The Power of Conversation

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It’s a well known fact that a problem shared is a problem halved, right? But when you’re feeling down or worried sometimes talking about your feelings can seem too hard. For some people it could be easier to bury these feelings and try and carry on regardless, or for others admitting how they truly felt would seem a sign of weakness.

As you may know it’s Mental Health Awareness week in the UK, so this year I’ve decided to write about the power of conversation, and why you don’t have to deal with everything on your own.

Talking to others about their feelings is something men can be particularly bad at, especially when it comes to any concerns about their physical or mental health. To quote the columnist and campaigner Bryony Gordon in her recent article “Women are encouraged to talk about their problems. Men just have football.” Prince Harry was recently praised for his honesty in talking about his mental health – something which will hopefully change the stereotypical view that British men should have a ‘stiff upper lip’ and not show any sign of emotion.

This gender divide has led to inequality in mental health. In 2016, 3 times more men committed suicide than women. Suicide takes more lives of men under the age of 45 than accidents or disease.

Why is it that men are more at risk of suicide than women, when more women are diagnosed with a common mental illness? One explanation is that men aren’t as good at accessing healthcare as women – for example in the first 3 quarters of 2015, only 36% of those who accessed Improving Access to Psychological Therapy (IAPT) services were male*. Men are also less willing to let others know if they have a problem, with one survey finding that only a quarter of men said they had disclosed a mental health problem to a friend within a month, compared to a third of women. Almost 30% of men said they never tried to access help for their last mental health problem, compared to just under 20% of women **.

Accessing the correct care early is vital in the successful treatment of mental illness. For most common mental illnesses, talking therapies are used as a form of treatment (possibly in conjunction with medication). These include Cognitive Behavioural Therapy (CBT), Psychotherapy, Dialectic Behaviour Therapy, or Counselling – just to name a few. Having the opportunity to talk about thoughts and behaviours with a trained professional can give you the space to work out the cause of your worry or identify any patterns in your thinking which contribute to negative feelings. Therapies such as CBT also try to change behaviours using set goals agreed between the patient and professional which can lead to an improvement in mental wellbeing.

This evidence shows that the culture has to change. Why should it be taboo for men to speak about their feelings in the pub with their mates, as I do with my girlfriends over dinner? Anyone should feel like they have someone to talk to about their problems, even if that person is a healthcare professional – they’re there to help.

On a final note – one project I’m proud to be involved in which is aiming to reduce the stigma of mental illness is a zine called ‘do what you want’. This includes articles from a range of writers and has been featured in the Guardian, BBC and Grazia. All proceeds go to mental health charities, and the ebook (and print version whilst it’s still in stock!) can be ordered here: http://dowhatyouwantzine.co.uk

* https://www.menshealthforum.org.uk/key-data-mental-health

**https://www.mentalhealth.org.uk/news/survey-people-lived-experience-mental-health-problems-reveals-men-less-likely-seek-medical

Exercise and Mental Health

This blog post was inspired by the recent London Marathon, who’s official charity was Head’s Together (a charity set up by the Duke and Duchess of Cambridge and Prince Harry, which aims to reduce the stigma of mental illness) making it the first mental health marathon.

As well as raising millions of pounds for charities which work to improve our mental health, the physical act of training for and running the marathon can also provide a boost to our mental health.

That high you get after going for a run, dancing with your friends or a hard gym session? It’s caused by an increase in endorphins, a neurotransmitter released by the pituitary gland which have been shown to act as a painkiller, and improve your mood.

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Exercise has been found to have benefits for people suffering from different types of mental illness, from depression (Balchin et al, 2016), bipolar disorder (Ng et al, 2007) and schizophrenia (Gorczynski & Faulkner, 2010). Other studies have suggested that exercise could also help protect people from neurodegenerative conditions which can affect us as we get older, such as Alzheimer’s or Parkinson’s disease, as well as improving symptoms and quality of life for people with these conditions (Deslandes et al, 2009). This could be because exercise stimulates blood flow in the brain as well as improving overall fitness. Increased levels of exercise in older adults has been linked to have several positive outcomes, including improved mental health and social integration (Chodzko-Zajko et al, 2009).

