Bipolar - bi-lateral? (Kipling said it...

Although I rejected psychiatric diagnostic labels some years ago, I did once unearth a study claiming a statistical association that may just point the way to something. (Alas I didn’t record the reference at the time, or I’d give it to you now). The claim was that if you have received a diagnosis of Bipolar Affective Disorder, you are three times more likely to be left-handed than the general population! There’s a poem of Kipling’s which has been a favourite of mine for thirty years.

The Two-Sided Man

Much I owe to the hands that grew -
More to the Lives that fed -
But most to Allah Who gave me two
Separate sides to my head

Much I reflect on the Good and the True
In the Faiths beneath the sun,
But most upon Allah Who gave me two
Sides to my head, not one.

Wesley’s following, Calvin’s flock,
White or yellow or bronze,
Shaman, Ju-ju or Angekok,
Minister, Mukamuk, Bonze -

Here is a health, my brothers, to you,
However your prayers are said,
And praised be Allah Who gave me two
Separate sides to my head!

I would go without shirt or shoe,
Friend, tobacco or bread,
Sooner than lose for a minute the two
Separate sides of my head!

Kipling, R (1993) Selected Poems (Penguin: London)

For all things asymmetrical go to http://www.righthandlefthand.com/ and McManus, C (2003) Right Hand, Left Hand: The of Asymmetry in Brains, Bodies, Atoms and Cultures Phoenix: London

It's the company you keep! (updated 2014)

(Christakis and Fowler 2008)

I've been directing people to the short article below since it first appeared on the Edge.org site almost two years ago. On the surface it's just a small investigation of a few hundred of the early student users of facebook - but give it some thought and a second read and the implications are enormous. Much of my writing on this blog insists that the real world, along with the virtual one, is like the article describes. Mental distress is made and unmade everyday through our interaction with others. When it persists for long periods we become progressively more isolated. Mapping social networks suggest how such a process works.

Social Networks and Happiness

(Nick Christakis homepage, and on video How social networks predict epidemics plus The hidden  influence of social networks)

The 'therapeutic relationship' explained

...or rather, how it comes about that often the relationships between mental health workers and their clients aren’t beneficial to either party.

We become clients of mental health services because we find it impossible to maintain happy social relationships - we may never have experienced them, or experienced trauma when they breakdown, or had difficulties in making new ones.

We then enter a system of care which doesn’t offer us ordinary relationships, or training in how to conduct and maintain them, but instead involves a form of social interaction based on the worker playing out two roles; that of bureaucrat on the one hand, and counsellor on the other.

Firstly, there is always the aspect of a ‘paid friendship’, so you can never be sure of the genuineness of the worker, their feelings about you are always hidden to a greater or lesser extent. They are not choosing to be with us. What are we to conclude when we see a mismatch between what they say and what they display non-verbally? They are of course observing the same in us, but usually concluding it’s an aspect of our character, rather than a reflection of their behaviour!

If the relationship should turn out to be a good one it is quickly terminated by the worker; if it is less successful it may persist for decades.

We usually meet them at a time and place of their choosing, often in a specially designated building isolated from normal social life. This is presented as an aspect of confidentiality and freedom to disclose. However, whilst the location often feels familiar and safe to the worker, for us it may be quite the opposite.

Given the isolating nature of mental distress, and the fact that the worker has many other clients, they are almost always (for good or bad) more important in our lives than we are in their's.

They assess us, and even if they accept our conception of our problems, even if we are able to assert our rights and entitlements, they remain the gatekeepers to care. We are promised confidentiality, but also told that when they deem it necessary they will consult others.

We are told the encounter is our space, ours to control or direct. Yet because they do not self-disclose - we are expected to talk about the most intimate, and therefore most difficult to articulate, aspects of our lives to someone who always remains a stranger.

Since the assumption is that we are the ones who bring our problems to the encounter, what is actually happening in the room is either ignored or grossly misinterpreted because of an unconsidered factor - what years of meeting everyday with a variety of people in mental distress has done to the health and perceptions of the worker! (Remember, they get their supervision from even more experienced workers).

Normal, healthy encounters are as follows. We meet as strangers, often have strong first impressions of like or dislike, intuitions of threat or safety (which we ought to follow, leaving immediately if necessary). It is only after some time that we reveal confidences, when some trust has been established based on both parties willingness to mirror and match the other with minor disclosures about themselves. Equality and reciprocity are built-in to normal social encounters. We are attracted by points of similarity between ourselves and the other person. Friendship may or may not follow. If it does, then it becomes appropriate to give advice or instruct. You earn the right to say - ‘don’t do that, I know what happened last time, even if you have forgotten’. When on the receiving end, you may not like what is being said, but by now you have undeniable evidence that the person cares about your wellbeing. And of course, all this time you have been meeting at a time and place negotiated between yourselves.

So how can these abnormal encounters with workers actually improve practical opportunities for more and better social interaction in the real world? You walk away from a meeting with a mental health professional and within a few hours, like all encounters, you remember little of what was said rather the atmosphere that was created. We leave with a feeling of whether it was a good or bad experience. But we should go further and ask ourselves, have I learnt something practical today which will make it easier to get up tomorrow?

Motivation and acting 'as if'

'Evolutionary theorists argue that social intelligence was the primordial talent of the human brain, reflected in our outsize cortex, and that what we now think of as “intelligence” piggybacked on neural systems used for getting along in a complex group' (Goleman 2007:334).

Given the social model I’ve been pursuing on this blog, then in what sense can an individual act purposefully and ‘make something happen’? Fulfil a fantasy about an imagined future - a ‘desired outcome’? Change and adaptation provokes anxiety for anyone who has become isolated. But to find a different way of being in the world requires getting back into some form of social involvement, navigating and negotiating a way back into public spaces in order to gain acceptance from others, some mutuality and sense of social belonging despite the overt and covert negative messages that come from society at large. And in what has become an unknown environment you have no choice but to jump in at the deep end, and act ‘as if’ you already have a competence you don’t yet feel. Once in a new environment however, motivated by others who have become important to you, you can begin to acquire new skills in living, by taking risks and acting as if you were already the person others desire you to be.

People like mysteries and not the idea that psychological abilities can be learnt as a set of skills. But the mastery of a skill brings joy, flow or happiness. That loss of self-consciousness first experienced in childhood play. Improvisation is innovation in one’s own behaviour. The traditional ‘four stages of competence’ learning model on the psychological states associated with the acquisition of skill (the origins of which are unknown) can be adapted for self-awareness in general. Unconscious incompetence (I don’t know, what I don’t know), conscious incompetence (I know I don’t know, but can’t do), conscious competence (I know, I can do, but others can see I’ve not mastered the skill) and unconscious competence (I and others take my competence for granted).

I learnt how to be crazy from imitating the psychologically troubled and becoming progressively isolated from the mental healthy - and I learnt to be sane through others ‘taking me by the hand’ and placing me in new social environments where I was forced to act in novel ways, and realise the way to mental wellbeing is to imitate the mental healthy.

Goleman, D (2007) Social Intelligence: The New Science of Human Relationships Arrow: London

Religion and mental health

Traditionally mental health services have been pretty bad at addressing the spiritual or religious needs of their clients. The problem can be very simply stated - a majority of workers don’t have strong religious convictions, whilst most of their clients do.

Until recently the strategy of most workers was avoidance, but that often came across as disrespect because so many clients describe their problems, and see the world at large, in religious terms. Establishing any kind of rapport requires some suspension of disbelief.

The ridiculous situations that can arise are well illustrated by a recent example from general nursing where a nurse from Somerset was suspended for praying for a patient! (I should state at this point - given the content of the rest of this site - that although I consider the psychologist Sue Blackmore, evolutionary biologist Richard Dawkins and philosopher Dan Dennett as intellectual mentors - I do not follow them in considering religious beliefs to be ‘dangerous memes').

Those of us without religious beliefs should also acknowledge the obvious truth, that local churches often provide a level of support and sense of belonging (social inclusion) which mental health services have never come close to! A great friend and peer of mine is learning to read and write by studying the Bible, he’s almost sixty and has undergone in the last four years the most rapid and fundamental turnaround in his mental health I’ve ever seen in any client.

In the last three years or so various leaflets and documents have been produced for mental health workers, clients and their supporters about mental health and religious beliefs. From the Royal College of Psychiatrists the leaflet Spirituality and Mental Health. From the Mental Health Foundation, Making Space For Spirituality - how to support service users plus their full report. Finally a video of theologian Karen Armstrong on the possibilities of transcendence through practical acts - do unto others, as you would have them do unto you!

