Review: The Other Side of Silence by Linda Gask (plus author Q&A!)

It’s always tricky reviewing a book written by a friend, which is what I hope Linda would call me although we have only ever met online, so of course I  come to this review admitting bias. If someone asks me to review a book I suspect will be bad I simply say no, as I would hate to have to tell someone that I think all their hard work has resulted in something that wasn’t very good. But I didn’t think twice in this case and reading The Other Side of Silence: a psychiatrist’s memoir of depression has been an honour and a pleasure. I’ll share my thoughts below but after that I want to try something a little different so I’ve set Linda some questions for a Q&A. Once I’ve hit publish the “floor” will of course be open for comments but I will be out of the country for the next week or two so I may be slow in responding.

Linda is a psychiatrist by training and spent years in the NHS, working her way up the ranks before moving into the academic world. She is now semi-retired, giving her more time to write (you can visit her blog here). The sub-title of her memoir explores what is so unusual about her situation – she has practiced psychiatry for most of her adult life despite suffering from severe depression. Research tells us that doctors have a high rate of depression and that many hide their suffering from colleagues, with staff in mental health teams particularly fearing the consequences of disclosure. It is clear that being a mental health service user and a psychiatrist has been a very tricky tightrope to have to walk on a daily basis.

The book weaves together Linda’s lived of depression, the ghosts from her past that have  contributed to her condition, the treatments she has sought, her life as a clinician and the learning she has taken from patients. I hesitate to use the phrase “case studies” when referring to the patients described as that sounds too cold. Perhaps “stories” would be better, but in any event Linda has shared her experience with a number of patients, some of whom she saw decades ago, which are woven into her personal narrative. Patients with whom she felt out of her depth as a newly qualified doctor. Patients who taught her what it means to listen properly and carefully. Patients who took risks, opening up in the consulting room, sharing their stories of past abuse, inability to love, or unresolved grief. All reminders that doctors have as much to learn from patients as patients do from doctors. learning that Linda passes on to junior doctors bound for psychiatry or general practice.

I don’t really like it when people call my writing “brave”. I don’t know how Linda feels about the word but it is a brave piece of writing. Even in life writing many people consciously or unconsciously present a less flawed or less damaged version of themselves. To focus as much on therapy as Linda does in the book is to acknowledge being a work in progress, that no matter successful a person might appear they are very much human and very much fallible. Linda however goes further, turning over a some very heavy stones and examining what is underneath, things that were at the time (and perhaps still remain) a source of shame, difficult to admit even to a therapist. Linda continues to be very open online as @suzypuss) not only about her personal difficulties but about her use of antidepressants. quietly but firmly seeing off those who see psychotropic meds as a dangerous plot cooked up between Big Pharma and psychiatrists.

I won’t say too much more, because I would encourage you to head on over to Amazon to buy a copy to read yourself! But to give you more a few more reasons yo do so I’m going to put Linda on the spot by asking her about the aspects of the book I found most interesting.

Doctors can often appear quite impersonal to patients. Did you set out to make doctors appear more human, or was this just a side effect of sharing your own experiences?

I didn’t set out to do that. I tried to be honest about the kind of interactions I’ve had in my life,  both with the doctors who treated me, and with my own patients. If that makes doctors appear more human, that’s good- because we are! However, not all doctors I know seem human (I’m pretty open about the fact that there are quite a few of my colleagues I would not wish to consult) and I suspect I’ve not always appeared that way to patients either. Appearing human without sharing too much of yourself inappropriately can be a difficult balance to achieve.

Quite early on in the book a colleague notes that you will be a good psychiatrist because you were the most sensitive person he had ever met. At the time you wondered whether you were sensitive or just thin-skinned. Is this a question you have ever resolved? And do you think now that sensitivity did play a part in having a career in psychiatry?

I think am both! Quite easily on I realised I was able to pick up on how people were feeling and that helped me in deciding to do psychiatry. However I am also thin-skinned. A thicker skin would have been helpful in my career- and I might have lasted longer in it, and been more successful as an academic and manager. But I’ve come to terms with who I am.

You make it clear in the book that you consider depression to have complex origins including biological vulnerability and particularly unresolved grief and loss, themes that run through the book. Could you say a little more for readers about how depression differs from a normal grieving process?

Grief is a normal human process we all go through when we experience loss. Feeling low and depressed is a normal part of that – but it usually resolves over time. We cry, desperately miss the dead person, and feel unable to do much other than think about the person we have lost and what has happened. There is no rule about how long this last before we begin to take up our lives again and don’t let anyone tell you “you should be over it by now.” Crucially it just gradually feels a little easier as time passes. If grief however is complicated the process can get stuck. You begin to feel worse, have ideas about suicide, wanting to join the dead person. This then becomes very hard to distinguish from depression – and is usually treated in a similar way. Grief can get complicated if you have had a difficult relationship with the dead person, like I did with my father, or, for example, if it was a sudden or really traumatic death or the person was never found.
If you are vulnerable to depression – for example if you’ve had it before or have a family history, the loss alone can also result in a relapse of your depression. The depression associated with grief resolves as you move through the process of grieving. A person who develops depression experiences more persistent low mood, sleep problems, weight change and all the other things we recognise, along with lack energy, hopelessness and suicidal ideas. If these continue week after week, or become very severe, thats not grief, that’s depression.

