Celebrating the launch of new book ‘Psychiatrists on Psychiatry' "If I have seen further up, it is by standing on the shoulders of giants. - Sir Isaac Newton Discoveries are often not result of a single person but rather a team building on the knowledge that exists. Academia thrives by challenging existing dogma and building on what has come before. This building on foundations set by others also highlights the importance of institutional memory. Institutions are made of people and so often it is the people who remember, hold and record memory about the function of the organisation and the field of academics relies on sharing data, findings, observations, results, and caveats. Institutional memory (or corporate memory) is helpful in understanding what has gone on before while building on strategies and skills and depends very heavily on what people recall and what is embedded in facts, concepts, experiences, and know-how held within an organisation. Of course, documents may not contain everything people recall and remember but institutions do hold the history and historical knowledge in a variety of locations. Minutes of meetings are just that often detailed discussions may not appear there. Furthermore, the impact of researchers, teachers and leaders be they in clinical settings or influencing policies can be significant. The institutional memory has both tangible and intangible components. Preservation of institutional memory is crucial. In a pre-digital era, constraints of space may have made such storage difficult. In the 21st century digital age, four ways of preserving institutional memory have been described: playbooks and checklists, protocols and policies, technologies and tools, and dedicated external individuals and/or teams. In this spirit, several years ago, well-known psychiatrist Professor Norman Sartorius suggested that I ought to interview a number of leaders in psychiatry from around the world. It took nearly five years to record, transcribe, and publish the interviews in Psychiatrists on Psychiatry, published by Oxford University Press. The book is being launched at the Royal College of psychiatrists on 24th October at 3:30pm. I had the good fortune of having three early career psychiatrists — Dr Mariana Pinto de Costa, Hussien Elkholy, and Antonio Ventriglio — who interviewed five of the leaders and I had the privilege of interviewing the rest; thus, a vast majority of the leaders. Of all the individuals who had been invited, three refused to participate for various personal reasons whereas the rest were willing to share their experiences and life histories without hesitation. The book contains transcripts of interviews with 26 psychiatrists from around the world. Of 26 interviewees, 12 were women. Although a majority came from Europe and USA, we had three from north Africa, three from India, and one each from Thailand and Japan. Regrettably, three interviewees — Sir Michael Rutter, Dame Fiona Caldicott, and Padma Bhushan Sarada Menon — had passed away but their families gave permission to publish the transcripts for which we are most grateful. The interviewees in alphabetical order are: Renee Binder (USA), Fiona Caldicott (UK), Silvana Galderisi (Italy), David Goldberg (UK), Billy Jones (USA), Shigeobu Kanba, (Japan), Marianne Kastrup (Denmark), Linda Lam (Hong Kong SAR China), Saul Levin (USA/South Africa), Mario Maj (Italy), Felice Lieh Mak (Hong Kong SAR China), Sarada Menon (India), Driss Moussaoui (Morocco), Carol Nadelson (USA), Amed Okasha (Egypt), Tarek Okasha (Egypt), Maria Oquendo (USA), Michael Rutter (UK), Norman Sartorius (Switzerland), Alan Schatzberg (USA), Nada Stotland (USA), Paul Summergrad (USA), Thara Rangaswamy (India), Pichet Udomratn (Thailand), Rutger Jan van der Gaag (Netherlands), and Laksmi Vijaykumar (India). There were similarities and differences in their upbringing, development, and their attraction to the discipline of psychiatry. The role of mentors was significant and many interviewees spoke very fondly about how various mentors guided and supported them. The impact of the Second World War was very important on the childhood, early adulthood, and consequent worldview of many of the interviewees. The reason why they chose to go into psychiatry varied, as did their views on how the practice of clinical psychiatry has changed. The question remains whether leaders are born or made and whether leadership skills can be learnt. There is little doubt that for leaders to emerge and function effectively, they must have followers who believe in them. In view of changing evidence, good leaders can change their mind and decisions to ensure best outcomes. In order to do this, once again, institutional memory becomes crucial. The book can be seen as an attempt to record history and institutional memory, but it also highlights challenges psychiatry as a discipline and profession has faced and how some of these challenges have been overcome. Institutional memory is the collective knowledge about institutions and their functioning and it can help leaders to ensure that institutions continue to run smoothly and deliver the vision leaders have. Carrying out research, as demonstrated by several of the interviewees, is about mentoring, team working, and, to a certain