A False Dawn

[It occurs to me that it is almost a year since I last posted (this took me somewhat by surprise, probably because I think about blogging here really quite a lot and it always feels like I’m just a little behind but I’ll soon catch up – I really must add ‘writing’ to my repertoire alongside ‘thinking’) so I hope the headline to this piece describes only the short piece that is to follow, not another brief flowering of the blog, followed by an ignominious and unnoticed return to a dissatisfied quiescence.]

Theresa May today announced all kinds of vague things in order to ‘transform attitudes to mental health’. There didn’t seem to be much detail – or indeed much funding. There were some smashing soundbites though.

The transformational plans include ideas like every secondary school to be offered ‘mental health first aid training’. I have no idea what this is. I’m not sure I like the sound of it. I definitely don’t like the sound of having to have an online symptom check before getting an appointment. To be fair, trying to make people less reliant on GPs and A&E for MH issues, which the Government promises, is a good thing (but not if they’re directed to a website instead). Improving support in the workplace is also good (depending what ‘support’ means), as is not making children travel out of their local area for mental health treatment (depending on what ‘local’ means and what ‘treatment’ means).

However, I can’t help but think that the Government is painting a very narrow picture of what mental illness is and how it can be treated. I fear we are being presented with a straw man that fortuitously can be addressed by what the Government wants to do. They have worked backwards from the solutions they believe they can implement and made them fit a particular presentation of mental illness, rather than wondering what the problems really are in the first place and how they might actually be addressed with a degree of efficacy.

(As a counter to this, this is an excellent piece that looks at the problems and then suggests solutions to address them https://paulkirby.net/2016/12/07/on-mental-health-weve-got-it-so-wrong-money-alone-cant-fix-it/ )

With no new money to go with these new ideas, it remains to be seen if this is simply yet another vacuous nod in the right direction.


Neuroscience of little value in treating mental illness

This thought-provoking article at the ever-brilliant Aeon site – https://aeon.co/essays/why-can-t-we-treat-mental-illness-by-fixing-the-brain – unequivocally punctures the notion that neuroscience is solving, or will solve, all ills.

By assessing the progress in medical science relating to other organs compared to that of the brain, it’s easy to see just how far behind we are in understanding the brain. Neuroscience is barely scratching its wrinkly grey surface.

Really, we shouldn’t be surprised. This article reminds us of the way neurons work:

“Neurons work in a particular way: the brain is an electrochemical machine. Each neuron is activated by a chemical released from another neuron: this then initiates an electrical signal that passes down the neuron’s fibre and, in turn, releases another (or the same) chemical onto the next neuron. But this isn’t a simple chain: each neuron can communicate with about 10,000 others, meaning that the permutations are unbelievably huge. There are around 100 billion neurons in the human brain, and around 1,000 trillion possible connections.”

The further problem is that even if we begin to understand the brain at the neuronal level, how do we relate or equate this to the functions of the brain, let alone how those functions translate into feelings, actions, behaviour?

Half way through the article is the fascinating and disturbing insight (that made me wonder, ‘can this really be correct? And if so, why aren’t we all up in arms about it?’) that no-one seems to know if or why chemical treatments for depression work. I quote:

“Ask any psychiatrist what happens in the brain to make people depressed, and she will probably mention serotonin. Serotonin is one of the many chemicals that neurons release. The psychiatrist singles out this one because most of the drugs used to treat depression seem to work by altering its levels in the brain. Altering noradrenaline (a related neurotransmitter) is also effective.

“And yet, there is no evidence at all that the levels of serotonin or noradrenaline in the brains of depressed people are any different from normal. The logic is flawed: you cover a cut on your finger by a sticking plaster, which helps recovery; but the cut was not caused by a lack of sticking plasters. So altering serotonin can speed recovery in some people – and there are those who question even this – without telling us anything about what depression is or how it occurred in the first place.

“At present, a pathologist looking at the brain of a depressed person could not distinguish it from the brain of someone who was mentally well.”

For an amateur like me, this is astonishing. Does everyone who works in this field know this? Is this old news?

The article goes on to describe the shortcomings of trying to classify mental illnesses (in the ever-burgeoning DSM for example) but for most people, I presume that this argument is pushing at an open door.