Exercise can also help to improve mood in sedentary (but otherwise healthy) participants. One study in Turkey (Taspinar et al, 2014) compared participants who took part in either a Hatha yoga or a Resistance workout program where they trained for an average of 50 minutes, 3 times a week for 7 weeks, to participants who did no extra exercise. The researchers found that participants in the exercise groups showed improved quality of life, body image, self-esteem and lower symptoms of depression after taking part. Participants in the control group showed no change. Yoga was better for improving symptoms of tiredness and depression, and self-esteem, whilst resistance training led to higher improvements in body image perception. This study also shows that it doesn’t matter what type of exercise you do to get the benefits – although it probably helps to find one you enjoy as it means you’re more likely to continue. In case you’re still not convinced, this graphic summarises the 5 main ways exercise can improve your mood:

Exercise

However it is important to note that if you are suffering from a mental illness, exercise on its own may not be enough. For some people, it may be hard enough to get out of bed in the morning, to them going for a run would be completely unrealistic. This is why exercise can be so effective in conjunction with other therapies, be it medication or talking therapies like CBT. Once symptoms have started to improve, then incorporating exercise could be a good way to manage your mood.

So next time you’re feeling worried about an exam, stressed about a deadline or feeling lacking in motivation why not try going for a walk or a dance class? You might get hooked on a new hobby which can do much more than just improve your fitness.

Imposter Syndrome – Not feeling good enough and how to beat it

I’m sure you’ve all been there – earning a promotion, getting into uni or finding your dream job. All your hard work and sacrifices have paid off, and you should feel on top of the world. And for most of the time, you do. You feel happy and accept people’s congratulations of “I knew you could do it!” But despite all this, what about that niggling feeling of ‘why me?’, the feeling that you don’t quite fit in with your peers and that they are all so much smarter and more deserving to be there than you? Why can you not share the confidence in yourself held by your friends and family? This is known as Imposter Syndrome and tends to affect high achieving individuals, and is especially common in women (although men can of course suffer from this too).

Imposter syndrome can negatively affect your self-esteem, mood, and locus of control (this means you feel as though you have little control over things that happen to you). It has been found to be worse in people who feel as though they are outsiders, which could perhaps lead to feelings of not being as good as those around you.

 

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The term Imposter Syndrome was first coined by Clance & Imes in 1978, where it was identified to affect high achieving women. They studied women who were towards the top of the career ladder, or who were studying at either undergraduate or postgraduate level.

The women in the study who had the condition reported that they felt like a fraud, and thought they had only achieved their PhD or got onto their current role because of other factors, for example a mistake in the admissions process or because of others overestimating their abilities. Despite their excellent achievements they didn’t feel qualified to be working or studying at the level they were at and were fearful of being found out. Clance & Imes explain that the women ‘do not experience an internal feeling of success’ which leads them to overlook their achievements.

This inability to have an internal feeling of success is an important symptom to note. One of the causes of imposter syndrome has been identified as having problems with attributions of success. For someone who suffers with these symptoms, they tend to explain a positive event such as a promotion as being down to an external unstable cause, such as luck or someone else’s mistake. The ‘external’ is important here, as it reinforces the fact that successes are not attributed to their own skills and actions. This has been shown to occur more in women than men, who are more likely to attribute success to an internal cause, such as skill or hard work (Deaux, 1976). This author hypothesised that if a women refers to a success as due to an unstable external factor, it does not give her confidence that she will be successful in the future, which causes a cycle of feelings of being an imposter.

So what next? If you’re suffering from Imposter Syndrome, what can you do to overcome it?

I spent a while searching academic journals for evidence on interventions that have been successful in reducing these symptoms. Unfortunately, any combination of the words *imposter* *syndrome* *treatment* or *overcoming* found no relevant results at all.

So instead, here are some recommendations that I did manage to find – mostly from various news articles or academic blogs (see below) mixed with my own advice. Also please remember that I’m not a healthcare professional, but I hope you find them helpful.

