Who Is Normal, Anyway? Part V

29 Nov

There is always some reason in madness

- Friedrich Nietzsche

V – What Does Work?

There are no simple fix-all cures, but there are techniques and tricks that can help.

Everything you do rewires your brain, alters your brain chemistry. Even making a cup of tea. What really beds in change is regular practice. For example musicians and taxi drivers significantly change their brains due to their practice. Neuroplasticity shows how we can rewire our brains to great advantage – recent research shows that we create thousands of new neurons each day, even into old age.

And so talk therapies can leverage this to get the root of the problem and literally rewire the brain. For example, many therapies can give you tricks to push your mind out of the negative rumination that is at the core of the destructive cycle of depression.

Study after study backs this up. And the evidence is clear that although drugs may reduce some symptoms in the short term as much as these therapies, the relapse rate with drugs is more than double that of these approaches.

Jonah Lehrer said: “patients who escaped depression with the help of anti-depressants, and then stopped taking the drugs, relapsed about 70 percent of the time. The chemical boost was temporary. However, during the 18 month follow-up period, only 28 percent of patients in mindfulness therapy slipped back into the mental illness. What we often forget is that therapy alters the chemical brain, just like a pill. It’s easy to dismiss words as airy nothings and talk therapy as mere talk. Sitting on a couch can seem like such an antiquated form of treatment. But the right kind of talk can fix our broken mind, helping us escape from the recursive loop of stress and negative emotion that’s making us depressed. Changing our thoughts is never easy and, in severe cases, might seem virtually impossible. We live busy lives and therapy requires hours of work and constant practice; our cortex can be so damn stubborn. But the data is clear: If we are seeking a long-lasting cure for depression, then it’s typically our most effective treatment.

In fact, psychotherapy and mindfulness mediation can even alleviate physical conditions, for example gastritis and tinnitus.

There’s a better way to understand people with psychological problems: psychologists and psychiatrists use formulation: “we don’t ask what is wrong with someone, rather we ask what has happened to them.

There are so many different theraputic approaches:

- Psychoanalysis looks at childhood, emotional drives, and the unconscious, usually drawing from Freud, Jung and the like.

- Cognitive Behavioural Therapy – rather than delving into the past looks at your perceptions, emotions and behaviour in the present.

- Systemic Therapy – looks a person as defined by their relationships with other people.

- Body Psychotherapy is pretty cool – using the body to gain a greater awareness of mind. After all the mind would not exist as it is, without the inputs from the body. I’ve tried Focusing and found it effective.

- Mindfulness is an approach I’ve been using for a few years and, while I don’t have issues with depression or the like, it has helped me to sleep better, to relax more, to appreciate the moment, and maintain more healthy relationships. Self awareness is what this practice gives you, which is the first and hardest step towards change, as most therapists will agree.

Point is, there are plenty of approaches, so you can choose the style that best suits you and your problems.

Part IV – Psychiatry in the previous post.

Who Is Normal, Anyway? Part IV

15 Nov

Crazy people are considered mad by the rest of the society only because their intelligence isn’t understood

- Weihui Zhou

IV – Psychiatry and the DSM

For someone working to help people deal with these conditions, it is helpful to look at specific symptoms, to classify, and to find common causes, and hence common solutions for these symptoms, if they are problematic for the person.

Systematising in this way is what we do well, and gives us our understanding of the world we have, so I don’t have a problem with it. In fact I fully support it.

However, with the failed biological model, this means that symptoms are given arbitrary disorder names and drugs applied to ‘fix’ them. The mainstream approach is predicated on an often unproven assumption of biological cause which leads to harmful decisions.

It also often means people give up responsibility for their conditions, and even for their actions. While this avoids blame it unfortunately goes further and avoids responsibility, resulting in people giving up and just living with their ‘condition’.

Tom Stafford sayswe know that self-efficacy is one of the best predictors of recovery, so denying people’s role in their own decisions just undermines one of their most important tools for recovery“.

The approach I’m advocating here is that you can take responsibility, and that you can change. It means empowering the individual to change for the better if they want to.

So much has been written on the problems with the DSM and approach of many psychiatrists that I don’t need to detail it here.

One purported disorder is pee-shyness, then there’s “caffeine intoxication disorder” and another is “intermittent explosive disorder“.

As you can see, “having some psychiatric symptoms is part of the human condition and does not by itself indicate the presence of mental disorder. The boundary between the worried well and the psychiatrically ill is fuzzy; arbitrary, and subjective—there is no biological test.