This excellent article was, for me, let down only because it excluded other solutions to mental disorders. It concludes with ‘neuroscience has no credible experimental model of any psychiatric illness’, followed by a wish for psychiatry to one day be refined enough to deal with all of these problems, probably chemically. However, what the whole article seems to indicate to me is that mental illnesses and disorders have their root in systemic, developmental and existential factors – all places that this article resolutely refuses to go.

So rather than looking to change the brain chemically, how about we look at changing society, the way we raise children, the role of religion, understanding what makes a good and satisfying life. Why do we insist on tinkering with the symptoms rather than addressing the causes?

As a society, investing in building on our body of knowledge around child development (and disseminating this knowledge widely) and in providing therapy to adults will surely pay rich dividends? For those of us lucky enough to live comfortably without fear of war or famine, our challenges are existential. To ignore that because it’s too airy-fairy is to ignore its consequences: growing mental illness and unhappiness, further schisms in society, religious extremism, damaging jingoism. The fabric of society is already under tremendous strain. Let’s not let it be torn apart while we search for impossible quasi-solutions.

Whose decision?

Yesterday the dual carriageway I was travelling on was closed because a teenage girl jumped from a bridge to her death.

A couple of months ago the House of Commons voted against an Assisted Dying Bill. A blunt summary might be to wonder whether being fully able-bodied is the only qualification you need to take your own life.

The Assisted Dying Bill has many opponents. Their arguments are by and large very reasonable, and it’s easy to see that insufficient safeguards could result in terrible situations of people being pressured, coerced and choosing a death they weren’t ready for. There’s a generation that is so selfless and would do anything for others – especially their children – at their own expense that it’s not beyond the realms of possibility that with little left to live for, they would make the ultimate sacrifice.

However, for me, choosing to die is a right everyone has as a human being. The problem with this position, though, is how to define and guarantee autonomy and influence-free decision making.

The young girl who took her life obviously chose to. However, there is every chance she was mentally unwell. At what point can we, society, take that decision out of her hands? If she could be cured, or at least made to feel a little better through treatment, shouldn’t we be obliged to prevent her making such a terminal choice before she had the opportunity to get better? Could she really have been classed as autonomous and making decisions freely?

What if she were not mentally ill by any clinical measure but had thought the matter through deeply and could see no value in living. Should we still prevent her? If not, why not – are we prejudiced against mentally ill people, or young people, or females? Does she have to pass an IQ test?

Would we fight with the same verve to prevent an 85-year old in great pain committing suicide? Probably not. We might conclude they’d had a good innings but the young girl’s life was all ahead of her. But maybe the 85-year old hadn’t had a good life and perhaps they should have had one more shot at redemption. And maybe the girl would go on to a life of pain and distress not only to herself but to others. Which is the right decision? And who should make it? And when deciding all this, who are the moral arbiters and by what principles do they act?

What could I do?

When my mum was in hospital, my visit to one particular ward stayed with me. It wasn’t anything to do with how she was – which was not well – but the whole experience of the ward.

It was a short-stay ward filled solely with older people. It smelt in there, it smelt of urine and faeces from the old people using the commode by their bed, or in nappies – or in a mess. It also smelt of futility and of lost hope. Drugs kept some people asleep, while others simply stared, others still called out in distress or sang strange songs. The television blared out but no-one watched. You got the impression that the noise was there as a mask rather than an entertainment.

I was sad that my mum had to be in there. She wasn’t well physically but was fine mentally. She was a fairly private person who wouldn’t have enjoyed being on a ward anyway and certainly wouldn’t have wanted to endure those environs while in such a physically debilitated state herself. She’d have understood that these other people couldn’t help any of this of course – she was kind, thoughtful, a mother, grandmother and former nurse – but this wouldn’t have made her time there any more comfortable.

The nurse was efficient and not unkind. He still spoke to the patients with respect but not with engagement. There was, though, little engagement available to him. This must be one of the least rewarding areas of nursing. No feedback, little thanks, not much hope.

