Posts tagged psychiatry
Posts tagged psychiatry
An online platform that helps people with bipolar disorder self-administer therapy has proven to be successful in a small trial, with 92 percent of participants saying they found the content positive.
Nicholas Todd, a psychologist in clinical training at the NHS Trust, has developed the site as part of a project he’s running called Living with Bipolar.
In it, he asked 122 people to use a sort of e-learning environment that uses audiovisual models and worksheets, incorporating parts of cognitive behavioral therapy and psycho-education known to be effective in bipolar patients. There’s also a peer support forum, which is moderated by a member of Todd’s research team, and motivational emails were periodically sent to those on the trial.
"Service users were encouraged to access the intervention flexibly and use it as and when they felt appropriate," Todd told Wired.co.uk. That’s because, as he presents in a paper on the platform, for patients “recovery is defined as people living a fulfilling life alongside their condition”. As such, it needs to fit in around them, their lifestyle and their changing needs.
One participant comments: “….for me recovery is certainly not about being symptom free… it is about coping and having a reasonable quality of life, being able to work productively and enjoy things outside of work.”
Thus, Todd explains, “service users did not focus on a ‘cure’ as their desired outcome but instead personally defined recovery goals and improved quality of life.”
By the trial end, Todd found that on average, users who stayed till the end completed 60 percent of the program. Of the people that completed the whole thing — 15 modules — 74 percent took under three months to do so.
The platform took a year to develop, spent looking at the most effective components of psychological therapy for bipolar disorder. As this was narrowed down, the group carried out five focus groups and tested it online via a consultancy group.
The system gets users to identify their own mood using an established scale, the idea being they — and the system — can track their own ups and downs. “Service users would then receive information about the most appropriate modules, given their mood symptoms,” says Todd.
The forum, he says, played a key role in the project’s success. One participant commented, “…part of it [bipolar disorder] is feeling very alone… you don’t get that and I do think that the forum works extremely well with the intervention…” Todd explains how participants used it to support each other not only through the new intervention process, but through life events.
"A balance was struck between allowing participants to offload, and posts which encourage or talk about acts of suicide, self-harm, harm to others and are unhelpful to participants’ recovery." A total of 70 percent of the users signed up to the forum, and 1,927 posts on 130 topics were accumulated. "The participants who used the forum tended to complete more modules, and all participants who completed the entire program used the forum, albeit in different ways."
The idea behind the platform is to help bridge those periods between appointments, or those appointments that a patient misses. As with depression, health services can be known to administer solely medication to help alleviate symptoms. More and more, the NHS is striving to ensure psychological therapy is integrated alongside a prescription for mood stabilizers, such as lithium. “However, severe inequalities in access to psychological interventions for bipolar disorder currently exist in the NHS,” Todd says. “This intervention aims to increase access to psychological intervention.”
Todd tells us the NHS is actively training more staff to deliver psychological therapy, to plug the gap. For now, that initiative is being piloted for severe mental health conditions. “This intervention may fit as part of this initiative in giving service users with bipolar disorder greater access to psychological therapy.
"Computerized interventions are not about replacing face-to-face interventions, but giving someone another option to receive psychological support. In fact, some people prefer accessing psychological support in this way as it fits better with their lives."
For one woman in particular the experience has been, in her words, “life changing”.
She said: “I have encountered insights in the modules that have significantly helped me to survive the blackest moments. I cannot measure the value of this, as it has contributed to their difference between life and death. My husband and I are sincerely grateful for the immeasurable impact this has had on our family.”
My mother was a woman hollowed out like a tree struck by lightning. I wanted to know why.
Ever since her first suicide attempt, in 1978, when I was 22, I had been trying to fill in gaps. She was gone much of the time in my early childhood, and when she returned nobody spoke about the absence.
I learned much later that she had suffered acute depression after my younger sister’s birth in 1957. She was in hospitals and sanitariums being shot full of insulin — a treatment then in vogue for severe mental disorder — and electricity. The resulting spasms, seizures, convulsions and comas were supposed to jar her from her “puerperal psychosis,” the term then used in England for postpartum depression.