Tom Stafford saysThe fact that the most senior psychiatric researchers in the US are now openly and persistently highlighting that the DSM is not fit for the purpose of advancing science and psychiatric treatment is a damning condemnation of the manual.

Neuroskeptic says that “many people are now being prescribed antidepressants for emotional and personal issues which wouldn’t have been considered medical illnesses until quite recently“. He adds that they don’t work very well either.

We really do have a lot to learn about the brain. It was only 60 years ago that Freeman and Watts went around sticking a rod up people’s eye sockets and wriggling it about to mess up their frontal cortex. The frontal lobotomy certainly made them tractable, but left them in a terrible state, usually mentally and physically retarded and sometimes dead. These guys had sod-all idea of what they were doing. Some may say, ‘ah but today we have such a clear understanding of these issues, science has come so far‘. But some of these drugs are like a blunderbuss to the brain. I think that in another 60 years time many of these drugs will be considered an abhorrent way of treating people.

It’s not a question of whether or not these behaviours exist. It a question of whether the psychiatric approach and classifications are helpful. The disease model is fundamentally flawed. And many psychiatrists recognise this.

Final part – What Does Work in the next post

Part III – Stigma in the previous post.

Who Is Normal, Anyway? Part III

1 Nov

In a mad world, only the mad are sane

- Akira Kurosawa

III – Stigma

When sometime does something that breaches our moral code we try to explain it away by calling them evil, brainwashed and mentally ill, for example Adolf Hitler or Anders Brevik.

It’s more convenient to dehumanise them, as then we don’t have to think about how someone might think it a good idea to do serious harm to other people.

But it’s just lazy, and says more about the person using this as a rationalisation, than the person with the purported behavioural problem.

This kind of labeling is why mental illness can be so stigmatising. Especially when the word ‘mental’ is used, which has so many unhelpful connotations.

Once someone has such a label it can be difficult for them to be socially accepted or professionally trusted. This is wrong.

Neil deGrasse Tyson said “Labels are a lazy way of presuming you know something about someone that you don’t actually know“.

People like labels. It reduces their responsibility for actually thinking about the results of their actions: “oh, sorry I was a twat, but you see that’s because I’ve got Disruptive Mood Dysregulation Disorder“.

It’s worth noting that people with mental conditions are no more likely to hurt another person. Simply having this false attitude can stop people with problems getting better. In fact, the psychiatric times says that “persons with mental illness are far more likely to be victims of violence than they are to be perpetrators“.

Calling them disorders, or mental illnesses, is technically incorrect, and removes the autonomy of the individual. There’s no evidence that most of the conditions we talk about are illnesses per se, rather they are ways that people react to bad experiences, and fairly predictable ways at that.

We can talk more about these problems these days – there’s more acceptance. Acceptance that depression is something normal, and nothing to be scared of. Things are getting better in this area but there’s still a long way to go.

People can go to a therapist with less stigma, especially in the US. Alain de Botton reckons the day will (or should) come where every high street has a therapist’s office, perhaps in between the chemists and the greengrocer.

Part IV – Psychiatry in the next post

Part II – Drugs in the previous post.

Who Is Normal, Anyway? Part II

18 Oct

It is sometimes an appropriate response to reality to go insane

- Philip K. Dick

II – The Drugs

One of my most popular posts discusses this area, but it’s worth clarifying some points.

My motive is simple – to get the best possible care for people suffering from sometimes debilitating problems.

The question is what does the evidence say is the best solution?

Drugs may ameliorate some of the symptoms of these conditions, but they do not address the causes.

Much like a pain killer is most welcome when suffering with appendicitis, so some drugs can be beneficial to deal with the worst of the symptoms for some of these conditions. However, to stretch the appendicitis analogy, if you only took the drugs to dull the pain, then the appendix may rupture and the results of that ain’t pretty. Besides pain – while unpleasant – is key to diagnosing the cause of the problem.

Similarly with mental problems, drugs can often mask issues. For example I’ve seen a number of people I know suffering from such issues be subdued with a cocktail of anti-psychotics and anti-depressants. Yes, it reduced their worst symptoms, but it also removed all their emotions, all their motivations and drives. One said to me “I feel like an automaton“, another “I’m just a zombie“. Max movingly saysI don’t know how else to explain them except mental handcuffs“. I’ve heard similar comments from other people. I very much appreciate that this approach took away the worst of their distress and behaviour, but it did not get to the root of their issues and help them deal with the causes of their distress. In fact in some cases I’ve seen, the ‘abnormal’ behaviour was a way of the person working through their underlying emotional problems, and this approach stopped their progress in its tracks.

