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Image by the author When home is temporary and belonging conditional, even the smallest decisions become acts of hope or self-protection. There are two types of winter coats. One is light on the pocket but good for a fast-fashion spin. Then there’s the down-filled workhorse, puffed with promise and designed to last year after year. Standing in the ‘Winter Essentials’ aisle, I stared at both and bought neither. I wasn’t sure I was staying long enough to need either kind of warmth.  I am Aysha, a curriculum developer, freelance journalist, and early career researcher who grew up all over the world before settling and getting married in Karachi, Pakistan. During my 10 years of working in education as an English teacher, I fell in love with writing stories and assumed that with a degree, I’d be able to do more of the work I enjoyed and do it at scale. That hope is what brought me to London to pursue a Master’s in Journalism two years ago. But the move itself came with the naiveté of children jumping off monkey bars, convinced that they would fly simply because they haven’t yet tasted failure. I’d been on the fence for months, but the final push came on May 9, 2023, when Pakistan’s former Prime Minister Imran Khan was arrested  and violence  tore through my city . Our house, perched on one of Karachi’s major arteries, Shahra-e-Faisal, filled with thick tear gas. I saw my 6-year-old daughter blinking furiously, trying to make sense of a world that suddenly burned. In that moment, I felt two things—guilt (as my own childhood had been spent in the blissful California college town of UCDavis, with no tear gas in sight) and longing. I wanted her to trust me.  Scrambling to capitalise on patchy internet through the riots, I sent a rushed application for my MA programme. Things moved swiftly. Within half an hour, I had interest. In a week, I had an offer. And by October 22 (delayed by a whirlwind of visa processing), five weeks into my course and aided greatly by my employers, we were finally in London: my husband, myself, my now 10-year-old twin sons and my daughter.  Two years later though, the ground beneath us still feels shaky. We still haven’t arrived. I’m used to telling other people’s stories. Once,  a sitar-maker  I profiled from the lush valleys of Maharashtra told me, “In telling our story, you strung your words together like pearls. You made all of us feel seen.”  It’s different though, when it’s my own story — less pearls, more splinters. Harder to hold, harder to tell…but still, it’s ours.    The Fine Print of Belonging  I began my course in a landscape rife with headlines of  reducing net migration numbers . It seemed international students — and their dependents — were suddenly framed as part of the record immigration numbers defined as a 'slap in the face' by politicians. I wondered if the five of us were tipping the scale, and though the dependent ban came into effect after we arrived, the rhetoric left a lingering aftertaste.  This was despite the eloquently argued view that, in many ways, students are  'the ideal migrant' . International healthcare surcharges, paid before one steps foot outside their home country, more than cover any burden on the NHS, and students contribute to diversified economic benefits .  International students often go to inordinate lengths to pursue a world-class education. Contrary to popular belief, we are not all scammers trying to  overstay our visas . And, as I said for Al Jazeera last year, our dependents are not ‘our grandmas’ joining us for a joyride. Before leaving from Pakistan, my professor told me, “There will be days you feel it would be easier to study without your family. But remember, they are  your biggest support system.” My children and husband have attended mayoral town hall meetings with me, flown to dusty Karachi archives last August for my dissertation, drawn comics to motivate Mama when a deadline looms, and been the bedrock of my education in every possible way. They are, I maintain, the best co-authors.  Image by the author Perils of the Graduate Visa Later, talk of the graduate visa being reduced  led to multiple sleepless nights. Yet even without new restrictions, the Graduate Visa is a zero-sum game, especially in combination with higher salary thresholds  for the skilled worker visa pathway. To be clear, I am not searching for employment elsewhere, but even a fleeting glance at job ads will tell you, sometimes subtly, at times outright: ‘Graduate visa holders need not apply’. Employers simply don’t see a worker with an expiration date as worth the training investment.  And yet, it feels contradictory: why does a country that teaches you to understand and challenge its power structures also make it so hard to stay and put that knowledge to use? I write this now for the benefit of other international students, not to discourage them, but to help them brace for a volatile policy landscape. Because the sad truth is, sometimes you can do everything right — I graduated with distinction, was selected to present my dissertation at Northwestern, Qatar, and grew my already robust portfolio of bylines to glowing praise — and still not feel welcome.  An Inventory of Impermanence  Pandemic studies have shown that uncertainties around visa security and family separation can fuel  depression and post-traumatic stress symptoms . Other research shows that people on more stable, long-term visas tend to fare better. Their mental health and social functioning improve when life isn’t lived on a countdown clock. But I argue a slow unravelling takes a far more insidious toll. Living in limbo heightens my vigilance. The tension settles not just in my news feed, but in my shoulders. I went to 17 schools across three continents growing up, which means I carry a catalogue of almost-homes. My father moved us from California to Canada in 2005. In some ways, I envy how he had the clear push of Islamophobia in 9/11’s grisly aftermath to fuel the move. For us, it’s far more subtle, felt in the subtext of policy. While I fully understand the logic behind these policies, the underlying sentiment hits hard. For us, this is not just abstract legislation — it has the power to shape my family’s future, our stability, and our sense of belonging. Living in uncertainty erodes mental health. Arbitrary as it might seem, I only purchase items small enough to fit into hand luggage.  Buy only what you can carry,  I tell myself. These tiny anchors are souvenirs from an ongoing maybe . I’ve become hyper-fixated on my own mental and physical health — “Wherever I end up, at least I’ll have my body,” I rationalise. Controlling the day-to-day gives me a fragile sense of stability in uncertain waters. But what if I didn’t want to be tumbleweed forever? What if, this time, I wanted to grow roots?   Image by the author Straddling Two Worlds  Today, when I see my daughter marvel at the ease of leaving our house to walk in light, smog-free air, I don’t know whether to smile or cry. How do you teach your children to enjoy their life in London — but not too much, in case we leave? Love fiercely , I whisper, but don’t hold on too tight .  Sometimes I wonder if it was the wrong decision, echoing the age-old question of whether it is better to have loved and lost or never loved at all. Is it better to have lived a tear-gas free existence for three years, or never known another reality?  There might be other pathways. My husband’s job in the healthcare administration sector offers a work permit building towards leave to remain. Recently, though, the proposed period has increased from five years to ten.  Once again, it’s jarring how policy updates can so callously flip our lives upside down. Double the birthdays, double the summers, double the winters without knowing if it will be our last.  Honestly, I’m not sure we’ll take it. 10 years seems like a long time to go without a coat.    This article has been sponsored by the Psychiatry Research Trust,  who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

© Crown copyright 2011 , UK Ministry of Defence . Licensed under the Open Government Licence v3.0. Some things in life you never expect to lose. Your orgasm is one of them. I am a Research Associate on the “Armed Services Trauma Rehabilitation Outcome Study” (ADVANCE). Within the ADVANCE team, we research the impact of serious combat injury on life after service and the rates and experiences of sexual dysfunction for UK Armed Forces personnel. Physical injuries and mental health can affect sexual function Several injuries and mental health conditions can affect sexual function. For example, traumatic brain injury, spinal cord injuries and injuries to the pelvic region (e.g. genitourinary (GU) injuries) can cause neurological and structural damage to the body, such that the intricate array of physiological processes which feed into the sexual response are prevented from performing as intended. Similarly, mental health conditions such as post-traumatic stress disorder (PTSD), depression and anxiety can sometimes impair sexual function too, as can the medications prescribed to support people with these diagnoses. © Crown copyright 2020 , UK Ministry of Defence. Licensed under the Open Government Licence v3.0. Combat injuries Some people lead lives which make them more prone to injury than others. For example, those who work in construction and transport are at higher risk of sustaining work-related injuries than those who work in office-based jobs. Similarly, those who serve in the military are at risk of injury both when they are in training and when they deploy to conflict zones. During their deployment to the conflict in Afghanistan between 2002-2014, over 2,400 UK military personnel sustained injuries. The extensive use of improvised explosive devices (IEDs), which explode from the ground upwards, meant that limb loss was the “signature injury” of the war in Afghanistan. The use of IEDs also meant that both US and UK militaries recorded the highest ever frequency of GU injuries. The ADVANCE study allows us to explore the effects of combat injuries on UK military personnel extensively. © Crown copyright 2012, UK Ministry of Defence . Licensed under the   Open Government Licence v3.0 . The ADVANCE study ADVANCE  is an ongoing longitudinal study set up to investigate the long-term physical and psychosocial effects of combat injury on UK military personnel who deployed to Afghanistan. In ADVANCE, there are approximately 1,200 male participants, of whom roughly 600 were injured and another 600 were deployed but did not sustain serious combat injuries. Women were not included in the ADVANCE study as they were only allowed to deploy in front-line combat roles from 2018, and the UK military had wound down its operations in Afghanistan by 2014. ADVANCE participants attend clinical assessments with our clinical team, during which they are asked to complete a series of questionnaires about their health and wellbeing. Amongst these questionnaires is the “Arizona Sexual Experience Scale”, also known as “the ASEX”, which asks about sexual dysfunction. The ASEX asks participants about their sex drive, how easily they get aroused, how easily they can maintain an erection, how easily they can reach orgasm, and how satisfying their orgasms are.   Analysing ADVANCE data My colleague, Dr Dan Dyball – whose own research explores the link between the mental health of UK Armed Forces personnel and their injuries – mentioned I might want to take a look at the data ADVANCE collects on sexual dysfunction. I think Dan knew that my statistical skills - which had been stored in a damp, dark cupboard since university – might need some sharpening and this dataset, in its simplicity, presented an ideal opportunity to do just that. Furthermore, in 2022, we heard from ADVANCE participants during interviews that they did not know where to turn to get help for the anatomical and psychological challenges they faced in their sex lives post-injury. This gap in support services experienced by injured personnel was echoed by veteran-specific support service providers, who said that they did not routinely ask about sexual function when injured beneficiaries presented at their services. As a team, we felt it was important to see if there was a difference in the rates between those participants who were injured and those who weren’t. As we can identify whose injury resulted in limb loss within the ADVANCE dataset, we thought that it would be useful to look at the rates of sexual dysfunction for those injured with and without limb loss. © Crown copyright 2012, UK Ministry of Defence . Licensed under the   Open Government Licence v3.0 . What did we find? Our analyses showed that those participants who had been injured were twice as likely to have sexual dysfunction as those who had not been injured. At this time, we did not know what was responsible for this difference, but the literature on this subject suggests that the aforementioned physical and psychological injuries, related surgeries, and medications play key roles. The rates of sexual dysfunction for those injured with and without limb loss were similar. This finding is in line with previous research studies, which have had mixed results when exploring the impact of limb loss on sexual dysfunction and our results don’t clarify this yet !   Our plans for the future The gaps identified by UK support service providers and ADVANCE participants themselves, combined with the twofold increased risk for having sexual dysfunction for injured personnel, have catalysed my enthusiasm to help ameliorate this condition.  Starting in February 2026, I shall undertake a PhD, funded by The Colt Foundation, to examine the prevalence rates of sexual dysfunction over the first ten years of ADVANCE and to find out what risks and outcomes are associated with these. I will interview ADVANCE participants with combat-injury-related sexual dysfunction about their experiences of this condition, how they have sought help, and what their ideal support service would look like. I’ll analyse this data in combination with qualitative data from a group of support service providers to discern intervention principles that can be implemented in the future. My goal with this PhD is to contribute to an evidence-based, population-centred health systems response, which will enable those living with sexual dysfunction caused by injuries to live the most fulfilling lives possible. Any one of us could sustain an injury and find our bodies changed in fundamental ways that we had never imagined. Sexual function is an intrinsic yet susceptible aspect of life; efforts are warranted to support those who have experienced circumstances which have led to its demise.

