#authorsforgrenfell – last day of auction!

Today is the last day Authors for Grenfell Tower auction, with all donations going directly to the British Red Cross London Fire Relief Fund.

Many excellent authors, editors, agents and publishers have donated time and skills and goodies for this cause and I am proud to join them.

I am offering a mental health/medical-focused full manuscript critique and you can bid on it here.

Bid early, bid often, and may the odds be ever in your favour!

Freudian Script Fortnight 25/04/17

A slightly delayed review of two weeks of mental health and disability in the news…

“Survival of the fittest” is bullshit, pass it on

As Petya points out later in the thread, the inverted commas are important here – this is a misuse of Darwin’s concept. It is “survival of the fittest” as used by survivalists, eugenicists and Nazis. It is arguably what drives the “American Dream” and Tory Britain – if you work hard and contribute, you will succeed.

Exploring this topic further, Darwin did not originate the phrase “survival of the fittest”. It was commentary by Herbert Spencer, which was incorporated into later volumes of Darwin’s work. It is used by biologists to refer to the survival of random mutations in a population.

One of my favourite examples is sickle cell anaemia. This is an autosomal recessive condition, which means you need a pair of defective genes to cause the disease. However, if people have only one gene, they can better fight malaria as young children. This is why sickle cell disease is common in people of Middle Eastern, Indian, Mediterranean and African heritage. The gene survives because there is an advantage to having it.

The point is: natural selection is happening on an unconscious genetic level. It is about sexual reproduction and the survival of traits. Humans have been interfering with this before we even knew what it was – agriculture is based on this interference, centuries before GM crops. This is also why I jump on the “childbirth should be natural” crew – because millions of women died in childbirth, often taking their babies with them. Does that mean we should leave them to die, “as nature intended”?

I became a doctor to fight natural selection. It seems our ancient ancestors had the same attitude. It’s a pity our government disagrees, but I will fight them too.

Prince Harry ‘in total chaos’ over mother Diana’s death (BBC)

Prince Harry struck a blow for mental health stigma by discussing his complicated grief following his mother’s death. I think this was particularly important coming from a high-profile man with previous military service and a family with a stiff upper lip.

Discussions online inevitably turned to his privilege and how he has access to resources that the average person cannot find, due to mental health funding cuts and the changes in the “benefits” system. He is also ostensibly improved, so is not asking anything of the British public except acceptance.

While I agree that money can improve access to psychological therapy, there are also disadvantages to being a celebrity with a mental health problem. Firstly, money cannot buy privacy, as much as it might try. People with a reputation have something to lose by having a mental illness, because of mental health stigma. Secondly, private psychiatry is not the best mental health care available. Why? Because it turns patients into customers, who can buy access to their clinicians and the treatments they WANT rather than what they necessarily need. Good psychological therapy relies on boundaries. It cannot function if a client can call up their therapist at any time and demand their attention, because it prevents people developing coping strategies away from their therapist.

Neither circumstance is ideal, though Prince Harry’s is certainly miles better than slowly starving without any mental health support. However, Harry telling his story is another battle in the war on mental health stigma. It is another victory in the fight for “parity of esteem” between physical and mental health conditions. These things are further evidence that mental health care should and must receive more funding, research and support across health and social sectors in order to help people be the best they can be.

United Airlines Uses The Police To Punish A Customer For Getting A Great Deal (Medium)

Further information has emerged about the circumstances surrounding the passenger who was hauled from a United Airlines plane because he “refused to volunteer” to give up his seat for crew. The article focuses on how the computer programme picked David Dao and claims it was because he was the least profitable customer, even though his demographic details (travelling with his wife, doctor working the next day) made him unlikely to oblige them.

A commentator on the article had this to say:

For those unfamiliar with the Milgram experiment, it goes like this: an authority figure (experimenter) commands a volunteer (teacher) to administer electric shocks to a subject (learner) as a punishment for mistakes. The shocks escalate in severity, with accompanying screams and physical protest from the learner, until they become unresponsive. If the teacher hesitates or expresses concern, the experimenter tells them to continue.

Unknown to the teacher, the learner was an actor and the experiment was designed to end if they refused to continue after four orders or they gave three shocks at maximum voltage. Milgram and his associates predicted that a very small percentage of people who administer the most fatal shock. It turned out to be 65%.

The reason this experiment drew so much interest at the time and why it continues to do so is the defence of “I was just following orders”. It was particularly relevant in Milgram’s time due to the concurrence of Nazi war crimes tribunals. It is relevant today due to the behaviour of DEA agents during America’s travel ban and now flight crew for United Airlines. It is also relevant in an increasing call for “patriotism” coupled with slurs against protest and dissent.

Sources of authority would prefer everyone was like the men in Milgram’s experiment. It is important to question why.

Freudian Script Fortnight 10/04/17

What’s the buzz on mental health for the past two weeks? Let’s find out!