You’ve shared some deeply personal things about yourself and your family, especially your father and your brother. Did you discuss the writing of your memoir with any family members still living?

You may be surprised but – no. While I was writing the second draft, my mother died. I haven’t mentioned it in this book. We had been estranged for many years, and I’ve seen very little of my brothers in my adult life. Apart from my husband and friends I’ve been very much alone. I’m in touch with my youngest brother now a little, after decades, and I’m not sure how he will receive it, as he was closest to my mother. However it was a therapeutic exercise for me to write it, and completing it has been an important task for me. I will let you know in time!

I was struck by how often you took on patients for psychotherapy rather than just offering medication or self-help skills. It seems quite rare now for psychiatrists to administer talking therapies. How do you feel about that, and do you feel it’s a component of the exceptionally long waits service users face for therapy?

When I was in training, and in my early period as a consultant I did see patients for psychodynamic psychotherapy with supervision, and I supervised trainees. I wanted to be a psychotherapist then, but got tempted into academia instead. Many of my psychiatric colleagues are trained in therapies which they do not have time to practice – they are increasingly expected to refer on to others and simply review medication. I think this is a terrible waste of their skills. However if I had become a consultant psychotherapist I may well have had problems retaining my job. Psychotherapy services have been savagely cut – and its almost impossible to get the longer term psychodynamic therapy I practised as a trainee, or received myself in the past, without going privately now. There’s been a huge loss of expertise, and I think that is so short-sighted. This contributes to the long waiting time for therapies other than CBT [cognitive behavioural therapy] such as dynamic psychotherapy and DBT [dialectical behaviour therapy]. Even CBT is hard to get, because many people who are waiting for it, might benefit from other short term help – but instead end up on long waiting lists with no support at all. You can see what gets me angry!

You describe having found antidepressants helpful and indeed having taken them for decades. What reaction have you experienced to this openness?

All types of reactions! I’ve had a lot of support from many colleagues over the years especially when Ive not been very well, but I’ve had others who look embarrassed when I reveal I take them as though I really shouldn’t be talking about that. I’ve had a person on twitter tell me that I would be positive about them, wouldn’t I, because I’m a psychiatrist! I found that reaction the hardest one to accept! I haven’t stayed on antidepressants for any other reason other than I need to take them to stay well – certainly not to prove a point. Some colleagues have told me how comforting it has been to know other mental health professionals take them too especially  if they work in settings where there are strong beliefs that medications don’t work, and find it hard to admit their own experiences.

So there we have it! Big thanks to Linda, who I hope enjoyed answering the questions as much as I enjoyed writing them!

Posted in Books and reading, Depression, Memoir, Psychiatry | Tagged , , , , , , , , , , , , | 3 Comments

Black bags in the night

I haven’t posted in a while. Somehow I find it very hard to blog when I’m doing well, and in fact I have been doing very well since returning from holiday. Four or five weeks of stability!

Until this week. Now I’m scared that things might be unravelling.

Firstly there is the small matter of voices. I say a small matter because their presence is small, although very unusual in I have never experienced anything like it before, and because compared with so many people I know who hear voices my experience is as nothing. Just two voices, each only uttering a single word. It would be easy to write them off as mishearing background noise, but they felt very clear and very definite and feel significant.

I have in the past felt that certain thoughts were not mine, that they’d been dropped into my brain like someone dropping a pebble into a pond, but I did not hear them as being outside of my own head. But now on two occasions a voice I can genuinely hear has felt as if it comes from a particular place outside of my body, a place I can kind of feel with my brain right now although I know that’s silly. It’s about 30cm away from my skull, behind and slightly above it, so almost as if speaking directing into my right ear. If that zone was somehow to be pulled from its place outside to touch my body it would end up at a certain spot on my head. Right now I can feel that spot kind of pulsating and I’m afraid to touch it.

The first voice occurred in Italy, when I was coming out of a mixed episode. I woke up feeling awful and very bipolar irritable, describing my state to Tom as like having a box of bees in my head. “Well,” said Tom, “we could cancel the walking tour we’ve planned. It would be a shame to come here and not see the sights, but it’s up to you.” And so I had to decide whether to push through the bees in the hope of enjoying the planned activity or just go back to our hotel room.

We set off, rather reluctantly in my case, but only got a few metres from the hotel before Tom realised he had forgotten his camera. I stood in the sun alone, wondering if I was doing the right thing, when a male voice said “Sí”. That’s all it said. I experienced it in that zone I’ve mentioned. It spoke clearly and distinctly. I looked around. There was no one near right ear, or indeed near me at all. Ahead was the thick wall of the 18th century hotel building. I looked to the left and the right; nobody was walking up the narrow, cobbled street. I looked behind me but there was nothing except a thick wall the colour of saffron a good two metres away. Tom came back and we went on our excursion and it was wonderful because I made the right choice. I said “Sí” to the opportunity. I don’t really know whether the voice influenced me or not, but I was so glad we went.