For Indian women, many expectations are placed upon us. Her hair, vaal , must be long and lustrous. She must have fair skin. Most importantly, she must bear children. The Omnipresent Evil Eye Infertility in South Asian families is considered a curse, that an evil eye  is cast upon the family. Evil eye, otherwise known as nazar , holds significant cultural and spiritual importance in South Asian culture. It stems from the idea that jealousy, envy, and negative thoughts can cause real harm and misfortune to another. Infertility, as well as illness and misfortune, is believed to be caused by the malevolent gaze of nazar . Despite these cultural beliefs, I have felt their consequences deeply. The guilt and grief around my infertility are intensified by the expectations within my community. When I speak of my experience, friends and family tell me, ‘chup kar’ meaning ‘be quiet.’ Speaking out is deemed unacceptable. My infertility was not a choice, yet it brands me as different, even cursed. Marrying a white man further distances me from my Sikh community, increasing my sense of isolation. Photo by Meruyert Gonullu on Pexels My Experience with Infertility As South Asian women, we often harbour internalised negative attitudes towards fertility in our community. My cousin has voiced, ‘In my arranged marriage, my in-laws told me I was damaged goods and sterile, as I cannot have children. I felt such burning shame and self-blame. After much grieving and stress, my husband was extremely supportive, and thankfully, we are a lot happier.’ My cousin now lives in Malaysia, lives away from her in-laws, and is doing better mentally.   My own personal health battles have clashed with both these spiritual and social issues. I lost my fertility, my periods, and my ovaries. Pieces of myself were stolen by relentless surgeries and brutal chemotherapy, yet I remain here, surviving. When I got Ovarian Cancer in 2016 and 2020, I could not have hormone replacement therapy as my type of cancer was hormone sensitive. I was devastated as not only had I become sterile at 38, but I also had to deal with horrendous symptoms like hot flushes, nausea, night sweats, fatigue, brain fog, mood swings, short-term memory loss, and vaginal dryness. This has greatly impacted my life in many negative ways. I must work less, cannot do high-energy exercises or activities, and I am legally not allowed to drive. In spite of this, I have become more aware of my health issues. I have been taking care of my diet and have incorporated exercising and meditating into my lifestyle. Battling through these health challenges independently, it took me a long time to find a therapist of colour who understood the nuances and idiosyncrasies of South Asian and Sikh culture. In many instances, when I raised my experiences with previous therapists, I was met with racism, bullying, and was ignored. Photo by Tima Miroshnichenko on Pexels I was gaslit by friends and relatives who said my seizure disorder was all in my head. I had to cope with the unbearable grief of losing my reproductive abilities, and I feared public outings as I was haunted by the loss of my hair. Perpetually terrified that the cancer will come back, I felt as though I had lost the most important part of my womanhood. Amid all this loss and fear, I tried to hold onto any fragment of hope I could find. Fortunately, I did get to keep my womb and was able to freeze eight of my eggs, but being 43, I feel the clock ticking away. The Isolation of Feeling Stigmatised Within our community, there remains a critical need to acknowledge and address the stigma surrounding infertility and pregnancy. The societal pressure to conceive can be immense, often rooted in traditional beliefs that equate womanhood and marital success with motherhood. As a result, women who struggle to do so may face social ostracisation, judgment, or marital strain. Seeking medical support, such as IVF, is continually considered a taboo subject, leading many to suffer in silence and discouraging them from accessing reproductive healthcare services. This silence also affects mental well-being. Despite efforts to reduce ethnic disparities in mental health care across the UK, South Asian communities continue to underutilise these services. Cultural expectations, fear of shame, and a lack of culturally sensitive mental health provision contribute to this gap. For instance, one UK-based study found that North Indian women, compared to their white counterparts, were more likely to believe that treatment for depression would be ineffective . Such aversion to help-seeking behaviours results in lower rates of diagnosis and labelling of mental health conditions  in our community. Spiritual and cultural beliefs may blur the lines between physical and emotional health, shaping how illnesses such as infertility are understood and responded to within families. Fear-based and Spiritual Thinking If infertility is truly of spiritual origin, such as the evil eye, does this make it harder for women to challenge harmful attitudes in their communities? We believe that envy and insecurity motivate people to invoke nazar in order to harm others. This may involve wishing ill health, including infertility, onto people they are jealous of. By placing a black dot (karla) on children, wearing black thread bracelets (thaga), hanging evil eye amulets in our homes, burning incense, reciting prayers, or performing cleansing rituals, we believe that negative energy from others can be eradicated. The fear of the evil eye can create significant psychological stress, particularly for couples struggling with fertility issues. The belief that one’s inability to conceive may be attributed to malevolent intentions from others can lead to feelings of powerlessness, anxiety, and paranoia. It can also contribute to strained interpersonal relationships within the community, alienating women from speaking up about their experiences. Photo by SHVETS production on Pexels Women may bear the heavier weight of these beliefs by being scrutinised for perceived behaviours that ‘welcome’ nazar, such as showing happiness openly or sharing good news. Over time, this can result in to form of self-surveillance. Women may suppress their emotions to ward off harm. This culture of secrecy and fear not only limits access to healthcare and support but further perpetuates generational cycles of shame and having to chup kar. The Importance of Support and Awareness Luckily, support groups exist both online and in-person, making seeking advice more accessible for all women. I was given a free membership to The Daisy Network , a UK-based charity that supports women with Premature Ovarian Insufficiency (POI), otherwise known as premature menopause. For the first time, I felt seen and understood in a space where my experiences weren’t dismissed or minimised. It provides information, community, and educates us on medical guidance, all while raising awareness among healthcare professionals and the public. By creating support networks through education, group counselling, or social outings, women can seek solace from one another and feel more empowered to share their stories. Although support groups on social media trigger me into remembering my painful experiences with infertility, it is good to know that support exists and that there are other women who understand my journey. If we continue to support each other, we can reduce the silence and stigma that surround infertility in our communities, building a future where no woman has to face this pain alone. This article has been sponsored by the Psychiatry Research Trust,  who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

On 10th October 2025, the Afghan Embassy hosted a forum featuring Afghanistan’s Foreign Minister Amir Khan Muttaqi in New Delhi, India. The embassy invited over sixteen journalists, yet not a single woman was present, let alone a woman from intersectional identities. Observers noted how women and foreign media were turned away at the gate, a situation that has sparked widespread discussion in the media . As a young woman journalist based in India, with intersectional identities and a background in feminist research, this event deeply affected me. The exclusion of women journalists from a forum discussing the Taliban's Foreign Minister felt like a personal affront. On behalf of women journalists everywhere, I felt insulted and impacted. Image by Imam Hassan on Unsplash This incident, combined with the Taliban government's stance on women, who are systematically excluded from positions of power and authority, has enraged women journalists across India. Being barred from an event that discusses international policies and the relationships between two countries raises serious questions about democracy. When leaders of the opposition and journalists questioned the Indian Ministry of External Affairs, they claimed they had no control over the guest list for the press conference. But why? India should have been at the forefront of this critical women’s rights issue, showcasing our best women journalists and advocating for their inclusion in political discussions. The Value of Women Journalists I first learned about this event through a flurry of messages in journalist groups and social media. My initial reaction was profound sadness. Women face significant hurdles in a field where they constantly challenge patriarchal forces. They are scrutinised for their work rooted in justice, often bringing hidden truths to light. An event like this, which dismisses their contributions, is a setback to the progress we have made as a society striving to empower women. Within a day, questions began to flood in: Why did the government allow this? Why were there no women journalists? Are women not an essential part of our democracy? Leaders of the opposition, women journalists, and activists were all expressing their anger, and I was feeling it too. The next day, the Taliban government claimed it was a technical issue due to mismanagement of the guest list, insisting it was not intentional. However, when questioned about the status of women in their own country, Muttaqi stated that every country has its own rules and customs. Beyond Gender: The Diplomatic Dilemma In one of the civilian political messaging groups I belong to, discussions erupted. Many were furious, while some attempted to explain why this issue transcends gender. "This is just how diplomacy works," someone argued. The crux of the argument was that maintaining good relations between India and Afghanistan is vital—economy, trade, airspace, defense—terms that often represent masculinity. So, how could women possibly matter in this context? Interestingly, the male journalists who were invited did not question the absence of women in that room. They should have had the courage to challenge this exclusion or even walk away in protest. It seems that men easily accept the absence of women. Are women merely secondary citizens, subject to the whims of powerful men? Snatching Our Seat at the Table As a journalist striving to be part of as many conversations as possible, this exclusion was particularly triggering. Being denied a seat at the table by my own government, which promotes itself as a champion of women's rights, is disheartening. India boasts exceptional female journalists who tirelessly challenge patriarchal structures that inhibit our society. The sacrifice of women journalists in the name of diplomacy raises questions about my own value within this system. As a Muslim journalist and gender studies researcher, I understand the positionality of women in Afghanistan and how their human rights are curtailed in the name of culture. The Taliban has been vocal about its stance on women. Yet, India, with its rich culture, diverse heritage, and core values of democracy and freedom, should have a clear stance on women's rights. Photo by Mikhail Nilov on Pexels Women Treated as Replaceable Commodities Why are women treated as commodities to be sacrificed at the altar of diplomacy and politics? Why do men in power get to decide their fate? How can 48% of a nation's population be treated as if they are invisible? Thousands of young girls in Afghanistan are being forced to abandon their