The problem is, these treatments tend to be predicated on the assumption of a biological cause.

Psychiatrist Dr Joanna Moncrieff says “psychiatric drugs…”work” by producing drug-induced states which suppress or mask emotional problems, which may suppress the symptoms of psychiatric disorders, along with other intellectual and emotional functionsThat sounds good. If your brain is not functioning properly“, however what if these reactions to environmental and psychological triggers are in fact adapted functions of the mind, evolved methods of coping with negative situations?

Professor Peter Kinderman saysPsychiatric diagnoses are not only scientifically invalid, they are harmful too. The language of illness implies that the roots of such emotional distress lie in “chemical imbalances“. This leads us to be blind to the social and psychological causes of distress. More importantly, we tend to prescribe medical solutions – anti-depressants and anti-psychotic medication – despite significant side-effects and poor evidence of their effectiveness. This is wrong.”

Allen Frances says that “Medication should be a last resort used only for the clearest, most impairing, and most persistent disorders. Instead the meds are often prescribed carelessly-almost like candy“.

It should be added that most of these conditions cannot be considered in the same way as physical diseases – the pathologies just aren’t there. They are arbitrary assignations that enable us to understand and treat certain common behaviours and feelings. (And that’s not to deride or belittle them in anyway.)

It is clear also, that positive effects of mind-altering drugs can be brought about through the power of the mind, say through meditation.

People say ‘But, but, look at all these people that call it an illness, that treat it with drugs’ – Appeal To The Crowd.

But this doctor with a white coat prescribed these drugs’ – Appeal To Authority.

But they have been treated this way for decades’ – Appeal To Tradition.

People talk about chemical imbalances: correlation? Yes. Causation? Not necessarily. In fact, such markers should be thought of as the result of difficult life circumstances. This is how the brain responds to external events. Hunger is a chemical imbalance. You don’t take drugs to make the feeling go away, you look to the cause of the hunger. You eat food.

While there is evidence of genetic markers that mean people are more prone to, say, depression than others, it’s still their environment that triggers those reactions. Epigenetics is still in its infancy, but it’s clear that environment can activate and deactivate genes.

The gene blame game makes popular headlines but is not scientifically accurate. It’s a little more subtle than that.

The biological / genetic model is appealing. Its reductionist and simplistic approach makes it easy to understand and to treat. However that doesn’t mean it’s always correct.

So beware the seductive but pernicious idea that medication heals people in all of these situations. The evidence shows it doesn’t. It only manages symptoms. Or worse, is used to make people manageable.

Part III – Stigma in the next post

Part I in the previous post.

Who Is Normal, Anyway?

3 Oct

The Mad Hatter: Have I gone mad?

Alice: I’m afraid so. You’re entirely bonkers. But I’ll tell you a secret: all the best people are.

- Alice In Wonderland

People who have had nasty stuff happen to them are likely to act a bit differently, particularly when placed under stress.

Some people who don’t act normally are called mentally ill, and given labels to say they have this or that disorder.

While there is utility in such arbitrary labels, it is clear that there are also counterproductive results.

It’s a matter of subjective judgement whether certain behaviours are considered abnormal. And that’s often as much down to the way society works as the individual.

For example not so long ago homosexuality was a mental illness, with it’s own symptoms and then it wasn’t. Just like that. Now it’s considered as normal and healthy. Even nostalgia was defined as an illness until recently. Again, whether delusions are considered problematic can be a grey area: “Delusions, in the medical sense, are not simply a case of being mistaken, as the everyday use of the term suggests. They are profound and intensely held beliefs that seem barely swayed by evidence to the contrary – even to the point of believing in the bizarre.” Religion is a great example of this, but we don’t pathologise such behaviour. The thing is, everyone holds some delusional beliefs – it’s part of the human condition.

It seems clear that psychiatry makes some of these judgements based on what is acceptable to society as much as what is unhealthy for the individual. It’s not exactly rigorous science. While there are biological markers for a few states of mind, for the majority there are not, so we resort to classifying behaviour. How do we define what behaviours are the results of “mental illness” and what are normal? One suggestion is defining the behaviour of the majority as the norm, and classifying everyone outside of that average as disordered. The faults with that approach are immediately clear. Another suggestion is whether that behaviour causes self harm. If so smokers, or those with a bad diet, are defined as mentally ill.