I thought nothing of it. OK, I thought something of it but it wasn’t scary and there was no repetition. But then yesterday I was in a shop trying to decide what to buy. I won’t get too detailed here but suffice it to say I was in the family planning section. Anyhow I was vacillating and a voice (of no obvious gender, but possibly female) coming from that same spot above and behind said very distinctly, “Hmm.” Again I looked around. There was nobody else in the aisle. There were people in the aisle behind me but certainly nowhere near close enough to speak so intimately near my ear, and in any case they were engaged in conversations of their own. Initially I thought that “Hmm” represented my indecision, but when I left the store I began to feel it had been critical, that it expressed disapproval at anything to do with sex, that it felt like it thought less of me for having sexual desire. That wasn’t a comfortable thought.

So much for those small voices. I’m more concerned by what happened to me a couple of nights ago. I’d gone to bed ahead of Tom and was lying in the darkness when I heard a rustling. I didn’t know what it could be. My heart started pounding and I didn’t want to get out of bed, so I turned on a little torch I keep on the bedside table and shone it around the room. I immediately saw that there was a large black paper bag with handles on the floor, a relic from our recent trip to get Tom’s wedding suit (for those who don’t follow me on Twitter, yup, we are getting hitched!). I say this because that bag should have been a benign item, something with positive associations, but straightaway I knew it had to be the culprit. I turned off the torch. The rustling resumed. Terrified, I switched the torch on again, only to find stillness and silence. After one final round of the darkness and the rustling and the torch and the silence I couldn’t stand to have that bag in the room so I grabbed it by torchlight, bundling it out of the door and into the hall (where Tom was bemused to find it later) saying to it, “Fuck you! Fuck you!”

There are really only two ways of interpreting these events:

  • I am slightly unwell and need to somehow balance the fact that these things really happened to me with the fact that they could not have happened to me. This creates a huge amount of internal conflict but is better than…
  • That they are the handiwork of THEM.

So things could be worse. I am lucky that I am in the realms of 1, not 2. The wedding is just days away and being psychotic would be supremely unhelpful – as would the alternative, being high sedated with antipsychotics. I am a bit high, which is disappointing after my period of stability. I’ve been struggling with compulsive hand scratching and wringing, which only happens when I am high (in fact, it’s actually worse than it’s ever been). I can only assume that the wedding planning, as fun as it has been, has been a source of stress, even if that stress is positive. I just keep thinking, “Please, please don’t let it get any worse.” No psychosis. The only break I intend on having is my honeymoon.

Posted in Bipolar, hallucinations, Psychosis | Tagged , , , , , , , , , , | 20 Comments

Whatever I do, I’ll probably be wrong

I’ve just been for a walk. This was a bit of an achievement, given that it took a tremendous effort to get out of bed and dressed, let alone to get myself outside (I didn’t manage to have a shower before leaving the house, but that can stay between us). Sounds like I’m depressed, right?

Yet last night I felt like my brain was running so fast after a fun, busy weekend that it was like being on a centrifuge. The sense of internal pressure and intolerable speed made me feel like I was going to fly apart, mentally and even physically. Sounds like I was manic, right?

Well, sort of. It’s complicated.

Before I had my last round of Home Treatment my Consultant thought that I was in a “mixed affective state”. A mixed state is when your brain decides that it’s not enough to just be hypomanic or manic. That’s it’s not enough just to be depressed, oh dearie me no. That would be too simple! So, often for no apparent reason, the brain decides to shake up the old brain chemistry a bit so that someone experiences both symptoms of a high and symptoms of a low in the same episode or even at the same time. It’s happened to me a few times now, and when it’s intense I find it incredibly hard to cope and have needed to seek emergency help. The one time I have attempted suicide was when I was in a mixed mood state, and it recognise as the most risky of bipolar mood states.

But a mixed mood can be very difficult to separate from ultra rapid cycling. When my Consultant suggested that I was in mixed mood, I wasn’t sure; I’d thought it was more that I was just cycling really rapidly. After the whole delusional thing blew over I remained confused about how to identify what was going on. I certainly wasn’t experiencing normal mood. There were high bits and there were low bits but whatever it was seemed fairly low key and manageable. And I was really looking forward to my holiday. I had in the past experienced mixed moods on holiday (one of which was quite disastrous) but Tom and I thought we had it cracked by making sure we didn’t replicate the conditions of those trips. So instead of choosing to be part of a big group, we go alone. Instead of staying put in a villa, we travel around, stopping for a few nights here or there. We allow for some relaxation time, but also do enough stuff to keep me occupied. So I was fully confident that as soon as I settled into holiday mode my mood would settle too.

Getting up for an early flight was hard. I was a med zombie and Tom had to walk me through everything. I was a mess during security, dazed and unsure what I supposed to be doing. I held everyone else up and felt anxious and miserable. Somehow the anxiety dissipated on the short flight. By the time we landed I was excited; when we picked up our hire car I was somehow elated. “I fucking LOVE the med!” I shouted, looking through my sunglasses at prickly pears, pine trees and bougainvillea. We were making use of a villa this time, but only for a few days either side of touring around. Nearing the village we spotted a Lidl and decided to stock up on things for the next few days. I threw stuff into the trolley with abandon. It was fun, it was like a game, buying whatever I fancied and knowing we had 14 wonderful days ahead of us. We explored the unexpectedly, delightfully large villa and its amazing garden and unpacked the car. That evening we ate outside and shared the bottle of wine our hostess had left for us.