degree, being able to take risks. Therefore, institutional memory plays a major role in what works and what does not. Of course, circumstances, society and settings change and good leaders have to be willing to change with these. Institutional memory is held by people and archives but nothing beats learning from individuals which can explain and express their reactions rather than relying on dry records. Thus institutional memories held by members of institutions becomes crucial to recognise that and hopefully this volume will provide that. It is important to be aware of the inherent value of institutional memory so that we can build on its strengths and manage its weaknesses. This is embedded in a collective set of facts, concepts, experiences and know-how all of which are held by a group of people at all levels in the institution. This means that a collective memory or history can be utilised to build on what has gone on before and how we take things forward. As people hold this knowledge and memory, it is crucial that we acknowledge their contributions and collect information in order to be able to transmit that to future generations. This will allow them to apply not only lessons learnt but, more importantly, how to stand on the shoulders of giants and look further up as Newton had so eloquently observed. As institutional memory transcends the individual, the recording and transmission are important in understanding and building on institutional cultures. I am humbled by listening to life stories of these giants of psychiatry — many of whom have created innovative research, clinical, and policy programmes. Saying thanks to them is a very inadequate way of expressing my gratitude for all they have done for the speciality, their patients, and the population as a whole. The book can be ordered from Oxford University Press.

In the digital age, narratives are constantly evolving, shaped by fleeting online trends that captivate millions. At the forefront of this revolution is TikTok, the app in which any story can find voice, rhythm, and resonance. Currently, one of the most notable TikTok trends is "#CoreCore": a rapidly growing trend depicting tales of male vulnerability, resilience, and introspection. The trend offers a poignant glimpse into men's mental health as users make videos compiling of short melancholic clips of people narrating their intimate struggles with sombre music in the background. But what is it that makes these snippets of raw emotion resonate with millions of viewers? Why are people so captivated by men's descriptions of loneliness, self-image, and their issues with society? I am a 2nd year Psychology student at the University of Warwick and I often find myself closely observing the evolution of social media narratives (particularly on TikTok) and their impact on society, specifically in the field of men's mental health. Conversations about well-being are becoming increasingly relevant, so now more than ever it is crucial to understand how platforms like TikTok contribute to said conversations and why they hold so much significance in our digitally inclined era. In this article, we explore the #CoreCore phenomenon in depth, hoping to unpack its appeal to masses and shed light on TikTok's powerful spotlight on the intricacies of men’s mental health. At the heart of the #CoreCore trend lies a profound variation from conventional portrayals of masculinity. On a societal level, expectations and gendered stereotypes have led to the damaging perception that for men to discuss emotional issues is a sign of weakness. For me, this trend is trying to make the point to that traditional notion that men are to be seen as stoic, strong, and unyielding in the face of adversity is now a dated and problematic view. As users watch these CoreCore videos that show this cathartic masculine display, it pushes back against previous stereotypes, offering men a digital space in which vulnerability isn't just accepted, it's celebrated. This is clearly a popular viewpoint as the engagement that these videos are getting is extremely impressive with the currently most viewed video (showing mindless scrolling followed by videos of planets to demonstrate a sense of how small we are and how our lives are ultimately futile) reaching 4.2 million likes, and the trend as a whole (videos listed under the hashtag) reaching a whopping 6.5 billion views. Credit- infosp4ce just breathe #corecore #space #universe#astronomy rises the moon- liana flores Another element of CoreCore that intrigued me was that many of the videos follow themes of nature and taking a break from technology. For example, there are many videos of people enjoying natural landscapes—be it through hiking, interactions with animals, or playing sport. However, the irony of this paradoxical notion amused me as the videos themselves are of course a form of social media consumption, viewed on electronic devices. This irony poses an interesting contradiction about the human relationship with technology as we seek authentic, off-screen experiences but are so reliant on platforms such as TikTok to discover and share these authentic adventures. When looking at CoreCore, it is clear that there are intentions to open a dialogue around men’s mental health and what it