“The Trauma of Facing Deportation” (The New Yorker)

Photograph by Magnus Wennman for The New Yorker

Sixty children in Sweden entered a coma-like state last year and no one knows why! Except we have a pretty good idea why – they are refugees and their families were denied asylum.

This is a classic example of “medicine” v psychiatry, particularly neurology v psychiatry. Perhaps more than other specialities, neurologists love tests. They are infamous in the medical world for ordering 101 tests – and shrugging their shoulders when they all come back negative.

So, when professionals say this condition cannot be explained – and neither can the “cure” of granting asylum – they mean the tests don’t fit or are inconclusive.

Psychiatrists are used to working in this zone of uncertainty. Most conditions we manage do not have easy tests or narrowly-defined definitions. When I describe things like non-epileptic attack disorder (seizures that are not epilepsy) to people, I tell them that this might be their brain’s method of telling them to remove themselves from a stressful situation and that we have to convince their body it’s safe to function again.

Neurologists tend to favour a model where they simply haven’t found the right test yet and “you’re not crazy!”. One of the most well-known support sites for functional neurological disorders goes out of its way to tell people that their physical health is not linked to their mental health.

In fifty years, I anticipate we’ll understand more about the brain workings behind mental health conditions, but I doubt that will mean the end of talking therapy and socially-focused solutions like granting asylum.

(And can we just take a moment to appreciate the beauty of “trygghet”? A word that should be in every therapist’s vocabulary to describe that particular feeling of trust, belonging and security.)

The above tweet is the beginning of an excellent thread by Zoe Stavri on ketamine and depression. It uses a “big picture” view of why individual trial results may look great until the wider implications are considered. In this case, it’s that ketamine requires intravenous administration to be effective for depression. In the case of cannabis for sleep, for example, the problem is the risk of psychosis. With St John’s Wort and depression, the main difficulties are its interactions with dozens of other medications, including the oral contraceptive pill.

Showing that something works is the easy part. Showing that it’s viable in a wider reality is where it gets tough.

The World Health Organisation tweeted a series of infographics related to depression, after its stunning but sadly unsurprising revelation that depression now has the highest global disease burden.

The one regarding economic benefits of treating depression was perhaps the most controversial, as critics felt it reduced people to their work-potential and did not capture their life-potential or acknowledge that returning to work might be detrimental to mental health.

In motivational interviewing, one of the key techniques is using affirmations. Unlike a compliment, which conveys the receiver’s worth using the giver’s value system, an affirmation is praising a person using something they value. For example, a man who values his role as a father might appreciate being told “you really put your children first this week”, whereas someone who prizes meeting targets might embrace “you are really dedicated to your gym time”.

I feel affirmations have an important role in politics. They are ultimately tools of persuasion and that is why they have such a powerful effect in therapy for addictions. If a Tory government values productivity and a healthy economy over piffling little things like the wellbeing of the populace, lines of persuasion need to speak to productivity and economy.

Which is why this statistic is useful when trying to secure increased funding for the treatment of depression and other mental health conditions. And if, as a byproduct, we get health, wealth and happiness, all to the good.

Freudian Script Fortnight 27/03/17

In which I look at mental health and disability stories over the past fortnight and commentate on them for writers and other interested parties.

“This is Why People With Anxiety Are The Best People To Fall In Love With”

We kick off with this gem that combines several of my pet peeves when it comes to mental health reporting and writing – romanticisation of mental health problems, illness as identity, and “all people with X are the same”.

Firstly, living with a person with anxiety is difficult. Both my personal and professional experience tell me this, as do carers groups and charities like Mind. This article implies its some kind of all-consuming rapture.

My second point is a controversial one. I hold my hands up – I am a psychiatrist and I favour a biological model of mental illness. Therefore, when a person with anxiety comes to me, I see someone with an illness that can be treated or, at least, managed to improve their daily function. There is often a distinction made between “trait” and “state” anxiety – i.e. that anxiety is a part of someone’s personality make-up or it’s a temporary condition. Whichever theories you might subscribe to you, this article is talking about advantages of a person remaining anxious because that leads to a great relationship.

Finally, anxiety is different for every person, like all mental health problems. To say that this advice applies to all of them is ridiculous at best. It is dangerous and it opens up all parties to absuive situations.

“Work can make you mentally ill, but we still have a lot to learn about the links between employment and mental health” (The Mental Elf)

This is a great review at The Mental Elf, the go-to resource for understanding mental health research in context. The research in question is a meta-analyses – looking at multiple research papers to gather all known evidence on a subject, which is considered the pinnacle of research evidence. It included themes like lack of control and high demands, a mismatch of effort and reward, and fairness in the workplace.

Writers are often self-employed and answering to agents, editors, publishers and film studios. Their worked hours don’t often match the financial rewards of their profession. And access to the ivory tower is a whole ‘nother issue.