The next morning I wasn’t sure how I felt. If I was being honest with myself, I was a tiny bit low, but didn’t want to tell Tom that so I kind of… squished it. Yet when I stepped out into the garden I felt that the expanse of clear blue sky was all the medicine I could ever need. I simply could not understand how residents of countries with a sky like that could ever be depressed. So I sat outside all day, reading, writing, looking up at the sky and listening to the sound of the sea breeze in the huge pine, cedar and palm trees. I was going to be OK.

On day three I got up, got dressed, ate breakfast and then… ran out of steam. I went back to bed, fully clothed. I didn’t feel I had choice. I felt that if I just lay there, very still and undisturbed, I might be OK. Of course eventually Tom came looking for me and touched me and asked me how I was and immediately that sense of maybe, possibly being OK dissolved. I think Tom could tell that I was feeling really rough as he let me be. Normally he would encourage me to get up fight it. But he didn’t. And as I lay there I knew that because of me we weren’t doing the fun things he’d carefully lined up for the day and I felt awful. I was messing up our beautiful holiday. What a fucking idiot.

As we set off on our round trip I was most certainly in mixed mood and totally consumed by it. I had the all physical and mental agitation of a high coupled with huge guilt about being ill on holiday and continual thoughts of self-harm and/or death. Previously in mixed states my body has seemed to know my thoughts or intentions before my conscious mind has even processed them. In just the same way I felt like a puppet, my mind causing me to jerk or twitch towards danger. I lurched towards the car door, suddenly unable to stop thinking about throwing myself from the vehicle. Maybe I could even manage to do it so that I would fall down a ravine. I was plagued with fantasies of going to the beach alone and filling my pockets with rocks. Suicide Virginia Woolf style.

When we got to our next port of call I had a total freakout in front of countless surprised Italian people. The awful energy made me feel that no, I could not sit down and talk, I could not stay the night here, I could not stay in Italy, I needed Tom to drive to Bari or Brindisi so I could myself a ticket home while he carried out the rest of the holiday plans alone. Tom pointed out, not unreasonably, that he wouldn’t find much joy in carrying on alone while worried sick about me at home on my own. He coaxed me into taking 5mg of diazepam and sitting in a park with me to see how things went. Within three hours I was bouncing off the walls, impatient to go out and explore the amazing mediaeval town centre and eat dinner and buy ice cream. I dressed up. I put on makeup. I posted a happy selfie on Twitter. I had an amazing evening.

Well, whether it’s mixed mood or whether it’s ultra rapid cycling my problem is the same: how on earth am I supposed to manage it? This is what kept running through my head on my walk this afternoon. Walking is good to fight low mood. Walking can be good to reduce agitation. But walking, especially fast walking, can sometimes feed mania. Which means whatever I do could be wrong. Staying at home more as a tool to reduce hypomanic overstimulation could be the right thing to do. Or it could make low and isolated. Mixing with supportive people over the weekend just led to me feeling high in a desperate, desolate way. And meanwhile I’m aware that psychotic thoughts could pop up again at any time and I’m powerless to stop that.

And so I am finding myself back at a place of learned helplessness. There is something ahead that might help me: five months after my consultant formally requesting that I start specialist CBT for bipolar (which was originally recommended back in November) I have an assessment at the end of the month. What I will do if I am not judged suitable, I have no idea. What I will do if I start the therapy and it doesn’t help or I don’t manage to develop a rapport with literally the only therapist around who can deliver, again I have no idea.

I think I’ll leave it there. I don’t have any neat endings, or anything else to say.

 

 

 

Posted in Bipolar, Crisis care, Travel | Tagged , , , , , , , , , , , , , | 8 Comments

What mindfulness isn’t

I have said many times that I am a fan of mindfulness and that in some ways undertaking Mindfulness Based Cognitive Therapy (MBCT) was a game changer for me. I might not have a regular formal practice (see below) but I use the skills I learned there every day. So I get angry and upset when I see descriptions of “mindfulness” that I simply don’t recognise or see skills wrongly applied so that service users have “have failed” or are “no good at” mindfulness (for a more thorough explanation of why I think that’s ridiculous see this post: https://purplepersuasion.wordpress.com/2012/11/30/mindfulness-for-bipolar-disorder-simpler-than-you-think/)

Pretty much every month or so there’s an article in the mainstream media on mindfulness and today it’s the turn of BBC health to report on the benefits of mindfulness in schools. It draws heavily on this paper from this paper, which appeared in The Psychologist. I’ve seen worse pieces on mindfulness but still they contain misconceptions that make me despair. I’ve written the piece linked about describing what I think mindfulness is, but I’ve been thinking for a while that I needed to write a piece on what mindfulness is actually not. It’s kind of a long read, so feel free to skip to the section that most interests you. Healthcare professionals: particularly pay attention to 4 and 7.

 So here goes. Mindfulness is not… 

1) A religious practice. I’ve got a lot from the writings from Thich Na Hanh and yes, he is a Buddhist monk. But the techniques people like Jon Kabat-Zinn and Tara Brach have taken from Buddhism have been adapted for daily life in developed countries and are completely secular. If it gets you interested in Buddhism, go for it. There is also a strong Christian tradition of meditation and some similarities with Quaker Meetings for Worship. Myself, I’m a happy atheist Quaker, and although group mediation has some things in common with sitting in silence in Meeting for Worship, there are a whole lot of differences. So don’t let your faith or lack of faith put you off. 