is now like to live as a man. Despite having continued and promoted the discussion around men's mental health, it's essential to consider the two-fold impact of such narratives. The advantages posed by CoreCore are rife as the trend encourages open discussion about subjects often considered ‘taboo’ for men (e.g. loneliness, self-doubt, and emotional struggle). This creates a sense of solidarity, making male viewers, who may potentially be struggling mentally, feel less isolated in their personal hardships. The importance of this community of young men who are struggling being built is shown by the engagement numbers on the videos, signifying a community eager to engage with these serious topics. Although, like any trend discussing sensitive issues, the potential downsides to the trend are, too, rife. One aspect I was wary of was the seemingly melancholic romanticising of suffering, and the portrayal as a defining aspect and complete description of masculinity. Whilst the intention of the creators of these CoreCore videos is seemingly in the right place, it's crucial to be aware of these potential downsides, as they raise questions about the responsibilities social media platforms, and users, share in fostering healthy perspectives on topics as important as mental health. My final wonder is regarding the longevity of CoreCore, whether the trend will evolve to be a movement that fundamentally changes the dialogue around men’s mental health, or of it it is a style of video that will ultimately ‘die out’? The potential of CoreCore should not be underestimated though, as I believe if continued carefully (by managing to evade the romanticising of suffering or incubating toxicity), it could provide a revolutionary effect on the style of discussions on men’s mental health. The sheer volume of engagement numbers (6.5 billion views and counting) suggests that there is an audience for such change, and CoreCore may be at the forefront of it. The #CoreCore trend on TikTok has struck a chord with many, whilst also drawing attention to the complexities of men's mental health. Furthermore, it opposes traditional stereotypes of masculinity in showing famous role models in a vulnerable state and highlights the positives and negatives of the ongoing online dialogue around sensitive topics. As a result, I believe CoreCore to be more than a mere fad as it demonstrates the new consciousness around what it means to be a man in today's digital age.

Walking for me, is akin to therapy. You have recently read about the benefits of nature and of nature soundscape. As a counselling psychologist, I am also interested to see how walking in nature could potentially benefit my clients to enhance not only their physical but also mental well-being. Robert Frost’s iconic poem of two roads diverging in a yellow wood stirs up images of the romanticism associated with walking. But it also points out the benefits of contemplation that walking offers us. We live in a world where we have access to state-of-the-art facilities for exercising our bodies. We have gyms, pools, courts for playing a variety of sports, and a host of classes including yoga and dance. Undoubtedly, while these help our bodies as well as our minds, the impact of walking, especially amidst nature is probably more profound, offering something more. When we talk about walking in nature, we are talking of a creative synthesis. The benefits of walking and of being in nature collide and become more than the sum of the individual parts. So, what is this unique and specific benefit that we are exploring here? Walking in nature fosters mental vitality. Daily action and thinking wear us out mentally. It saps into our mental vitality, which is the essence of creativity, mental effectiveness, and sound action. Nuances of Attention In an article exploring the benefits of walking in nature, Raymond De Young addresses how mental vitality can be restored without much effort. This is important for us since, in the world we inhabit, we are frantically searching for more time as we rush about our schedules. The answer, he says, lies in the concept of attention. While we know about "directed attention" that requires mental effort on our part, there is another form of attention, that William James called "fascination", which is innate. Directed Attention Fatigue is what happens when we feel mentally tired. While the ability to direct ou attention is crucial to productivity and to our very existence as we go about our lives, it is fascination that comes to our rescue when we experience mental fatigue. Today, research is showing us what philosophers of the past knew. Cal Newport, the author of the book Deep Work elaborates on the concept of the outside office, which holds secrets of more deep and intense productivity. As he mentions in his book, one of the activities that often provides "solutions" or "breakthrough ideas" for certain problems is taking a long walk amidst nature on a well-known route. He uses the "attention-restoration" theory to explain this phenomenon in part. The Attention-Restoration Theory was proposed by Stephen and Rachel Kaplan in The experience of nature: A psychological perspective. They proposed that there were four stages of attention on the journey towards