During visiting hours one day, the woman in the next bed was talking to her son. She seemed to be just chatting away normally but I began to notice that she occasionally disappeared down verbal rabbit holes and uttered things that had me wondering if I’d heard right. Clearly she was slowly losing her mind – or losing the mind that she once had, the mind that had defined her for so many years – but the strange thing was the way she veered seamlessly from normal chat to bizarre ramblings and back again, occasionally punctuating a flight of fancy with a withering insight. ‘If you had your chance again, would you do anything different?’ she asked her son out of the blue.

She asked for a hair brush and followed it up with, ‘The rats and mice are in my hair. The dog’s going to lick my hair dry.’ Then she followed this up with some nursery rhymes, one of which ended in a non-traditional fashion and used the word ‘bum’ quite a lot. If you were looking for a definition of tragi-comic, here it was in all its glory.

Rhyming was something she did a lot of, some real words, some nonsense ones. It was as if rhyming were some sort of primal linguistic retreat. Is this because it’s a natural sound we like to hear or one that speaks unconsciously of the reassuring comfort and certainty of childhood – or indeed of parenthood? The verbal dexterity behind the nonsense she spoke was remarkable. We’d be praising it in a child, I thought. I wonder if we could bring ourselves simply to enjoy it from an old person, if we were to ditch our expectations and just delight in the moment?

‘Where’s my cup of tea?’ punctuated the whole conversation this lady had with her son, along with cross complaints of ‘no-one’s listening to me’ to her son, who was calm, said he was listening. But you could see, he was tired. Tired of it all. He went early, telling her that visiting time was over despite everyone else still being there. ‘I’ll see you tomorrow Mam,’, ‘Will you?’, ‘Of course I will.’, ‘Are you going to give me a kissy-wissy?’, ‘Of course I am Mam, I’m not going without a kiss.’, ‘Oh, you’re a good boy. He doesn’t hit his wife you know.’, ‘See you tomorrow Mam.’, ‘Do you have to go?’,  ‘Yes.’,  ‘See you tomorrow son.’

She returned to her songs and calls for tea.

Scenes like this, I imagine, are enacted all the time all over the country, all over the world. Children sit with their parents, who still look like their parents but don’t act like it so much anymore. They behave in ways that would have been excruciating to them just a few years before. The child becomes the parent and vice versa.

A bit later, the lady tried to address me. I didn’t know what to do. I’d have been happy to exchange a few words with her, whether those words made any sense to either of us or not. But I knew that if I turned round once then I wouldn’t be left alone. And I’d come to see my Mum after all and she needed me with her. So I ignored this old lady who simply wanted the comfort of the company of another human being. It’s not much to ask. I hoped the nurses would come. One came, fleetingly, asked if she was ok, ignored the faecal stench coming from her, said she’d help her to sit up and then went away again. She hadn’t come back half an hour later, the stench remained, the lady had not sat up.

But what do we do with people like this? Old people with many medical problems and varying stages of dementia on top. They’re still human beings and deserve to be treated as such. But they are shadows of their former selves and all the rules of social engagement have changed. How do we honour their life but treat their current selves? What is the treatment hoping to achieve? Do the rules change if the person doesn’t even understand the rules anymore? Is this simply a test of our humanity and if it is, do we pass?

As I left, the old lady near the door looked at me and called the name of, presumably, her son or husband, called it plaintively then ‘please, please, please’ as I walked past and out of the door.

What could I do? What could we do?

What we can learn from the dying

13 July 2015

Bronnie Ware, a palliative nurse who has counselled the dying in their last days, has revealed the most common regrets we have at the end of our lives. These are the top five regrets, as recorded in  her book The Top Five Regrets of the Dying:

  1. I wish I’d had the courage to live a life true to myself, not the life others expected of me.
  2. I wish I hadn’t worked so hard.
  3. I wish I’d had the courage to express my feelings.
  4. I wish I had stayed in touch with my friends.
  5. I wish that I had let myself be happier.

No surprises there, you might say. We all know all of this already don’t we?

So why are these five things still the top five deathbeds regrets? Because we know it but don’t do anything about it. I know it’s not as easy as it sounds but making these changes is down to us and us alone. These changes don’t happen to us, they happen because of us.

We can decide, now, to learn this lesson. Or we can leave it too late and just confirm what everyone already knew by dying full of regret, unfulfilled and disappointed.

For more detail, see Bronnie Ware’s own website: http://bronnieware.com/regrets-of-the-dying