2) Sitting on the floor. OK, sometimes it can be that. Some people enjoy and benefit from what’s usually known as sitting practice or formal practice (what people actually do in formal practice I’ll come onto in my next point). But sitting on the floor is certainly not obligatory! You can do formal practice sitting down, lying down, lying on your back with your legs on a chair: anything that accommodates your physical needs or disability. But here’s the key part: you don’t have to undertake any formal practice at all if you don’t want to. What mindfulness is really about is a kind of waking up and paying attention to what we’re doing and what is around us. That’s pretty much it. So it means you can engage in any activity mindfully. Yesterday I walked home from the town centre, and when I got in I couldn’t really remember the journey because I had been totally lost in my own thoughts. If I’d chosen to be mindful I would have got home via the same rout in the same time period but I would’ve literally smelt the roses, the deep pink roses than overhang the fence round the corner. I might have notice green parakeets winging their way between the trees. I might have noticed the temperature of the air on my skin, the feeling of my flip-flops on my feet as they hit the pavement. Anything. Everything.

In Peace is Every Step Thich Nhat Han suggests a way of mindful eating. Recalling with great relish he would eat a cookie as a child he describes a “tangerine meditation” in which the experience of eating a tangerine becomes mindfulness practice. Focusing on the smell of it, the feel of the skin, consideration where it has come from and then the taste and the texture and juice then becomes the practice. Mary Rose O’Reilley describes watching a monk at a Buddhist retreat savouring an Indian sweet in 16 bites (she counted!) to be told, “Mindfulness is a sneaky way to live a rich life” (The Barn at the End of the World).

 3) Deep/abdominal breathing. Abdominal breathing is more a yoga technique than one that belongs to mindfulness. The essence of mindfulness is to notice. To pay attention to what is happening inside of you and outside of you, to really experience what is happening instead of getting lost in your thoughts. Breathing is at the heart of mindfulness meditation, but that’s all there is. You just breathe. You don’t try to make your breath slower, deeper, longer – or anything else, because you don’t try to do anything to your breath. You simply watch what it’s doing wherever it is you can feel it most clearly. This could be nose, throat, chest or, yes, abdomen but the idea is to notice where you feel it, not make yourself feel it anywhere in particular.

4) A crisis management tool. If I have to read/hear about one more person being asked by a Crisis Team, “Have you tried mindfulness?” I’ll… well I don’t know what I’ll do. Go on a mindful rampage. No one without a very clear understanding of what they are talking about should suggest others “do” mindfulness. This especially goes for staff, whose position of power can make service users feel anxious or guilty because they keep hearing about it but they don’t really know what it means. Secondly, you cannot just “try” mindfulness. The relegates it to the level of, “Have you tried making a couple of tea?” Mindfulness is an experiential skill. Anyone who wants to can try it, but it usually takes a some classes or some useful books and CDs to get the idea.

And finally, it is totally inappropriate for crisis. Distraction is often recommended in crisis and is much more appropriate – people need a break from intense thoughts of harming themselves. Mindfulness is the opposite from that – it’s a focus on what is going on mentally and physically. Sitting silently with thoughts of suicide or self-harm can create a kind of echo chamber for those thoughts to become more developed. And someone who is highly agitated or distress is just not going to able to wash up mindfully. Not going to happen. The teaching that I received was clear: if your thoughts are too painful or distressing, get up and walk away. Don’t sit. Distract.

Jon Kabat-Zinn suggests thinking our mind as the surface of a lake ocean, and our thoughts as waves. Sometimes they’re just little ripples and sometimes they’re big, but they can be churned up by winds when the water is churned up and pulled in different directions. “People who don’t understand meditation think that it is some kind of special inner manipulation which will magically shut off these waves so the mind’s surface will be flat, peaceful and tranquil. But… you can’t artificially suppress the waves of your mind, and it is not too smart to try.” (Wherever You Go, There You Are). 

5) A relaxation exercise. Many mindfulness teachers use guided meditations to help you along. For example, many MBCT courses start of with the “body scan”, an exercise where you work your way all around your body, from your little toes up to your head. This can seem a lot like the kind of guided relaxation exercises many people will be familiar with from yoga classes or meditation CDs, but again the emphasis is very different. In a guided relaxation, there is a goal: relax as much as possible in each area of the body you examine. Mindfulness has no goal so when you tune in to your toes you’re not asking them to do anything. You’re not asking them to relax or to let go of tension. You’re just observing them, just as you would observe your breath, with a sense of detached curiosity. Do they feel cold or hot? Is there any sensation of tingling or burning? Does your little toe still hurt where you stubbed it on the desk on Tuesday? And… that’s all.

6) A means to a state of happiness. As I hope I’ve made clear so far, there is no goal in mindfulness. It’s true that sensations of joy or wellbeing might crop up as a result of mindfulness (especially when you smell the roses) but it is a kind of a by-product of paying attention, not a state to aim for. Much of the time sitting practice can be far from blissful. It can be uncomfortable, boring, frustrating, or lead to a sense of being trapped in your own body. It can lead to doubts about what you are trying to do and why you’re even bothering. These things emphatically do not mean you have “failed” or that you are “doing it wrong”. Mindfulness is paying attention, and you are paying attention so you are being mindful! Then you have choices – what is safe for you? Do you want to carry on? Do you want to stop completely, or to get up and do a different practice like mindfully walking round the room? It’s fine to decide that what you’ve been doing isn’t for you.