restoration. Firstly, there is a need to be away and clear existing thoughts. In the context of nature, it promotes a chance to be away and "clear the head" by letting thoughts flow. Next, there is space for recovery from the need to pay "directed attention". Third, the mind is open to soft fascination which is where being in nature comes in most strongly. Finally, there is the scope of reflection and complete restoration. One of the environments that provide us with this "soft fascination" much required for restoration is nature. The role of nature in restorative settings is historically established. Great thinkers like Thoreau, Albert Einstein, Charles Darwin, and more were known to be routine walkers. We need less directed attention to maintain our interactions within a natural setting. This is why walking in nature provides scope for restoration and, at the same time, the physical benefits of walking synthesise with the mental benefits of being in nature, to give us the combined benefits of green exercise. Green Exercise Green exercise, defined as physical activity in natural settings, may well be the path forward for holistic wellbeing. Jules Pretty and colleagues studied the mental and physical health outcomes of green exercise and found that it led to improved blood pressure as well as self-esteem and mood, leading the researchers to conclude that it was indeed a "tonic" for coping and resilience. Resilience, put very simply, is the ability to bounce back from any kind of setback or trauma. While it is an innate ability, often called "ordinary magic", it is also true that several environmental factors have a role to play in how resilient a person is. A study by Berman, Jonides, & Kaplan in 2008 measured the cognitive benefits of walking in nature, thus providing support for the attention restoration theory and validating a phenomenon that people have been experiencing since time immemorial. The researchers found that subjects taking a walking route through a tree-lined arboretum separated from traffic performed significantly better at mental tasks (such as an exercise in backward digit span and an attention network task) than another group of subjects who walked on a route of similar length in the same area but without the same greenery. In other words, an improvement in directed attention abilities was seen in the group walking along the natural route. Urban environments capture attention more dramatically and require more directed attention, contrasting the way the interesting stimuli in nature catches our attention. This allows for the restoration of the cognitive faculties. For instance, imagine that you are walking in a tree-lined park. You don’t walk with the aim of looking for something, and yet, there are stimuli that will gently seek your attention. Some examples include the colours of flowers, the movement of butterflies, the sound of birds, the feel of the grass, or the fresh fragrance of the pure air. This gives the mind a rest from directed attention and thereby reduces cognitive fatigue. But most importantly, the sheer diversity of the exposure leads the mind gently to stretch itself and break patterns, and engage in more fluid thought, breaking rigidity. A lot has been achieved on a long walk! A description of the history of Eye-Movement Desensitisation and Reprocessing (EMDR) traces the birth of this evidence-based intervention for trauma, to a long walk. Francine Shapiro (1987), the originator of the technique, was on a walk in a park when she noticed the therapeutic and desensitising impact of rapid eye movements. As the walk ended, she noticed a decrease in the negative emotion associated with the memory. Today, EMDR is used by trained practitioners as a reliable intervention to deal with traumatic memories. And to think, it was a simple walk amidst nature that started it all! A Practical Guide Having established the argument for walking in nature to foster better wellbeing, here are some tips that will help optimise the process: Choose a couple of routes or locations that will offer you the opportunity for soft fascination, and yet a familiar and safe environment. Walking on planned nature-filled routes reduces the attentional demands of navigating and yet provides the restorative benefits of nature. Both quiet fascination and deep reflection can be fostered in these walks. Start with solitary walking as it may be more restorative than walking with someone. However, if the walking companion is also engaged in nature and the conversation does not demand directed attention beyond a point, then it may work. Use all senses to engage in nature as you walk. Listen to the sound of the birds, feel the freshness of the breeze, smell the fragrance of the flowers. For restoration, the mind must interact with the physicality of the setting. Electronic gadgets must not disrupt the walk in nature. Multitasking is also not recommended. A daily walk in nature is helpful. Also, aim for long weekly walks and a yearly break to take in nature! Perhaps the overarching message of this essay is best described in the words of Professor De Young, "Thus, a prescription for enhancing mental vitality is simply to walk, to walk outside, to walk regularly, and to walk surrounded by and mindful of everyday nature".