In 1958, my mother was admitted to the Holloway Sanatorium, the sprawling Victorian Gothic fantasy of a 19th-century tycoon, Thomas Holloway, who amassed a fortune through the sale of dubious medicinal concoctions. The sanitarium, opened in 1885, was a great heap of gabled redbrick buildings, topped by a tower rising 145 feet into the damp air of Surrey.
Run initially as a private institution, the Holloway Sanatorium became a mental hospital within Britain’s National Health Service after World War II. It was not closed until 1981. Many of its records and casebooks were burned. The gutted building became a setting for horror movies. Directors could not believe their luck. It is now a gated community of luxury homes.
Some records were preserved at the Surrey History Center. In the faint hope that a trace remained of my mother, I wrote to inquire. My parents had never spoken in any detail of her first depression. A letter came back a few weeks later. References to June Bernice Cohen had been located in the admissions register and in ward reports from July 1958.
These showed that “she was patient number 9413, was admitted on 25th July 1958 and discharged on 12th September 1958.” The ward reports for most of August and September had vanished. I applied under Britain’s Freedom of Information Act to see the records.
My re-encounter with my mother involved painstaking negotiation with an archivist. At last I was presented with the weighty register for female patients. Entries are written with fountain pen in cursive script. In columns across the page my mother is identified. “Name: June Bernice COHEN. Ref Number: 9413. Age: 29. Marital Status: Married. Religion: JEW.”
I stared at her age — so young — and at the capitalized entry under religion: “JEW.” The noun form has a weight the adjective, Jewish, lacks. It seems loaded with a monosyllabic distaste, which was redoubled by the strange use of the uppercase. June was not religious. She is the youngest on the page. She is also the only non-Christian.
The first ward notes on my mother read, “History of depression in varying degrees since birth of second child, now fourteen months old. Husband is engaged in medical research. Patient has some private psychotherapy and also modified insulin treatment at St. Mary’s last month, being discharged July 8th. On admission she was depressed, tearful and withdrawn.”
The doctor examining my mother was struck by how “her tension increased remarkably on mention of latest child.” I ran my fingers over the page and paused at “JEW.” I wanted to take a soothing poultice to her face.
On July 28, 1958, my mother was visited by a Dr. Storey. He “confirms diagnosis of post-puerperal depression and advises Electro-Convulsive Therapy (ECT), which patient and husband are now willing to accept.”
She first underwent electroshock treatment on July 30, 1958. I see my slight young mother with metal plates on either side of her head, flattening her dark curls, her heart racing as her skull is enclosed in a high-voltage carapace. I can almost taste the material wedged in her over-salivating mouth for her to bite on as the current passes.
The treatment was repeated a second time, on Aug. 1, 1958. That was one day before my third birthday. So, at last, that is where she was.
I now have some facts to anchor memory, fragments to fill absence. My mother, who recovered sufficiently to be stable, if fragile, for about 15 years through my childhood and adolescence, would suffer from manic depression, or bipolar disorder, through the latter third of her life. She died in 1999 at the age of 69. The ravages of this condition I observed; the onset of her mental instability I only felt.
The hidden hurts most. Mental illness is still too clouded in taboo. It took me a long time to find where my mother disappeared to. Knowledge in itself resolves nothing, but it helps.
Acceptance — it comes down to that. This is how I came to this point, and to this place, by this looping road, from such anguish, and I am still alive and full of hope.
Loser! You messed this up again! You should have known better!
It’s that know-it-all, bullying, mean-spirited committee in your head. Don’t you wish they would just shut up already?
We all have voices inside our heads commenting on our moment-to-moment experiences, the quality of our past decisions, mistakes we could have avoided, and what we should have done differently. For some people, these voices are really mean and make a bad situation infinitely worse. Rather than empathize with our suffering, they criticize, disparage and beat us down even more. The voices are often very salient, have a familiar ring to them and convey an emotional urgency that demands our attention. These voices are automatic, fear-based “rules for living” that act like inner bullies, keeping us stuck in the same old cycles and hampering our spontaneous enjoyment of life and our ability to live and love freely.