7) Something that’s suitable for everyone

I was disturbed to read this phrase in the Psychologist article: “There is no downside risk, and the evidence shows these things work.” First of all there is no intervention without some risk and it’s ridiculous to suggest such a thing. Applying mindfulness – well, mindlessly, does put people at risk. People who have asthma or other breathing problems may find the focus on the breath stressful or distressing. People who have experienced trauma, especially bodily trauma such as sexual assault, may well have developed coping strategies that involve not feeling that inhabit their bodies. Forcing them to feel what it is like to be in their bodies can be extremely triggering and damaging, especially if they feel trapped inside.

Also: what does this quote mean when it says: “the evidence shows these things work”? There is a growing evidence base, but this seems strongest in terms of people who have been depressed but are in remission, in terms of being a relapse prevention tool. That’s about as far away from a crisis as you can get under the mental health umbrella. (Also, can I just say: “‘mindfulness resistance techniques’ might help people avoid the temptation of chocolate”? Just no.)

So there you have it. These are the things I wish healthcare professionals would consider. There’s still a place for mindfulness in the NHS but if we are serious about mindfulness we need to be putting professionals through at least the 8 weeks of experience practice on MCBT. Leaving people with mental health problems feeling that they have “failed” or are “no good at” mindfulness can damage already shaky self-esteem or sense of self-efficacy. Meddling with people’s minds with technique you don’t fully understand is risky.

Peace is Every Step Thich Nhat Han

Radical Acceptance Tara Brach

The Barn at the End of the World Mary Rose O’Reilley

Wherever You Go, There You Are Jon Kabat-Zinn

Posted in Bipolar, Mental health, Mindfulness | Tagged , , , , , , , | 16 Comments

Don’t fence me in: 10 signs of hypomania you won’t find in a textbook

Whenever I tell a new doctor that I’m hypomanic they ask me to describe what I mean when I use that word. I hate the question, because it’s glaringly obvious that they’re assessing my answers against criteria they have in their heads, probably derived from the big diagnostic manuals (DSM-5 or ICD-10). Obviously when hypo I do display classic indicators like decreased sleep, increased energy, increased libido, increased productivity and so on. And of course I understand there are core set of experiences people in a hypomanic state may share which is why they they tend to appear on mood monitoring charts or apps and in self-help books.

The problem with being measured against a general checklist is that accepted symptoms are not usually what I find herald hypomania. There are a whole a range of deeply personal things that I consider much more important in making my own assessment. So the risk of giving an honest answer is that I won’t match the checklist. I will not fit in the prepared box, so the clinician will conclude is that I don’t really know what I am talking about when I explicitly state that I’m hypomanic. This causes me huge frustration; I have worked and worked to be acutely aware of my mood states and to have that expertise dismissed because it’s unorthodox is upsets me every time it happens.

So I think I’ve decided I’m giving up on truthfulness with new professionals because I’m sick of my consistent, reliable signs of hypomania being seen as irrelevant. So I think I’ll share them here instead, and if I get up enough courage I might even pop a copy in the post to the psychiatrist ;)

Funny fingers. Whenever I’m going high I get this thing where I have to scratch or rub my fingers, especially the outsides of my little fingers. I have never successfully conveyed this experience to anyone. I tried to explain to the team registrar recently that it is something that I do it because my need to feel something there. He misinterpreted that and it’s written on my discharge letter that my fingers are numb. Not a bit of it. My fingers feel and function normally, but they need more sensation. I have to do it, I have to meet that need and give them more, otherwise the agitation builds.

Swagger. I’m hardly the sort of person that swaggers around the streets of London. In fact I’m often quite timid, scared of people when I’m depressed, ashamed of my body size and dreading the next time I’m asked me if I’m pregnant (no, just a quetiapine baby). Throw a little hypomania into the mix and I couldn’t be more different. Suddenly I walk in a completely new way. I stride. I sashay. I swagger. It’s a mixture of confidence, the certainty I am sexy, a touch of arrogance and a readiness to engage in confrontation. The best I can describe it is to suggest that you walk along to the track Battle Without Honour or Humanity and see how that feels.

Necklaces. When high, I dress differently – or as the registrar recorded, with more panache. It’s not just that I think more about my clothes than I would when I am depressed. It’s not that I go out and buy new clothes. It’s that apparently great outfits I hadn’t noticed now leap out of my wardrobe. Because my self-confidence is high I am also certain of my own attractiveness so it never occurs to me that I might not be able to “work it”. Most noticeably, the necklaces come out to play. Now, I will readily admit that I am a necklace fiend, if not a hoarder. I have about 50, all of them beautiful, and yet days or weeks can go by without me wearing a single one. In comes hypomania and suddenly the biggest and boldest, the “statement” necklaces, are also leaping out at me (and the compliments I receive of course reinforce my belief that I have great taste in jewellery and should hang on to every necklace I own, so yay).

Pointy teeth. For me one of the earliest indicators of a high is having pointy teeth. Of course my teeth aren’t really any pointier than usual; a quick check in the mirror proves that, as does the knowledge that this isn’t Bon Temps. But they feel much more pointy and I can’t stop running my tongue over them. This is part of a broader package of enhanced senses; my feet are more conscious of the interior of my shoes; things sound louder; colours seem brighter. But it’s always the teeth thing that tips me off.