Trigger Warning: The following article discusses themes surrounding sexual harassment and contains some explicit language. I had heard the name Russell Brand before. But recently I realised just how much of his content I have consumed in the past without necessarily realising. When I was younger, even from across the pond, his name was plastered across headlines. I knew him as the guy who divorced Katy Perry. The guy from those funny films who makes those funny jokes. That's it. However, as I began writing this article, delving deeper in order to understand who he really is, I started to question why I had never raised an eyebrow regarding his content in the first place. Right then I saw an opportunity to learn, not only about his ongoing controversy, but also about the complex nature of sexual harassment within, and beyond, comedy. Russell Brand is one of the comedy world's most prominent figures. The presenter, comedian and actor is best known for his time working for the BBC Radio 2 and Channel 4's "Big Brothers Big Mouth," as well as starring in Hollywood films such as “Forgetting Sarah Marshall,” and “St Trinian's.” However, recently, Brand has faced grave allegations that have cast a shadow over his career and reputation as an entertainer. Following a joint investigation by The Sunday Times, The Times and Channel 4 Dispatches, Brand has been accused of sexual harassment, rape, predatory behaviour, and emotional abuse by four women. The allegations pertain to a period in his career spanning from 2006-2013, which he labelled as a very promiscuous time in his life. When addressing the allegations, Brand emphasised that during this time of promiscuity, his relationships were “always” consensual, and continued to “absolutely refute” the allegations. Instead, he commented how he was the victim of a “co-coordinated attack” made by the media against him. Despite these shocking revelations, they appear too hardly come as a surprise to those in the comedy world. In an article by The Guardian, a female comedian stated that the allegations against Brand are "just the tip of the iceberg” for the comedy industry. This comment echoes the sentiments of other comedians such as Kate Smurthwaite, who commented how "we all knew" about Brand and that these allegations "barely scratch the surface" of the underlying issues plaguing the comedy world. Hiding in Plain Sight Along with the allegations, Channel 4 Dispatches aired a documentary titled “Russell Brand: Hiding in Plain Sight.” As I looked back at Brand’s career, it now became easy to identify several instances that might have served as warning, or so-called “red flags,” about his behaviour towards women. As mentioned, Brand’s promiscuous past is no secret. Awarded "Shagger of the Year," in 2006-2008 by The Sun, the entertainers’ public persona, movie roles and comedy bits all follow one theme: sex. I found multiple interviews where Brand makes comments such as: "Don't be afraid of your own sexuality, do be afraid of mine though" and "Look at the women in this room. Even a bold estimate would be that I’ve slept with half of them. Currently.” Perhaps most disturbing, is the leaked BBC Radio 2 interview with "guest star" Jimmy Saville, where Brand jokes about sending his female assistant to visit Saville, naked. Since the interview was leaked, parallels have been drawn between the rise of Brand to that of the notorious Saville. Andrew Neil, journalist and broadcaster, sparked this discussion by criticising the hypocrisy of individuals and prominent institutions as they urgently distance themselves from Brand following the allegations. Neil raises questions regarding their association with Brand in the first place, and draws a parallel to Saville, not in terms of their actions, but rather in terms of how the media and public elevated the two to be figures deemed worthy of interviews and shows for the BBC and Channel 4. Notably, both broadcasters have been linked to the allegations, following reports that Brand sent a BBC car to pick up a 16-year-old schoolgirl whom he was allegedly having an abusive relationship with, and allegedly pursued audience members for sexual encounters during the filming of Channel 4’s Big Brother Spin-off. Both of these claims currently being further investigated. Despite the fact that Brand’s film roles do not serve as evidence for his behaviour. Some have questioned whether the characters he portrayed in his films seem like a magnified version of his off-screen self. For instance, in the comedy “Forgetting Sarah Marshall,” Brand plays a former drug addict and lead singer, who spends most of his screen time discussing, engaging in, and making references to sexual activities. Shortly after the film was released, his co-star Kristen Bell revealed that she had to intimidate Brand to prevent any unwanted sexual advances, casting an uneasy link between his on-screen and off-screen behaviour. Similarly. in “St Trinian’s,” one of his Hollywood hits, Brand plays a corrupt businessman who has a crush on a school’s head girl. This might now be seen as a disconcerting foreshadowing of the allegation regarding