education rights. They are compelled to wear head-to-toe niqabs and cannot travel without a male companion. These are not choices; they are severe limitations on their agency. As a women's rights activist, I am acutely aware of their reality—the erasure of their identities to conform to patriarchal norms. At the heart of this anger lies fear. Is a woman's identity so insignificant that it can be made to disappear to uphold patriarchal ties of diplomacy? Viewing women as replaceable or expendable should provoke rightful outrage. Image by Pavel Danilyuk on Pexels More than 60% of women journalists in Afghanistan have lost their jobs since the Taliban regime began, according to the International Federation of Journalists. Furthermore, 87% of women journalists in Afghanistan have reported discrimination. It’s no surprise, then, that women were excluded from this forum. They are an army of men serving other men. This is where India’s role becomes crucial. A feminist government must protect all genders and their social and economic positions. Countries like Canada, Sweden, Germany, and France have adopted a feminist foreign policy that extends support and protection to their women journalists. A feminist government is the only viable opposition to a regime like the Taliban's. Whether in South Asia, Asia at large, or globally, all governments must incorporate feminist policies into their governance. This means that when a government that does not support women’s rights visits, we should present our best journalists, regardless of gender. No friendship, whether between individuals or nations, can exist without showcasing our true selves. A patriarchal governance system will continue to harm the mental health of all women as long as it remains in power. A Beacon of Hope The women journalists in India did not back down. They harnessed their anger, raised questions to ministries and government pillars, and at the next, more public press conference with Muttaqi, the front row was filled entirely with women journalists asking hard-hitting questions. From discussing women’s rights to expressing their outrage, they made it clear how they felt about the exclusion. I am immensely proud of them. May we all rise and find the strength and courage to fight back. Image by Polina on Pexels This article has been sponsored by the Psychiatry Research Trust,  who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

As I mother my own small children in the UK, I can’t help but think of mothers and children in Gaza. Image Source: Emad El Byed on Unsplash Like thousands of others worldwide, I have been watching the genocide in Gaza unfold over the last two years, literally live-streamed to us through civilians on the ground, from their phones to ours. Watching the most horrific war crimes in real time has been both deeply surreal and gut-wrenching. No human being should have to endure what the citizens of Gaza have, no matter the age or gender, but as a new mother myself, it has been particularly awful to see small children killed in their thousands. I am of Jewish heritage, with both sides of my lineage descending from refugees. I do not come from a religious family, so I struggled at first to claim this part of my identity. However, I have always been aware and proud of my heritage. I vividly remember learning about the Holocaust in primary school, looking through footage of Auschwitz and knowing that this was not just a historical ‘issue’ to me, but my heritage. I took hope from ‘never again’ as a child, who knew nothing about the suffering of Palestinians under occupation. Flash forward to adulthood, and not only was I witnessing in real time people being murdered and starved, but we were also being told that to speak up against human suffering was to be antisemitic , because of the awful events of October 7 th . This feels like a conflation of vastly different issues to me, and I feel compelled to speak out in whatever ways I can, such as writing this article. Perinatal depression or a normal response to bearing witness?   Photo by Chris Yang  on Unsplash Within weeks of finding out I was pregnant with my second daughter, I was hit with a deep depression. I had suffered from low mood and anxiety throughout my first pregnancy, but the intensity this time felt all-encompassing and, at just two months pregnant, I went to the doctor asking for antidepressants. I picked up the prescription but kept putting off taking them each day with one excuse or another. My eldest daughter was two years old when Israel’s deadly retaliation against Palestine began. She is now four. I can’t help thinking about the stark juxtapositions of experiences between her and the children of Palestine. In these two years, she has turned from a toddler to a school-aged child, having nurturing, educational experiences, making friends and starting to learn to read.  In Gaza, schools have been destroyed, and more than twenty thousand children have been killed . In this time, I have also had another daughter who is now one. Each step of becoming a mother for the second time has been marked to me, knowing what the mothers and children in Gaza have been living through. When I was pregnant, exhausted and often struggling to walk with pelvic girdle pain, my mind was filled with images of pregnant women like me running from bombs and sleeping in tents. When I had an emergency C-section, I couldn’t help but think of the women forced to have caesareans without anaesthetic . Each time my baby or toddler falls over and hurts themselves, reaching out for a cuddle, I think of the babies and toddlers whose mums and dads have been killed. ‘WCNSF - Wounded child, no surviving family’ is an acronym created in Gaza, because of the sheer volume of children in this position. When I breastfeed my baby, I think of the mothers whose milk has dried up due to malnutrition and stress and babies starving because Israeli forces are blocking baby formula from entering the border.   Deciding to take action   Photo of Sapphire giving a speech at a vigil as a member of Na’amod One day, I had a frank heart-to-heart with my husband, which made me acknowledge I had been depressed before I found out I was pregnant. Clearly, the hormones had made the intensity of what I was feeling no longer manageable, but through many tearful conversations, I realised I had been feeling this way since the events of and following October 7 th . On reflection, I had told myself, it was ridiculous to feel real feelings about something happening that is not directly related to my own life. People close to me told me ‘just don’t look’ – but I already knew, and the images and testaments I had seen and read wouldn’t just leave me. It felt like I was grieving: not people I knew, but real lives I had witnessed, livestreamed into my palm, being literally ripped apart. I knew that continuing to ignore or pretend I didn’t know or care was not going to help me; I needed to take action. Once I accepted how angry I was, I looked for ways to put my anger into action.  Therefore, one cold, dark afternoon, I took the bus to Brighton and sat in someone’s living room among a group of other Jewish people, to start our ‘orientation’ for Na’amod , a group of British Jews against the occupation. We are all different ages and genders, all of us have distinct differences as well as shared overlaps, but that day I felt a deep sense of peace and connection, that this is where I am supposed to be. Twenty months later, I am now one of the comms coordinators for this rapidly growing movement. Volunteering within the comms team is logistically practical, as there is so much that can be done online, after the kids are in bed. Moreover, it allows me to put my skills as a writer into something pragmatic and feel part of a collective. Watching or even reading such depressing news constantly is deeply detrimental to our mental health , but volunteering is beneficial to our mental health. We may not be able to click our fingers and stop the horrors of the world, but we do, not just those suffering, but ourselves watching them, a great disservice if we refuse to at least acknowledge these problems and validate our own feelings as members of shared humanity. If we can also find ways, however small, to take action, we can collectively make the world a better place, and feel better ourselves in the process. This article has been sponsored by the Psychiatry Research Trust,  who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

My journey and why video games help My name is Michael. I am no stranger to adversity in life, as I suffer from mental illness. I have almost died from mental illness and addiction. Depression, anxiety, and Post-traumatic Stress Disorder have occupied big parts of my life for decades now. There are many ways, both good and bad, that I have found to cope with my illness. After decades of struggle and through trial and error, I am continuing to seek new ways to cope with depression, anxiety, PTSD, and addiction.  I have attended three years of college in psychology (but alas, did not graduate). I have a very “been there, done that” approach to mental illness. My lived-experience insights have helped me through bad times, and helped me to see the good in the bad.   I humbly admit I have made lots of mistakes involving self-medication, denial, self-sabotage, and addiction. These mistakes, however, led me to cut out and eliminate life strategies that are not good for my mental health. While I once resisted medication and a few other different treatment, I now use every available tool at my disposal to treat my mental health with a combination of medications, talk-therapy, and play therapy. All the therapists and healthcare providers I have had the pleasure to work with have played a very critical part in my mental health journey, but it was on the advice of one of my favourite therapists, Austin, that I began to use video games to cope with life challenges. He started off by suggesting that I might enjoying playing chess because of my competitive mind fit with the strategic nature of the game. He then shared his own passion for video games, encouraged me to use them as a tool to manage the high-functioning traits that I often neglected. This advice opened up a whole new world to me, by allowing me to see my gaming hobby to be more than just some frivolous waste of time. It allowed me to see gaming as a healthy and useful tool for healing. Video games, and now more recently, virtual reality, continue to be a helpful treatment for my mental illness and my addictive tendencies, as they allow me to use virtual environments and adventure gaming to heal and cope with my mental health challenges, without losing control of my habits.  That being said, this reflects my personal experience; while others may also benefit from gaming, it is equally important to acknowledge that it can also have negative effects and, for some, may contribute to unhealthy patterns or even addiction. How does play therapy help your mental health? Screenshot taken from: Symphony (PC Version) [Video Game]. (2012) Empty Clip Studios.  Ask anyone who has suffered from a mental illness what helps bring the most relief, and they will say most often that they need something to distract them from their bad thoughts and something to ground their inner child in play. The enormous digital landscapes afforded by modern entertainment fit this profile in a way that is both engaging and distracting.    Feeling the Beat As an example, one of my favourite virtual reality games is called “Beat Saber”.  This is a rhythm and reaction game set to music, which has you swinging two light sabers at various shapes in rhythm to music. Picture yourself holding two lightsabers at a music festival. Then, holographic squares start flying toward you with arrows on them. As you slash the squares in the right direction, the beat of the music festival is blasting around you in perfect timing. The musical aspects of this game are grounding and harmonising, while the immersive nature of a virtual reality headset allows one to block out the noise of the world to truly feel the beat. This is all played in an environment that is entirely within the user's control to enter and exit as one sees fit.   