Asinging and adancing. Based on my Twitter connections, this is a pretty common indicator but I’ve definitely never seen it on any mood chart. On an upswing I find myself travelling from room to room via the medium of Zumba-ish dance moves. When I would normally stand still – washing up, hanging the washing out, cleaning my teeth – I am side stepping or bum kicking or scooping (sorry, that probably make much sense if you’ve never done aerobics!). I chair dance while writing. I get up and start dancing when I should be working. I’m also very into singing, loudly and confidently, loud enough for my son to complain that he can hear me through two walls and a pair of headphones. At least he says I’m good.

Comely commuters. Often I will sit on the Tube and be oblivious to my fellow passengers, buried in my phone or my Kindle. Sometimes I will plug myself into my headphones and do a little people watching. But sometimes, hypomanic times, I find that the carriage is filled with unfeasibly attractive strangers. Everywhere I look there’ll be someone hot. I know I’m staring and that some people have noticed that I am staring and look puzzled and uncomfortable but I can’t help myself. They are literally mouth-watering and my breathing gets shallow, my pupils dilating. Luckily I am never quite manic enough to proposition anyone.

Sunsets. On an upswing, sunsets become almost unbearably beautiful. On long summer evenings when the pressure is high and the sky changes from blue to lemon to streaks of intense pink, I almost cry at so much splendour and the elation spikes and pulsate.

Tweet rate. I do type pretty fast – I learned in the fast-paced chat rooms of the very early noughties – and I do tweet a lot. But hypomanic I tweet a lot more, bam, bam, bam, one tweet after another and another. Online friends sometimes (with good reason) check in with me when they see how fast I am getting my tweets out there, but of course if I feel great I’m unlikely to want to tone things down. But I will probably note what they’re saying somewhere in the back of my mind.

Head music. Head music is another one I’ve frequently heard from other with bipolar but have never seen “officially” acknowledged. It is, I guess, a pseudohallucination – something that is “heard” within the head, but not as an actual sound as someone might experience if they hear voices. For me, it’s usually a loop of a particular song or piece, a particular musical phrase, a snatch of melody or, at its most annoying, a single word over and over again. It can easily be linked with a switch to mixed mood as I become very agitated by being unable to stop the music.

In the loop. Strangely the head music often has no connection at all to what I have been listening to. Which is a good thing, as despite the fact that I have 219 Spotify starred songs when I’m high I will play just one over and over, all day long (hoping the neighbours are at work). When Tom gets home and opens the door there is sometimes a very audible “Uh-oh!” as he clocks what I’m listening to. Again.

I’m not asking anyone to change any diagnostic criteria or mood apps on my account. In fact, I’m asking clinicians to do less work. I want them to sit back and trust that I know something about my condition and remember that I’m monitoring myself for the 23.5 hours a day while they get a 30-minute window. Now, I’m willing to bet that pretty much anyone who experiences hypomania has something weird and quirky that they know they need to watch that’s outside the diagnostic box. This is the stuff that professionals should value; they should be learning from our quirks. Don’t fence us in.

Posted in Bipolar, Hypomania, Mania, Self-management | Tagged , , , , , , , , , , , , | 28 Comments

I asked for help

I asked for help when I was 12.

I looked, alone, in my middle school library

at a teenage health book. It told me that

depression is an illness. It is real. You can be helped.

It took me days to summon up the courage

find the words to say, “I think that I’m depressed.”

“Everyone’s depressed!” was the response.

I left it there.
I asked for help when I was 13, 15,

already suicidal, finding school a torment.

“All teenagers have mood swings.”

“It may be PMS, so track your periods.”

I asked for help when I was 17.

I got propranolol. Whatever that meant.

I didn’t feel it did much, but someone cared.
I asked for help when I was 20.

The psychiatrist, the first I’d met,

portrayed me as a liar and implied that I might drink.

He sneered at my choices

of university

of course

of fiancé

and gave me fluoxetine, which sent me high.

He didn’t care.
I saw another guy who thought I had bipolar.

Lithium, he said, was the drug of choice but

it can cause thyroid problems

renal problems

seizures

coma

death.

You need blood tests

ECG

chest X-ray

and you must not get pregnant, no matter what.

No one talked it through with me.

No one helped me understand what it might mean to have bipolar.

No one gave me options.

It was lithium, or nothing.

I chose nothing.
I asked for help when I was 25.

I filled in a depression scale.

No, I cannot cope

and yes I cry a lot

and yes I think about death.

My toddler’s behaviour is out of control

my newborn’s crying is out of control

my depression is out of control.

The Health Visitor frowned.

“You’re score is very high.

I think it’s just because you’re self aware.”

And I had thought it was because

I was so depressed.
My GP tried to help.

With sertraline

and paroxitine

and trazadone

and venlafaxine

with no onward referral

and I remained in a kind of hell

an empty of husk of a mother

an empty husk of a person.
I asked for help when I was 27

if by asking for help you mean

spewing the contents of my medicine cabinet

from my stomach to the floor

of a curtained A&E cubicle.