Some psychologists believe these are residues of childhood experiences—automatic patterns of neural firing stored in our brains that are dissociated from the memory of the events they are trying to protect us from. While having fear-based self-protective and self-disciplining rules probably made sense and helped us to survive when we were helpless kids at the mercy of our parents’ moods, whims and psychological conflicts, they may no longer be appropriate to our lives as adults. As adults, we have more ability to walk away from unhealthy situations and make conscious choices about our lives and relationships based on our own feelings, needs and interests. Yet, in many cases, we’re so used to living by these rules we don’t even notice or question them. We unconsciously distort our view of things so they seem to be necessary and true. Like prisoners with Stockholm Syndrome, we have bonded with our captors.
If left unchecked, the committees in our heads will take charge of our lives and keep us stuck in mental and behavioral prisons of our own making. Like typical abusers, they scare us into believing that the outside world is dangerous and that we need to obey their rules for living in order to survive and avoid pain. By following (or rigidly disobeying) these rules, we don’t allow ourselves to adapt our responses to experiences as they unfold. Our behavior and emotional responses become more a reflection of yesterday’s reality than what is happening today. And we never seem to escape our dysfunctional childhoods.
The Schema Therapy Approach
Psychologist Jeffrey Young and his colleagues call these rigid rules of living and views of the world made by the committee in our heads “schemas.” Based on our earliest experiences with caregivers, schemas contain information about our own abilities to survive independently, how others will treat us, what outcomes we deserve in life, and how safe or dangerous the world is. They are also responsible for derailing intimate relationships.
Young suggests that schemas limit our lives and relationships in several ways:
A woman we will call Diana has a schema of “Abandonment.” When she was five years old, her father ran off with his secretary and disappeared from her life, not returning until she was a teenager. The pain of being abandoned was so devastating for young Diana that some part of her brain determined she would live her life in such a way as to never again feel this amount of pain. Also, as many children do, she felt deep down that she was to blame: she wasn’t lovable enough, or else her father would have stuck around; a type of “Defectiveness” schema.
Once Diana developed this schema, she became very sensitive to rejection, seeing the normal ups and downs of children’s friendships and teenage dating as further proof that she was unlovable and her destiny was to be abandoned. She also tried desperately to cover up for her perceived inadequacies by focusing on pleasing her romantic partners and making them need her so much that they would never leave her. She felt a special chemistry for distant, commitment-phobic men. When she attracted a partner who was open and authentic, she became so controlling, insecure and needy that, tired of not being believed or trusted, he eventually gave up on the relationship.
Diana’s unspoken rule was that it was not safe to trust intimate partners and let relationships naturally unfold; she believed that if she relaxed her vigilance for a moment, her partner would leave. In an effort to rebel against her schema, she also acted in ways that were opposite to how she felt; encouraging her partner to stay after work to hang out with his friends, in an attempt to convince herself (and him) that she was ultra-independent. This led to chronic anger and dissatisfaction with her partner.
Diana did not understand her own role in this cycle. Diana (and her partner) needed to understand how her schemas resulted in ways of relating to herself and others that are repetitive, automatic, rigid, and dysfunctional. By acknowledging and connecting with her unresolved fears and unmet needs, Diana could become more flexible and allow her partner more freedom without feeling so threatened.
The schema concept helps us understand how early childhood events continue to influence adult relationships and mental health issues, that we need to recognize their influence and (with professional help, if necessary), begin to free ourselves.
Six Things You Can Do Right Now
The tools and tips below will help you begin to identify your core schemas and take some corrective actions.
2. In close relationships, think about your partner’s background, beliefs and behaviors to see whether they fit into one of the schema patterns identified here. Think about the times when your communication gets derailed and you both get angry or defensive. What schemas may each of you be bringing to the table and how may they be setting each other off. For example, a partner who has an Entitlement schema may act in needy and demanding ways that trigger the partner with an Emotional Deprivation schema to feel uncared for.