his relationship with a 16-year-old schoolgirl. “Coming forward” Since documentary’s release, several women have come forward with further allegations about Brand’s behaviour. As more instances are revealed, I have heard people question: “Why did they not come forward earlier?” This question frequently emerges when high-profile cases of sexual misconduct, within and beyond the entertainment world, are reported. However, raising this question can be problematic. While some individuals might ask it out of genuine curiosity, perhaps without understanding the complexity behind it, others might use it as a tool to shift the blame and divert the attention away from the more critical issue at hand. Take, for example, Donald Trump. As E Carroll Jean defended her case against him in court, Trump’s lawyers attempted to cast doubt over her story by questioning: if what she is claiming is true, why did she not report it immediately? Research conducted by the University of Exeter sheds light on the persistent fixation surrounding this question. The researchers compared the needs and actions of individuals who have experienced sexual harassment (experiencers), with the expectations of those who have not (imaginers). The findings revealed a significant gap between the two. The experiencers seem to prioritise a wide variety of needs including safety and social support, over pursuing justice through formal actions such as filling a complaint or contacting the police. The experiencers noted that they were more likely to discuss the instance with friends and family or even keep it entirely to themselves. In contrast, the imaginers anticipated themselves as being more proactive and assertive if found in that situation, envisioning themselves as more likely to seek justice by taking more formal actions. While reporting the instance might seem like the number one priority, the reality is that victims often prioritise actions to meet a wide range of needs, not just the need to seek justice. Something which I recently came to learn as well. Beyond Brand Throughout my research I came to realise that the accusations against Brand are just a drop in a pool of allegations made against comedians. Another example dates back to 2017, when The New York Times released a report detailing several women’s accounts of instances where the renowned comedian Louis C.K. made inappropriate and unwanted sexual advances towards other female comedians, something which C.K. has confirmed. Similar to Brand, C.K.’s behaviour was an open secret. Photo by Bogomil Mihaylov on Unsplash If we know this is happening, why do we ignore the warnings? One reason might be that the comedy itself disguises the issue. In terms of Brand, he might have used his comedic style to inadvertently mitigate his inappropriate behaviour, perhaps fooling the public into thinking it was just a public persona. Much like me, his audience might have not given his content much thought. We might have been too distracted by the laughter and applause to question whether jokes with strong sexual innuendo, might have been a genuine cause for concern. We see comedians successfully using comedy to make light of their inappropriate behaviour. In C.K. return to comedy, for example, he unabashedly joked about his confirmed allegations, making comments such as “I like to jerk off, and I don’t like being alone.” Ellie Tomsett, a media lecturer at the University of Birmingham, investigated the barriers that hinder women’s participation in comedy. In an article, she commented on how there seems to be a pattern where woman who do complain are often met with comments such as “it is just a joke” or “it is just part of my character” as well as accused of lacking the sufficient sense of humour to appreciate it. A point which has been reiterated by several female comedians. This does not just happen within the comedy world. I often find myself saying “you cannot say that” as a response to a “joke” about a woman passing by. A statement which I usually accompany with laughter and a playful push, ultimately leaving me confused. As a young woman in my twenty’s, still figuring out who I am, I find addressing these comments to be a tricky thing. If I say something I feel like I am being “too intense,” If I do not, then I am not supporting women? If I do not laugh then I get told “relax it is just a joke” but If I do laugh I feel guilty? Writing this article has given me an opportunity to continue to understand the complex nature of sexual harassment, not just within, but also beyond comedy. Amidst the chaos surrounding the accusations against Brand, I hope society also sees this as an opportunity to keep learning. It might not always be easy to call someone out regarding their behaviour or comments, I know I do not always. However, I believe the focus should be on why these comments are made in the first place, whether in front of a large audience or just one person. If you wish to keep learning, have a look at Inspire the Mind's articles discussing similar themes, such as the burden of catcalling, personal experience and more on controversial public figures.