For writers to have sustainable careers, self-care is vital. The research shows that the environment can affect some of these factors, so the publishing and production industries need to take note. Because stories need writers.

As an interesting aside – taken from medicine but definitely application to other professions – take a look at Dr Elin Roddy’s career path as illustrated here:

And finally…

In the last FSF, I talked about hysteria and linked it to the invention of the vibrator. Sadly, the talented Kate at Whores of Yore has debunked that myth in a fascinating read: Buzzkill: Vibrators and the Victorians (NSFW).

Freudian Script Fortnight: Mental Health In The News

In a new series called Freudian Script Fortnight, I will be looking at news items relevant to mental health and disability and commentating on them/snarking at them/throwing them in the sea.

Mary Creagh MP is not “hysterical”

This beautiful speech against the use of the word “hysteria” is rooted in mental health history, where women’s emotional state and mental wellbeing was entirely attributed to the womb. More specifically, the “wandering womb” – the travels of an entire organ around a woman’s body, making her inexplicable and quite, quite mad. The clue is in the word itself – from hysteros, the Greek for womb, from which we also get the word hysterectomy.

I wish I could say that such silly notions had gone away, but note the continued use of “PMT” or “time of the month” to dismiss a woman’s anger, concerns or complaints. Note an MP using the word “hysterical” to describe one of his colleagues in the House of Commons.

For a more light-hearted education of the subject of hysteria and its treatment, I recommend the 2011 film of the same name.

Why people with learning disabilities should be allowed to work for less than the minimum wage (The Spectator)

The arguments embedded in this article can be boiled down to one question – is the work and time of a person with a learning disability worth the same as a person without? The article says no, because employers won’t pay for them (the “market forces” argument) and they don’t need the money anyway (because they all live with their parents, apparently).

Firstly, what is a learning disability? The author mentions her daughter with Down Syndrome, which is a genetic disorder caused by three copies of chromosome 21 instead of the usual two. However, Down Syndrome is not synonymous with learning disability and not all people with Down Syndome have a learning disability. The mental health definition of learning disability (or intellectual disability) is an IQ below 70 – more specifically, mild is IQ 50-70, moderate 35-49, and severe 20-34.

While IQ points might indicate a person’s functional ability, it’s a meaningless test for real-world applicability. Assistance and adaptations can lead to fulfilling employment and lives well lived, with the right investment and support – and the payment of a living wage.

University bans phrases such as ‘mankind’ and ‘gentleman’s agreement’ in favour of gender-neutral terms (The Independent)

This move by Cardiff Metropolitan University caused a kerfuffle because it was seen as censorship and limiting free speech in academia. While their stance on gender neutrality drew the most attention, the document also included guidance on other potentially harmful language. It advocated avoiding generalised terms like “the disabled” or “the blind”. Interestingly, it advised against “people with disabilities” because people are disabled by society rather than inherently disabled.

You might be familiar with the maxim “your rights stop where mine begin”. For those who cry over “free speech”, xkcd says it better than I ever could:

John Humphrys Suggests Jo Cox’s Murder Was Not Act Of Terrorism During BBC Radio 4 Today Programme (Huffington Post)

“But in that case wasn’t that just a very deeply disturbed man, mentally ill wasn’t he? That slightly muddies the water doesn’t it when we talk about that as terrorism? I mean, it was a murder, wasn’t it?”

In a winning combination of mental health stigma and implicit racism, John Humphrys said on the Today programme that Thomas Mair’s murder of MP Jo Cox was not an act of terrorism because he was “disturbed” and “mentally ill”. It is notable that Mair’s own defence team seem to disagree with Humphrys assessment, as they did not submit any medical evidence – i.e. they believed any mental health problems that Mair had did not have a significant impact on his actions on that day.

In the UK, to enter a plea of “not guilty by reason of insanity”, the M’Naghten rules must be satisfied. These originate from the mid-19th century case of Daniel M’Naghten, who killed Edward Drummond, personal secretary to Prime Minister Robert Peel. He mistook Drummond for Peel, who he believed was personally responsible for his misfortunes. The M’Naghten rules state that all people are presumed sane and able to reason, until proven otherwise. Legal insanity can only be demonstrated if the accused person did not know what they were doing or, if they did know, did not know it was wrong.

By this definition, Mair might have been “disturbed” and “mentally ill” at the time of Jo Cox’s murder, but he was not legally insane. And the judge called him a terrorist.

Freudian Script: Narcissistic Personality Disorder

Could you recognise a narcissist?

This highly topical Freudian Script explores Narcissistic Personality Disorder, and is brought to you by my friend and colleague, forensic psychiatrist Dr Bernard Chin.

DISCLAIMER: This blog post is designed for writers of fiction. If you are concerned that you or someone you know has symptoms of mental health problems, please see your doctor. Or your local government representative.