3. Pay attention to when you or your partner are getting triggered. You may notice feelings of anger or helplessness, thoughts that contain the words “always” or “never,” and feelings of tension or discomfort in your body. You may feel reactive and tempted to withdraw or say something impulsively.
4. Practice the STOP technique when you are triggered during a conversation with your partner. This is a practice from the Mindfulness-Based Stress Reduction course developed by John Kabat-Zinn. STOP what you are doing, TAKE a breath, OBSERVE what you are doing, thinking, feeling and what your partner is doing, thinking, feeling. Think about whether your schema is calling the shots and if you would like to change tracks. Then PROCEED with a more mindful response.
5. At a time when you are both calm, sit down with your partner and try to figure out the cycle that happens when both you and your partner get reactive to your schemas. Decide how to communicate that this is happening in the moment and call a break.
6. Train yourself in the skill of cognitive flexibility. Deliberately think about other ways to interpret your partner’s behavior that are not consistent with your schema? Perhaps he is withdrawn because he had a hard day at work. Are you personalizing things too much?
Schemas are more likely to be triggered when your emotional needs are not being met. Take some time alone to reflect on what these needs might be. Then practice some healthy ways of taking care of your own needs for love, security, comfort and so on. Harness your inner “Healthy Adult” to proactively take care of yourself so you’re less likely to feel deprived and reactive.
Scientists came to the conclusion after speaking with 60 schizophrenics 20 came from California, 20 from Accra, Ghana and 20 from Chennai, India In America, voices were intrusion and a threat to patient’s private world In India and Africa, the study subjects were not as troubled by the voices. The difference may be down to the fact that Europeans and Americans tend to see themselves as individuals motivated by a sense of self identity. Whereas outside the West, people imagine the mind and self as interwoven with others and defined through relationships.
People suffering from schizophrenia can often hear imaginary voices so terrifying that they are left traumatized.
One American patient described the voices as ‘like torturing people, to take their eye out with a fork, or cut someone’s head and drink their blood.’
A study has now found that these voices can be shaped by culture, with Western cultures experiencing far more disturbing psychotic episodes.
Schizophrenia is a severe brain disorder that can cause people to hear ‘voices’ that other people don’t hear. It affects about one per cent of the global population over the age of 18.
Many people in Western cultures have reported hearing voices claiming other people are reading their minds, controlling their thoughts or plotting to kill them.
In Africa and India, however, these hallucinatory voices appear as harmless and even playful, according to the study by Stanford University in California.
While there’s no cure for schizophrenia, this study suggests that therapies urging patients to develop relationships with their imaginary voices could prove useful.
As part of the study, Professor Tanya Luhrmann interviewed 60 adults diagnosed with schizophrenia; 20 each in San Mateo, California; Accra, Ghana; and Chennai, India.
Overall, there were 31 women and 29 men with an average age of 34, who were asked about their relationship with the imaginary voices.
While many of the African and Indian subjects registered largely positive experiences with their voices, not one American did.
Instead, the U.S. subjects were more likely to report experiences as violent and hateful.
For instance, they spoke of their voices as a call to battle or war – ‘the warfare of everyone just yelling.’
The Americans mostly did not know who spoke to them and they seemed to have less personal relationships with their voices, according to Professor Luhrmann.
But among the Indians in Chennai, more than half heard voices of kin or family members commanding them to do tasks.
'They talk as if elder people advising younger people,' one subject said. That contrasts to the Americans, only two of whom heard family members.
The Indians also heard fewer threatening voices than the Americans – several heard the voices as playful, as manifesting spirits or magic, and even as entertaining.
Finally, not as many of them described the voices in terms of a medical or psychiatric problem, as all of the Americans did.
In Accra, Ghana, where the culture accepts that disembodied spirits can talk, few subjects described voices in brain disease terms.