In Part 1 of this series we discussed what the RCRP is and why the Met police are implementing it in London. Today, in Part 2, we will look at the responses of different stakeholders to this decision. Despite the recent public cooperation between health partners and The Met, there are still great concerns that implementing RCRP by October 31st, 2023, will have negative consequences. ITM talked first to Dinesh Bhugra CBE, professor at KCL, honorary consultant psychiatrist at South London and Maudsley (SLaM) NHS Foundation Trust and former president of the Royal College of Psychiatrists. Professor Bhugra responded by saying: “It is really disappointing that the Police have come to this decision”. He emphasised that not all patients require police involvement but that a “blanket ban” could put both staff and patients’ safety at risk in the rare cases where police support is needed. Furthermore, he eluded to the potential wider implications, stating: “Such an exclusion is also likely to increase stigma against mental illnesses and patients and families who are suffering”. ITM also spoke with mental health and anti-racism campaigner and expert by lived experience, António Ferreira, who actively collaborates with The Government and Police forces to strengthen legislation, guidance, and training around policing within a mental health crisis. He is concerned that police call responders and officers require further training to be able to accurately “flag the matter as mental health related”, and that more “lived experience input remains the most critical change”. Lived experience input is particularly important to influence the police’s perception of people with mental health problems, which is coloured by the fact that they only meet them “when their symptoms are at their most severe”. Echoing Professor Bhugra’s concerns about increased stigma, Antonio highlighted research showing that the stigma levels of emergency services professionals are already significantly higher than that of the general public. Dr Lade Smith CBE, president of the Royal College of Psychiatrists, responded to ITM by pointing to a statement online saying that, “for this agreement to be a positive step for patients” there is a need for “police and mental health services” to “come together in the spirit of collaboration”. Dr Smith highlighted the need for a “realistic timescales and planning” as well as “additional Government funding” to safely implement RCRP in London, and that this decision “should not be taken as a green light for a unilateral discontinuation of police presence in mental health emergencies”. Finally, she also worried that the consequences of RCRP for patients is unknown, as it has only been trialled in one region (Humberside) with “no evaluation of clinical outcomes or benefits and harms to the local population”. This resonates with a comment from Kirsten Bingham, a mental health team leader at Humber Teaching NHS Foundation Trust. In a recent Channel 4 News segment, Kirsten said that it needs to be understood nationally that the implementation of RCRP in Humberside “isn’t something that has happened over night, it’s not been 3 months, 6 months, it’s been a journey of years and it’s been about phases.” Indeed, The BMJ (The British Medical Journal) reported last month that, while giving evidence to the House of Commons health select committee on Tuesday 19th September, Dr Sarah Hughes, Chief Executive of Mind, warned that in some areas funding had been withdrawn and referred to a “postcode lottery” developing in terms of crisis response, with not everyone having the same planning in place as in Humberside. Responding to the initial announcement, she had previously said that “The way this decision has been framed is deeply worrying and sends completely the wrong message to the public and to local police forces (...) at the heart of any decision like this should be the people that the police serve, not the potential hours of work saved.” Rachel Kelly, mental health speaker, author, and ambassador for SANE, also responded to ITM, saying that she recognises the “frustration of the police in substituting for mental health services”, while describing police as a “safety net” for people in crisis. “I fear for the many individuals and families for whom the police are the only people to respond when they feel they are reaching crisis point”, she added. Kelly also stated that many “distressed callers” contacting SANE struggle to get a response from NHS crisis lines and that without police these people “may have nowhere to turn for help”. On the other hand, many have argued that without a firm deadline such a change would have taken years to implement. One health source spoke to The Guardian saying: “it is not malice, but the NHS is notoriously slow. If he [Rowley] did not give a deadline, we would have been here for 10 years.” Dr A, a medic that ITM spoke with (but who wished to remain anonymous), voiced a similar opinion, saying that “the police are standing up for themselves”, and that, having worked in the NHS, only “a metaphorical knife hanging over its head” seems to get any real progress done. While Dr A is hopeful that this will lead to “better mental health care provision in the long term”, he said that “if their solution