been cut more than ever before. What services do exist are withdrawn at school leaving age and very many of those who have succeeded in getting help fail to meet the ever more selective criteria of adult mental health services, unless they have been lucky enough to be seen in some of the newer services which don’t recognize this traditional cut-off point, which is completely unsupported by what we now know from research:

not only that adult mental health disorders are common in the population, but that most of them have their onset by adolescence. This period of life after puberty also sees a range of important organisational developments in the brain that last until the late 20s and usher in adulthood as might be defined from a developmental rather than a social or legal point of view.’

Yet this is exactly the period when adequate mental health care is perhaps most difficult to access.

I was recently asked in an interview (by Ruth Hunt) what my priority would be for funding when the new money promised for mental health care, too little once more, finally arrives. I didn’t hesitate. It has to be for children and young people, if we are going to begin to try and prevent the cycle of suffering. More families failing to cope and the next generation experiencing the same problems.
It has to be children and young people first.

My memoir about depression and Psychiatry: The Other Side of Silence is available now

A life in the NHS

I arrived in this world seven years after the birth of the National Health Service. My life has been framed by it. I was born in a cottage hospital and regularly weighed by the nurse at the district clinic. As I grew I was taken to the General Practitioner who for many years had a surgery attached to the side of his home. I don’t remember much about those visits other than on one occasion my mother took me along expecting the GP to advise her (and me) what should be a reasonable bedtime. I know she was disappointed by his response.
‘She’ll sleep when she’s tired.’
An American psychiatrist I met many years later suggested I may have had ‘Oppositional Defiant Disorder.’ I remember retorting, ‘No I’ve just always been difficult.’ My mother certainly seemed to think so anyway.
When I left school, I studied medicine, and qualified as a doctor and then as a psychiatrist, working in the NHS in Scotland and the North of England for over 30 years. I was, and still am, proud to have been part of the massive social experiment that began the day Aneurin Bevan was symbolically handed a large bunch of keys by the matron of Park Hospital in Davyhulme.

I’ve seen firsthand what life is like in a country where the market governs healthcare. Several years ago I spent a few months studying the American health system as a Harkness Fellow in healthcare policy. A few memories from my time travelling between clinics in Washington State remain with me, indelibly burned into my memory.

• The young woman with poorly controlled asthma stifling her tears because she had to say goodbye to her doctor even though she was not moving away from town. She had changed jobs and her new employers’ insurance system contracted with a different ‘provider’.

• The middle-aged man on the telephone in the waiting room pleading with his friend down the line. ‘Can you lend me some money…I can’t afford to pay for my insulin.’

• The young man in paint splashed overalls who lay flat on the front seat of the bus writhing in agony, getting himself to the Emergency Room by public transport; probably to avoid having to pay for an ambulance he could not afford.

• The general practitioner who told me how she struggled to help a young woman in her clinic who was acutely psychotic. Her basic state medical insurance didn’t cover specialist mental health care, so the visiting psychiatrist, who was in the next office, was unwilling to either see her or advise.

• The nephrologist who specialized in treating African Americans in a southern state with a high prevalence of diabetic renal disease who told me that he could personally ensure his low income patients without health insurance got the care they needed through his academic interest in them, but others would not. He seemed curiously accepting of the status quo. ‘That’s how it is here.’

Don’t get me wrong. The NHS is a complex many-headed beast, fraught with problems. I have not only benefited from it, but I have suffered from it, and seen others do so too. I have struggled with and been bullied by bureaucratic and hostile management and survived an attempt to remove me with some serious consequences for my mental health. I’ve also known visionary managers some of whom became friends. But I’ve also seen the NHS try and fail to entirely abolish traces of the mentality of the huge county asylums it inherited in 1948. I’ve worked with many extraordinarily compassionate and caring practitioners, yet I still hear service users relate examples of attitudes and behaviour towards them, which are all too familiar from my early days as a consultant in a decaying mental hospital.

The gap between physical and mental healthcare, which was wide even when the new district general hospital psychiatric units were attached to the rest of the hospital by long corridors, grew to a chasm with the separation into acute and mental healthcare trusts. Despite evidence that investment in mental health care might have significant impact on the spiraling costs of physical healthcare, the concept of ‘parity’ still seems something to which little more than lip service is paid. Mental health care has been cut by a greater percentage in funding than any other area. And now, with the decline in numbers of GPs and funding of primary care, where 90% of mental health care is provided, we should not be surprised that it is harder than ever for people to get the help they need when they are in acute distress.

Throughout my adult life I’ve been in receipt of mental health care, most of it provided by NHS staff, who went the extra mile even though I wasn’t always easy to help. I’m still and always have been contrary. No one ever suggested it wasn’t in his or her contract to treat me but the goodwill that used to ensure mental health professionals didn’t have to receive treatment in the places where they work has largely disappeared. Rules reminiscent of what I encountered in my times in the USA are becoming increasingly used to determine who gets help.
‘We’re not commissioned to provide care for people with (you name it- Aspergers, Autism, Personality Disorder, Analgaesic abuse….the list grows).’