So we then look to the perceptions and feelings of the person. Phenomenology, is the best tool for this, but is again subjective and imprecise. We can also look at whether these behaviours affect a person’s ability to lead a normal life, which requires normality within their culture to be defined.

Of course there are many difficult conditions that one would have difficulty arguing against being classified as problematic in any society. I’m acutely aware that severe depression can be debilitating, that psychosis can mean a person is unable to care for themselves. I’ve seen it first hand. Mind says that 1 in 10 adults are experiencing depression at any one time. Over 10% of mothers experience post-natal depression. Around 1% of people experience bipolar symptoms at some point.

However, while these methods will have clearer conclusions at the extremes of behaviour, there are massive grey areas in between.

The conclusion then, is that this is not a simple, easily solvable area. An acceptance that we don’t have black and white definitions is necessary, much as that is not satisfying. And as a result we don’t have panaceas either.

Part II – The Drugs in the next post

Egonomics by David Marcum and Steven Smith

16 May

Written in an accessible and conversational style, this book is an easy read. Marcum and Smith decided to study ego, within the context of business, setting out with the idea that the ego was “negative and needed cold-blooded elimination”.

Once they started studying it (and I suspect clarified their definition), they found it can also be very helpful, hence the subtitle of the book “What makes ego our greatest asset (or most expensive liability)”.

While the book is written with a business focus, it’s blatantly applicable to life in general, and the business context simply gives a nice set of examples through which to understand the concepts they’re teaching.

The most interesting idea from the book is that our greatest strengths can be turned against us when our “ego isn’t balanced”. Some examples:

-         assertive becomes pushy

-         charismatic becomes manipulative

-         discerning becomes judgemental

-         pragmatic becomes uninspired

-         determined becomes stubborn

-         innovative becomes impractical

This is a double whammy as our weaknesses can feel almost the same as our strengths, so it can be a dangerous blind spot. This is where having trusted people around you is important – we are great at spotting the faults in the reasoning in others, but not in ourselves.

Marcum & Smith give some nice systems to aid awareness of these issues. When ego is working against us it is likely that we are:

1)      being comparative

2)      being defensive

3)      showcasing brilliance

4)      seeking acceptance

Being comparative means we become less competitive, as we give up our own potential to the goal of only being better than the person with whom we are competing.

Being defensive is when we start to defend ourselves rather than an idea. If we separate ourselves from our ideas then we can let the best argument win.

Showcasing brilliance means that we want people to recognise our expertise. The irony is that while we’re showcasing, people will tend to ignore the good points that we are making, however brilliant they may be.

Seeking acceptance is when we need others to validate who we are. It’s important to be aware of what other people think, but that must not keep us from being our true selves.

To counter these they give “three principles of egonomics:

1)      humility

2)      curiosity

3)      veracity

In the second half of the book they expand on these principles to give practical advice on how to put them in action.

They make the excellent point that intensity should not be confused with aggression, and humility should not be confused with meekness. They define intensity as the ability to argue a position with passion and strength, and humility as the ability to question everything. Both of these qualities are needed to come to the best conclusions. Otherwise you either have confrontational clashes without conclusions, or courteous but meaningless exchanges. They argue (strongly!) that vigorous debate is extremely productive if there is humility alongside it. People need to understand that it is ideas that are being questioned, not their identities. I think this distinction is very, very important.

Regarding curiosity, it’s easy to go with the first solution that presents itself, especially if that solution is your own. The ability to take other solutions on board and weigh them equally is key. So the authors give 4 questions to aid curiosity, a mini-version of Socratic questioning:

1)      What do we mean?

2)      What are we seeing?

3)      What are we assuming?

4)      What does that lead to?

The final area is veracity. They define veracity as an active searching for truth. People often avoid this as “the reaction to hard-to-hear truth when revealed isn’t usually favourable. As a result of the typical reaction to candour, most people believe truth telling is risky… A major barrier to hearing truth is our belief that dissent is disloyalty. If we view dissent as disloyalty, we’ve closed our mind. More often than not, there’s positive intent behind a negative comment.” Both those speaking truth, and those hearing it, have equal responsibility towards humility.

To counter these issues, before speaking up they suggest you:

1)      establish permission

2)      make your intentions clear

3)      be candid.