This convenient flexibility makes virtual reality an exciting and controllable escape. This doesn’t require the twelve-hour commitment of a night of drinking. Some studies, in fact, suggest that video game therapy can lead to faster symptom reduction . Being able to turn on and off a video game allows me to balance my recreational time with my responsibilities. Video game therapy also does not require a month or more to begin to help depression (as in the case of most antidepressants).    On becoming my own hero:  Screenshot taken from: Devil May Cry 5 (PC version)[Video Game]. Capcom Co., Ltd.    Another aspect of therapeutic value in video games involves the mastery and strategy required to excel at them. I first encountered the confidence-building effects of solving complex problems in video games when I was around ten. Ever since then, I still feel just... that much... more capable of solving my real-world problems when I can successfully navigate a digital storyline full of puzzles to solve. This is a known boost to one’s self-efficacy that comes with accomplishing something that one sees as challenging.  I also find some of the roles and scenarios one finds themselves in when playing a superhero to be able to personally empower other aspects of my life. This is not to say I become a superhero just by mashing buttons, but it is helpful to try to see myself as a protagonist in my own story, overcoming my own challenges. When I am in the deep and dark throes of a major depression, the sense of disempowerment and victimhood is often unbearable. When I am battling these states, it is of great benefit to imagine a stronger state of being.    How stigma gets in the way of wider acceptance During highly stressful periods of my life when my anxiety becomes intense,  grounding my thoughts is what is usually most necessary in counteracting the anxiety without heavier medications. I have been able to avoid the risk of benzodiazepines and other medications with habit-forming potential through the use of rhythm-based games like “Symphony ”, “Beat Saber” , and “Ragnarock” . These digital experiences allow my thoughts to slow and my focus to return when I am suffering from the racing thoughts that accompany anxiety.      Video games have been getting a bad rap from non-gamers ever since their inception. They are often demonised as a catalyst for violence or become targets of generational politics. This has gotten worse the more commonplace they have become in our society.  Another thing that is now different from when video games first began is that there is no longer any doubt about the fact that they are here to stay. I personally have observed a rather glaring lack of study devoted to the more therapeutic and positive effects of digital entertainment, as it applies to mental health. However, while consistent findings on video game therapy are still limited, there is a growing interest in exploring the potential of game-based digital interventions to support mental well-being.  There seems to be a lingering stereotype of poor health associated with abuse and a sense of laziness tied to video games. While gaming carries potential risks of overuse and addiction for some, research confirms that there is no direct link between video games and poor health , classifying it as a healthy leisure activity for adolescents. This bias around video games is similar to the stigma of laziness or weakness associated with mental illnesses like depression or addiction. These stereotypes, however, couldn’t be farther from the truth in countless cases like mine. The cardiovascular workout I get from “Beat Saber” alone clearly contradicts the laziness bias... without a doubt. Likewise, the benefits of moderate levels of digital child’s play have an underestimated therapeutic power.    My message to those who suffer from mental health concerns:  I recommend that those who suffer from mental illness be open to exploring video games as a helpful addition to other conventional treatments. I advise everyone to always be honest and clear with their doctor and follow their directions first and foremost before making any changes to their routine. This is so that the best outcome possible can be achieved. I hope no one becomes discouraged by any criticism of their chosen video game preferences and platforms. Everyone has the right to their preferences, which can range from “Pokémon: Sapphire” to “Doom: The Dark Ages”. Nobody’s chosen gaming genre is superior to anybody else’s.  The world of adulting and adult responsibility can get overwhelming for the best of us. I recommend that this not be an excuse to throw healthy play out the window. Your mental health may very well find a pleasant and manageable boost in the wake of daily responsibilities from a quick gaming session. Your inner child just might thank you!  This article has been sponsored by the Psychiatry Research Trust,  who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

I have to admit it: I was sceptical when the Netflix show Emily in Paris first came out, which is why I didn’t give it a chance until earlier this year. Surprisingly, that wait proved worthwhile: I binge-watched all four seasons in just a few weeks, and now I’m counting down the days until Season 5 premieres on Netflix on December 18th.   Video from Netflix on Youtube However, my enthusiasm is not widely shared, with many strongly dismissing the show for depicting an overly romanticised version of expat life.  As an Italian who has been living in London for over 9 years, I totally agree that Emily’s journey fails to fully capture the reality of expat life. The show overlooks many challenges that come with living in a foreign country, such as navigating homesickness, endless bureaucracy and financial hardship. Moreover, even when it touches on some real expat struggles, such as language barriers and immigration hurdles, it does so in an a very unrealistic way.   Nonetheless, I believe that behind its hilarious and at-times superficial plot line, this show shares some profound insights into expat life. But before delving into that, let me introduce you to Emily.  Who is Emily? And what is she doing in Paris?  For those who are new to the show, Emily Cooper (played by Lily Collins) is a young marketing executive from Chicago, who is unexpectedly offered the opportunity to move to Paris for a year, to assist her company with the acquisition of a French marketing firm. She decides to indulge in this brief Parisian fantasy before returning to the life she has carefully planned in Chicago: landing a major work promotion, marrying her boyfriend Doug and buying the house of her dreams.  However, when she moves to Paris her life takes an unexpected turn. Beyond the irresistible French pastries, fashion-forward outfits and glamorous parties, Emily struggles to fit in her new office. Her professional challenges start to be matched by personal upheavals when Doug breaks up with her, and she finds herself entangled in a love triangle with the boyfriend of her close friend, Camille.  As the seasons progress, Emily successfully navigates her new sophisticated workplace, earning recognition even from her uncompromising boss, Sylvie, who eventually persuades her to permanently move to Paris and work for her. Meanwhile, her personal life remains a rollercoaster, complicated by shifting friendships and romantic entanglements.  Being an expat myself, I know first-hand that living foreign country is far from this fantasy of glamorous outfits, lavish parties and intricate romances — so, what deeper truths does Emily’s story reveal beyond the drama?  1. Diversity is a strength  When Emily joins her new office, she really struggles to fit in. Although her marketing strategies quickly win over clients and result in a great success for the company, her co-workers dismiss them as bizarre and unsophisticated, or simply “too American”.   Image from @emilyinparis on Instagram This storyline reveals an uncomfortable but real truth: expats’ perspectives are not always welcomed. This is not necessarily out of malice, but simply because they fail to conform with established cultural norms. Yet, this lack of social acceptance and support in the host-country can contribute to mental health challenges and poorer sociocultural adjustment among expats.    Nonetheless, Emily’s story also shows a more positive side to this experience. In the end, her colleagues accept that her unconventional perspectives are exactly what leads to success, recognising that what once set her apart is what makes her truly invaluable.  This is why I think that — especially at a time when difference isn’t always welcomed — Emily serves as a powerful reminder that diversity is a strength worth celebrating, not a barrier to belonging.  2. You can embrace a new culture without losing your roots Another aspect of Emily’s journey that struck me is how she successfully blends in a new culture without losing her heritage. For instance, when her work ideas are continuously dismissed, she doesn’t abandon her marketing approach to fit in; instead, she stays true to her voice and thoughtfully embraces French practices to strengthen her strategies. Similarly, even though she dives head-first into French culture (who wouldn’t, right?), she doesn’t do so at the cost of her own identity. Indeed, even with Michelin-star restaurants at her fingertips, she still gets wildly excited about having frozen Chicago deep-dish pizza!   Image from @emilyinparis on Instagram Remaining grounded in your cultural roots can be quite challenging when you are constantly immersed in another culture. Over time, you start to internalise the language, lifestyle and traditions of your host country, while gradually losing touch with your own. For instance, I’m a bit ashamed to admit that since living in London I sometimes struggle to speak Italian, as I tend to default to English in both my personal and professional life (reassuringly, I am not the only one experiencing this !)  Many expats, myself included, feel this internal tug-of-war between the person we were in our home country and the one we’re becoming abroad. This tension can threaten one’s sense of identity and belonging, leading to psychological distress .  While Emily experiences this challenge too, I think the lesson lies in the way she moves through it. She doesn’t choose between her American and French selves; instead, she holds onto both, reminding us that belonging in a new culture doesn’t mean erasing your old self, but expanding it.  3. It’s never too late to start over  I believe the show’s most powerful message is that it’s never too late to start over. When Emily moves to Paris, her life appears to be perfectly planned; in one year she’ll return to her big promotion in Chicago, marry Doug and buy the house of her dreams. Yet, life abroad disrupts her plans, making her realise that the future she had carefully laid out for herself is no longer the one she wants. Ultimately, I think that her decision to remain in Paris doesn’t simply reflect her love for the city, but a deeper acceptance that change is part of the journey of becoming who we are meant to be.    Image from @emilyinparis on Instagram While this truth probably resonates with anyone who has ever faced change, it feels especially powerful for expats, who leave everything they have ever known behind to take a leap into a completely new reality. I think Emily vividly portrays this experience, reminding us that, while letting go of certainty is scary, it opens up a whole new world of possibilities and versions of ourselves that we would never have had the chance to experience otherwise.  So, what’s my final take on Emily in Paris?  I’ll admit it: I watch Emily in Paris partly because it’s an irresistible guilty pleasure; but I also think the show holds far more truth than it gets credit for. Beyond the glossy Parisian fantasy, Emily’s journey captures some surprisingly authentic aspects of the expat experience, showing us that adapting to a new culture is messy and challenging, but equally transformative.  As season 5 takes Emily to Rome, I am excited to see how she navigates this new chapter of her life and what insights her journey will reveal.

