World Mental Health Awareness Week - Thursday - Recovery

I was first diagnosed with clinical depression in 1995 when I was admitted to a mental health respite care home when living in Wales. At the time I had no idea what depression was let alone understanding the concept of mental health recovery. I remember the term used to describe my long period off work at the time was ‘experiencing a breakdown’. My next admission, this time to a hospital psychiatric ward was in 1998 in Kendal. After a further two admissions over the next year, it wasn’t until 2000 when I started working in the Mental Health field I came to hear of mental health recovery as a particular process.

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I don’t think it’s true now, but in those early days, my experience of engaging with the concept of mental health recovery was a political one (with a small p). Service users as we were known were gaining voice with regards to our right for our involvement within our mental health treatment. Up until this period in time, as far as I could make out, treatment for mental illness was administered with medical authority where the expert was the psychiatrist. Through a growing movement for change within service user groups and charities, the model for mental illness treatment was shifting from an authoritative top down approach to one where the patient’s personal experience and awareness was increasingly taken into account and validated as shared expertise. In short, it was becoming accepted that mental health sufferers were very much experts in their own suffering.

In 1993, William A. Anthony Ph.D., then the Executive Director of the Center for Psychiatric Rehabilitation at Boston University wrote a paper titled, “Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s.” (link here). Within this article he explored and outlined his understanding and vision for a recovery-oriented mental health system. Essentially, he describes a treatment oriented approach as one where the symptoms of mental illness were managed and alleviated. He describes a recovery incorporated approach as one where recovery can occur even if the illness is not ‘cured’. Recovery from mental illness involves much more than recovery from the illness itself.

It is that last sentence which hugely impacted me when I first read it in 2000 and for the first time, I began to consider my own mental health recovery process.

Twenty years later and I’m still working through the implications for myself of the recovery philosophy W.A. Anthony so wisely espoused. It is his wisdom which continues to inform me about my mental health journey and my pathway towards recovery. Indeed, this is a journey without a destination but always with achievable horizons. There are many other recovery centred models which are variations of a theme. However, I chose to adhere to this one simply because I like the apolitical nature of it. I have never signed up to the political nature of service user emancipation. Although I am antiauthoritarian, I do trust the expertise of the psychiatric professionals involved in my care. I prefer to work with them within the psychiatric system as it is, rather than ‘against’ the system where I determine my rights for recovery set precedence over anything else. This is not to say I do not disagree with those who follow a different path to me and in fact, I support many who have negative experiences of past mental health treatment and seek change as a result. I accept too there are many aspects of our current mental health system of care which could be enhanced, but I hold the view, we are fortunate to have access to what we have here in Scotland and I’m appreciative of this.

This is how I endeavour to live my recovery from my mental illness, the roots of this process set within the words from W.A. Anthony. I understand my recovery is a deeply personal and unique process where I’m developing my attitudes, feelings, goals and skills based on my mental health at any given time. My recovery is about me fostering new meanings and purpose in my life as a I continue to grow beyond the effects of my depression. I am hopeful this will lead me towards living a satisfying life where I believe I contribute even within the limitations set by my illness.

Helping me along my recovery path are these truths.

• Recovery can occur without professional intervention. This is important for me to accept. I hold the key to my recovery, not anyone else. It is down to me when to seek the interventions and support I require. By accepting this personal responsibility, I become responsible for my eventual recovery from a depressive episode. I do not rely on the mental health system to ‘cure’ me and rather view my relationship with them as a partnership.

• A common denominator of recovery is the presence of people who believe in and stand by me, the person in need of recovery. Crucial to this statement is the non-judgemental relationship I need with those close enough to be involved in assisting me through my mental illness. Key of course is my marriage with Karen and her unswaying support throughout my distressful episodes and subsequent periods recovery. Without her love I would not be here today. My collaborative relationship with my Community Psychiatric Nurse is another key example of where I am supported in an equitable and empowering manner. Knowing I am not being judged for being depressed is fundamental to my recovery.

• A recovery vision is not a function of one’s theory about the causes of mental illness. It is extremely helpful to me in my recovery process for an archaeological exploration for the roots my depression to become a key element in my treatment. The fact I suffer from the illness is enough and there is little to be gained by seeking the causes. Understanding a triggering catalyst may help in terms of increasing awareness for the future.

• Recovery can occur even though the symptoms reoccur. This is hugely important awareness for me to embody. By doing so, I accept the possibility of becoming ill again as a reality. This way I will never hold the expectation I will never suffer from depression again. I may hope this may be the case, but this is different to expecting it to be so.