Online meditation and Wisdom2.0

Think of the Web as an add-on to your brain. When you combine it’s increasing connectivity with the memetic selection of searching you have a partial reflection of how the mind works. What was once a very weak analogy between the brain and computers, is becoming stronger.

Whether your influence over the domain in which selection takes place is greater than you have in your social environment is unclear - it appears that way, but it could be an illusion. However the dangers of too greater specialisation, leading to extreme dependence on a particular environment are very real. The more precisely you search and the more limited your connections, the more you exclude and put blinkers on yourself. Another form of emotional and cognitive isolation.

Equally the stressors in the virtual world often mirror those in the physical one. The idea of applying meditation techniques to the way we use computers and the internet has been taken up by Soren Gordhamer in his book Wisdom2.0

http://www.amazon.co.uk/Wisdom-2-0-Creative-Constantly-Connected/dp/0061651516/ref=sr_1_1?ie=UTF8&s=books&qid=1264459010&sr=1-1 Later this year there will be a Wisdom2.0 conference http://www.wisdom2conference.com/

Soren writes columns for The Huffington Post

http://www.huffingtonpost.com/soren-gordhamer and Mashable.com http://mashable.com/author/soren-gordhamer/

At http://www.youtube.com/watch?v=9QBcEFUNCOk&feature=PlayList&p=3B93FF3D190E0C51&index=6 there is a short video.

My first time as a 'peer supporter'

...Earlier in the year I had moved into a flat of my own. It was located in a multi-ethnic, working class area of the city. I set about the process of applying for nurse training. I discovered that if I could get accepted there were two hospitals within reasonable distance which had an intake the following May. I thought about doing some voluntary work in the meantime. It turned out that there was a day-centre for the mentally ill within ten minutes walk, I offered my services.

You can’t imagine a grimmer place to live, the centre was in the middle of a concrete shopping centre surrounded by high-rise residential tower blocks, but located underneath the concrete ‘piazza’ style shopping area. The entrance to the day centre itself was through what should have been the fire exit. (The main entrance was the ‘front office’ of the charity which ran it). The centre had just over thirty regular attendees, about half of whom lived in residential units supervised by the charity. It was a ‘social maintenance’ centre for ‘chronically mentally ill clients’ who had become ‘socially impaired’. My first challenge was to get to grips with the language.

In the vernacular of the centre, people were not ‘mentally ill’ they had ‘mental health problems’. They were not patients but either ‘clients’ or ‘service users’. In practice the users were ex-psychiatric patients who had spent long periods in hospital, been to various degrees institutionalised, and were now trying to live something like a stable existence ‘in the community’. There were three staff; a psychology graduate, a social worker and an art therapist. They were anxious to provide a safe and stable environment, but worried about recreating the kind of dependence that clients had developed in hospital.

Early on, I think the manager must have asked me to write down what I saw as my role as volunteer, for I found the following rough draft in my file:

‘1/ Objectives; a) help users/clients to help themselves, cope with
day to day problems, greater independence in the community. b) participate as a member of staff in promoting user-led service.
2/ How?; being there for clients, befriending, listening, providing information and practical assistance.
3/ Problems; clients reluctance to take responsibility, lack of motivation, confidence, dependence.
4/ Tasking problems; being with them and participating in their attempts to undertake new tasks.’
The document is not dated but must have been from the end of 1989. I was a volunteer there for six months. It feels strange reading it now, for since then, over the last twenty years several people have provided exactly the same service for me!

Strictly speaking it was not a ‘drop-in’ centre, but it felt like one. There were the constant changing faces of clients and their friends. Undoubtedly the atmosphere was dominated by the oldest client, he must have been approaching seventy, had been in hospital for many years, been diagnosed with paranoid schizophrenia, but now refused all medication, and was very thin. He was such a presence because he never stopped moving, mostly pacing up and down, sitting only for a minute or two at a time and even then swinging his legs rhythmically. Often, though the centre didn’t open to clients till ten in the morning, he would be pacing outside by nine when the staff arrived. Every day he walked six miles to and from his room in a ‘bed and breakfast’ that took DHSS clients. He appeared to ‘hear voices’ constantly and would mumble, or occasionally shout back at them. He looked mad, (sorry, ‘damaged’) and knew others thought he was. When he had to move, one of the staff helped out and said his entire possessions only filled two black bin bags. The centre was a kind of sanctuary for him, he was the first to arrive and the last to leave. He was at one and the same time a pathetic example of neglect, and a monument to endurance and the determination to survive.

The guy I came to know best lived down the street from me and had also been labelled a paranoid schizophrenic, but was very different. About thirty-five, very outward going and sociable. He took medication but was often drowsy in the mornings and a little overweight. I asked him many months later when I was a nursing student, (and had an essay to write on: ‘Is mental health a valid concept?’) ‘What does mental health mean to you?’ He replied; ‘…being in control…having my own thoughts, no alien thoughts’. His mental condition had become obvious to himself and others when he was in prison, but he had been lucky enough to serve the last six months of his sentence in a regional secure unit, a small scale unit for offenders with mental health problems. It was while we were sitting drinking coffee in my flat one day that I witnessed for the first time someone rapidly becoming psychotic, and then just as rapidly normal again. I must have inadvertently ‘cued’ him, for half way through a sentence he interrupted me and began speaking much faster in the voice of an evangelical preacher about his own sins and those of others. The contrast with his normal voice was striking, not just the speed, but volume, passion and incoherence. I thought for a moment, realised what had set him off, then choosing my moment said something about the topic we’d been discussing much earlier. Just as easily he came back to normal speech quite unselfconsciously. I’m afraid my curiosity and enquiring mind got the better of me. I deliberately cued him again, then brought him back as quickly as I could. That satisfied me, anymore would have seemed unethical…

…One of the activities open to clients was to attend the ‘health shop’ run by the local health authority and take part in the ‘stress clinic’. This was a course run by a young man who was later to become well known for developing ‘laughter therapy’ in Britain, based on the Indian practice of a group of people going to piece of open ground in the early morning or evening and deliberately making themselves laugh together for a while. One of the exercises in the stress clinic was to write one’s own ‘obituary’ and part of my attempt survives; it’s a bit embarrassing really, but perhaps it illustrates how I was thinking at the time:

‘Nick Hewling died this week at his farm in Provence aged seventy-four, where he spent the last twenty years of his life cultivating his vineyard and promoting his own wine. He moved to France after a distinguished career in the National Health Service, first as a psychiatric nurse and lecturer, then as a psychotherapist. However he will probably be best remembered for his best selling books on mental health. Although widely respected as an innovator in psychiatric care, he didn’t enter the profession until his early thirties, previously he had been… Later he was a professor at the University of … He leaves a widow and two children.’

Also I find a copy of a ‘life events’ stress questionnaire, where you mark up and score stressful events from the previous two years. (This was early 1990). Low stress started at one, fifty being the average or medium(?) and one hundred being high stress - I scored one hundred and five! (I think it must have been some sort of ‘adaptation’ of the Holmes-Rahe Life Stress Inventory). The facilitator also tried getting us to use what he called ‘stress meters’ to monitor our levels throughout sessions (as in Galvanic skin response, polygraph etc.), but with us monitoring ourselves - as the needle swung back and forth one quickly became anxious about what was making one anxious!...

Self-management - practical and emotional resources (updated 2014)

Practical resources I can usually organise for myself. They allow me to go where I want, when I want. They allow me to reach the emotional support and motivation I need - for that can only come from others.

My practical resources all centre around my leather satchel for which I paid almost £130 three years ago - an extravagant purchase you might think for someone on £91.80 per week benefits, but it’s intended to last a lifetime and it does the job required of it. It contains all I need to survive, it goes wherever I go!

So what’s in the bag?

It contains; diary/ address book, A-Z for Exeter, Torbay and Plymouth, several Stagecoach Devon timetables, a First Great Western timetable, A4 writing paper, pencil, red pen, yellow highlighter, post-it pad, red and black whiteboard markers, cloth for cleaning white board, extra tobacco and papers, spare lighter, re-usable cloth shopping bag, extra large plastic bag, sun glasses, reading glasses, benefits letter, CV, photocopy of some meditation techniques, my WRAP (on 2 sides of single sheet A4), bottle of tap water, Mac-in-a-Bag, sun hat, comb, spare key to my flat, Ventolin inhaler, 8 combined Aspirin/ Paracetamol/ Caffeine tablets, 6 low dose sleeping tablets, 2 condoms, 2 sticking plasters, 2 x 20p, a AAA battery, digital voice recorder, student ID and carrier, memory stick (back-up for my own computer, but also allows me to work on anyone else’s; contains hundreds of emails/ contacts, all my own writing, electronic versions of articles, bits of books, policy documents, reports, guides to everything that seems worth knowing about mental wellbeing!)