And now I’m getting older, and I have recently been diagnosed with kidney disease, I know there is a very real possibility I will one day be as dependent (a sorely unfashionable word I know) on the NHS as the day I was born, only this time for dialysis. I’m worried about whether the NHS will exist when I really need it to save my life, or whether I will struggle, as the patients I saw in the USA, to obtain care from an uncaring system.

Last time I visited Park Hospital, now known as Trafford General Hospital, the black and white pictures of the great day the NHS was founded were still on the walls of a corridor in an old part of the building, but clearly forgotten and sorely neglected. Their state seemed to me to represent the ways in which successive governments have tried to forget, suppress or actively derail Bevan’s extraordinary achievement. For all of our sakes let us not sleep walk compliantly into a future when it will suddenly not be there for any of us to depend upon.

In order to do this we must never stop being ‘difficult’. I prefer to call it ‘creatively contrary.’

Ambivalence

I wish they had taught me about ambivalence at medical school. It would have made my life immeasurably easier if I had understood it earlier. Instead I was quite a long way into my career before I really began to see how important it was both to my patients, and to me personally.

I was taught what to do for each clinical problem with the expectation that a person would be ready, and willing, to accept my advice. If he or she wasn’t, they were something of a nuisance, indecisive, unable to recognise what was good for them. ‘Oh she’s ambivalent about it,’ I would be told if a person was shilly-shallying around. Ambivalence as a concept was confused with indecision. But it isn’t. It’s something much more than that. It’s about wanting to have something at the same time as not having it. Wanting to be thin, but to eat a large slab of chocolate every day.  Wanting both the benefits of sobriety and inebriation. Even wanting to be both dead, and alive at the same time. I know from talking to people who have tried to kill themselves and failed, that they sometimes wanted to be both still here among the living, yet dead and out of their suffering too. Some of them changed their minds as soon as they had acted to end their lives and came to seek help. Ambivalence underpins so many of the problems people have brought to me, and my own difficulties too. I was an ambivalent medical student, and for many years an ambivalent doctor. I wanted both to belong to a profession and all the benefits that come with it, and not to belong because of the cost to me personally and emotionally.

If you haven’t read Kenneth Weisbrode’s recent short book on the topic, entitled ‘On Ambivalence’ I can highly recommend it.

‘Ambivalence lies at the core of who we are. It is something more subtle, and more devastating than human frailty. Weaknesses can be remedied. Ambivalence comes, rather from too much ambition. Desire begets dissatisfaction, and vice versa. Optimization becomes a fetish. Wanting the ‘best’ means that we must have both or all and are reluctant to give up any option lest we pull up the roots of our desire. That is why ambivalence is so hard to confront, understand. Or master. And why it can be so disastrous.  Most of us know this. Yet we continue to deny it.’ (p2)

 

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The person who is ambivalent about their eating, or drinking, or lifestyle ( add ad infinitum) is not only unable to choose the from the options they have in front of them, but refuses somehow to admit that there is even a choice to be made at all. It’s both a painful yet oddly pleasurable place to be. We cannot have it all, but still somehow  want to believe that we can. We don’t have to decide what to do, to change our lives, because there isn’t a decision to be made. Yet we suffer because we struggle to live what is an impossible existence, only we don’t admit how impossible it really is.

If I had understood this when I was younger, I might have been able to recognise how much suffering is rooted in ambivalence. I began to understand it when I worked in addictions, and later with people who had eating disorders.  I’ve talked to many people who have felt judged rather than helped by those they have consulted; who have been labelled as weak because they are unable to ‘choose to change their behaviour’, rather than essentially ambivalent about life and what they wanted from it. I was influenced by Bill Miller, who first described Motivational Interviewing in the 1980s. I remember reading about how the clients of the clinic where he worked were routinely asked if they were willing to accept the label of alcoholism and accept treatment. That was exactly what I witnessed as a junior doctor:

Consultant: ‘So do you think you are an alcoholic?’

Patient : ..’No… I don’t’

Consultant: ‘Are you prepared to attend AA?’

Patient: ‘Why would I want to do that.?’

Consultant: ‘Well, if you aren’t prepared to admit that, you aren’t motivated to accept help. Come back again when you are.’

We may say it doesn’t happen quite like now, but it does. A person who doesn’t see the need to make a decision about taking up therapy and attends only intermittently is rapidly discharged for being unmotivated.  Instead of trying to understand their ambivalence and empathising with the problems they are experiencing which make it impossible for them to contemplate a decisive response to their problems, we treat them as wasting our time. When he first described Motivational Interviewing, Miller emphasized the responsibility of the therapist in helping the client to acknowledge and explore their ambivalence. When the person is ‘unmotivated’ we are discharged, as therapists, from our responsibilities.