  • Be mindful of your self expectations. Don’t expect to be the best at everything and accept you don’t know it all and that’s okay. Don’t be afraid to ask if you don’t know something, that’s much more productive than sitting there feeling inadequate because of it.
  • Make sure you acknowledge the work you’ve done and remember that you’ve worked hard to be where you are now. Once my colleague corrected me when I described myself as ‘lucky’ for getting my current role – “no you weren’t, you applied to loads and worked really hard”. It turned out to be a very helpful comment – good things don’t just happen, you have to make them.
  • Aim to be ‘good enough’ – it isn’t realistic to strive for perfection. If you’re trying to make something perfect, it is likely you will never finish it. Instead accept that ‘good enough’ can sometimes be the way to go.
  • Finally, talk to someone about how you’re feeling – they will probably say they’ve felt like that before too, and you’ll realise you’re not alone.

 

Whether or not you are a student or work in academia, I can recommend this posts on Imposter Syndrome: http://jameshaytonphd.com/phd-impostor-syndrome/

 

 

Body Image Therapy for Anorexia – what is it and how does it work?

Today’s post is for eating disorder awareness week, which this year has a focus on early detection and intervention. Often, sufferers are unable to access treatment until they have been ill for some time, which makes recovery so much harder than if treatment happened once symptoms first began. As well as having obvious benefits for patients, there is also a financial advantage of early intervention (sadly, cost has to be taken into consideration when deciding if a new treatment is worth it). With the current state of the NHS it is important from a financial point of view, as preventive rather than curative medicine is much cheaper overall. So with the benefits of early intervention being brought to our attention, today I thought I’d write about a type of treatment for anorexia – Body Image Therapy.

For those of you who aren’t already aware of the symptoms, Anorexia Nervosa is characterised by:

  • severely restricting food intake, leading to extremely low body weight
  • a fear of gaining weight
  • distorted body image perceptions, with sufferers believing they are fatter than they are.

 

Contrary to what you might think, it isn’t just girls and young women who can have anorexia, men make up about 10% of total suffers (although some studies estimate higher). It is also becoming more common, with inpatient hospital admissions increasing by about 7% a year since 2005. As well as this increase, raising awareness and improving treatment is so important as anorexia has the highest mortality rate of any mental illness.

One of the reasons anorexia can be so hard to overcome is that sufferers have a distorted body image and believe they are much bigger than they truly are. This reinforces the cycle of restricting food or overexercising, and makes anorexia hard to beat. Studies have also shown (e.g. Fairburn et al, 1985) that the symptom of body image disturbances is also a predictor for relapse once therapy has been completed.

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Diagram adapted from Fairburn et al (2008)

Therefore, it makes sense to include body image therapy when treating a patient with anorexia. It is a type of cognitive therapy, which aims to reduce the harmful thoughts about body and weight. One type of body image therapy is Mirror Therapy, in which patients view their body in front of a mirror during a therapy session. Exposure can be increased over time and leads to an immediate emotional response which can be discussed during therapy. The therapist encourages the patient to look at their body as a whole rather than focus on perceived flaws, and to describe their body accurately as opposed to using negative language. This helps patients to learn that there are other ways of viewing their body and the consequences of negative thoughts about it (Delinsky & Wilson, 2006). Over time, cognitive therapy with mirror therapy has been shown to be more effective in terms of reducing body dissatisfaction and avoidance compared to cognitive therapy alone (Key et al, 2001).

Body image training in anorexia is therefore important as it could help to overcome the cognitive processes which make it hard to break the cycle of disordered eating and improve recovery rates for people suffering from an eating disorder.

Thanks for reading, and don’t forget to help spread awareness using the hashtag #eatingdisorderawarenessweek

If you would like to read more about the possible causes of eating disorders then see a previous post here or read about body dysmorphia in anorexia here

If you or someone you know is suffering from an eating disorder then there is help available. Contact your doctor or charities such as Beat, who can provide you with the correct support.