Author's Note: ‘Who Art In Heaven’ is a piece of fiction, but the concept is something entirely real to me, and to many others. OCD is not just liking things to be clean, and if you didn’t know that already, hopefully you will by the end of this story. Photo by Ayşenur  on Unsplash Casey Mattocks doesn’t remember the last time that her hands were clean, but she remembers the first time she told someone that they were dirty.   For the second night in a row, she had woken up to the sound of a distant, house-shaking thud, but this time hadn’t been able to fall back asleep. After tossing and turning, half-smothering herself in her vigorous cocooning, she had given up and gone wandering, scrambling down the two flights of stairs to the basement level that held her father’s study.   She knocks, but there’s no answer.   Scowling, it had taken her a painful few seconds en pointe  to move her wisp of a figure up to the keyhole, the gullet of which she knows gapes wide enough for her to peer through. She presses herself against the door, skin stretching to cover the slats and the grooves, the edge of the door jamb digging into one shoulder.   Inside the study, ringed by the blackened edges of the lock, she can see only the portion directly ahead of her. One side of the desk, half a rug, and the brown leather desk chair. Earlier that day, she had curled herself up in it and spun round and round until the world spun with her.   Sucking in a breath through her teeth, her gaze snags on her father’s slippers. The toes of them barely poke out from behind the desk, pleated blue with wooly, cream-coloured insides. Casey stares down at them, willing some movement back or forth, a twitch of motion as her father shifts his feet. Living people could shift their feet and dead people could not, and thus, if she saw them move, she would know that her father’s still alive. Licking her lips, she recalls the thud she had heard from upstairs. Cacophonous, like a gunshot. Deafening, like thunder. The sound of something falling, someone  falling. Her mouth tastes of bile, and she knocks again on the door.   Inside, the shoes do not move.   “Dad?”   Her hands cling to the oversized doorhandle, ornately carved but set in cheap brass. She can feel a layer of the metal coming off on her fingers. When she lets go, she holds them up to her nose and smells blood.   “Dad!”   Casey blinks and thinks once, for a split second, about going back to bed. But, she reasons, it’s better to be safe than sorry. What kind of daughter would she be, who turned away from her own father, dying on the floor of his study? Curling in on herself, instinctive, she readies herself to run at the door.   She barrels ahead, body colliding with the wood, but not budging it an inch. The hinges rattle like her bones, molars clacking together in time with the door clicking. Her shoulders drop into a heaving pant, and she tries again. And again. Bruising feels a distant, barely-there problem, drops of blue-green pain that wash down her shoulders but don’t soak through her skin. Still, her technique isn’t working, so she begins to fiddle with the lock.   Licking her lips, Casey tries driving the handle back and forth, staring at what little she can make out of the shifting mechanism inside. She had read up on lockpicking once, in case she ever needed it, but the ideas of pushing down the right pin and following the internal sequence are hazy, superfluous. Chewing on her lip, she tries to stick a finger into the crack between door and frame, inching her nail closer to the shot-through bar of metal, as if she might be able to push it back.   She shoves too hard, some of her nail ripping away from its bed, and starts to bleed. The edge of her skin turns hot, pulsing, and she shoves it into her mouth in an attempt to soothe the ragged pain. A little noise escapes her. Half a sob.   The edge of a memory: Karate Kid and the smell of sweat-soaked leather. She had been ill – nausea – and had been sitting in front of the TV with her brother for two days without moving. The crane kick had looked so strong and fast. That boy had looked lethal…   She pulls herself back onto her left foot, gathering all of her weight onto the ball, the down-curved stretch of muscle still touching the floor. As coordinated as she can muster, while shaking like a leaf, she shoves herself forwards, the momentum carrying her close, and switches feet. Her heel connects, jamming right into the crevice of the lock.   Casey yowls, mouth open as a pair of tears streaks the bottoms of her undereyes, and the door doesn’t move.   She pants, one-two, and runs away, down the corridor, her stomach starting to burn.   Barely reaching the toilet, her body convulses, throat burning as more tears drip into the puddle of vomit at the centre of the basin. The back of her hand wipes away the spittle around her mouth.   When she blinks, a blurry image starts to come into focus. Her father, soft-stomached and bright-eyed, stood up from his desk chair too fast. The world spinning around him, tilting, tilting, tilting until he can’t hold his own weight anymore. A dress shirt with a silly tie rustle and shifts before he comes undone, off-kilter.   He clutches at the space over his heart, nails digging into the fabric of the top pocket.   A face appears in the window, something glinting just out of reach.   The coffee on the desk steams, swirling. A thread of green seems to wrap itself around the centre.   A dying man. Her dead father.   Casey vomits again, scratching at the skin over her biceps. She forces her eyes open, ignoring the way that they start to ache from not blinking. Her hands twitch; she tries not to look at them.   They’re dirty. Crusts of blood and soil, an itching that she doesn’t dare scratch, and a barely there tingling seem to set her nerves ablaze. She holds them out in front of her, careful not to touch. Careful not to get the stains on any of the teal bathroom tiles around her.   Casey stands up and hovers her hands over the sink, nudging the tap with the very end of her pinky. From the limescale stained end, a jet of water sprays, near-scalding, as she scrubs all the way up to her elbows. The shadows from the buzzing electric bulb over her head cast flickers over the basin, as if the silhouettes are disappearing down the drain. Casey licks her teeth.   The tingling lessens, goes back to a faraway sensation. Her fingers still feel wrong when she touches the door handle, but she swallows the nausea back. She throws one more look over her shoulder. There’s no dirt in the sink, or marks on her hands where it had been.   Standing in the hallway, feet sinking into her mother’s pride and joy - a purple plush carpet in the shape of a snail shell - she realises that the keys to the backdoor are still in the lock. Her body moves like an automaton, and moments later she finds herself standing under the window to her father’s office. The curtains are drawn, and there’s no shadow visible on the flower-print.   One of the windows at the top is open. It’s the kind that swings up and outwards, not sideways, the fulcrum sending the end towards the sky. Barely wide enough to fit a person, and difficult to enter with no purchase on the windowsill.   She squeezes herself into the glass and red brickwork, some of the white-painted ledge starting to rot where it's been exposed to the wind. Bare feet find one side of the frame, toes jamming into the cement, as she braces her forearm on the other side.   Sucking in a breath, she expands, body hovering in the air as the wind swirls dizzyingly around her.   In the space of a second, she realises that she has to make a grab for the ledge, and lunges, throwing herself up in the air. For a moment, she’s weightless, small-knuckled hands clutching at the gap in the window. As she finds grip, she pulls herself higher, kicking off against the brick as the corners scrape along her soles.   Casey blinks, and she’s resting precariously in the open window, body positioned in perfect symmetry with the ledge. Sideways on and swaying ever so slightly.   She peers inside the room, down towards where her father should be.   Casey squints.   They are just shoes. Empty, pilotless shoes.   Sweat starts to pour down her face, cheeks puffing out in an attempt to control her breathing. Slow and unsteady, she tries to shift herself to one side so that she can slide back down.   Then, she is overbalancing, body cracking over the sill and legs losing their footing.   She turns, rolling off her perch and into the room, everything twirling once as she falls fast enough to pick up speed. A crash. She hits the ground; body crumpled under the flowery curtains. Bruises lick up the inside of her thighs, and her shoulder screams so hard she sobs.   Curling in on herself, Casey knots herself up into the foetal position. She doesn’t even hear the door open.   “Casey?”   She can’t even raise her head, tiny body resorting to stuttering cries, then howling sobs that rips themselves straight from her mouth. A pair of hands turn her over, dragging her to her feet until she can stand on her wobbling knees. She wraps her arms around herself as she stares into her father’s furrowed brow.   “What are you doing here?”   “I thought something had happened to you,” She sniffles.   Her father works his jaw, stubble shifting over his skin.   “Why would you think that?”   Casey looks down at him. Her mouth opens. Closes. Opens again. She coughs into her elbow, hacking and slow, before shrugging. Tears bead in her eyes as her father pushes some of the tangled, loose hair off her face. She says nothing. There is nothing.   “Alright, well, let’s get you back to bed, yeah?”   Casey nods, then shakes her head. Her hand shoots out, snagging on the sleeve of his shirt.   “Can we check on Mum?” She asks, bile slicking her throat, hands burning, dirty, “I’m worried about her.”   Her father looks down at her, lips in a twist. Casey picks at the ends of her nails, blinking away soil. Eyes following her motion, her father leans closer, scrutinising for whatever it is she’s trying to pry out of herself. Eventually, he gives up. There’s a sigh, and it hangs in the air.   “Okay, but in the morning, we need to talk about this. Seriously talk.”   “Can I wash my hands? Before we go and see Mum?”   Her father takes a step closer, holding out a hand. Without thinking, Casey holds hers out, palms up. Her eyes trace the rings of mud and the thin trail of blood mixing through and beginning to settle in the grooves of her lifeline. Stomach revolting, she inclines her head, nodding down at them so that her father understands.   He stares, motionless.   “But they’re clean.”   Casey blinks, slowly, ignoring him. He looks a little pale, and she’s worried that he’s starting to get ill.