I was personally fortunate. I had a therapist who was prepared to engage me in acknowledging that I both wanted to succeed and to fail in my career, and ultimately to both to live and to die. I’m still ambivalent, but I don’t want to talk about that now. There isn’t time. My cat is currently driving me crazy, wanting to be on both sides of the back door at once. Now that’s ambivalence.

 

Fear of flying

Last week I had one of the most frightening journeys I’ve ever experienced in my life. I flew back into Orkney in the middle of the ‘weather bomb’ that hit Northern Scotland. Despite the forecast, it was surprising calm as the Loganair flight left Aberdeen, but after we had been served the customary tea and Tunnock’s caramel wafer I always look forward to, the wind began to buffet the plane violently, not only from side to side but also up and down. As we came out of the clouds towards the islands we turned on dipped wing into a curve that I soon recognised as the familiar holding pattern.

“Sorry about this,” came the calm voice of the female co-pilot, “there’s a snowstorm at the airport in Kirkwall so it’s going to be a little while before we can land.”

For the next fifteen minutes or so, it may have been longer I lost track of time, we jerked through troughs and peaks of stormy shades of grey, occasionally illuminated by a flash of lightning. My hands, cold and clammy by now, gripped the armrests. My stomach rose up into my throat as I shared false smiles with a woman seated across the aisle. Behind me, another passenger lost the contents of her stomach. As I caught occasional glimpses of the flinty sea just below I began to have those familiar thoughts: ‘is this where it will end, after all?’

A few days before I had been working with fear of a different kind as novice therapists I was teaching about suicide talked about the anxiety which comes with not knowing how to cope when you, as a mental health worker, are faced with someone who might want to end their life.

From my early days in psychiatry I had to try and learn how to cope with uncertainty. I often meet doctors, nurses and other health professionals who quiz me about what is the ‘right’ thing to say or do in a particular situation; as though we can always be prepared for whatever we have to face in a consultation, and handle it ‘properly’. As if, by some magic, we can always find out exactly what the chances are of a person seriously harming themselves by asking them the ‘right’ questions, and manage any situation by being ‘ready’ with the ‘correct’ words and interventions. So that they will be safe…and we will of course not be criticised.

The problem is that it simply isn’t possible for any of us, therapists, doctors, patients or service users, to be sufficiently primed to deal with everything in work (or life) beforehand. There are too many different permutations possible. You have to learn how to use the knowledge, skills and particular talents you have and the information you can glean at that particular moment, to do the best you can to help someone in the time available. In talking to a patient, a mental health worker has to work hard to gain a person’s trust so that the answers to his or her questions will be at the very least some reliable refection of how they are feeling. In order to achieve this the worker has to be able to contain their own anxieties; about their own performance, the safety of the patient, what might or might not happen, in order to help the patient contain theirs. If the worker is struggling to deal with their own fears, such as being simply overwhelmed by the enormity of the person’s problems, the person seeking help will not feel safe enough at that moment to share how they feel- and the worker probably will not obtain an emotionally accurate sense of what is happening for them.

Its not only novice mental health workers who find it hard to manage uncertainty. I meet some quite experienced professionals who are still very obviously struggling to cope with their own fears. For me, it indicates they need a time and place to share their worries about the job. Supervision is still sorely lacking for many workers. As a consultant psychiatrist I regularly shared my concerns with my closest colleagues but I had no formal arrangement for support and supervision. But I have seen how, if we don’t learn to cope successfully with the uncertainty and fear we face in our work, we manage it in other ways. By detaching ourselves from the pain and becoming less empathic; by trying to dissolve it in alcohol and other substances; or just trying to exert an even greater control over the world, searching for answers to those unanswerable questions I get asked at the end of lectures which always raise an uncomfortable laugh from the audience. Our fear is palpable to our colleagues as well as patients.

If we can acknowledge the limits of certainty we have a least a good chance of reaching out and helping a person to tolerate the fear they are experiencing when they begin to tell us about something awful- like their thoughts about dying or the abuse they faced in childhood. Then we can begin to give them some hope. The first step in this must be staying calm, and showing we can take it.

I used to be very afraid of flying. I suppose I’ve undergone a prolonged course of desensitization over the years, but my palms still sweat at every take off and landing. Last week they were wringing wet.

After one run at the airfield which was aborted because of a ‘build up of traffic waiting to get in’ we eventually landed at Kirkwall. I was emotionally drained and almost tearful. But I know that what helped me to contain my fear of dying in the storm was the reassuring commentary of the co-pilot. Her calm professionalism helped. There could have been panic in the cockpit. But it didn’t show.

“Ladies and gentlemen, I know it’s been a difficult flight but you’ll be pleased to know they have just checked the runway; it’s safe and we’ll have you on the ground in a few minutes now.”

I wanted to thank and hug her, but I didn’t…being British of course. So I just said ‘goodbye’ with a teary smile, and stepped onwards into the rain. Happy to still be alive.