There once was a hunter from Thespiae, who was famed for his beauty. As he was so beautiful, many loved him. However, he only had disdain for those that loved him, as none could be as beautiful as he was.

He grew proud and one day he was drawn to a pool where he saw a reflection of himself. Not realising it was merely an image of himself, he fell in love with it (or perhaps coming to the realisation that he could only truly love himself) and was unable to leave the beauty of his own reflection. Losing the will to live, he stayed there, staring at his own image until he died.

His name was Narcissus.

What is narcissism?

Narcissism is a personality trait and Narcissistic Personality Disorder is a recognised mental disorder in the American Psychiatric Association’s biblical tome, the Diagnostic and Statistical Manual of Mental Disorders 5th Edition.

(The World Health Organisation did not include Narcissistic Personality Disorder in its International Classification of Diseases Version 10 as a distinct entity but instead chose to include it as almost a side-note in the Other Specific Personality Disorders category. Think of that what you will about the Americans.)

So what do we mean when we say someone is narcissistic? Do lay members of the public have a similar definition for narcissism as me, a forensic psychiatrist?

I work with people with severe and enduring mental illness as well as people with severe personality disorders who end up on the wrong side of the law – sometimes through a series of unfortunate events relating to their mental illness and sometimes entirely through their own devices completely unrelated to mental illness.

Narcissism as understood today was first publicised by the psychoanalyst, Otto Rank in the early 1910s, who linked it to vanity (egocentrism) and self-admiration. It is a descriptive term used widely in our daily lives. It is often used in a derogatory manner to indicate that someone is “full of themselves”, indicating that one has passed miles beyond being confident and self-assured into the realms of egotism.

We often use public figures as examples of “narcissists” – someone so full of themselves that they have essentially failed to recognise their own failures or absurdity. Case in point, a particularly “esteemed” Health Secretary or an exceptionally “bright” president-elect. Do these individuals have Narcissistic Personality Disorder? Many would like to believe so but it is dangerous to speculate without substantiated evidence or data to prove it.

Diagnosing someone with a personality disorder takes time – roughly three hours to interview the individual and a further two-three hours to locate and absorb any other information one can find on their background and relationship history.

This is, of course, if you are trained to diagnose individuals with a mental disorder in the first place. It also helps if one receives specific training to diagnose personality disorder, such as in the use of the International Personality Disorder Examination (IPDE).

But in a nutshell…

To understand Narcissistic Personality Disorder, we first need to ask what is a personality disorder? One explanation is included in this post on emotionally unstable personality disorder (EUPD).

To recap:

Personality is a set of characteristics that makes a person who they are. It is essentially the way that a person sees the world, interacts with the world and those in it. It also governs the way we feel and think about things.

Personality disorder (PD) is when our personality is different from what it should be, which then leads to the development of distress or conflict within ourselves or with others. It usually starts in our developing years due to some form of trauma which forces us to develop in such a way so as to protect ourselves whilst growing up.

Unfortunately, this may lead to a pattern of behaviour which is unhelpful when we are expected to be “fully functional” and “productive” members of society, despite it being helpful when growing up in a deprived or physically, psychologically, emotionally, and/or sexually traumatic environment.

Now that we have a rough understanding of PD, let’s delve into Narcissistic PD.

According to DSM 5, Narcissistic PD is:

A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognise or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviours or attitudes.

This can be someone who routinely overestimate or inflate their own abilities and accomplishments – appearing boastful and pretentious. They expect or assume others attribute the same value to their efforts and abilities and would often be surprised when they are not praised as they feel they deserve. They would also underestimate or devalue the contribution of others purely because they do not see the worth in others or does so to inflate their own achievements.

They can often be preoccupied with fantasies of power and unlimited success in whatever they do – love, beauty and so forth. They believe that they are superior, special or unique and they expect others to agree and recognise them as such. Often they will only mingle with the best of the best because only the “gifted” can understand them whereas the hoi polloi are just that.

However, these gifted people may be devalued themselves if they were to disappoint the individual with Narcissistic PD. Case in point – a patient of mine would rather speak to me instead of my junior doctor as I have more seniority but as soon as I disagree with him, my value immediately drops to just another doctor who isn’t the best in the country or the top expert in the field.

What causes narcissism and how does it manifest?

The narcissist’s overdeveloped sense of self and constant need for excessive admiration likely stems from an incredibly fragile self-esteem. They would constantly be preoccupied with how well they are doing and how favourably others regard them, constantly fishing for compliments using that great charm of theirs.

All this ego would of course be accompanied by a great sense of entitlement – they expect to be treated like gods. For, in their minds, they are nothing less and cannot understand why others do not or cannot see them that way.