• Recovery changes the frequency and duration of symptoms. Essentially, symptom reoccurrence becomes less of a threat to my recovery as I become increasingly accepting of living with depression as an illness.

• Recovery does not feel like a linear process. As someone who’s professional life has been involved in facilitating personal development awareness for others, I understand my recovery will involve growth and setbacks. There will be periods of change and times of little change, moments when I experience powerful insights, and times when I feel directionless. It is an acceptance that there is nothing gained from planning my recovery and hoping for systematic outcomes.

• Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself. As an example of this, I continue to struggle with the awareness because of my last episode of severe depression, I damaged important relationships in my life at the time. Coming to terms with this is just as difficult for me as it is suffering the symptoms of my illness.

• Recovery from mental illness does not mean that I was not really mentally ill. Again this is an important truth for me to embody. As I become increasingly lucid after a depressive episode, I have the tendency to become apologetic for ‘being the way I was’. I minimise the illness as a character failing rather than an integral aspect of my overall health.

All of this is of course not the complete story of my recovery process. There are many subtle nuances which contribute, some more helpful than others. The key for me to understand and accept is the fluidity of my recovery and with this to be patient with its developmental path. Key too is trusting the fact I will recover, the truth that periods of depression will pass to be replaced with opportunities for my life to be lived to its fullest extent.

Talking Suicide

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September 10th 2018 was World Suicide Prevention Day. To mark the day from a personal point of view, I put up a post on my Facebook page and Tweeted too. A few weeks ago I was filmed by the RNLI Film and Image Unit for a short film they are making about my voluntary role with Tobermory RNLI Lifeboat and my accompanying mental health struggles. I recently had a long and helpful appointment with ‘my’ Community Psychiatric Nurse after a long period of not seeing her. This blog entry is a description of how I live with my suicidal thoughts. I hope by sharing this incredibly intimate aspect of my self, I will help increase awareness and understanding about deep depression and suicide. This is an account of my personal experience and cannot be read as a generalisation of suicide per se. I am confident though, that there are contextual similarities with others who struggle like me which will be helpful.

Recently, despite the many good aspects of my life and my uniquely privileged lifestyle, I have been fighting familiar intrusive thoughts that my life is worthless, that I am worthless and it follows that the most natural conclusion is to take my life. These are not constant thoughts which continue to eat away at me through the day and night. They intrude at the most inopportune moments, sometimes fleetingly but generally with enough force to stick for a good while. They are private thoughts, triggered by any number of interpersonal interactions, thoughts, memories and moments. An incredibly astute observer might see for a split second, a grimace of pain cross my face when these thoughts of death reach into me. They would also hear me emit a muted cry of pain or a deep, lingering sigh.

Since I’m so used to this happening, I find myself burying these thoughts and feelings, fighting them inwards and hiding them deep within me. I used to be a psychotherapist so ‘internal dialogue’ fits comfortably as a term which describes what’s occurring. The thing is, there is no voice attached to these thoughts. I do not hear myself or anyone else, actual or imagined. They are thoughts accompanied by powerful emotional and physical feelings. Essentially they are beliefs - basically an overarching belief that my life should come to an end because of my ineptitude as a person.

Whether these thoughts are serious enough for me to become worried about my intentions and I consequently reach out for help, depend on how I grade them. Because I recognise them so clearly now, I give them levels of seriousness depending on how they arrive in my psyche, into my being and how durably they ‘stick’. First off I have the fanciful thoughts. The ones which are romantic notions of taking my life. This could be anything from the day being a lovely and sunny one, when I might think, “this would be a nice day to die”. Or, “I could head out in my kayak, capsize and drift off towards the far horizon”. The latter might be a response to recalling a moment of embarrassment when I believe I behaved badly to someone in my past. This kind of fanciful thinking serves to assuage my painful thinking in the moment by being a distraction, where I fantasize about a semi-honourable death, drifting off towards slow oblivion in a suitably restless sea.

A level up from the fanciful ideations are the ‘thought punches’ into my head and the ‘body blows’ into my being. These are powerful enough to stick and set in train semi-serious thoughts of suicide. Unchecked they might build into more enduring beliefs that the most obvious solution is to take myself off to my chosen tree and hang myself. If they occur in the dark hours of the deep night when I ping wide awake, as I often do, I might consider slipping out onto the deck of our yacht and lowering myself into the night-time sea to eventually die of hypothermia. I would be clad only in my underpants because I never want to be found naked. These thoughts and feelings of powerful desperation are promulgated by the more entrenched self-beliefs I hold about myself. Examples of these being; believing I’m a feckless father, a life failure in employment and business, a wasteful daydreamer, an untrustworthy person, a poor friend, I have nothing of worth to offer, I am a burden, and so the seemingly inexhaustive list continues. These thoughts and feelings may present themselves at any time, whether life is going well or I’m struggling with a dose of depression. Generally of course, they are stronger and more present when my mood is low. I have learned to rationalise these thoughts, to attempt to see them for what they are and realise that it’s certainly not logical to act on them. If I think I’m struggling with this process I might express to Karen (my wife), that I’m having a tough time and “I’m feeling suicidal”. This one simple sentence, spoken out loud and knowing I have been heard, is usually enough to dissipate the strength of the feelings and/or the thoughts I’m experiencing.