 

 

Prevention is better than cure – Youth Mental Health in the UK

In Theresa May’s recent speech to parliament she stated that she wanted to end the stigma of mental illness and improve the state of mental healthcare in the UK. As a researcher into mental health services for children and adolescents, I hear often about the struggle parents have to get an appointment for their child to be seen by a psychologist, or the problems they face when care ends at 16-18, without the smooth transition to adult services enabling continuity of care.
Whilst it is vital that more money is spent on the NHS as a whole (recent talks of ‘crisis’ in A&E departments shows the obvious need for more resources), money which is promised to mental health services cannot be diverted to other areas which are struggling. These areas are definitely important, but they should not be funded to the detriment of youth mental health services.
Research by Young Minds (2014) found that 77% of NHS Trusts who responded had cut or frozen their Child and Adolescent Mental Health Service (CAMHS) funding between 2013 and 2015. Significantly, demand for these services increased over this time. This increase reflects a general trend over the last 20 or so years, for example the number of 15-16 year olds with depression nearly doubled between the 1980s and 2000s, and the number of young people being admitted to hospital for self harm has gone up by a massive 68% in the last 10 years (http://www.youngminds.org.uk/training_services/policy/mental_health_statistics).
Current services do not meet the need for care, with up to one in every four or five teenagers thought to have a mental illness. In a typical school, this would be around 3 in each classroom in the UK. With 75% of mental illness having an onset before the age of 24 (Kessler et al, 2005), it is vital that young people can access the services they need during this critical time in their development.
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As mentioned above, care at CAMHS often ends when a young person is between the ages of 16 and 18. There are separate services for children and adults (CAMHS, versus AMHS) and this can represent a significant disruption of care. Young people have to move to a new adult service, in a new location and form a relationship with new healthcare professionals.  Previous research has found that only 4% of patients experienced an optimal transition (Singh et al 2010). Problems identified included a shortfall in time spent planning for transition, inadequate information transfer, and poor continuity of care. There may not even be an appropriate adult service in the local area which the young person can move to, for example in the case of autism or attention deficit disorder.
I am a researcher on the Milestone Project, an EU funded study currently investigating transition in nine different countries in Europe. My role involves interviewing young people and parents about their experiences of mental health services in the UK, and following them up over a period of time to see what happens to them when they leave CAMHS. The results of this study won’t be ready for some time, however it is clear to me that more needs to be invested into improving access for young people to mental health services.

Behavioural Activation

This week’s post is about a technique used as part of cognitive behavioural therapy for people with depression. As you probably know already, symptoms of depression include low mood, low self-esteem, feelings of anxiety and helplessness, and having low motivation and interest in activities which they previously enjoyed.

Behavioural activation focuses on the ‘B’ of the CBT model, in this case on the last symptom in particular – the withdrawal from usual activities and friends. For example, they may start to avoid social engagement and ignore invites from friends or make excuses as to why they can’t meet up, whereas before they would have been happy to go. Although in the short term this avoidance causes a temporary relief, such as a lowering of anxiety, it simply reinforces feelings of low mood or low self-esteem. This maintenance of the condition is illustrated by this diagram below:

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Therefore, in order to break this cycle, behavioural activation aims to change the unhelpful behaviours which continue the cycle of low mood. It does this by gradually building up activities that the person can do, which is turn will improve their mood, and lead eventually to them getting back to activities they used to enjoy. This progression is important, as the change in mood is needed before larger behavioural changes can occur.

Key features of Behavioural Activation are as follows (taken from Jacobson et al, 2001):

  • Firstly, the model is presented to patients by their clinician, who explain a bit about it and why it works. This is called a treatment ‘rationale’ and it is important for the patient to feel confident that this will work. A good relationship and trust with the therapist is also important.
  • Developing treatment goals through collaboration between the patient and the therapist – these goals are new behaviours rather than moods or emotions.
  • Analysis of causes and maintenance factors of the depression
  • Graded task assignment – e.g. starting with something small such as walking to the corner shop. This is scheduled in between sessions, and a hierarchy is discussed with the therapist.
  • Establishing a routine, in the hope this results in improved mood.

Ultimately, the aim of Behavioural Activation is to help the patient re-engage and find joy in activities which they have been avoiding. This will raise mood, and therefore help someone recover from depression.

How can you tell if a treatment works?

Sorry for the delay in writing this post – I had a bit of a break for finals and moving back home, but here I am with something I found interesting during revision: How can you tell if a treatment works?