Some people with Narcissistic PD have a predilection for the exploitation of others due to their great sense of entitlement and underdeveloped empathy. Friendships and romantic relationships are formed if it serves their purpose – to advance in society or somehow enhance their self-esteem.

They find it difficult to recognise the desires or feelings of others – children and “loved ones” become extensions of their selves. The only purpose these individuals served is to advance the narcissist’s own needs.

Envy is the emotion most often felt by those with Narcissistic PD – they feel that the successes of others are better served being theirs. They often come across as snobbish, disdainful or patronising.

Their fragile self-esteems make them particularly sensitive to criticism. Criticism may cause what psychologists term a narcissistic injury (essentially, an injury to the person’s ego and sense of self), leaving them feeling humiliated, degraded, hollow and empty. In order to repair or obliterate the injury, individuals with severe Narcissistic Personality Disorder may react with disdain, a defiant comeback or, on rare occasions, extreme rage. This could lead to social withdrawal, a façade of humility masking the grandiosity or sometimes, even violence.

That isn’t to say that overwhelming ambition and confidence has no place in society. On the contrary, these traits are useful and can lead to high achievement and progression if tempered with a suitable amount of humility and grounding.

Unfortunately, those with a disordered personality have difficulties managing their traits. The incessant need to protect their over-developed sense of selves may lead to avoidance of situations that would paradoxically lead them to achieving what they desire. If a narcissistic injury were sustained, the overwhelming feelings of shame and humiliation would often lead to persistent low mood and potentially a depressive disorder

Would you be surprised to learn that 50% to 75% of those diagnosed with Narcissistic PD are male? Probably not.

The core of the disorder is the intense fluctuation in self-esteem and the need to refer to others to regulate this and to define themselves.

Narcissistic PD in fiction

One example of Narcissistic Personality Disorder in fiction is Patrick Bateman, the titular character from American Psycho. He isn’t a pure example, although he shows certain traits one would find in a real life individual suffering from the disorder. Lacking empathy, utilising “friends” for his own goals to advance his self-esteem, grandiose sense of self-worth, associating only with “important people”, and highly sensitive to criticism and setbacks (for example – the business card scene as depicted in the movie).

Like in real life, there are features of other personality disorders evident in Patrick Bateman – Antisocial Personality Disorder being the other prominent feature. He is also likely suffering from a psychotic episode near the end of the novel and movie adaptation.

He is probably one of the more extreme and malignant examples I have come across in fiction. There are other examples that are slightly more benign and “played for laughs”, such as How I Met Your Mother’s Barney Stinson, although Barney’s attachment to his friends appear to be genuine friendship which goes against one of the more common traits in Narcissistic PD.

Narcissistic PD in reality

What are individuals with Narcissistic PD like in real life?

Depending on the severity of their personality disorder, they can be very much like you or me. There are certain points in my life when I thought that I displayed narcissistic traits. Whether I can be diagnosed with the disorder though remains to be seen.

As patients, people with Narcissistic PD can be difficult to manage. This difficulty stems from whether someone sees what he has as distressing to him or not. If I were told that I had a Narcissistic Personality Disorder and this was becoming a problem for other people but I do not see this as a problem for me, then I am less likely to engage in treatment. They may also have unrealistic expectations of the treatment, the service delivering the treatment, the outcome, the doctor that deals with them and a whole range of things.

I think what doesn’t come across well in fiction is the difference between narcissism and Narcissistic Personality Disorder. Narcissism is a personality trait which can be extremely useful in certain trades (such as mine) where overwhelming ambition and, to a certain extent, self-confidence and even a little bit of vanity can lead to a good outcome.

Narcissistic Personality Disorder is like it says on the cover – a disorder. There has to be a level of impairment or distress that goes with it (for the individual or for others in their lives, which would eventually lead to some form of impairment in their lives).

So, is America’s president-elect narcissistic? Oh god yes.

Does he have a mental disorder? I have no idea and I am afraid to comment… (wink)

Bernard Chin is a Forensic Psychiatrist with a background in genetics and psychology. He has worked with individuals diagnosed with personality disorders throughout his career in psychiatry and is specifically trained in understanding and assessing personality disorders as well as psychopathy. In his free time he enjoys torturing medical students and other junior doctor colleagues with lectures and role play. He also rants at the government on twitter (@berniebchin).

The Anti-Stigma Thesaurus: Rewriting the Language of Mental Health

Words taken from Rose et al (2007)

Despite how the nursery rhyme goes, words can hurt. They can also be used to reinforce mental health stigma, particularly in crime fiction.

Words are powerful – and “with great power comes great responsibility”. The longevity and influence of words can be epitomised in that one quotation, first used centuries ago and popularised by a comic book adaptation.

Words are the building blocks of the writer’s craft. They are our weapons and our tools. We can fuss for hours over the right choice of word to fit a sentence, a tone, a character. When it comes to fighting mental health stigma, we need to choose our weapons carefully.