About my person I carry keys, coins, tobacco, papers and filters, lighter, tissues, wallet containing single debit card, driving licence, folding money, stamps, a couple of passport photos and my mobile. And last of all my go anywhere/ anytime Gold Mega Rider bus pass for Stagecoach Devon.

All the above gets me by bus/ train/ walking to my emotional resources and sources of motivation; and they in turn mark-out the limits of my territory (between Exeter and Plymouth with occasional forages as far as Bristol).

My only goal is the next horizon, my only need to meet someone there I care about - who will teach me something I don’t already know!

 

(..but now all that has changed. As of November 2014 I have a new satchel - there is nothing wrong with the old one I just want it exclusively for beachcombing - and there has been a lot of change to the contents too, brought on by my inevitable switch to a smart mobile device. The new bag cost just as much as the old one, and contains the further luxury of a proper leather bound Filofax to replace the diary/address book. Just as others are coming to depend on an electronic organiser, I take seriously the research that suggests that when it comes to memory and recall, then the hand/eye work of handwriting is much more likely to help than a keyboard/console with a screen. The A4 pad has also gone in favour of the back of the Filofax. The attraction of Google Earth plus maps plus GPS means I’m down to one local A-Z, and far fewer transport timetables! I still rely on the Bus Pass, though I can drive if I need to. Increasingly the smart device leads, it satellites around the laptop at home, plus relieving me of the need to carry a digital voice recorder, a calculator, a book…)

Psychological Skill

Psychology is best understood as a set of physical skills. Now I suspect that sentence will seem odd to most readers, but a small minority will be thinking, ‘tell me something I don’t know!’

Unfortunately as my writing gets better, along with my confidence in understanding our social world, there seems to be an ever greater risk of losing what modest readership I already have. Perhaps one should just practice psychological skills, rather than try to write about them.

You see the problem is, there is this strange phenomenon of people liking mysteries and not wanting them explained. A lot of modern magicians have experimented with building explanation into their acts, but have sooner or later hit a wall - and it‘s not just a need to maintain trade secrets in order to earn a living. People want to be amazed, in awe of, and frightened (up to a point). In the world of mental health it often appears that someone in distress, does not want, nor responds to, either explicit explanation of their difficulties, or to training in techniques to relieve them. It’s even got to the point in our individualistic society where many will argue that there are no universal ways of understanding or helping - apart from the mysterious ‘love conquers all’! And the more knowledgeable person certainly doesn’t want to end up suffering the emotional isolation of what I call Sherlock Holmes Syndrome - of going to the trouble to explain (about inductive and deductive reasoning, how he built-up his library, apprenticed himself to learn about such things as horses and dogs, the logic of railway operations and timetabling, etc, etc) only for Watson to call it all inborn ‘talent’ and ‘genius‘, the police to call it ‘luck‘, and the public ‘…well when you put it like Mr Holmes, I can see it really is so simple anyone could…’ It was others who set him apart. People fear something is lost in explanation when in fact the reverse is true - it only adds to the wonder of the world.

But there is a more fundamental problem about explanation, learning and skill. For those of us who did not learn our social skills unconsciously and naturally in early childhood, it is a cause of fascination to watch the socially skilled finding themselves quite incapable of describing what they do so self-evidently well! Conversely it is alarming to watch one’s own continuing incompetence at the same time as knowing exactly what one is doing wrong. The old truism that those who find a subject or skill difficult to learn make the best teachers, often holds-up. Now we are into the domain of tacit knowledge, the knowledge and skills we know others have, know to be vital to much social interaction, whether work or leisure, which have proved impossible to write about or codify in other ways?

There is a huge body of knowledge (useful or otherwise, effective or harmful) that one knows is learnt, over long periods of time, possibly quite unconsciously, when alongside the most experienced of practitioners. You know they have ‘it’, that’s why you place yourself alongside them; they know they have ‘it’ but can’t articulate it to you.

Consider the following. The range of human emotions are universal and so is the way they are expressed. Human emotion is communicated through facial expression and tone of voice. (Whilst thoughts are communicated through the content of speech and hand gestures). There is relatively little individual variation. Emotion is felt as your facial muscles react to what you see or hear in the other person. Emotion comes first, thoughts follow.

Some of you will be thinking ‘well that’s bleedin’ obvious’, for others it may be a ‘bolt from the blue’.

I don’t do empathy (the ability to feel what others feel). At least not very well, and not most of the time. I didn’t learn that basic human skill in early life, which most people acquire so un-self-consciously that they don’t even name it. It’s not a ‘learning disability’ - I have the capacity, it simply became blocked. Hence my adult life has been one long painful process of mechanically acquiring the skill. And I’m not fluent in it - others can see the joins, often become fearful of me, and turn away. (Doing one of Paul Ekman’s tests I correctly guessed only 3 out of the 8 universal emotional expressions - and that was with 30 seconds to think about it!)

As for a ‘theory of mind’ (knowing how others think) well, a long time ago when I was a patient on a ward a student nurse demonstrated a few NLP basics, such as the reasoning behind ‘eye accessing cues’ - you see I’m profoundly left-handed, I’ll move anti-clockwise when 90% of the population are moving clockwise.

Twenty wasted years in the psychiatric system. Being diagnosed with depression, schizoid affective disorder and manic depression - actual taught me nothing. They only described, rather inaccurately, how my limbic system reacted to such dodgy data!

Psychiatry, clinical psychology and mental health nursing don’t know they are stuck at the end of a cul de sac - ramming each other out of road rage, whilst the rest of the world passes on the main road. Paul Ekman’s Facial Action Coding System has been available since 1978 but I know of no mental health worker who has ever learnt it. And of course any part of NLP has been thought ‘beyond the pale’ for the last twenty years.

There is much that is not mysterious. Simple laws can lead to massive complexity. Complexity does not mean something is necessarily complicated to understand. Darwin taught us that 150 years ago - he also guessed right about facial expressions!

The 'demanding' patient?

For the service user there is only one thing worse than the sinking feeling you get when you realise that others are saying they hear what you say, but are looking upon you as ‘mad’; and that’s the moment when you express suicidal thoughts and the worker stops listening, at the same time as insisting on not leaving your side - until you stop sharing those thoughts!

In my twenty year ‘career’ as a psychiatric patient it has been impossible to separate my changing or persisting notion of ‘self’ or personality, and the problems I may have, from the real social experience of being part of the mental health care ‘system’. And some of my peers will go so far as to state that it was the experience of hospitalisation itself that caused what others subsequently labelled a mental illness.

All I ‘know’ as a client (diagnosed as Bipolar) is that over the years I have met other clients, who after getting to know them a little will mention that at some point they have been given the label of a Personality Disorder; that it almost always came after having been given other diagnostic labels; that in terms of discrimination and stigmatisation it is the ‘shitty-ist’ label you can give someone; and that throughout my life I have satisfied many of the criteria for various types of personality disorder, though no one has given me that label - yet! My experience of mental health care, has meant that when I ‘see’ what others call aspects of a personality disorder, it is almost always in the context of some form of confinement; of people forced to live and work together who would, given a free choice, choose not to be there - workers, clients and carers. But the explanations offered by others for those behaviours, displayed in the present moment by people who have often experienced mental health care for many years, centre around traumatising childhoods - a failure to emotionally attach, dodgy learning, and the fixing of an identity at a young age with little change thought possible, until in middle-age they appear better able to cope.

Being on a ward for twenty-four hours a day, means the influence of clients on each other is much greater than that of staff. You learn to communicate very rapidly because you have no choice. What remains incomprehensible speech and bizarre behaviour to staff, becomes more and more understandable amongst peers. What looks like nonsensical behaviour to the outsider who spends most of their time away from the ward begins to make sense to those within it. Equally amongst new workers, what might be called a ‘myth of inarticulacy’ grows up. There is no sense to the client’s world, when viewed by those who are confident that they are ‘normal’ and living in the ‘real world’, therefore the obligation remains with the client to fit-in by making themselves understandable - staff come to have a an ethnocentric outlook. And the only way out for the client is to start ‘performing’ for the staff, you learn what it takes to get what you want, you do your best to manipulate the situation you find yourself in - until in middle-age you get so good at it, it looks like improvement and a change in personality. The only problem is, by then you’re a mental health ‘junkie’ and have to resort to such methods as writing your way out of it!