At first glance, it might seem like this question can be easily answered, but it is not enough to give a group of a patients the treatment, and then see if their symptoms got better. For example, what if they would have got better anyway? Or it was something about the act of talking about their problems which caused them to feel better, not that the specific aspects of that therapy worked? I will now outline the method needed to conclude whether a psychological treatment is effective or not:

Randomised Controlled Trials (RCTS)

These are a type of experiment, known as the ‘gold standard’ for psychological experiments. The main feature is that participants are randomly assigned to different groups, for example, an experimental group, which receives the treatment, and a control group, who do not. Ideally, the patients in the control group are matched to patients in the experimental group e.g. same age, level of education etc. This is so that the effects of these other variables can be minimised, and so any difference in outcome can be attributed to the treatment. The control group is important to show that patients wouldn’t have got better anyway. For example, Mayou et al (2000) studied the effects of debriefing after trauma and found an objective drop in symptoms 3 years later. However, a control group who received no debrief had almost no symptoms 4 months after (see graph below). This shows the importance of a control group who received no intervention.

mayou et al

As well as finding out if a treatment is more beneficial than no treatment, RCTs can also be used to compare the effectiveness of different therapies for a psychological disorder. For example, Clark et al (1994) compared found cognitive therapy was the most effective treatment for panic disorder, compared to exposure therapy, applied relaxation, or imipramine (a drug treatment).

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RCTs also include a follow-up some time after treatment, which enables researchers to tell if the treatment can cause long-term benefits. For example, in the Clark et al study shown above, you can see from the diagram that they carried out a follow up one year after treatment, and that patients in the cognitive therapy group still showed the largest reduction in panic symptoms.

RCTs are the method used to compare therapies, and in order to tell whether a treatment is effective, they need to feature:

  • A valid measure of symptoms at pre-treatment and post-treatment e.g. Body Sensations Interpretation Questionnaire (used by Clark et al to assess misinterpretations of body sensations in panic disorder patients).
  • Broad assessment e.g. patient and independent assessor. (Needed because patients have a tendency to report feeling better than they actually are to the person who’s been treating them).
  • Assess significant pre-treatment to post-treatment change.

It is important to tell whether a treatment works, as if it is shown to be effective, it is more likely to secure funding, and be used on patients within the NHS.

Thank you for reading, I’ll be able to get back into a routine with blogging again now my exams are over so check back soon for new posts!

Why more money needs to be spent on improving access to mental health treatments

This week in the UK is Mental Health Awareness Week, so today’s post will be a bit different – what are the main issues about treating mental illness in our society, and how can access to therapy be improved?

Firstly: not enough money is being spent to improve access to mental health services in the UK. Fact. This means not everyone who needs access to treatment gets it, which, as well as having a massive impact on society, has an extreme effect on our economy too.

The statistics are striking:  only 25% of people with mental illness are in treatment, compared to almost 100% of people with physical health issues (Layard et al, 2012). And mental illness isn’t rare – the World Health Organisation found that mental illness makes up about 40% of all illness in developed countries. In the UK, 15% of the population of the UK suffer from anxiety or depression, but only 5% of those are in treatment (Depression Report, 2005).

Morbidity among people under age 65
Morbidity among people under age 65

And why are these individuals not receiving treatment? A report carried out by several mental health charities found that 1 in 4 primary care organisations do not offer Cognitive Behavioural Therapy – the treatment recommended by NICE for all anxiety disorders and depression. It is therefore clear that more needs to be done to improve access to therapy in the UK.

However, once a patient has been offered therapy, the problems of lack of funding do not go away. Waiting lists can be as long as several months, by which the problems could have got worse. This is another area where there is a massive disparity between mental and physical health services.

Therefore, it seems obvious that more money should be invested in mental health services within the NHS. This comes at a time where the NHS budget is stretched to the limit, and the government are looking at cutting funds to public services. And here’s the clever bit: improving access in mental health services would pay for itself. 

