It’s often assumed that it is good to talk. But talking is not without risks.
The main mental illnesses/ symptoms that patients present to me (a GP) are chronic anxiety +/- OCD and PTSD +/- chronic depression.
Chronic anxiety and chronic depression are like chronic pain, in that the symptoms persist in the absence of a causative stimulus. Which is to say that the nervous system generates and sensitizes you to anxiety/ depression/ pain of its own accord. It is not to say that if you have chronic pain, it won’t help to have me stop stepping on your toes, or if you have chronic depression it won’t help to have financial security or if you have chronic anxiety it won’t help to get away from a violent partner.
Without a clear explanation for these chronic symptoms, sufferers and clinicians inevitably spend a lot of time alone and together trying to figure them out. Uncertainty abounds.
Care of patients with chronic symptoms requires time to build trust and a therapeutic relationship. This develops through talking (dialogue). What we discover by talking is what it’s like (the phenomenology), where it comes from (the biology and the biography) and what it means (the hermeneutics).
Trust and time
Feminist, activist and professor of psychiatry Judith Herman warns that we may push for more facts before the patient has had time to deal with the emotional impact of the facts already known. Before exploring the past, it’s important to understand the present. Cognitive empathy is informed curiosity – asking questions that prove we’ve got an idea of just how bad anxiety and depression can be, but are sincere in wanting to know what it’s like specifically for the person in front of us. As one of my patients told my students, “I’m not going to open up if you don’t know where to look”
Quite frequently the physical symptoms of anxiety are so severe that it’s barely possible to get into the psychological side of things. Incontinence, breathlessness, chest pain, severe headaches, spasms and so on need to be attended to first. This can take time.
Once these are within reasonable limits the patient (and the doctor) need to be able to bear the emotions. Joanne Bourke, historian of Pain, says that the problem with pain [suffering] isn’t just that it’s hard to talk about it, but that it’s painful for the listener. I think I can bear to bear witness to suffering, but it is exhausting emotional labour. We have limits on how much we can hear, but as professionals we need to work on these.
Next, the patient needs to have authority over her memories; she needs to be able to choose what to remember and what to put aside. It’s not up to the doctor to decide.
There may not be a story to tell
Traumatic experiences happen when stress hormones like adrenaline and cortisol are surging. Because of adrenaline the experiences are only partially stored as memories and because of cortisol the storage is disorganised.
Experiences become stories by the acts of telling and re-telling. Traumatic events are not the stuff of anecdotes, they aren’t turned into stories, mostly they are the symptoms of fear, agitation, arousal, dread, pain, bloating, fatigue, sweating and palpitations – The Body Keeps the Score. Recalling traumatic experiences is traumatic – which is why the preconditions above matter. The consequence of all this is that there may not be ‘a story’ to tell, let alone one that makes sense. At least not to begin with.
Telling someone that you are suicidal, that you have everything in place to take your life – is a risky strategy – good ways to respond, from the perspective of someone who knows what it’s like are in this brilliant blog which I’ve had reason to refer to already, twice this week. But an unsympathetic ear, or a panicked response – can be catastrophic.
Working back from present symptoms to past experiences takes time. This week I spoke to two patients I have known for about 10 years and started hearing about their trauma for the first time. Without continuity of care, and trust that can develop over time, these kinds of conversations might never happen.
Every patient has their own unique story
Underlying their anxiety and depression, one person will have a strong genetic prediposition with a secure childhood, another will have have suffered abuse and another will have suffered significant losses in early life, for other the cause will remain a mystery. The aetiology of mental suffering is complex and varied. How much genes, attachment, experiences and so on contribute to each person’s presenting symptoms can be hard to judge. I think it’s important to help patients figure out what’s significant to them, bearing in mind that self-blame can be predominant and we can help to shift that. Often though, there is someone to blame; too many children are abused and too few of those responsible are bought to justice. But we have to avoid blaming others when there wasn’t abuse and when it’s not clear what has happened.
Groups are often very powerful – validating, empathic, non-judgemental – far more so than professionals. It is tempting for professionals to try to ‘fix’ people’s problems when what they need is to be cared for, because a lifetime of anxiety and depression cannot be cured. Talking may be much easier with people who share their experiences, but without respect and facilitation groups can be undermining.
Responsiblity
Being mentally ill can make people very vulnerable to exploitation, fearful and acutely sensitive to the ways that other people respond to what they have to say. These feelings are not just symptoms of their illness, but an entirely rational response to the ways they have been treated in the past. Talking is good, but more of the responsibility needs to lie with the listener.
Talking is not enough
Once you’ve talked to more than a few people suffering from mental illnesses, it’s obvious that social injustice, violence and stigma, not only cause illnesses, but worsen them and impede recovery. Political action is imperative. This is why so many people who work in this field, like Judith Herman, Jay Watts and many more are clinicians and activists. If you’re good enough to listen, you need to take action as well.
We need properly funded mental health services, and well-trained health professionals. We need Trauma-informed health services throughout the NHS. Talking does help, but we need more treatment too.
Links:
The Language of Trauma – brilliant graphic novel describing this blog https://floridareview.cah.ucf.edu/article/the-language-of-trauma/
On Language and Psychiatry. Dariusz Galasiński http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30040-3/fulltext
How neoliberalism is damaging your mental health – The Conversation http://theconversation.com/how-neoliberalism-is-damaging-your-mental-health-90565
As a psychologist I see the fantasy of neoliberal values having a devastating effect on mental health treatment Jay Watts – Independent http://www.independent.co.uk/voices/mental-health-treatment-tory-government-nhs-funding-access-work-benefits-a8037331.html
Mental illness and the welfare state David Bell Centre for Health and the Public Interest https://chpi.org.uk/wp-content/uploads/2013/12/David-Bell-analysis-Mental-illness-and-its-treatment-today.pdf
A Better NHS 
You have summed up my feelings of unease when hearing about the very laudable ‘people need to talk about mental health’ initiatives. I know from personal experience how damaging an ill informed, unprofessional or offhand response, however well meaning, can be to someone suffering mental trauma.
Trust is so important and is earned gradually and I have learned to mistrust professionals first in order to survive and not cause myself any further trauma. This is not to say that I have not experienced some excellent support too but consistency of such excellence is sadly not currently replicated across NHS services.
Talking is not enough – just as talking about having a heart attack and doing nothing else would be seen a ludicrous so is ‘just talking’ about serious mental illhealth and is potentially life threatening.
Brilliantly put!