She said she had been watching me since I’d come down from the secure ward three days before. Between supplying me with cigarettes, she told me how I’d changed and was getting better - no nurse was ever quiet that observant! She described me to myself and gave insight. That was sixteen years ago. We met on and off in all sorts of mental health type locations over the years. When she was agitated (she would have said anxious) she’d seek me out repeatedly - maybe half a dozen times an hour. And perhaps ten times in as many years, we had in essence the same conversation about depression, suicidal thoughts and actions. By the end she had been in ‘the system’ forty years, me a mere twenty - she was the consultant, I just the junior doctor! Others, sometimes found our talk ‘inappropriate’, how naive - we were the ones in the moment, in reality and staring life in the face.

She described herself as Bipolar, but had a reputation for being terribly demanding and dependant. To me what she was doing was forever testing everyone. All those decades of receiving care but never any long term relief, had left her profoundly distrustful of workers and sometimes other clients. Thirty-five years of lithium hadn’t done much - now her kidney’s were packing-up. There had been repeated suicide attempts from which she’d achieved only greater competence. But then so too had those around her, leading to a kind of ‘arms race’: ‘My husband’s put a lock on the medicine cabinet’. A cascade of questions:

‘You know what it’s like don’t you Nick’
‘Yes!’
‘You’ve been there haven’t you Nick’
‘Yes!’

Always testing, always eyeball to eyeball, but acutely observant too when I was trying to explain something to others about the way it was - me knowing I’d better get it right or she’d lose her trust in me. What all the experience and mistrust had meant was that she valued honesty above all else. Physically she looked terribly slow, mentally she was quick, subtly rewording again and again what might seem like the same question but wasn’t, she tried to trip you up, because she had learnt others could not to be trusted. The answer was to concentrate on the question, and respond straightaway with the honest answer, however inappropriate or absurd it might sound! Only then did she get consistency, reliability. You had to be focused on her, not caring if you looked crazy to those around you. Workers, trying always to be supportive and consistent in their care therefore came over as the opposite, because they weren’t actually listening to the precise question. She didn’t care what the response was as long as it was honest.

It had become our routine that I was the one who always finally walked away. The last time we met we were together with others for several hours; me frustrated, wanting the workers out the way. But our personal relationship had a good ending. Knowing I was leaving she stood up, came over and brought it all down to four words;

‘Will I be alright?’
‘I don’t know’

I turned and left. She didn’t mean will I get better, she meant will I get to where I want to go. As usual when trying to tell workers that something else should be done I get back ‘client confidentiality’ and ‘inappropriateness’ and told my view is just my own and no more valid than anyone else’s. A couple of days later she died. Almost a week later I am told she has killed herself, whilst workers around me have known for days. It was ever thus.

Depressive, manic, rapid cycling, avoidant, dependant, borderline, obsessive? Sure, all of them at various times, persistently and enduringly over forty odd years; learnt, played-out and inseparable from the relationships made with those who make up the mental health system.

… but this is getting to be too much of a reconstruction, with the benefit of hindsight - and as we know every act of remembering involves a degree of reinterpretation.

Clients may not be being ‘demanding’ but ‘testing’ - behaviour firmly grounded in their previous experience of workers rather than imagined consistencies in a ‘personality’ glimpsed by others. Equally a major problem may be workers, believing they are giving consistency of care, but not being quick enough to follow changing emotional states, ending up giving rapidly changing inconsistent responses!

Christmas On The Ward

...I finished my essay on: ‘Is mental health a valid concept?‘ and returned to work. I’d only been in hospital for about ten days. Work was okay for a couple of weeks, and I was free of those experiences that had seemed to place me on the edge between reality and psychosis for a few hours at a time. We had a visit to the local prison which fascinated me; the kitchens, the hospital wing, being shut in a cell for a few minutes - my overriding memory was of the warders whose lives were dominated by their keys. We were introduced to different ‘nursing models’ and different wards where they were supposedly used. I attended an out-patient clinic, my talks with the consultant seemed to be all about medication, when and how I should reduce it. Then one night the snow came.

I was enthralled by it, I believed it was building higher and higher on the roof into a kind of tower. I decided to rearrange the flat. Move everything from the bedroom into the living room and vice versa. I took a couple of objects at a time from one room to the other, picking up some new ones for the return journey. Soon the scene became totally disorganised - like the inside of my head. I remember a walk at night, following street lights, trying to make sense of their patterns. Once I saw Bill (who two years earlier had been my therapist and was now one of my nurse tutors) standing in the shadows, he didn’t do anything but it was good to know he was looking out for me. I can’t remember the events that led to my return to hospital, but I know I was taken there again by ambulance and for a while refused to get out. I was disorientated in time and space, physically uncoordinated, disassociated from my surroundings and recent events. It was then that I was sectioned for the first time (compulsorily detained under the mental health act - either because I posed a danger to myself or others). I was taken to ‘intensive therapy’ (a locked ward).

I found this first period of confinement claustrophobic, the ward was too hot, the windows fixed so as to only open a few inches, there was one living area and a corridor with five single rooms on each side. We ate with plastic cutlery, our belts were taken away. If you wanted a cigarette you had to ask for one at the nursing station and they would give you a light. In the first few days I learnt just how interactive live TV could be. You had to watch from a certain angle, and synchronise eye movements, but then the people on the screen could send you personal messages.

I was only there for a week or so. After a few days my mood began to fall and I was relatively normal for a while. In a more rational state you begin to remember basics truths - like the easiest and fastest way out of a prison is the reverse of the way you came in. Whilst physical means of escape present themselves at times - the real trick is to get those who wanted you in, to want you out. It was a long walk through the remaining snow to the new acute ward. The section was lifted about a week later, now I settled down to trying to get on with another set of strangers, staff and clients. I started to feel depressed. The ward had been recently renovated, the contrast with the rest of the hospital was striking. The staff seemed proud of it, anxious to keep it neat and tidy. Despite being aware on some level that it was longer-term changes in mood, coming from within me, that were in some way fundamental; I was prone to deny it, and think in terms of ‘fate’, or of sometimes being ‘surprised by joy’ and of course - of being in ‘control’ of my responses to life events.

But my mood continued to drop and my surroundings appeared grimmer and grimmer. The most depressing place I’ve ever seen in my years in the world of ‘mental health’, was the patient Snack Bar. It was in the basement, poorly ventilated, with low artificial lighting. The one place in the hospital patients could get tobacco. Through the gray mist, ghostly figures sat a stools, communicating only with themselves. A nightclub for the half-dead. To be outside was too cold, roaming around inside did nothing to lift the mood. I did manage once to get access to a full size billiard table for an hour or so, but it required getting someone to unlock several doors in order to get there. I slowed down, time slowed down. The consultant stopped the tranquillizers, and started me on an anti-depressant. (No one explained the basic facts; that they take about two weeks to start to work [anything else is environment or placebo] reaching their maximum impact after six weeks. If you haven’t improved by then - you may be amongst the 20% for whom they have no effect). I was not aware of the pills helping me, but I kept taking them. When I started to express suicidal thoughts I was sectioned again. Soon I was facing the prospect of spending Christmas on the ward.