More than a century ago, psychiatrists spoke of ‘climacteric insanity’: the strange and sudden madness said to strike women at the end of their reproductive years. Physicians in the late 19 th century described vivid delusions, sleeplessness, and emotional turmoil appearing ‘at the change of life’, when the female body ‘lost its balance’. Image Source: The Ethicalist A hundred and fifty years later, we still see the same pattern: the transition through menopause can trigger new or worsening symptoms of psychosis. And yet, we still do not fully understand why this happens or how best to treat it. My path to studying psychosis in women My name is Bodyl and I am a postdoctoral researcher at the University of Oxford. My work centres on understanding psychosis in women, and improving treatment options for the changing vulnerability we see across the female lifespan. My interest in this topic began, perhaps unconsciously, with my own experience of how changes in sex hormones during my menstrual cycle affected how I felt and thought. This made me curious about the subtle ways biology shapes our mental state. During a clinical placement, I met people with psychosis and was fascinated by how different it could look from one person to another. At the same time, I noticed clear differences between men and women in how the illness manifested and evolved. There, and also later during my PhD, I began to see consistent patterns. Young male patients were severely impacted by psychosis, while older males seemed to have reached a more stable stage of illness. Female patients, in contrast, tended to do relatively well earlier in life, but I noticed more instability in those who had reached midlife. The oestrogen protection hypothesis Clearly, I was not the first to notice this female-specific deterioration after midlife. The 19 th Century observations of menopause-associated “instability” have been cemented by large-scale studies showing a second peak of psychosis in women around midlife. In the 1980s and 1990s, scientists also began to uncover that oestrogen does far more than regulate reproduction. Oestrogen shapes the brain by protecting brain cells from damage and supporting neural plasticity, (the brain’s ability to reorganise itself by forming new connections). These observations led to the oestrogen-protection hypothesis - that oestrogen has a protective effect, shielding women from psychosis when levels are high.   Image Source: Teena Lalawat Menopause and psychosis vulnerability Oestrogen levels are not constant throughout life. For example, in menopause oestrogen levels signficiantly reduced. Women enter the menopausal transition (‘perimenopause’) around age 45 and reach menopause (12 months without menstruation) at about 50. The average female life expectancy is around 75, meaning that women spend roughly 1/3 of their lives in this postmenopausal stage – a proportion that will only increase as life expectancy rises. Changes in treatment effectiveness around menopause Despite extensive evidence for oestrogen’s protective effects on the brain and women’s increased vulnerability to psychosis around midlife, it remains unclear how treatment responses change during this period. Understanding how reaching midlife affects treatment response could help tailor more effective care for women with psychosis. In one of the studies conducted during my PhD, we looked at how treatment for women with schizophrenia changes as they reach menopause. We used nationwide data from Finland, following over 61,000 people (both male and female) diagnosed with schizophrenia or related disorders between 1997 and 2017. We looked at how each individual’s risk of being hospitalised changed when they were taking antipsychotic medication compared to when they were not. We did this by comparing the risk of psychotic relapse between men and women above and below the age of 45. Our findings were striking; women over 45 had a markedly higher risk of relapse than all three other groups. This suggested that after reaching menopausal age, women become significantly more vulnerable to psychotic relapse, and that the effectiveness of these medications may shift over time and across different stages of life. Image Source: Elena Mozhvilo Interpreting our findings The decline in oestrogen around menopause offers an obvious biological explanation for this female- and age-specific vulnerability. But, it is unlikely to be the whole story. Reaching midlife and menopause also involve psychological and social transitions which may contribute to this increased vulnerability to psychosis (see also this piece by Dr Alice Onafrio). Most importantly, our findings suggest that our understanding of how to best treat women with psychosis at this stage of life is still limited, and that current approaches may fail to address the complex, interrelated factors facing women. You might wonder – how is that possible? The reason lies in the long-standing sex bias in medical research. Across nearly all health disciplines, women have historically been underrepresented in preclinical and clinical studies ,  as previously been discussed by Samrina Sangha for ITM . For decades, new drugs were tested almost exclusively in men, with the assumption that results would automatically apply to women too. While things are improving , the female sex remains under-represented in many studies. In psychosis research, the problem is even more pronounced: most clinical trials include participants aged 18-50, effectively excluding postmenopausal women. Our current treatments are therefore based largely on a male body of evidence and thus sex-specific presentation and treatment of psychosis remain underrepresented in clinical training and treatment guidelines, perpetuating gaps in care and awareness among healthcare professionals. Steps towards female-specific, hormone-informed care The results of our study were striking and made us wonder whether the increased risk after midlife could be reduced with different treatment approaches. With the oestrogen protection hypothesis in mind, we investigated whether oestrogen-based menopausal hormone therapy (MHT - widely used since the 1960s to treat menopausal symptoms) might help to reduce psychosis relapse in women. Using a cohort of 3488 women aged 40-62, we compared periods where they were taking MHT with periods where they were not. We found that the use of MHT was associated with a 16% decrease in risk of psychotic relapse . MHT may therefore help to counter the reduced effectiveness of standard antipsychotic treatment after menopause, pointing to a promising female-specific approach to improving outcomes in psychosis. Together, these studies indicate that current psychosis treatments are not sufficiently tailored to the female body and brain. Yet the results offer hope: we may be able to treat, or even prevent, this menopausal worsening by harnessing the protective effects of oestrogen and developing female-specific treatment strategies. Why equal treatment isn’t always fair There is still so much to explore when it comes to female-specific treatment strategies for psychosis, and potentially other psychiatric disorders. We need to move away from the assumption that if something works for men, it will work for women. We must begin to account for how different reproductive life phases shape vulnerability and treatment response – and design care that interacts with and accounts for those changes. Men and women should not be treated equally. They should be treated fairly – with care that is shaped to male and female bodies, so that both can receive the treatment they need and deserve. Source: New Yorker

I am a psychiatrist with a long interest in researching topics like mental capacity, that lie in the borderlands between psychological medicine, ethics, and law. In this context, I do something unusual for a psychiatry professor: I teach psychiatry in a law school.   Image Source: José Martín Ramírez Carrasco on Unsplash Teaching fundamentals For several years, I’ve been teaching students with a range of academic backgrounds the ‘concepts of psychiatry’ and it’s been a very stimulating part of my life as a psychiatrist.   We start off with the mind/brain problem: how do mental phenomena and physical phenomena relate? This is a problem that powerful minds over millennia have not solved to the satisfaction of philosophy, but it is a problem that psychiatry quite literally sits upon. We explore in seminars how psychiatry struggles with this problem, not as an abstract puzzle but as a deeply contextual challenge related to real people in real clinical scenarios. Students realise that they can have a very strong position on the philosophical problem whilst not implementing their position consistently across varied clinical cases which we discuss together. For example, students who strongly believe the mind/body problem is unsolveable are willing to solve it in the direction of reductive materialism (i.e., the mental reduces to the physical) when discussing a case of delirium. The human situation, with its clinical particulars, emerges as more fundamental than the generic, abstract relation.   Then we move on to the basics of psychopathology. The psychiatrist Anne Farmer once stated: "descriptive psychopathology is the basis of measurement in psychiatry" and "descriptive psychopathology requires empathy".  We consider in class the significance of that statement. It implies that psychiatry as a science (its most basic measurements) require, or depend upon, an empathic function that belongs to the humanities - i.e., imagining oneself in the shoes of another human being or grasping a lived experience. We think through what it means that psychiatry, at its very roots, is an explanatory, or natural, science AND an interpretative or humanistic inquiry.   Following this, we move to classification. For example, the Diagnostic and Statistical Manual of Mental Disorders or ‘DSM’ (sometime referred to as the ‘bible’ of clinical psychiatry) and the more recent classifications based on neuroscience. We trace the various ways in which people deeply involved in mental health rebel against classification. We understand what is means to say: “time to get rid mental disorder labels!” or “biology does not read the DSM!” or “complexities of mental life do not reduce to brain circuits!”. But we also imagine, in class, a psychiatry without classification and whether that could offer help to people presenting to clinicians with suffering. Suddenly attempts to classify feel more human again.   We also consider suicide, as it is traditionally seen in psychiatry, namely as a harm to prevent. But we also consider it, as it is increasingly seen in the context of end of life, as a human right - the right to death or to assistance in suicide. How can we manage the cognitive dissonance between policies that require psychiatrists to take a ‘zero tolerance’ approach to suicide and policies requiring psychiatrists to assist people to end their own life if they choose to? Resolving that dissonance would seem to require us to consider anew what suicide means as a human behaviour both to individuals and their communities.   Image Source: Wesley Tingey on Unsplash Towards the end, we grapple with the complexities of involuntary treatment, including accounts from ‘anti-psychiatrists’ who seek to abolish it entirely. Traditionally, involuntary treatment is seen as necessary for public protection. We unpack the motivations of writers who want to free people with mental disorders from any psychiatric power to treat them without consent. Is their motivation a desire to move society to a place where treatment would only need to be voluntary because everyone would be sufficiently supported? Or it is a desire to move society to a place where everyone has their just deserts and where we should not seek to protect people with mental disorders from the reach of the criminal justice system or from the choice of homelessness? We then consider what patients with severe mental illness say about periods when they have been gravely ill and had involuntary treatment; or what they want to happen if they were to get gravely ill in the future. From these accounts students often conclude that it would be inhumane not to have a framework for involuntary treatment whilst feeling motivated to try to improve it. In discussing freedom and mental disorder, we appreciate how closely psychiatry lives to politics.   All of these topics – each one core to psychiatry - relate, in different ways, to human nature. I have noticed that it can be easier to see that relation when teaching psychiatry at a basic level, as I have done in the law school for years. In psychiatric practice and research, we tend to take it for granted. Over the years it has become clear to me how unsettled the concept of ‘human nature’ has become in general intellectual life outside of psychiatry. Our era often self-identifies as a postmodern one, namely we reject any singular story or ‘grand narrative’ about who we are as human beings, leaving a multitude of perspectives. In other words, the postmodern view takes contested interpretations of ourselves to be our lot, negating the concept of any nature . However, our era equally self-identifies as a biological one, meaning we accept an account of ourselves as a byproduct of evolutionary forces in which there is no essence or purpose that defines us other than those of the mechanisms of the natural world. Both of these influential reflections on human nature may not be compatible, but they share the feature of being curiously anti-human nature.   This combination, of teaching that psychiatry relates deeply to human nature whilst realising that our general intellectual life has become antagonistic to the idea of human nature, propelled me to writing a book about it.   ‘Psychiatry and Human Nature: Classic and Romantic Perspectives’, by Gareth In writing the book I returned to some older philosophical ideas about human nature to help with current problems. An idea that I make use of, and build on, in my book is Goethe’s distinction between the ‘classic’ and the ‘romantic’. Roughly speaking, the ‘classic’ perspective is the human being’s capacity to detach, whilst the ‘romantic’ perspective is the human being’s capacity to participate . Becoming more aware of the classic and the romantic perspectives allows us, I argue, to balance the goals of psychiatry better. And it gives us a distinction (a dualism even) that suits our nature better than any Cartesian dualism of mind and body can.    I hope curious readers pick up the book, engage with the themes and decide how persuaded they are of a need to renew interest in psychiatry and human nature! You can buy Professor Gareth Owen's book here .