Let’s look at the economic cost of mental illness in the UK. In 2005, it was estimated that anxiety and depression cost the UK about £17 billion per year. About half of disability benefits are paid to people with mental illness. One study found that less than 25% of people with long term mental illness have a job, compared to about 75% of the rest of the working-age population. Therefore, this results in a massive loss of revenue from taxes, as well as increased expenditure on benefits and sick pay.

Even when people are at work, mental illness can reduce productivity and so cost the company money. A NICE study found that improving management of mental health in the workplace could save 30% of reduced productivity and sick pay costs. If a company has 1,000 employees, this equates to a saving of £250,000 per year.

Mental health also has a significant impact on our physical health, which causes more pressure on the health service. Hutter et al (2010) found that individuals with mental health problems use 60% more physical health services than people who are equally ill but do not have mental health problems. This costs the NHS about £10 billion per year. These figures are striking, and show more money, not less, needs to be invested in mental health services.

The massive economic costs of mental illness are clear, but what about savings from improving access to treatment? Layard et al (2007) found that its costs £630 to treat a patient, but this leads to £4,700 in benefits to society in the form of more people off disability benefits and back as work, so paying more taxes, and less spent on physical health services and sick days.

Fortunately, things are being done to make mental health treatment more accessible. For example, Improving Access to Psychological Therapies (IAPT), which aims to train more therapists for specialised local services. So far, this initiative has treated about 756,000 patients a year, with 45% recovering completely, 60% showing a reduction in symptoms, and 5% being well enough to come off sick pay and benefits and return to work.

This just shows the positive impact of expanding mental health services in the UK, and making treatment available for those who need it. At a time when the country is undergoing a change in government, these issues need to be remembered and prioritised. Even with cuts, and less money available, these statistics show that more money, not less, needs to be spent on mental health services in the UK.

CBT: what is it and how does it work?

Cognitive Behavioural Therapy,  or CBT is one of the most well known types of psychological therapy.. But how does it work, and why is it so effective?

CBT was developed from the 1950’s, and came to prominence in the 1980’s. It was based on form of Behavioural Therapy, usually used to treat people with phobias. This was based on the principles of classical conditioning: that a conditioned stimulus, when paired with an unconditioned stimulus, produces a conditioned response. This is illustrated by the classic Pavlov’s dogs experiment, as shown below:

CS-US

This process was used a basis for techniques to reduce fear, for example through systematic desentisation – gradually exposing patients to the phobic stimulus in a hierarchy system in order to reduce their fear (e.g. bottom layer of hierarchy: looking at picture of a spider – top layer: holding a spider in your hand). Part of this therapy is to teach the patient to relax during each step, as that prevents anxiety.

CBT builds on the exposure used in behavioural therapy in order to also address the cognitions behind the fear or anxiety. For example, in panic disorder,  patients suffer from recurrent panic attacks which cause intense fear and distress. The cognitive theory of panic disorder (Clark & Wells, 1995) states that panic attacks are brought on by a misinterpretation of physiological symptoms of anxiety such as palpitations or dizziness. The individual interprets these as that they will immediately suffer a physical or mental disaster e.g. a heart attack.

Part of the CBT for patients with panic disorder is exposure – they will go into a crowded place (if this causes panic attacks for them) and record their feelings, in order to discuss with their therapist. However, it has been found that exposure alone is not as effective as if the cognitions which maintain the disorder are not addressed. These are known as safety behaviours (Salkovskis, 1988): for example if a person who has anxiety about crowds and thinks they are going to faint if they are in a crowded place, they might sit down so they don’t faint. The sitting down is the safety behaviour – it prevents people from realising they wouldn’t have fainted from being in a crowd, they think they only reason they didn’t faint was because they took that action. If exposure is paired with strategies to reduce safety behaviours, it is much more effective at reducing panic and anxiety (Salkovskis et al, 1999).

CBT is recommended as the treatment of choice by NICE (the public body which develops treatment guidance for the NHS) for depression and all anxiety disorders – not just panic disorder. In order for it to be effective, Clark et al, 1994 have shown that a ‘cognitive shift’ must occur in patients (a change in their beliefs), or risk of relapse is much higher.

 

Let me know if you’ve got any questions or would like more posts like this – hope you found it interesting!