The last time I wrote about this, I merely complained that writers should do better. This time, I’m going to do better.

The following words and phrases are all in common usage but have the potential to be harmful to people with mental health problems and reinforce stigma about them. I have here presented alternatives that will convey similar meaning but without the baggage.

NOTE: I have made some assumptions about the intention behind the use of these words. The alternatives will not fit every situation. If you have a question about options in context, please feel free to comment or contact me for suggestions.

The Anti-Stigma Thesaurus

asylum/loony bin noun
mental health unit, psychiatric hospital

bipolar adjective
capricious, changeable, fickle, flip-flopping, oscillating, unstable

commit suicide verb
complete suicide, die by suicide, kill him/herself, take one’s life
(For more guidance on writing about suicide, see Samaritans’ guidance. For a personal and professional perspective, see this note from Dr Alison Payne in the BMJ.)

crazy/insane/mad/mental/nuts adjective
1. general use
i. bizarre, eccentric, odd, outlandish, peculiar, strange, unbelievable, unusual, weird
ii. amazing, astonishing, awesome, incredible, outrageous, stunning, unbelievable
2. referring to mental health:
rephrasing is preferable – e.g. “person with mental health problems” or “he has a diagnosis of depression”
(See the “Time to Change” guide to language.)

demented adjective
absurd, nonsensical, ridiculous

OCD adjective
exacting, fastidious, finicky, meticulous, neat, tidy

psycho adjective
1. general use
violent, unpredictable, unstable, wild
2. crime fiction – referring to a murderer
cold-blooded, cruel, detached, remorseless

retard noun
idiot, imbecile, moron
(NB: The words I have chosen here are all archaic words for a person with mental health problems, but they have lost that connotation in modern usage)

schizophrenic adjective
conflicting, contradictory, incongruous, inconsistent, indecisive

Do you have suggestions for other words to include in this list? Please leave your ideas in the comments.

REVIEW: Pulling the trigger by Adam Shaw and Lauren Callaghan

Pulling the trigger: The Definitive Survival and Recovery Approach for OCD, Anxiety, Panic Attacks and Related Depression

ptt-cover Adam Shaw spent his life running away from the terrifying thoughts which tormented him. This lifelong struggle with mental illness ultimately lead him to a railway bridge and the brink of suicide, and it was at that point that he met psychologist Lauren Callaghan and was finally able to get the help he needed.

They share this practical approach in their new book, Pulling The Trigger: The Definitive Survival and Recovery Approach for OCD, Anxiety, Panic Attacks and Related Depression. The book, divided into two helpful parts, provides both first-hand evidence for sufferers that recovery is possible, and a user-friendly blueprint for mental health support and recovery.

For my review of this book, I enlisted the help of Huw Davies, football journalist and OCD sufferer. Davies has written about his own experiences with OCD for publications such as The Guardian and ShortList.

huwdavies-icon People with obsessive-compulsive disorder, perhaps more than others with a mental health issue, often feel they’ve heard it all before. I know I have, after experiencing various treatments and coping strategies for my own OCD over the years, as well as interviewing people when writing about the condition. For some sufferers it’s mere ennui, but for others it can feel more like despair.

So it’s refreshing to read about a new approach – or, at the very least, an approach presented in a new manner. To my mind, there’s nothing revolutionary about most of the tasks, both physical and mental, that psychologist Lauren Callaghan sets. However, the focus on compassion as well as practical solutions, emphasised by Callaghan and OCD sufferer Adam Shaw alike, is something often missing from books outlining a treatment.

rosieclaverton-icon During my work as a psychiatrist, I have helped treat a number of people with OCD, including at the National Specialist Service in South West London. I therefore have a good (if inexpert) knowledge of the diagnosis and treatment approaches in OCD.

While there is nothing novel about the “Pulling the trigger” approach, the combination of Shaw’s personal story with Callaghan’s professional commentary really aids understanding of OCD. The book also deals with the common mistakes in attempting to self-manage OCD, and gives an accurate impression of the impact of the disease. The Accept, Embrace, Control model is also easy to remember and understand.

huwdavies-icon The book’s biggest asset is its accessibility. In the first section, Shaw recounts his lifelong battle with OCD in a memoir that will engage the vast majority of its target audience (although as much as he strives to be neutral, Shaw’s own experiences inevitably paint other approaches to treatment in a negative light). Callaghan interjects regularly to explain Shaw’s malfunctioning thought process and how she helped him to tackle it head-on. It’s enlightening and occasionally a little shocking: more than a few OCD sufferers reading the book will gulp as she persuades Shaw to hold a knife to her neck, even as she feels safe in the knowledge he will not enact on his fears of being violent to others.

rosieclaverton-icon While very accessible to its intended audience, the PTT approach is quite vague – for example, it doesn’t go through breaking down the worries into a hierarchy, as would be common in OCD management (and cognitive-behavioural therapy in general), and then tackling them in a stepwise fashion.