Eight evidence-based approaches to beat burnout Two years into coping with the pandemic, evidence-based tools and techniques to beat burnout are vital for our mental health. Photo by Dids  on Pexels— Sleep is one evidence-based strategy to counter burnout The COVID-19 pandemic changed life as we know it. On January 9th 2020 the WHO announced Coronavirus-related pneumonia in Wuhan, China. Two years later, the new Omicron variant of COVID-19 continues in circulation. How ever much we want it to be so, a clean ending to the pandemic looks unlikely. By this point, fatigue has set in. Burnout combines exhaustion with cynicism and a reduced sense of competence. It can result in serious physical and mental health consequences, including substance addiction, Type 2 diabetes, and insomnia (difficulty falling asleep or staying asleep). Unfortunately, as well as the health consequences, professionals experiencing burnout may be unable to return to work, depleting the workforce further, and in turn, the economy. This is a double blow, given that some of the workforce is already absent due to contracting or exposure to the virus. Recently, Charlie Massey, Chief Executive of the General Medical Council stated: “The danger is that, unless action is taken, workloads and wellbeing will continue to suffer, and future burnout rates could get even worse. As we move on from the pandemic, it is vital that doctors’ training and wellbeing needs are central to service recovery plans.” Burnout in healthcare workers is a global phenomenon . Stressors include a high workload, insufficient Personal Protective Equipment (PPE), lack of knowledge, long working hours, and direct exposure with patients. A study among 3,100 nurses and 992 physicians working in Asian intensive care units in 16 countries in Asia found that nurses and physicians had high levels of burnout, 52 and 50.3%, respectively . Whilst healthcare workers are particularly affected, the pandemic affects us all and workers in other types of industries are also at risk of burnout. Because burnout was already a major issue in healthcare jobs before the pandemic, a lot of the evidence of what works draws on studies with health care providers. In general, for all professionals, if you have a heavy workload and work long hours, have difficulties maintaining work life balance, you work in a helping profession and you have limited control over your work, you are at increased risk of burnout. This blog is the final piece in a 3-part series on the topic of burnout for digital magazine, Inspire the Mind . As a recap, part one offered up an introduction to the science of burnout. Part 2 looked at the effects of Zoom in relation to burnout . In this final blog, I’ll share 8 evidence-based ways to prevent or recover from burnout. As a researcher at the Evidence Based Practice Unit , I’m passionate about projects that are based on evidence of what actually works. I think that it’s important we refer to the evidence base before testing out programmes that sound great but might not actually work. Most of us wouldn’t take a drug if it had not been scientifically tested, so perhaps it’s important to exercise a degree of caution with our mental health. First, a quick recap on how psychologists define burnout. Researchers, Maslach, Schaufel & Leiter, describe the concept of burnout as having 3 parts, that include: Emotional exhaustion , this means feelings of being emotionally overextended and depleted of emotional resources Depersonalization, refers to workers’ negative, callous, or excessively detached feelings towards their clients/customers Reduced personal accomplishment and equates to feelings of incompetence and lack of achievement at work (Maslach, Schaufeli, & Leiter, 2001). As established by the World Health Organisation burnout is a workplace phenomenon. Why is it important to draw on evidence-based interventions to tackle burnout? It takes a lot of resources and time to deliver a programme across a whole organisation, or even within one department. Before embarking on solutions, checking existing research for evidence of if a program works in other settings increases the chances that it will “work” for employees in the organisation. Evidence that a programme is really effective is most reliable when a trial has been conducted with a control group (a more or less identical group of people that have not received the programme to compare with the group that had the programme), and there are a number of different peer reviewed studies (subject to critical examination by specialists in the field). Evidence based programmes to burn out have ideally been tested on a large group of people, multiple times. Other factors that inform evidence-based interventions (and if a program might work) include a clinicians perspective and an individual’s values. Disclaimer: this blog is only a rapid overview and a full systematic review is needed on this topic. 8 EVIDENCE BASED STRATEGIES ONE. Cognitive Behavioural Therapy (CBT) to Reduce Stress The good news is that t here is lots of evidence that CBT can reduce stress, burnout and promote wellbeing . CBT is one of the most widely used approaches to treat depression, anxiety and stress, here in the UK it’s available from the NHS for a range of mental health difficulties . CBT involves a technique that can be quickly applied to change thinking patterns that in turn have an effect on behaviour. CBT may be learned via a pre-recorded video or taught by a facilitator or therapist. CBT programmes often include: Recognising unhelpful automatic thoughts and unhelpful beliefs. Automatic thoughts are those that just pop into our heads unfiltered that may not be based on facts. For example, “I’m terrible at choosing gifts”. Recognising them is like conducting “quality control” where we check that our thoughts are warranted. Unhelpful beliefs are things that we tell ourselves all the time but may not be true. Setting goals — setting goals can help us to achieve what we want from life and work and from the therapy itself and provide greater meaning and a sense of achievement. Understanding your attributional style — how we understand the meaning of events and what causes them. Identifying thinking patterns such as — catastrophising, the tendency assume that the worst outcome might follow from a small event. The challenge is that, whilst effects are seen after the intervention, these changes are not always maintained months after the intervention. TWO. Coping interventions Coping is key to managing stress. Programs that teach coping strategies have found to be effective , for example, coping and support groups for nurses to increase coping with difficult situations and encourage positive coping strategies. Lee’s review of a range of studies found that coping interventions for 6 month to a year led to a reduction in emotional exhaustion, depression, and ultimately burnout among nurses . Coping can involve confronting a problem head on, while avoidance is an aspect of burnout. A range of coping strategies may be used in a given situation that include confrontation, distancing, self-control, seeking social support from others, accepting responsibility, putting our head in the sand, avoidance, problem solving, and positive reappraisal (viewing the problem in different terms). Coping interventions often enable people to consider some of the disadvantages of their current range of coping strategies (e.g., watching Netflix) and provide them with new ones, (such as seeking support, exercise and meditation). THREE. Novel approaches There’s some evidence for novel approaches that are less widely researched. A study of Qi jong for physiotherapists found that emotional exhaustion decreased amongst participants that engaged in “White ball exercises”. Massage and touch therapy has had mixed results with some studies finding it effective and others not . Workplace appreciation events were found to have a significant effect in increasing performance and reducing depression and burnout among nurses and physicians. Photo by Herbert Santos - Some research finds that martial arts can help beat burnout. FOUR. Learning and skills training and professional identity development Learning and training can reduce burnout in mental health care workers . Interestingly, these types of interventions also increase employee performance. The pandemic has been a huge learning curve and those organisations that have learned and adapted have succeeded. Professional identity development programs have also been found to reduce burnout of the nurses. FIVE. Taking a holiday Photo by Stefan Stevancik on Pexels Taking a holiday may not change the organisation, but there is some evidence from an Israeli study led by Etzion and colleagues that it can reduce burnout in the short term, but it’s not maintained upon return to work . With lockdowns and shortages of staff, there may have been much less opportunities for staff to take holidays and to take holidays that fit with our ideas of holidays (covid testing pre, during and post trips can change our notion of what a short get away looks and feels like). SIX. Practice Psychological Flexibility Researchers have found that people that are psychologically flexible, are better able to cope with setbacks in a work environment and studies show effectiveness at reducing burnout. Psychological flexibility refers to being aware of the situation you are in and taking action based on your own values. SEVEN. Learn mindfulness Mindfulness involves observing one’s thoughts and feelings from a noncontrolling, nonelaborative, and non-judgmental perspective: A way of thinking commonly described as mindful . Mindfulness is a skill that can be learned as outlined in this blog . Researchers Luken and Sammons (2016) ran a systematic review of mindfulness practices for reducing job burnout in health care professionals and teachers. They found evidence that mindfulness practices effectively reduced job burnout. Other reviews find evidence of mindfulness reducing related conditions of anxiety and depression. Inspire the Mind has previously published blogs on what mindfulness is and on its scientific basis . EIGHT. Sleep Photo by Ketut Subiyanto on Pexels We are asleep for up to a third of our entire lives. The links between poor sleep and burnout have been well researched particularly for healthcare workers and nightshifts workers. Guidance for improved sleep includes: aim to get 7–9 hours per night, avoid drinking before bed, only use beds for sleep or sex, keep the bedroom quiet and relaxing, limit bright light exposure in the evenings, be careful of naps disrupting sleep patterns. Light from both lamps and screens can potentially disrupt circadian rhythms. The links between Sleep loss, burnout and health conditions by Stewart and Aurora, 2019 Takeaway In summary, 8 evidence based strategies have been briefly proposed: 1) Cognitive behavioural therapy 2) Coping interventions 3) Learning and skills training 4) Novel interventions 5) Taking a holiday 6) Psychological flexibility 7) Mindfulness 8) Sleep These approaches can be pursued through self-help books, online videos, apps, joining a mindfulness course online or in person, or seeking support from a licensed therapist or coach. Hopefully, employers will also be seeking to assess risk of burn out in their organisations and put strategies in place to maintain the wellbeing of their employees. Finally, there are other strategies, from talking to your employer about your mental health, to employers practicing better communication with staff to forming a support group for working parents. It is not that these other strategies do not work, they are just less studied in the literature. Many thanks, valued readers, for reading.