When my vital organs were deemed well 

I went home

five pills of chlorpromazine

in a brown childproof bottle.

They sent a CPN.

“What do you want from me?” she sighed.

“This service is for people

with serious mental health problems.”
And she left.
They sent me for assessment with a clinical psychologist.

At last my problems, the overdose, seemed taken seriously

and my name went on the waiting list.

We didn’t hear and didn’t hear

and so we phoned.

“Oh, you’ve been taken of the list.

We had a case conference and

you were not in sufficient need.”
I asked for help when I was 28.

The psychiatrist looked into my file

but did not look at me.

Every session was the same:
your GP seems right

your current medication seems right

so see you in a month, then.

Repeat in August, in September, repeat repeat repeat.
I asked for help when I was 30.

and received a new and inaccurate diagnosis

something that I only knew when a letter came my way.

I did not recognise this version of the assessment

this description of my “psychopathology”

I did not recognise myself.

The unexpected upside of being told

that my personality was partially disordered

was I got the therapy I had needed 18 months ago.

I was profoundly grateful. I was profoundly angry.
I asked for help when I was 37.

I received it.

Posted in Bipolar, Child and adolescent mental health, Depression, Mental health services, Psychiatry | Tagged , , , , , , , , , , , , , | 18 Comments

She took to her bed: safe spaces and danger zones

Today I have been trying to explain to my Consultant that I feel that there are a number of zones in which They have more chance to get at me, where their power is stronger. Places like what I am now calling “Banana Alley”. Seriously, apart from streets that are used as markets, never have I seen so much fruit um, detritus, on a pavement or in a gutter. Today there were skins from about three satsumas or clementies (I did not take time to ascertain which), plus a whole manky one, plus a lone, heavily bruised apricot. This in a distance of perhaps 250m, a “passage” from tube to bus.

It’s becoming clear that although it’s often quite neutral, a lot of what I experience in my home happens in the hall/passage. Mostly I’ll walk back and forth without giving it a second thought, but when I start to become afraid it becomes a danger zone; inconvenient, because it is necessary to pass through the hall to get from any one room to another.

One of my earliest experiences with Them occurred a couple of years ago as Tom was driving us along the North Circular. Obviously we all know that the North Circular is hell. That’s a given. However, there’s a certain section which feels downright dangerous, a stretch between a certain bridge and a certain building. Once, on a tube train, I saw an ad for a product made by the company in that building (I hadn’t even known that they made anything) and I was flooded with anxiety. Still, we passed through it yesterday with no ill effects, holding my breath the whole time.

All of these spaces are liminal, a zone between or an intersection of safety and danger. Or maybe they are littoral, places where the terrifying and the pathological smash against the normal and the ordinary, I don’t know. In the case of the hall, well, I have to move through it. It’s that or buy a commode and have Tom bring all my food to me and give me bed baths. In the case of the North Circular, it is the most direct way home from many trips out but I am sure if I felt really distressed Tom and the satnav would find us another route. When I was explaining about Banana Alley to my consultant he asked me if there was another route I could take. I was astounded. I am familiar with the area well from my past work, so I on one level I knew perfectly well how to catch the bus without hurrying down the Alley, my eyes flickering from gutter to hedge on high alert for fruit. Yet on another level it really hadn’t even occurred to me. (On the way home I went one better and took a different bus. It took me about twice as long to get home but I felt I was making a statement.)

I was asked today whether I thought I needed to be in hospital. I didn’t think so. I am not at any physical risk. I am despondent at this change in my symptoms, the fact that this means I can’t up my game, can’t defend myself against whatever bipolar throws at me because it’s different with every crisis. My mood also dips when I have had a very difficult or distressing day, but that’s understandable. I am not of low mood in the clinical sense. Being admitted now would actually take me away from the points of safety in my life. Firstly, Tom. When he’s around, things are OK. I get confused and muddled about whether things really happened and if so when, but They don’t trouble me much. He’s like an amulet. Or, I don’t know, a sort of protective bubble of safety. There are places in my home too that are safe zones, even if I have to cross the hall to get to them. Twitter followers will know how much time I spent in the bath, and that becomes even more important when distressed, an enclosed space that I can fill with relaxing music and scented oils that provides a period in which something like diazepam can get to work.

The safest place of all is my bed. And the more ritualised and specific “bedtime” is, the safer it becomes. The bed has to be made, properly. The scatter pillows on top need to stay there, although the serve no actual function. The sheet and the duvet and the bedspread must be as straight as I can make them. Extra safety points are accrued by going to bed immediately following a bath; extra extra points by putting on a clean nightgown or PJs. Getting into bed in this state, especially in the day, makes be feel born again, cleansed, and not just on the outside. It gives me the best possible chance of surviving a period home alone. There is one problem, however. Although I’m not remotely suicidal at present, this feeling of being newborn is slightly risky because it is exactly what I was aiming for in some anonymous hotel where I intended to spend my last night.

So no, I don’t think it would be beneficial for me to be in hospital. The only bed I am interested in accepting is the king sized one in my room. I don’t even know what could be achieved in hospital in terms of medication that can’t be carried out in the community.

This is another post I don’t know how to end. I only meant to write a couple of hundred words. I should link to some other posts but I am too tired, sorry.

Posted in Bipolar, Crisis care, Psychosis | Tagged , , , , , , | 1 Comment