The high point of the day was the arrival of Mary. She was one of the night staff and was the one person I seemed to be able to relax with and have a normal conversation. It was easier to settle down at night and get some sleep when she was there. The future looked awful, I’d never be able to hold down a job or maintain a relationship. I was defeated. As usual the TV was on all day, with nothing but news of the build-up to the Gulf War. The future was unbearable to think about - I could only look to the past. About a year before I had bought an audiotape of Laurie Lee reading some of his poetry. I thought of one entitled Boy In Ice:
　
O river, green and still,
By frost and memory stayed,
Your dumb and stiffened glass divides
A shadow and a shade.
In air, the shadow’s face
My winter gaze lets fall
To see beneath the stream’s bright bars
That other shade in thrall.
A boy, time-fixed in ice,
His cheeks with summer dyed,
His mouth, a rose-devouring rose,
His bird-throat petrified.
O fabulous and lost,
More distant to me now
Than rock-drawn mammoth, painted stag
Or tigers in the snow.
You stare into my face
Dead as ten thousand years,
Your sparrow tongue sealed in my mouth
Your world about my ears.
And till our shadows meet,
Till time burns through the ice,
Thus frozen shall we ever stay
Locked in this paradise.
　
Just before Christmas my father made the long journey to see me, baring gifts from my mother. He was supportive, as he always is. His apparent simple ability to endure never ceases to impress me. Something I am still trying to emulate. His being there reminded me for a while that there was a life outside the hospital. Christmas would have been tolerable if the staff had not decided to give us a party on the ward. Music, a DJ and disco lights for what seemed hours on end. Now I slowed down even more, spending as much time lying down as possible, I hadn’t the energy to kill myself anymore. I thought again of Laurie Lee and Twelfth Night:
　
No night could be darker than this night,
no cold so cold
as the blood snaps like a wire,
and the heart’s sap stills,
and the year seems defeated.
O never again, it seems, can green things run,
or sky birds fly,
or the grass exhale its humming breath
powered with pimpernels,
from this dark lung of winter.
Yet here are lessons for the final mile
of pilgrim Kings;
the mile still left when all have reached
their tether’s end: that mile
where the child lies hid.
　
(Mary came alone to my single room, knelt by the bed, put her head close to mine, and spoke for a few minutes. She took my hand, then stroked my arm; but it was with a lover’s touch, and it was enough - she gave me undeniable evidence that I was alive, and likeable).
　
For see, beneath the hand, the earth already
warms and glows;
for men with shepherd’s eyes there are
signs in the dark, the turning stars,
the lamb’s returning time.
Out of this utter death he’s born again,
his birth our saviour;
from terror’s equinox he climbs and grows,
drawing his finger’s light across our blood -
the sun of heaven, and the son of god.
　
Slowly my mood began to recover a little, I was taken off the section, but the increased suicide risk was not recognised by others. (At the lowest point of depression you do not have the energy or organisational ability to kill yourself, the greatest likelihood of an attempt comes before, and after). Three times I went to the bridge over the motorway ready to throw myself off. My stolen car was found by the police, but then my flat was burgled. One night I didn’t return to the hospital, the police arrived, put me in a cell for an hour or so whilst the duty psychiatrist was found, after which I was returned to the hospital. At one point I spent many days in bed in my flat, but was visited by a couple of the nurses from the hospital who persuaded me to return to the ward. My diary shows an appointment with the consultant, presumably as an out-patient as late as mid-April. There was talk of returning to work, joining a new intake who had started in September, it would mean doing just one essay to catch up. Then one day I was looking at the reading, it was all about ‘nursing models’, and what should have been a simple task for a graduate to take apart and critically analyse - just seemed totally nonsensical. What I was reading just didn’t register, I had no concentration, it was utterly baffling. It was then that I threw in the towel. (I’ve not worked since). I would resign, leave the flat, stay with my parents on the coast. I was almost thirty-two, had been trying my best since I was eighteen, and had lost…
　
(That was the third period in my life when I’d been in and out of madness, and there have been many more since, some more extreme, others less so - yet you learn nonetheless, up to the point where now it seems I can live in parallel realities, switching between them at will!)

The above events took place at Christmas 1990 at All Saints Hospital in Birmingham, a Victorian asylum next to Winston Green Prison. Neither exist anymore of course, the Home Office acquired the hospital site, and the other Victorian asylum was renamed The Birmingham Prison.

2015

Lee, L (1985) Selected Poems Penguin: London

What is social neuroscience?

Neuroscience has expanded hugely in the last fifteen years or so since researchers have been able to buy time on hospital fMRI scanners during off-peak periods. By attaching ever more sophisticated computer technology, it has become possible to collect data that promises to close a major ‘missing link’ - between how the brain and behaviour of one person, influences that of another - how the physical science of the human body links to the psychological and the sociological. How the verbal and nonverbal communication of one person becomes that of another. Equally the results show a trend towards the brain being much more flexible, adaptive and capable of new learning (in all age groups) than was previously thought. Indeed the key question to ask now may well be; how do people manage to stick to habits and routines which narrow the possibilities of their lives when their brains have the capacity to do otherwise?

(Most neuroscientists proceed on the assumption that Darwinian evolution by natural selection applies to the human species - both biologically and culturally; or to phrase it differently; the rules of evolution apply to the maturation of the physical structure of an individual brain, plus all it’s acquired contents - all the learnt stuff!)

So researchers are now talking tentatively about a social neuroscience; how the daily physical experience of the world of others maps into the creation and growth of new connections in the brain leading to the strengthening or weakening of neural pathways (a physical process of chemical encoding) and of course, how it all comes out again before proceeding into someone else’s brain.

Asking ‘why?’ type causal questions, or trying to attribute agency becomes increasingly pointless. Rather we should stick to ‘how?’ When someone makes an assertion, the right response really is; who told you that? Nothing written on my blog is original, it’s just a series of links - OK! (And how come all these brain scientists are into eastern philosophies and meditation?)

Start with two very short TED talks; first Chris deCharms

http://www.ted.com/talks/christopher_decharms_scans_the_brain_in_real_time.html then proceed to the mighty ‘Rama’ http://www.ted.com/talks/vs_ramachandran_the_neurons_that_shaped_civilization.html For a good written introduction go to Daniel Goleman’s Social Intelligence http://www.amazon.co.uk/Social-Intelligence-Science-Human-Relationships/dp/0099464926/ref=sr_1_1?ie=UTF8&s=books&qid=1263909589&sr=1-1 (he finally got the right title for a book!)

The Recovery Movement (part 1)

The current fashion for the Recovery approach in mental health, means it is inevitable that it will feature in many of these blogs. I am, in part, a product of it myself, having been a client of one of the services which uses it, however I am also one of its critics. I don’t believe that the turnaround in my own mental health over the last four years or so can be attributed to the ideas and practices that Recovery-focused practitioners use.

Most people approach Recovery from an individual perspective - a worthwhile personal experience leads them to recommend it to others. I, on the other hand, have always seen it as a social movement within the world of mental health (hence the capital R).

The easiest way to introduce the subject is to signpost to short documents from individuals and organisations using the approach from here in Devon and the rest of the UK - I’ll leave the large number of connections to it in the US, NZ and Australia until part two (A brief history of Recovery).

In essence the Recovery movement has sort to change the way mental health services are organised and delivered in order to be more responsive to the stated needs of clients and their supporters. A set of ethical, moral and political values has emerged which are intended to inform the personal conduct of workers in their interactions with clients. To date, the movement has not generated any new theory of human behaviour or understanding of mental distress, nor has it advocated specific therapeutic interventions, and as such has not challenged the legitimacy of any of the occupational groups within the world of mental health.

A good starting point is the list of Recovery - concepts and applications devised by a group of commissioners, providers, service users and carers from Devon in 2008 and collated by Laurie Davidson http://www.scmh.org.uk/pdfs/recovery_concepts.pdf (There were originally eleven, not ten items - but that will be the subject of a future post!) The concepts were then used to inform the writing of Making Recovery A Reality published by the Sainsbury Centre For Mental Health http://www.scmh.org.uk/pdfs/Making_recovery_a_reality_policy_paper.pdf They were also reworked into a simpler form for the pamphlet Putting Recovery at the heart of all we do issued to all employees of Devon Partner NHS Trust http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/info/Putting_Recovery_at_the_heart_of_all_we_do.pdf In 2009 the SCMH issued Position Paper - Implementing Recovery: A new framework for organisational change http://www.scmh.org.uk/pdfs/implementing_recovery_paper.pdf laying out specific proposals from which standards and outcomes could be set. Finally, the Recovery movement, client-centred as it is, offers the user‘s own ‘story’ as the principal form of evidence for Recovery. A recent example Beyond the Storms: Reflections on Personal Recovery in Devon http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf edited by Laurie Davidson and Linden Lynn.

An evolutionary approach to mental health

What follows is a temporary, but necessary diversion into ‘grand theory’. Necessary, because any approach to mental health that isn’t compatible with a theory of human behaviour in general doesn’t stand a chance. (Those stuck in the insular world of psychiatry and clinical psychology please note). I’ve included references this time, just to give pause to those tempted to come down on me ‘like a ton of bricks’!