When people talked about their voices, 10 of them called the experience predominantly positive; 16 of them reported hearing God audibly. ‘Mostly, the voices are good,’ one participant remarked.
The difference may be down to the fact that Europeans and Americans tend to see themselves as individuals motivated by a sense of self identity, said Professor Luhrmann.
Whereas outside the West, people imagine the mind and self as interwoven with others and defined through relationships.
In America, the voices were an intrusion and a threat to one’s private world – the voices could not be controlled.
However, in India and Africa, the subjects were not as troubled by the voices – they seemed on one level to make sense in a more relational world.
Still, differences existed between the participants in India and Africa; the former’s voice-hearing experience emphasized playfulness and sex, whereas the latter more often involved the voice of God.
'The difference seems to be that the Chennai and Accra participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind,' the researchers wrote.
The research, Professor Luhrmann observed, suggests that the ‘harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia.’
The findings may be clinically significant, according to the researchers and adds to research that shows specific therapies may alter what patients hear their voices say.
'Our hunch is that the way people think about thinking changes the way they pay attention to the unusual experiences associated with sleep and awareness, and that as a result, people will have different spiritual experiences, as well as different patterns of psychiatric experience,' Professor Luhrmann said.
Mental and emotional health issues are still stigmatised in Ireland, even though mental health is the largest unmet health need in our society, writes Dr Jim Lucey.
The topic of the Merriman Summer School this year is the emotional life of our country.
It is a timely agenda as our nation approaches its 100th birthday. Much of our national dialogue appears to be about economic and political agendas as though these existed in a vacuum.
But what is the emotional state of Ireland today? More speculatively let me ask this: what is it about a nation or a culture that nurtures and sustains emotional wellbeing? The answer to this second question could inform us as we try rebuild our country following its financial collapse.
Mental and emotional health issues are still stigmatised in Ireland, even though mental health is the largest unmet health need in our society.
Unfortunately the typical response to mental distress in Ireland is neglect, or postponement at best. It has been said that if your car breaks down today, you could probably have it repaired within an hour, but if you or I have a mental breakdown today, it is unlikely that we will get help for at least 18 months. The delay is largely in our inability to have the mental health conversation.
However, there is a pressing need to widen our discussion because of the importance of our mental health. It is necessary for us all to enter the mental health debate.
There is much said about our vision for change in mental health services in Ireland, but for many this vision is an Ashling rather than a reality. There is still no national strategy to tackle the problems of suicide in Ireland. The problems and the costs of alcohol and substance abuse are still given insufficient priority, since in Ireland today, the drinks industry has disproportionate influence.
So what is it about our mental and emotional health which makes it such a taboo subject? The answer is complicated. It has not have been helped by the poverty of our language around mental wellbeing or by our asylum history of shame, fear and guilt. The problem is also with our mental and emotional consciousness, and this is political and social and cultural.
Modern Ireland is very different from the nation imagined by its founders. It is still, as St Colmcille called it, “a small island on the edge of the world”, but today, Ireland is struggling to become “the best little country in the world… to do business in”. We might question whether this vision is sufficient for the real challenges we face.
The first one 100 years of Irish freedom has been as traumatic as the century before it was tragic, and these memories are persistent. Memories of trauma are not usually lost even if they do not remain in the forefront of our consciousness.
Our independence emerged on the background of the great famine and of the Great War. The “peace process” which brought to an end 30 years of bloody civil war, a conflict we euphemistically called “The Troubles” has left many questions still unanswered. Since then, nearly every institution in the State has been discredited to a greater or lesser extent. With each shameful disclosure, denial has been followed by incremental half truths seemingly extracted in dental fashion. This establishment response to distress, a game of cat and mouse with the truth, was well rehearsed long before the banks collapsed.
In psychological terms, this process of denial is damaging, not just because it postpones understanding and prolongs the struggle to find recovery, but because like Pavlov’s dogs, we may have become conditioned to non-disclosure.