Sometimes I write on my research. Sometimes on topics I am politically passionate about. Sometimes on things that happen to me. And sometimes a scene from a tv series affects me so much that writing about it is the only way for me to understand why. Welcome to my attempt to emotionally and cinematographically dissect the famous scene “Max’s favourite song/Running Up That Hill” in #StrangerThings4, Chapter 4. Spoiler alert: if you have not seen this chapter, or indeed the series, come back here after you have done so. Max in Chapter 1 of #StrangerThings4, while listening to Kate Bush’s Running Up That Hill. Image source: Netflix. Let me do the “professor thing” first. I don’t want to claim that #StrangerThings4’s writers are particularly knowledgeable in mental health topics. The depiction of the asylum (also in Chapter 4) is a mix-and-match of the worst movie tropes depicting psychiatry and psychiatrists, from One Flew Over the Cuckoo’s Nest to The Silence of the Lambs . And the whole narrative of the final #StrangerThings4 chapters is based on the discredited theory of repressed memories  — let alone the unbelievable premise that you can re-live part of your life by simply floating in a dark bathtub with your eyes closed while videos of your childhood play on the ceiling. There is no attempt to be scientifically accurate here. But. Someone among the writers who delivered the “Max’s favourite song/Running Up That Hill” scene must have had profound personal knowledge of what mental pain truly is. And how the monsters of the mind feed on shame and guilt. This scene has excited viewers , has been discussed in the news , and has projected the song at its centre, Kate Bush’s 1985 song Running Up That Hill , at the top of the charts again. For those who don’t know the main story underpinning the tv series Stranger Things , Max is part of a group of friends that fight against dark supernatural forces killing people in the fictional town of Hawkins, Indiana, in the early-to-mid 1980s. Within the horror/sci-fi/teen drama genres, the series explores themes such as the transition from childhood to adulthood and the true horror of “not fitting in” in high school. But the main theme of Season 4 is mental pain. The new monster, Vecna , kills adolescents that suffer from mental pain. Image source: Netflix Chrissy, who is killed in Chapter 1, has an abusive mother. Fred, who is killed in Chapter 2, has caused a girl’s death in a car crash. Patrick, killed in Chapter 5, has a violent father. Nancy, whom we leave at the end of Chapter 7 possessed by Vecna, is haunted by the death of her friend Barb at the hands of the Demogorgon, another monster, in Season 1. And Max suffers from unbearable guilt for her brother’s death. We know from Season 3 that Max’s brother, Billy, is killed while fighting the dark forces, and in doing so he saves Max and her friends. Max herself talks about her guilt in the lead up to the scene, reading a letter to Billy sitting by his gravestone. Image source: Netflix Max: “I play that moment back in my head all the time… I imagine myself running to you, pulling you away… but that’s not what happened… I stood there, and I watched… for a while I tried to be happy, normal, but I think that maybe a part of me died that day too… and I haven’t told anyone this, I just can’t…”. And this is when Vecna arrives. Because Max’s inability to connect to her friends is what truly feeds the monsters of her mind — the monsters that Vecna symbolises. Max has shut everybody out. She has broken up with her boyfriend, Lucas, and has pushed her friends away. Lucas tells her this in the lead-up to the scene. Lucas: “Just talk to me, to your friends, we are right here, I am right here… I am here”. But Max does not connect . She is not here . This is the central and painful symptom of mental anguish. This feeling of shame. The inability to share the pain we feel with the people who are closer to us. Instead, the monsters. Call these monsters depression, workaholism, or just fear. The monsters feed on loneliness and shame. This is when Vecna arrives, and the scene starts. You can watch it all here and then look at the stills below. The scene starts when Vecna kidnaps Max from the real world, traps her in a different dimension (the “Upside Down”), and ties her up with his tentacles on a sacrificial pole. Max’s emotional detachment now becomes a physical one. Now she really is not here anymore. People who are in mental pain describe this as a feeling of numbness, or as being behind a glass wall. The scriptwriters put a real inter-dimensional wall between Max and the people she loves, and who love her. In the real world, Max is in a state of trance. Max’s friends’ only hope to reconnect with her across the two dimensions is by using music. They decide to use Max’s favourite song — Kate Bush’s Running Up That Hill. They start the music, and Max and Vecna can hear it. The music opens a passage, through which they can both see her friends on the other side calling her. The cinematographic dance between their dialogue, the song’s lyrics, and what Max sees in her mind, is just astonishingly beautiful and powerful. Friends: “Max, wake up. We are right here.” Image source: Netflix Lyrics: You don’t want to hurt me, But see how deep the bullet lies. Unaware I’m tearing you asunder. Ooh, there is thunder in our hearts . Vecna: “They can’t help you Max. There is a reason you hide from them. You belong here with me.” Image source: Netflix Lyrics: It doesn’t hurt me. Do you want to feel how it feels? In the real world, Max starts to levitate. We know — and her friends know — it means she is going to die imminently. Image source: Netflix Lyrics: If I only could, I’d make a deal with God, And I’d get him to swap our places. The scene continues to cut between a montage of Max’s memories, her fight with Vecna in the Upside Down, and her trance state in the real world. Because this is what mental pain feels like. You are both with your monsters and with your friends. In your nightmares and in the real world. All the time. In Max’s mind: multiple memories of her and her friends. Lucas telling her again “I am here”. And scenes from her past. Laughing with Eleven. Dressed up as Ghostbusters with Dustin and Lucas. Skating with Mike. Shopping. At the cinema. Hugging. Kissing. High-fiving. Image source: Netflix Lyrics: C’mon, baby, c’mon darling, Let me steal this moment from you now. C’mon, angel, c’mon, c’mon, darling, Let’s exchange the experience, oh Through the energy that she gathers by acknowledging that her friends love her, Max manages to rip off the tentacles and she runs toward the opening. Image source: Netflix But it is not finished. Recovery is not so easy . The monsters will throw everything they can at you. They don’t want to let you go. And so Vecna starts shelling Max with big rocks that fall from the red skies. She is running and running. She falls, she gets up, she runs again. Image source: Netflix Lyrics: And if I only could, I’d make a deal with God, And I’d get him to swap our places, Be running up that road, Be running up that hill, With no problems. Now I become tearful. She is not going to make it , I say desperately to my wife, who is also tearful by then (I talk in Italian, actually: Non ce la fa, non ce la fa!) Max is running and running, toward her friends. Cut to black and to silence. I really thought she would die. That the monsters would have taken her back. But she makes it. She reaches the opening. She returns to real life, back with her friends. Lucas: “I thought we lost you.” Max: “I am still here.” Image source: Netflix I know from my clinical experience as a psychiatrist, and from my personal psychotherapy, that recovery from a mental health problem is strengthened by sharing our pain with others. Of course, it’s not enough to run to your friends just once. And each step that Max takes toward the people she loves — in the mud, under a shower of boulders — is weeks and months of recovery in real life. But the scene works because it touches our hearts. The right message. The right symbols. The right conclusion. We can escape our monsters, but only by sharing our pain with others.