However, there are times when these body blow suicidal thoughts stick like a ball of mud thrown against a brick wall. With sun, the mud might set rock hard and become insoluble. (It reminds me of when I was a boy in Africa, my friends and I used to have battles with clay lakkies - hand squeezed balls of mud on the tips of whippy sticks, which when flicked like a tennis serve, sent the mud screaming through the air. Brutally powerful and accurate. Great fun as well to plaster house walls with nasty splats of mud!) What happens is, I find myself unable to now rationalise my thinking with any certainty. The thoughts metamorphose into beliefs and these then set deep within me. The primary belief being that the time has come to end my life and there is no point in lingering any longer. It could be that I might be berating myself for being a horribly curmudgeonly husband or as with 2017, a useless sea kayak guide. The belief that I am eternally useless, worthless and a burden to others, takes root and instead of distracting myself from this belief, I find myself arguing, “why not kill myself?”

This is a dangerous time for me. This is when the thought of death has become realistically pragmatic. It has shifted from being an attractive desire, to one where it is now the most reasonable solution. When I am at this depth, I begin to make my plans. I have already chosen my tree. It is local, within ten minutes walk and hidden from public view. I know the type of rope I will use and its length. Being an outdoor instructor, I know the specific knots I will tie. The only unknown is whether to leap off the branch in the hope I break my neck, or lower myself off and hang until strangulation has done its work. More recently I have been considering immersion in the sea and dying of hypothermia but here, I find myself pulling up short, because I don’t want my Tobermory RNLI colleagues to be the ones who find me. In terms of being found, I have in the past prepared letters for the local police and coastguard with GPS coordinates of my suicide location. I have also written letters to individual family members.

When this is occurring for me, I am now in the grip of deep depression with a very strong desire for suicide.

Even in this state, with every fibre of my being now craving my obliteration, I find within myself a desire to hang on to life and I make my thoughts and intentions known, not only to my wife but my community mental health support network too. This may be the psychiatrist, the community psychiatric nurse or the local GP. I will do so knowing that I may be admitted to hospital and in some respects, this is what I desire for hospital is a safe haven for me. What I fear most, is that the final decision to take my life will be made beyond my conscious awareness. I know within myself from my adventure activities, that before a risky undertaking I have a propensity to weigh up all the factors, and once done, if they are in my favour, to suddenly act without a conscious decision to do so. It’s almost as if my body moves into action before a cognitive process has taken place. I believe that if (when) I take my life, this is how it will be. I will be in the firm grip of a belief that death is the only course of action to take, I will have negated the consequences and I will act on this - suddenly. I use the word courage to describe the motivating emotion which will literally see me release myself from the tree branch I will hang from..

Equally, it is courage which drives me to struggle against the forces raging within me. The belief that I must die is real - in that it appears very real. Any amount of dissuasion by concerned others does not seem to work. I hear their words but do not take them in. In a vain act of self-aggrandisement, I argue the reasons why I believe I have the right to choose my own path and it’s far better for me to end the pain I am struggling with - for pain it is! It’s a palpable emotional, cognitive and physical pain, gripping my thinking and emotions along with a agonised chest. My mind is a continuous maelstrom of self-destructive thinking and the dreadful reasons why this should be the case.

In these moments despite my firm belief that I must die, I do find myself making agreements to keep safe and to make contact with the health professionals if I’m feeling close to acting. In this regard, I’m thankful that I’m a person of some honour because I feel duty bound to keep my word. When I’m considering taking myself off to my death, I find myself agonising with the fact that I would be breaking my word if I went through with the act. However, even then, I have moments when the desire for death is more powerful than my reasoning and this is when I will choose to be admitted to a psychiatric ward. Here, cocooned in the warmth of the ward, I believe myself to be safe.