From what information is given in the book, PTT appears to be based on a basic CBT model, though without the typical emphasis on preventing a response to the exposure, such as strategies to resist rituals. I therefore feel it would be difficult to design your own programme of OCD treatment solely by reading the book.

huwdavies-icon There’s arguably nothing much radical about “Pulling the trigger”, but then Shaw and Callaghan call it “the definitive survival and recovery approach” – not “an entirely new one”. Most sufferers will have heard their advice before, dressed in different robes. But perhaps because of its compassion element, readers of the book are still likely to feel more confident about recovery after reading it.

rosieclaverton-icon “Pulling the trigger” is not without its problems. The repetition of “you’re not going mad” supports OCD sufferers at the expense of people with other mental health problems, reinforcing old stigmatising stereotypes. The section on exercise, while framed as useful encouragement, does not address issues of ableism by exploring exercise alternatives or support available.

While adopting a healthy attitude to medication, the book perhaps overly emphasises independence of the OCD sufferer from the wider healthcare system. This is perhaps because Shaw took this approach, due to his inability to access NHS services.

Overall, “Pulling the trigger” is a good background book to help understand the experience and management of obsessive-compulsive disorder, but I feel it needs further development to be used as a standalone self-help book for people with OCD.

Pulling the trigger: The Definitive Survival and Recovery Approach for OCD, Anxiety, Panic Attacks and Related Depression by Adam Shaw & Lauren Callaghan (CPsychol, PGDipClinPsych, PgCert, MA (hons), LLB (hons), BA) (Trigger Press Limited, 1st September 2016)

Find out more at Pullingthetrigger.

INTERVIEW: Sara Barnard on Mental Health in YA and Beautiful Broken Things

In Freudian Script, we love to hear how authors tackle the accurate and sensitive portrayal of mental health problems in fiction. Sara Barnard, author of Young Adult novel Beautiful Broken Things, tells us her tale.

beautiful broken things cover

What led you to explore issues of mental health in Beautiful Broken Things?

I was interested in the aftermath of trauma and violence, and how these experiences can affect young people as they grow and develop. In a lot of cases, unfortunately, people recovering from past pain go on to struggle with their mental health. It struck me that we don’t see much of this in YA fiction – stories tend to focus on the traumatic event itself and not what comes next – and I wanted to change that in a very small way with the book I wrote.

I was also aware of how mental health is so often used as The Big Issue in YA, as if it is the defining feature of a character. So I wanted to also feature a character who had mental health issues that were incidental to the actual plot, to show that living with a condition like bipolar disorder – as Caddy’s older sister does – can be part of everyday life instead of a big drama.

There’s a lot of stigma around mental health. What do you think are the best ways to combat it?

I think fiction can be really important in this area – in books and on TV, we should be seeing truthful and authentic portrayals of a range of mental health issues. For many people, this will be the first (and sometimes only) time they are exposed to a particular mental health condition, so it’s important that it’s not one-dimensional or stereotypical. It also shouldn’t be used as a transparent plot device – this is one of my biggest bugbears with mental health in TV and books.

As a writer, would you recommend any particular films/TV shows/novels that do a good job of portraying mental health that other writers could use as inspiration?

Holly Bourne’s novel Am I Normal Yet? contains an amazing portrayal of a teenager struggling with OCD. She’s in recovery but is fearful of relapsing – this is also something we don’t see enough of in books or on TV.

What would you like to see more of in terms of young adult characters?

It would be great to see a little more of characters living with conditions rather than a story being based entirely around them “discovering” they have a condition, if that makes sense. Mental health – and physical health – is about so much more than the initial diagnosis, and it would be nice to see a bit more of that reflected in fiction. Though I think we are getting better.

What one piece of advice would you give a person struggling with their mental health?

Talk to someone. That doesn’t have to mean in person, or even someone you know personally – those of us who struggle with mental health are very lucky in one important way, which is that we’re living in the age of the internet. Taking that first step of finding help can be as simple as opening a webpage.

And what advice would you give to writers looking to portray that struggle accurately and sensitively?

Ask! Again, the internet exists, so there’s a whole world of information available on so many aspects of mental health. Research is so important, but I also think that should be done with the character in mind, rather than as something separate from them. So rather than “How does bipolar disorder affect teenagers”, for example, it would be “How does bipolar disorder affect MY character, with this life and this family, with these character traits?” etc. Just like people in real life, a character doesn’t begin and end with their mental health. If you are true to the character and their struggle, it will follow naturally that the portrayal will be accurate and sensitive.

But having said that, I’d recommend finding a beta reader you trust to check your novel specifically to give you feedback on the mental health aspect.

sara-barnard-author Sara lives in Brighton and does all her best writing on trains. She loves books, book people and book things. She has been writing ever since she was too small to reach the “on” switch on the family Amstrad computer. She gets her love of words from her dad, who made sure she always had books to read and introduced her to the wonders of secondhand book shops at a young age.