I have an evolving definition and explanation for what mental distress (disorder or illness, mild or severe) is. It shows itself as a misplaced fear of others. Personal relationships breakdown, followed by an inability to form and maintain new ones. The sufferer becomes progressively more emotionally and cognitively isolated (which may or may not involve physical isolation too).

Madness results from our failure to constantly update and modify the mental map of the world we have in our brain. If we do not ‘test’ our predictions, beliefs, dreams, thoughts, internal dialogue, fantasies, hypotheses, plans, ideas about how the world is, and what the people within it think and feel, our map becomes rapidly out of date. If we act with an out of date model of the world - we will look mad to others, and they will treat us as mad. If others don’t share a large part of our model of reality we are emotionally and cognitively isolated. Though none of us ‘see’ the world as it really is, we all rely on making a more or less accurate map; by sharing we come to have a more complete understanding than we could ever achieve alone. The ability to doubt and live with uncertainty, and hence know that we must constantly test our vision of the world - is sanity. To control and fix our view is the first step on the road to disaster. And of course the only way to maintain an unchanging outlook is to isolate oneself from any evidence that might contradict it. If we fail to observe (insufficient data) or misinterpret (wrong theory) then the map becomes more out of date. If our prediction disagrees with the experiment it is wrong. An unmodified and out of date model of the world is one where our thoughts and feelings are anchored in the past, hence our predictions of the future may be hopelessly wrong. Mental disorder is emotional and cognitive isolation to varying degrees.

Emotional reactions always come first, from what our five senses are telling us in the present moment, only afterwards do we attach thoughts. If we attach thoughts that come from the past, then we are operating with an out of date model of the world. So often we are not aware of what, in the present moment is ‘cueing’ our emotions and reproducing redundant thoughts. It is natural to be in a meditative state and to focus on the present moment. When the mind drifts away the discipline is to learn to let go, again and again. It is the opposite of taking control. It is about allowing decisions to make themselves, of not worrying about an unknowable future and refusing to get involved in hopes and expectations. The goal should be greater mental awareness of others, at the same time as being more physically relaxed. A full-time activity done with the eyes open. Meditation is not a set of skills that once acquired, can be called on at leisure; for one’s inability to operate in the world, based on the learning made in past relationships, will always return unless such skills are continuously practiced. Unwanted emotions and thoughts from the past will always ‘crash-in’ - meditation is a continuous process of letting go. The myth of self-control leads most to imagine that without it, mayhem and moral collapse will ensue. In practice, the need to manage others falls away and you become a better companion!

The best introduction to meditation I have come across, as a way of operating throughout the day, is to be found in Harrison (1994), and can be read along with his articles on how the core skills have been extracted from their religious context (Harrison 2005-). Sue Blackmore goes further, much further, by placed meditation techniques in the context of human cultural and biological evolution, and how we have evolved the very idea of a ‘self’ (Blackmore 2000:219-246). It’s possible to move towards a resolution of the contradictions of modern life, and the mental distress they give rise to, by developing both an evolutionary perspective and by being aware of the promise of social neuroscience (deCharms 2008, Goleman 2007, Ramachandran 2009). If you view daily life as evolution by natural selection, from minute to minute as well as on a timescale of the last 180,000 years (since we became homo sapiens with our full range of mental capabilities and capacities), see the biological and social as evolving in parallel and feeding back on each other (though at very different rates), then other kinds of questions and explanations suggest themselves (Oppenheimer 2004, Dawkins 1989, Blackmore 2000, Stevens & Price 2000, Nesse & Williams 1996, Nesse 2006).

We have lived out ninety-five per cent of our history as hunter-gathers, moving through and living from the environment. The last eight to ten thousand years, since we have sought to transform the environment (with the invention of agriculture, ideas of ownership and permanent settlement), has been an exceptional, perverse, untypical and abnormal period. Our point of reference for mental wellbeing should be the pre-agricultural world, where we evolved to be nomadic, as part of groups (‘bands’) of no more than about one hundred and thirty people, consisting of relatively close genetic relatives. You cannot ‘know’, as in feel an emotional attachment for, more than about that number of people.

Empathy (the ability to feel what others feel) and a ‘theory of mind’ (knowing how others think) derive from humans almost unique ability to imitate using the ‘mirror neurons’ of the brain, and give the capability to identify with, and be accepted by your group! (Blackmore 2000, Ramachandran 2000, 2003:97-131, 2006, 2007, 2009) If these abilities are blocked by life experience, then you become isolated from the people you are genetically most attached and attracted to. The last eight to ten thousand years has seen the construction of a world containing mental illness. And the culmination is the development of mental health workers, with the normal human capacities, who then try to empathise and share the ‘theory of mind’ of the unhealthy! This leads to the maintenance or reproduction of mental distress. Therapists should be leaders, mentors and role models to whom a client can apprentice themselves, and should not try to connect or catch the habits of the ill. As clients we must imitate the mentally healthy. Three out of four people don’t have a mental health problem during their life times.

And it’s not ‘faulty’ genes either, it is because we did our early learning with very close genetic relatives to whom we are automatically attached. Problems arise as a result of conflicts between the quality of our learning and our attachment to the person from whom we learnt. If you were separated from your close genetic relatives, your learning may well have been exceptional, but your life may become a search for those you are instinctively attached to. Equally you may search the world in vain for a ‘soul mate’, because it is so unlikely in modern society that you will ever meet that person, from the edge of your natural ‘group’, with whom you have a relatively close genetic attraction. It never was nature or nurture - but the ways in which your personal learning, your own cultural evolution, conflicted with the demands of your own biology. Your genes will determine to whom you are attached and attracted to, but it is with your learning that mental disorder is created and maintained.

References　
Blackmore, S (2000) The Meme Machine Oxford University: Oxford
Dawkins, R (1989) The Selfish Gene Oxford University: Oxford
deCharms, C (2008) Christopher deCharms looks inside the brain TED conference presentation Feb 2008

Goleman, D (2007) Social Intelligence: The New Science of Human Relationships Arrow: London
Harrison, E (1994) Teach Yourself To Meditate Piatkus: London
Harrison, E (2005-) articles for Nova Magazine available at http://www.perthmeditationcentre.com.au/articles/index.htm [10.1.10]
Nesse, R.M (2006) response to the ‘2005 Edge Question’ in Brockman, J (ed.) What We Believe But Cannot Prove Pocket: London
Nesse, R.M and Williams, G.C (1996) Evolution and Healing: The New Science of Darwinian Healing Phoenix: London
Oppenheimer, S (2004) Out Of Eden: The peopling of the world Robinson: London
Ramachandran, V. S (2000) MIRROR NEURONS and imitation learning as the driving force behind “the great leap forward” in human evolutionhttp://www.edge.org/3rd_culture/ramachandran/ramachandran_p1.html [19.7.08]
Ramachandran, V. S (2003) The Emerging Mind Profile/BBC: London
Ramachandran, V. S (2006) ‘Mirror Neurons And The Brain In The Vat’ response to the 2006 Edge Question at; http://www.edge.org/3rd_culture/ramachandran06/ramachandran06_index.html [3.6.09]
Ramachandran, V. S (2007) Self Awareness: The Last Frontier http://www.edge.org/3rd_culture/rama08/rama08_index.html [6.1.09]
Ramachandran, V. S (2009) The neurons that shape civilisation TED conference presentation.

Stephens, A and Price, J (2000) Evolutionary Psychiatry: A new beginning Routledge: London

Physical therapy for mental health

The brain and body are so intimately connected it makes little sense to separate them when conceptualising mental health. The appropriate ‘treatment’ for mental health problems may well be a physical one. When in the presence of someone who is ‘psychotic’, you probably won’t understand their speech content - why not just watch the body?
Tone and rhythm of speech, facial expression, eye and head movement, gestures, body posture and body movement. What would a physiotherapist see? Suppose on encountering someone for the first time you ignore the apparent mental problems; offer just physical relaxation techniques, enforce a regular but limited sleep pattern, strictly control diet and everything else they put in their bodies - and wait. Introduce mindfulness techniques - for better anxiety and stress management, for greater mental awareness as well as physical relaxation. Then what you are left with is someone with communication problems! A blocked ability to empathise, and a limited ‘theory of mind’.

Reintroduce the most powerful communication tool of all - touch! So they can learn, or more often relearn to be intimate with others - healthy others like you. You offer intimacy. You teach them to dance, to play table tennis and pool, for hour after hour - to gain ‘balance’ (physical coordination) and the ability to ‘navigate’ (in space and time) in that social landscape of others. You provide daily massage, so the client cannot deny the world of others. On such a foundation clients can start to learn again. Acute psychiatric units could be reorganised to provide physical not mental care, for the first week to ten days of any admission, only a client's physical signs and symptoms of ill health would be treated.