To be able to understand these lessons, and apply them to myself, I found it practical to digest this book in small chunks over time. I read a few chapters every week or so, then observed myself and others, looking at ways to improve.

Usually we are our own worst enemies, so it’s worth a read if you find yourself slowing down your own progress.

Insomnia

17 Apr

Insomnia sharpens your maths skills because you spend all night calculating how much sleep you’ll get if you fall asleep right now.

- Anon

Like one in four of the population, I get problems sleeping. I tend to wake up in the middle of the night and find it hard to get back to sleep again. Others I know struggle getting to sleep in the first place.

Experts aren’t completely sure what sleep is for, though we know that it has lots of health benefits, physical and mental. But learning about these really doesn’t help you getting to sleep, it just makes you more frustrated.

So in the years of getting pissed off by lack of sleep, I’ve picked up lots of tips. There is no panacea, but with a combination of physical and mental approaches, you can go a long way.

Physical

  • if you’ve been lying awake in bed for a long time, get up and move around – this releases tension in the body, and takes the mind off whatever thoughts are distracting you from sleep.
  • wash your face – I can’t remember the details of the research I read on this, but the face being cool helps getting to sleep.
  • don’t eat sugary snacks before bedtime – slow release energy is better, such as cereal with milk, or yoghurt with granola. If you have chocolate for example, your blood sugar will drop shortly afterwards, and your body will wake you up for you to get food. Slow release energy will keep the blood sugar stable so you are more likely to stay asleep.
  • get lots of sun in the day time, avoid light before bedtime and keep your bedroom dark – there’s a little receptor in the back of the eye, not used for seeing, that is sensitive to blue light. The blue light makes your body suppresses melatonin production. In the dark, the body produces melatonin, which makes you feel sleepy. Getting this light at the right time of day helps to regulate your sleep cycle. It’s interesting that for me sleep is better in summer and worse in winter. I’ve recently got a daylight bulb in the living room, and a daylight lamp in the office. And the corollary is to stay clear of strong light the hour before bedtime. If you must use a computer or mobile phone, get an app that reduces the blue light (you can use f.lux for the PC and there are plenty of mobile apps available).
  • it may be an obvious suggestion, but no drinks after 8pm is good idea – a full bladder can wake you up.
  • keep the same sleep schedule on weekends as you do during the week.
  • steer clear of the drugs – they may be of help in the short term if you’re desperate, but in the long term they can have really messed up side effects, and can often make the problem worse.

Mental

  • try not to get annoyed and frustrated about it. That keeps you awake longer. Acceptance really helps. It’s interesting to know that back in the day two sleeps of around four hours was the norm – in between sleeps they’d get up for a few hours and chat, eat, or even indulge in a spot of rumpy pumpy.
  • if you have things on your mind, write them down before sleep. Even if you feel like you don’t have anything consciously going on, it may be worth writing whatever comes to mind when you can’t sleep.
  • the standard advice is to keep your bedroom for sleep only; don’t have a telly, or use it as an office.

Often with insomnia, the mental state when lying in bed is key. It’s easy to get stuck in the mind, perhaps re-living a past event, or thinking about the future. Maybe getting stuck in a loop. There are two approaches here: calming the mind, or taking your focus out of the mind altogether.

  • mindfulness, is a great way to break out of that cycle and relax the mind. I did a mindfulness course last year and it has a lot of benefits. I know it sounds like airy-fairy nonsense, but take it from an inveterate skeptic: there is a lot of scientific evidence behind it. Check out my recent post on the topic.
  • try to take your focus out of your mind. An easy one is just wriggling your toes, maybe once with every breath. Another approach is the body scan – it’s a mindfulness exercise that works most times with me.
  • while I would normally agree with the mindfulness training I’ve done, and say that watching the breath without controlling it is preferable, when trying to sleep I think slowing the breathing down is useful, as it can help to calm the body and mind.

Alternatives

It’s worth bearing in mind that insomnia can, in many cases, be a reaction to life circumstances. Much like depression, it can have great utility; when we have a problem, laying awake at night can be a way the mind gets our attention that we have a problem to solve. Also, as described here, it can give us the time, free from interruption, where we can contemplate our situation away from the mundane pressures of the day, and come up with solutions to improve our lot.

As a result many recommend CBT as a way to beat insomnia.

And if you’re up for trying something a bit more edgy, get a load of lucid dreaming.

I do hope some of these suggestions are helpful. I’ve largely beaten this issue using the mindfulness techniques, but if you have other things that have helped you, feel free to add them below.

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