Recovery happens. Inevitably it takes root within the process of my struggles and inexorably I begin my long climb back to normal reality. Slowly and surely the light and colour returns to my world and to my thinking. Through dialogue and peaceful ‘time out’, I readily grasp onto nuggets of hope and my beliefs of the inevitability of my death are replaced with aspirations and plans for the future. Needless to say this process of recovery is not linear and there will be times when it seems as if I slip backwards. These moments or relegation become sparser as time goes by until at long last, I’m feeling like my happier adventurous self again.

Recovery does not mean an absence of my depression. This will always be there in my life and very recently, I have come to accept that it is an illness I will have to live with, rather than constantly seek a cure. Not having acted on my suicidal desires and thoughts does not mean that I do not have them or that they are not serious. These are not prosaic cries of help which I have often heard suicide referred to in the past. They are real for me and it is only through fighting hard for myself, that I manage to keep myself from acting on my desires.

Being open about my mental health struggles is becoming increasingly helpful for me. Each time I share my struggle (as I am doing here), I gain confidence in sharing more often because of the warmth and the love I receive when I do. My online community of friends and acquaintances are instrumental in this process. Twitter for me is a power for good! I hope that by being open I may normalising the dialogue around the subject of suicide. This is my hope, that increasingly, our society will become less offended or frightened by the subject and becomes willing to really listen to those who need to talk about their suicidal thinking. It is my experience that it is not helpful when I express my suicidal desires some people either change the subject away from the issue, or attempt to make it better by telling me of all the reasons I have to live. I term the latter a sticking plaster approach. Both responses are undoubtedly well meaning and I am grateful for any time I am given by those who have a desire to see my internal pain healthily diminished.

To bring this blog entry to conclusion, I want to say, at the moment of writing this I am safe. I am currently experiencing suicidal thoughts and feelings but I have these in check. There is enough firm reality in my life for me to focus on and I have exciting plans to fulfil. Additionally, there are the powerful metaphoric insights I gained from my 3 Peaks by Kayak journey earlier this year to remind me that suicide is a permanent solution to an impermanent situation. The simplest and most enduring of the metaphoric insights being “live life” when I saw a tragically injured Gannet on the island of Ailsa Craig and “this discomfort will pass” when I was struggling across the eighteen long miles of Luce Bay against a strong ebb tide.

Finally, thank you for reading what I have shared and I welcome any responses you may have. If you have been touched by what I have written and my words resonate and have a personal impact on you, please don’t dwell and find someone you are able to chat to about what you are experiencing. Please take good care of yourself.

Thank you.

This Thing Called Depression

Yesterday I had my monthly appointment with the Psychiatrist who is responsible for my care. I like him and more importantly, I trust him. He is personable with an easy yet professional manner. He is a yacht owner too so we share yachting stories and he likes to tell me of his recent trips.  Amongst these short conversations we also speak of my clinical depression, how I'm doing with this, and checking how safe I am with myself. He is thorough in his assessment of my current situation and willingly offers suggestions for new approaches. This certainly was the case yesterday.

At the moment I'm locked in to a severe bout of depression which is not shifting in anyway shape or form. The medication I have been taking is simply not making a dent on my low mood or even imprinting any form of colour into my life. The upshot is a diagnosis that I'm struggling with 'treatment resistant' depression and if this cannot be overcome with medication alone, then other treatment courses will have to be attempted. 

My Psychiatrist has prescribed one last medication which he hopes will provide me with increased energy and thus motivation to turn my current lethargy around. However, there are risks attached to this medication (see my previous blog post) and it may not suit me. Hopefully this will not be the case and it will work the magic he thinks is possible. It's not a medication for depression per se but there is evidence that it works for people like me, who have been fighting a deeply stuck low mood. 

If this new medication does not work then I will be admitted to hospital for further assessment and possibly a referral to a specialist NHS unit for people with severe and enduring clinical depression. Apparently there are non-medication approaches which can be explored, some of these almost experimental. Thankfully it seems that I'll not be put through ECT again because this clearly did not work for me.

Bringing my session with him to a close yesterday, my Psychiatrist implored me not to give up hope, assuring me that we were nowhere near the end of the road and I was not going to be given up on. One of the struggles I'm dealing with at the moment is a strong sense of hopelessness, sometimes to the point where I believe there is no reason to continue fighting for my recovery. Associated with this, is the gnawing belief that I'm nothing but a burden to my family. I'm not sure if I was entirely mollified by his assurances that I will recover but I did leave the Health Centre with a little more hope than I had before.

I have started to take the new medication which is an adjunct to my current pill regimen. Time will tell if this will work or not. Sadly I will not be able to celebrate their success or deal with their failure with my Psychiatrist because he is moving on to new pastures. I will miss him for his professional and affable care, and the ease with which I'm able to communicate with him. 

Here's to HOPE.