A cold body is physically and mentally stressed, warmth is relaxation - too hot and you are anxious. The body and mind feedback on each other. Health in body and mind are the same thing. The source of health lies in natural environments - just as nothing in nature can be ugly, only the man-made! We evolved to be outside and on our feet all day, with our eyes resting naturally on the horizon - catching the sun. Depression is entombing yourself all day, with a slumped body posture and nothing but artificial light, consuming more calories that you use up. It’s about having a fixed territory, being stuck in one place and one time, and defending it in both a mental and physical sense. Mental wellbeing is about being happy with movement and change.

It is not a sign of progress that the modern world is able to offer mental health care! It is offered because the need has developed since we started transforming our natural habits and ways of living. Anxiety and the heightened awareness that goes with it, is the normal response to perceived danger - the natural reaction is either fight, flight or to remain motionless (the predator notices first the moving object). In the absence of real danger, anxiety should rapidly fall away. It is normal to fear ‘outsiders’ or ‘strangers’. Anxiety is part way on the continuum from happiness (loss of self-consciousness) to intense fear. Misplaced fear of others in the modern world, or the inability to attribute fear to the right people (or less often other things in the environment) is what makes others appear as permanent strangers, outsiders or simply mad.

Most communication is non-verbal, and cannot be spoken or written down - but can be physically observed and physically responded to. The meaning of any communication is the message received. You can only be conscious of a tiny fraction of what your brain is doing in any one moment - including thoughts and emotions. You can only ‘know’ your character by what you put in your body, and by the kind of people you spend your time with. The best diet for physical and mental health is a pre-agricultural one; the absence of refined sugars, cultivated and ground grains, domesticated animal meat and milk. The inability to navigate with sight, sound, touch, smell and taste, is a fundamental element of what some call psychosis. A lack of balance, not being able to let the eyes rest naturally on the horizon, which is obscured by the built environment, and feel the natural contours below one’s feet, equally obliterated in the modern world, shows in the long term mental as well as physical ‘crippling’ of the body!

Meditation techniques for mental health

Meditation is about being more physically relaxed at the same time as gaining greater mental awareness - throughout the day and with your eyes open! It’s about being in the present moment and therefore more grounded in reality. Despite the rather naive acceptance by some psychiatric authorities of mystical claims about ‘altered states of consciousness’; misunderstanding over an apparent connection with trance, dream like states and psychosis; and the timid approval by the NHS of just one aspect of meditation known as Mindfulness (sometimes referred to as ‘kitchen-sink meditation’) - it is, once stripped of its religious elements, the most important tool I have against madness. It’s the best anti-psychotic there is.

Untangling the myth however is not easy, you need to ‘suspend your disbelief’ and consider for a moment that the meditator is more in touch with reality than you are. You may imagine someone on a mountainside, eyes closed in the lotus position, but the real practitioners may be passing you in the street unnoticed - they blend into the social landscape because they are in the here and now, whilst you are preoccupied with your own thoughts. Your conscious thoughts can only be about the past or future, in the present you only have your senses with which to literally ‘feel’ your way around. Realise your emotions come from the data your senses are giving you now - then you’ll have it! It’s a shock, like waking up from a dream, you are back in the real world for the first time since - when? Suddenly self-consciousness, anxiety and fear can be put to their proper use; of spotting the occasional occurrence of real danger. You can get back to the proper use of your time, finding activities that match your skills and can become absorbed in, achieving some degree of ‘flow’, that sense of happiness that comes from the loss of self-consciousness - something we all felt in childhood play.

The first ‘pay off’ from meditation is the awareness of where you feel fear in your body, what in the environment has triggered or cued your brain to remember some past unpleasant association. It may be an unwelcome series of sensations to begin with, but it soon becomes a useful revelation. This is followed by learning to let go of unwanted thoughts and feelings about the past and future. In the process you can stare life in the face - as it is now.

One of the things meditation tackles well is our ‘illusion of self-control’. We like to think we are consciously in control of ourselves all the time. We distrust our basic, spontaneous impulsive actions. We must be constantly choosing all the time as free independent individuals. As a result we have become acutely self-conscious. Yet there is only so much we can keep at the forefront of our minds at any one time. We come to consider it a failure or lapse in our own standards when we inevitably end up following the impulses of biology, and the learning we unconsciously achieved earlier in our lives. Meditation, by placing us back in the present moment and allowing us to feel what cues us, what stimulates our senses, shows us just how unnecessary the time and trouble we spent on worrying about decisions really was. Decisions are all about an unpredictable future over which we can exert little control. However, we can learn to trust our own brains to get on with it, become grounded in the environment of the present, reconnected to the social world of others, and just be.

Objectives

- to concentrate on the present moment all the time; let go of any thoughts that come up (knowing they can only be about the past or future), know too that in any one moment there is no observable ‘self’; to notice what is happening (not a series of events but continuous change), to pay equal attention to all that can be seen and therefore know what habitually cues you to feel or respond in a particular way (your attention, reactions, emotions, and the ‘story’ you tell yourself about who you are) - and so ultimately realise that it is the actions of others that is creating you.

- to understand that the ‘I’ or ‘me’ that appears when you want something is an obstacle to your sense of wellbeing; to allow decisions to make themselves (unconsciously) since the conscious self is not in control and actions happen whether or not you will them - sense the freedom that comes from knowing you don’t have to try to do anything!

- to refuse to get involved in desires and hopes (about an unknowable future), to know that it is quite possible to live without hope (now is all there is), that in the world of the present you can stop inflicting your desires on others, stop the harm we often do and be able to notice others more.

Finding A Focus

At the core of meditation is the ability to focus on something; whether it be within the body, an external object or a mental image. Focus is not concentration as such, but a fixed point of reference, something you always come back to. A fixed point, baseline or benchmark from which you can navigate your mental interpretation of the physical world. Physical relaxation must come first and the easiest way in is to focus on the breath - not control it, just ‘watch’ it. Once relaxed you can begin to focus away from yourself towards the environment you find yourself in. In a natural environment it makes sense to let your gaze rest on the horizon and make that your focus. Whether we like it or not our attention will be constantly distracted by whatever our senses pick up from the environment and the internal thoughts and feelings prompted by those cues. The ‘trick’ is to always come back to the focus, again and again. You acknowledge the thought or perception, and let it go in the act of always returning to the focus. When truly focused, for however shorter time that may be, you think of nothing else. However the choice of focus at any one time does need to be something that holds your interest - something you enjoy exploring. Good focusing is a joy, as you begin to learn to let go you can start to recapture that childhood sensing and feeling, which never required conscious thought and has a fascination all of it’s own.

Balance

There is however a need to create a balance, between physical relaxation (too much of which leads to sleep) and greater mental awareness (which if not matched with the right degree of relaxation, may provoke a degree of anxiety about ‘what’s going on’ and increase self-consciousness). Stress is not an external force, but occurs within the body, our attention is usually directed outwards so we don’t recognise it in our bodies. In the process of physically relaxing we can identify stress and let it go; so our increasing awareness becomes a tool with which to see the world rather than a product of anxiety that may cause us to turn away.

Relaxation

If the first requirement is physical relaxation, and that is dependant on focused breathing, then an unrestricted diaphragm is a precondition of meditation - it is not the choice of posture itself that matters, but how you hold yourself in it. You can meditate whilst sitting, lying down or walking. The breath naturally changes throughout the day and from minute to minute, if you can learn to watch it and not seek to control it, you notice how it automatically adjusts itself. After meditating for a while you realise it was your conscious attempts to control it that caused the problems in the first place. Unrestricted breathing then allows you to ‘listen’ to the body. Normally when we relax our minds have a tendency to wander, to fantasise or free associate, leading to sleep. Meditation usually has the opposite intention, beginning with the kind of self-knowledge that arises from a greater awareness of the body. You can literally feel mental stress as physical pain - as you begin to relax. Much mental distress is a shutting-off of awareness, of stopping feeling. Becoming more aware of the body begins to put you back in ‘touch’! Much of the tension in our bodies is an attempt to suppress unacceptable emotional responses. The technique known as a ‘body scan’ starts with an awareness of the breath, followed by deliberately focusing bit by bit on every area of the body, identifying tension, gently flexing the muscles, at the same time as noticing the thoughts and feelings that arise. And in the act of physically letting go, it’s a shock to realise just how much mental preoccupation seems to float away. Fear, anger, sorrow and desire all disappear when we are truly relaxed.