Recent historians have described how to some extent in the early independent Ireland, we believed “we were a chosen people… a people set apart”. It was against this background of national self-deception that the earliest whistleblowers, as well as artists and reformers, must have struggled, since our processes seemed incapable of getting to insight.
On the other hand, our stated beliefs about Ireland have changed and “changed utterly”. Now we are given to question everything, and now we know at least some of the truths.
Our “states of fear” have been exposed so we now we know that in our asylums, 2% of our population was incarcerated against its will. We know that many of our young people and vulnerable adults were physically and sexually abused in church/state institutions and industrial schools, in the laundries, in the mother and baby homes, and all the rest.
These revelations have been so shocking that the sadness of it is too much to bear, too hard to hear, and yet we must hear it in order to understand and recover. We have only begun this work.
Despite these positives, the reality is that social and economic inequality is the biggest risk factor for poor health in Ireland. The mental and emotional health of nearly one quarter of our population is in jeopardy. The most common disorders are depression and anxiety.
So what does the description of mental disorder in Ireland tell us about the emotional health of our country today? The truth is there is no evidence that we are a depressed or an anxious nation. The measurable hallmarks of low mood and all the rest are not endemic in Ireland today. We do not lack energy and certainly we possess the drive and concentration to meet most challenges and succeed.
Equally, the features of anxiety disorder are not evident in our nation. If anything, it is impulsivity that is more typical. Experience shows that in Ireland, we are in distress and this is in response to the traumas of recent times.
In our next century, we could learn from our experience to create a culture that promotes and celebrates our mental health. We could prioritise the wellbeing of our people and build a concept beyond our current ideas of wealth. The mental capital of our country is our economic capital, and our economy can thrive again only if we include all those currently in distress within our recovery plan.
Surely a renewed conversation about values would be restorative. Perhaps then, the emotional and economic value of our homeless and unemployed would be acknowledged. Just as the emotional consequences of excluding the mentally ill needs to be recognised, the right to more effective means of recovery for all our people and our society needs to be endorsed.
So is there hope? Absolutely.
Our tendency to denial, dissociation, and non-disclosure, may not have helped us resolve our conflicts to date, but ultimately, we must re-engage if we are to recover.
How then can we move on from the distress of our past? This question is surely important for any nation which truly wishes to make progress, but only one nation that I know of has a specific word for the process. In Germany they call it “Vergangenheitsbewailtigung” or “wrestling with the past so as to come to terms with it”.
The meaning of this process for the German nation has been profound and the benefits are measurable. Denial is no more tolerable there than is dissociation. The result has been a cultural rebirth. Now as our 100th birthday approaches, is it possible that we would begin a cultural renewal based on a genuine dealing with our past? A cultural wrestling with our past could lead to the rebuilding of our country on universal principles of human rights. Into our second century, we could emphasise priorities that would make our young people and our old people strong and emotionally resilient. We could begin to include our homeless and our mortgaged, our emigrants and our immigrants, our believers and our unbelievers in a journey towards an Ireland that would be well and not only well-off. An emotionally healthy Irish life is not something that will happen by chance.
Certain resilience factors contribute to the development of a mentally healthy, emotionally resilient populations. They include a secure base, education, social competence and friendships, talents, interests and positive values. A renewed Irish society dedicated to building these resilience factors might prioritize them as much as finance or foreign affairs, and so future political and cultural decisions could be made congruent with these goals. A renaissance of our culture, of life and work and spirit, balanced with our sport, music and arts and respect for beliefs could emerge.
This working towards positive values would sustain growth; and with resilience the next generation could grow together to better withstand its traumas and rebuild itself.
Out of a sincere re-engagement with our history, we could make peace with ourselves and rediscover what it is to be truly mentally and emotionally well; so that more people could live independently, work productively and most of all, love each other with a whole heart.
Edited version of the keynote speech delivered by Dr Jim Lucey, clinical professor of psychiatry at TCD and medical director at St Patrick’s mental-health services, to mark the opening of the Merriman Summer School in Glór, Ennis, Co Clare.