Sara is inspired by what-ifs and people. She thinks sad books are good for the soul and happy books lift the heart. She hopes to write lots of books that do both. Beautiful Broken Things is her first book and a dream come true.

Freudian Script: Work-Life Balance

Another junior doctors’ strike, another blog post from me!

My theme, however, is one that is relevant to all professionals but particularly writers of all stripes. I am talking about the mythical work-life balance.

rock-balance What is work-life balance?

This term is most commonly used when talking about the proportion of life spent on employment compared to family, hobbies and rest. It is most often applied when talking about how jobs can be all-consuming and gradually take over your entire existence, like a life-sucking parasite. Ahem.

One of the reasons the junior doctors’ contract negotiation is so emotive is the discussion of Saturday working – is Saturday a normal working day or is it special? Retail jobs, for example, mainly consider Saturday a normal working day, as do the police. Professional jobs consider Saturday a non-office day in the main, but people may be working from home. Schools and childminders definitely consider Saturday a non-working day.

Writers do not enjoy such demarcation lines. Professional writers can write any time, any place – 3am on Sunday is the same as 10am on Tuesday. Meetings, studio commitments, and play rehearsals might occupy more conventional hours, but writing is 24/7.

For writers with day jobs, we are looking at the balance of work-life-workagain. Bank holiday weekend: three days dedicated to the family, or to the novel?

This is where a broader psychological framework may be helpful in understanding how balance can be achieved.

Mastery and Pleasure
When therapists look to rebuild a life ravaged by depression or another serious illness, they look to balance from the outset. If you are starting from a wide-open schedule with nothing in it but sleep and TV, filling your days can be daunting and anxiety-provoking.

The theory goes that what makes life fulfilling is not merely the pursuit of happiness, but the balance of mastery and pleasure. In plain English – we want to feel useful and we want to enjoy ourselves. You can’t have one without the other. Having a purpose for the day is equally important to having a good time.

Doing household chores is good for you. Taking a walk is good for you. Doing only one of those things without looking to the other isn’t going to lead to satisfaction and contentment. This is why many people get antsy at the end of a holiday.

The other problem is those lines between work and leisure time are increasingly blurred. When your smartphone can fetch your email at any time, and we rarely turn the things off, when are you not at work? Am I at dinner with my husband, or am I also answering my email, Whatsapping my friends, and checking the cricket score?

The current investment in mindfulness, both in healthcare and the wider public consciousness, is partly fuelled by our need to escape distractions. The idea is very simple: be completely in the moment. The execution is very difficult, however, unless you’re a practised yogi. Focussed on breathing and your immediate environment, acknowledging but not engaging with your worries and thoughts, is a powerful experience but not a template for life.

However, principles of mindfulness can carry over well to the everyday. How about this: concentrate on one thing at a time. For example, watch TV but don’t check your phone. Eat dinner, and don’t check your phone. Talk to your partner – and don’t check your phone.

(Aside – I am terrible at this. This blog post has taken me twice as long as it should because I CAN’T STOP CHECKING MY PHONE. Reminder to us all: the “Do Not Disturb” setting exists for a reason.)

Work-life balance in practice
So, how can you improve your work-life balance?

The answer is to look at your life and be honest about what parts are necessary features and what parts of it are bringing what benefits to you.

We have to sleep and we have to eat. We have to work to pay the bills, or have some other purposeful activity in our lives. We have to spend meaningful time relating to other people. We have to do things that we enjoy. These are the building blocks of life.

Here are some simple take-home tips:

Make an activity diary: Look at a week or two and see what you’re doing with your time. Are you spending two hours on Facebook because it’s bringing you joy or because there’s nothing else to do? Did you try to work on that screenplay but were distracted by that Tweet you sent three hours ago that’s had more favourites than you can shake a stick at? Prioritise the things you want and need most.

Recognise what you enjoy: I like going out to dinner, watching my favourite TV shows, practising yoga, reading books, and taking long hot baths. These activities are restorative. Your list probably looks completely different. Recognise these activities and use them to help yourself decompress.

Invest in relationships: You don’t have to spend all your time and energy on a person to have a good connection to them. Yet the time you do put into those relationships means you can rely on that support at more fallow times.

Turn off your phone: I’m not talking about a digital detox, because I think the idea is unsustainable and unrealistic. We need to adjust to having these always-on, always-connected devices in our lives. How important is it to be able to answer your email at any time? Can you afford to put your phone on silent for two hours?

The answer is probably yes. If it isn’t, maybe your work is actually a life-sucking parasite.

How do you strive towards a work-life balance? What strategies work best for you? Is the whole idea an impossible dream? Tell me in the comments!