Meditating for sleep is different, with the eyes closed you may wish to initially focus on the breath, and body scan. But you shouldn’t seek greater awareness nor be tempted to move on and fantasise in a controlled, ‘story making’ way. Rather think of how dreams are when you’re asleep - less coherent, more a free association of thoughts. One technique is to explore a single visual image rather than imaging a movie.

The link between mental and physical relaxation becomes obvious when you see what great physical performers can do, and realise they could never do what they do unless they were relaxed in a holistic sense. But an even greater revelation comes when you see and hear those same people interviewed! If you want exemplary examples of ‘mental health’ look to the great dancers.

Awareness

Many people equate being alert with conscious thinking. But we can only be conscious of a very small amount of the brain’s activity at any one time and much of it we are never aware of. And we don’t need to be. What is useful is to educate ourselves from time to time about those things that habitually cue us to behave in a certain way. Not so much in order to change, but to stop ‘beating ourselves up’ over those things we have consciously decided should not be part of our self, our ‘I’ or ‘me’. Indeed with a lot of practice you can have consciousness, but no consciousness of self - just awareness!

Mindfulness is a basic technique to help you move from motionless meditation at an allotted time, to incorporating it into what should be continuous movement throughout the day. It’s about focusing on, and paying close attention to the detail of what we are doing in any given moment. Being very aware of the sights, sounds, smells, tastes and textures of the moment, becoming awake and tranquil by focusing intently on minute details. (There are obvious parallels here with being absorbed in the physical practice of a skill, but without the prescribed outcome). When eating just eat, when walking just walk. Walking is a good way to face each day a fresh, when you walk you ‘own’ nothing, you’re in constant movement and there is nothing but change around you, it feels natural to be nomadic - or it should do!

Mentally letting go again and again, brings greater awareness in the hear and now. It is the greatest reward of meditation to be suddenly flooded with insight, an intense feeling or a change of mood. To wonder where it came from, stop, look around, and then be amazed a second time to realise what cued that change. Understanding, and acceptance, of how things just are - in the same moment. And then to let go again. To borrow from Wordsworth: ‘Surprised by joy - impatient as the Wind …’. You lose nothing by letting go of good, as well as bad thoughts and feelings, because as you change, the ones that are useful and real will come back time and time again. Equally tranquillity comes not from changing the world, but from allowing the moments of emotional pain to die a natural death. Sometimes we don’t want to let go of our worries and fantasies, the conflicts that preoccupy us, they become part of our identity and maintain the world as it is, giving the illusion of self-control - the feeling that we can predict the future. But if we can be relaxed and aware in the present, all that falls away - we forget what used to preoccupy us.

When out and about the focus may switch from the breath to a visual object, a fixed point for navigation, but equally there is visualisation, an imagined image for still periods, usually with the eyes closed. But then there are transition states too, for example, ‘body asleep, mind awake’ which can have a better quality than sleep alone. You gain the benefit of an asleep body, but the mind, rather than having the chaos and illogical thoughts of dreaming, stays clear and focused.

And there are the times when it doesn’t matter if what we are sensing, tasting, touching with our bodies is pleasant or not! You just don’t feel the need to explain, understand, or solve, but simply watch and feel - then the realisation of the ‘right thing to do’ will occur at the time when it is appropriate to act. If we are open to the world, not preoccupied with ourselves, then our instinctive responses (which we have been taught to mistrust or contain) will fit the facts and we just feel the appropriate response in a given situation.

To Be More ‘Grounded’

Once grounded, we change and move on automatically. A connectedness to the physical world around us should be our moment to moment preoccupation. We cannot see others in our environment as they are, without it. When we are not preoccupied with ourselves, then we can see the needs of others. And it is in this state that we can approach an understanding of what may be the true basis of what is called spirituality or religious experience. Making others, and or, other things, rather than oneself, the central focus of our lives, allowing transcendent experiences - going beyond our usually limited perception of others. But it is equally valid to assert that in the past there must have been a time when we were all very effective at meditation. That in some sense it must be a natural state, for it is hard to imagine our hunter-gatherer ancestors being able to survive without such skills. Think of hunting, of long hours on one’s feet, of the constant gentle movements needed to pick up a trail, to track and stalk, feel movement in the air, the physical coordination, the ability to navigate, feel the sudden stress of real danger, but be able to let go when it passes, the need for so much stillness, and the quick flowing response. And afterwards, to squat for a while under a tree, to be within the only real temple there is - not enclosed by the buttressing of the branches, but open to the vaulting of the sky beyond. Later, the making of fire - the focus of community and collective narrative.

'To see a world in a grain of sand
And a heaven in a wild flower
Hold infinity in the palm of your hand
And eternity in an hour.'
William Blake 1757-1827: ‘Auguries of Innocence’ (c.1803)

That might well serve as a description of the potential of meditation and truly being in the moment. And Blake of course, experienced visual hallucinations from early childhood onwards. Meditation is a discipline that takes time and effort; though the more competent one becomes the more effortless it feels! Nonetheless like any set of skills, if you don’t practice then you lose them. It’s often when you feel at your lousiest, and have to ‘try’ the hardest that the most rewarding meditations follow. It is not unusual to suddenly feel worse as you relax and become more aware - you realise what’s been going on! This is the crucial moment to learn to continue meditating and not turn away - it is when the benefits really begin. At its best meditation gives a series of ongoing, ever deepening natural ‘highs’ based solely on increasing awareness of the fascination of the world around you. But don’t become a ‘bliss junkie’; stuck in a particular form of meditation, confined by time, place and routine or ritual - with a fixed set of beliefs about what is happening to you and your state of mind, seeking a continuous high, but effectively isolated from the rest of the world.

Meditation offers greater enjoyment of the sense world, deeper more varied emotional experiences and a sense of there being enough time. It feels like life with the ‘blinkers’ off, of a mental fog having lifted, in which we no longer fantasise - but then you catch yourself losing the focus again! But that’s as it should be, when navigating your way around a world of continuous change. Scientists and researchers in search of an ‘evidence base’ for meditation may object that whilst you can demonstrate a link with physical relaxation, the idea of greater mental awareness is not amenable to experimentation. Perhaps they are looking in the wrong place. I would wish to argue that it is the heightened awareness that comes with sudden stress or anxiety, and which to some extent has been measured, which through the discipline of meditation, is being harnessed by an individual who nonetheless remains physically relaxed.
　
Catch Tomorrow Now
　
Can you stop?
Let go of thoughts and feelings
Of the past and future
And just be in the present moment.
Now is all there is.
Reattach your emotions to your senses
In the real physical world of the present.
Notice what cues your thoughts now
Acknowledge them and let them go
Good or bad.
Allow yourself to feel the bad when it happens
Then it passes quickly.
Allow yourself to be ‘surprised by joy’
And let go those feelings too.
Knowing they will return unbidden.
Think of yourself as having no fixed self.
Able to construct a self anew every day
Attentive to others, unconcern for an ‘I’ or a ‘me’.
Aware of the others who make you what you are.
You learn most by imitation.
You only remain fixed
When you remake yourself today
As you were yesterday.
You imagine the past must persist into the future
But only because you reproduce it afresh everyday.
Don’t look forward or back, but around.
Seek to be more relaxed and aware.
Absorb what’s around you
And catch tomorrow now!
　
The Rules
　
Can you stop?
Let go of the past and future - again and again
Be in the present moment
Pay equal attention to everything
Notice in the moment what cues your thoughts and emotions
Now is all there is
Let decisions make themselves
Refuse to get involved in hopes and expectations
Physically relax yourself continuously
Always have a focus

Catch Tomorrow Now - part 2

Can you replace your assumptions about others,
With curiosity and fascination?
And can you unlearn as you let go?
Your routines should be made to work for you,
Habits should be unconscious,
Leaving you free to notice other things.
There is no such thing as a mistake, only new learning.
And the meaning of any communication,
Is always the message received.
Every thought comes with an emotion attached
And rationalising is just a way,
Of putting emotions on hold!
Experiences just make you feel good or bad,
Meanings become attached afterwards;
And meanings never started anything!
Motivation for action can only come,
From an emotional attachment to others.
But it’s a misplaced fear of others,
That is the consequence of mental disorder!