is to work, it will require an almost overhaul of the current system.” Disappointingly, other junior doctors we approached for this piece were either unaware of the changes or did not know how these changes would be affecting the medical field. David Bradley, Chief Executive of SLaM NHS Foundation Trust, in a recent NHS blog indicated that misinformation may be misleading people. “Some recent media coverage has suggested RCRP will mean the police will no longer attend any health incidents. This is not the case.” He reiterated the central role of the threshold for police involvement in the RCRP model saying that when the threshold for police involvement is met, police will attend. As discussed in Part 1 of this piece, this is: to investigate a crime that has occurred or is occurring, or when there is a real and immediate risk to life or of serious harm. However, Christina Cheney, a national lead in Adult Social Care Mental Health, expressed, in the aforementioned Channel 4 News segment, the concern that blanket refusals from the police to attend mental health callouts are happening: “We are hearing anecdotal reports from our members that there are already forces that either aren’t implementing or are part way through implementing, (and that) officers on the street and call handlers are saying the words “we don’t do mental health anymore“. The Bottom Line In response to the initial criticisms, Met Commissioner, Rowley, has maintained that allowing the “status quo to remain” ensures “we are collectively failing patients and are not setting officers up to succeed”. “My urgency”, he adds, “does not speak to a lack of compassion for those in mental health crisis, quite the opposite.” Undeniably, such system-wide change will require significant funding and resources. Reassuringly, the “London Mental Health Crisis Care Concordat” presents the framework of how such changes will occur, including the establishment of the NHS 111 number for mental health and an increase in mental health joint response cars. However, whether sufficient resources and staff are available to deliver these new services does not seem clear. As an academic-based magazine, ITM shares Dr Smith’s concerns that research on the clinical outcomes and on societal benefits and harms following such profound changes has not been conducted. Saving police hours or even A&E visits does not necessarily translate into better mental health in the community. Yet, if these changes do work, they could benefit not only the police but also the community of people with mental health problems. Early access to trained mental health staff at the initial engagement and assessment phases could prevent unnecessary use of the Mental Health Act or of places of safety, as we discussed in Part 1 of this blog. The devil will be, as usual, in the details: will the police be always able to assess if a mental health callout meets their threshold for attendance? And will this threshold, and the training required, be implemented consistently across all boroughs of London, or indeed nationally? A continuous monitoring of the situation on the ground, especially early on in the implementation next month, will be the only way to discern if the public should be alarmed or reassured.

In recent months, police and health services across London have been involved in what The Guardian described as a ‘behind-the-scenes row’, as Met Commissioner Mark Rowley has pushed for London police officers to stop attending mental health callouts, in an attempt to free-up police time and resources. The discourse was sparked on the 24th May 2023 when Rowley sent a letter to the Met’s health and social care partners, informing them that police would stop attending mental health callouts from 31st August 2023, as part of the implementation of the Right Care, Right Person model (RCRP) in London. This left health partners just 99 days to prepare for an overhaul of the current system in order to cover this workload. A month ago, The Guardian reported that, after tense talks between The Met and Health Partners, and with the Met taking legal advice, an agreement has been made that the deadline will be pushed back by 2 months to October 31st, and changes will be introduced in phases. In return, the Guardian reports, health partners will not publicly criticise the police’s decision and will rush to accommodate the change. Inspire The Mind wanted to understand the impact that this sudden decision could have on those suffering a mental health crisis, as well as the knock-on effect on NHS services. For this two-part feature, we investigated the reporting on this issue, and we talked (or tried to talk) to multiple stakeholders on both sides of the debate. Here is what we found. Why do the Police Want to Stop Attending Mental Health Callouts? Police forces feel that they have become the first port of call for mental health-related concerns, rather than a service of last resort. Police curren tly respond to mental health callouts when a person in crisis, concerned friend or family member, or member of the public, call for help. They also complete welfare checks and look for vulnerable/ missing persons. In 2018, the Metropolitan Police reported receiving a mental health call once every 4 minutes, and it is currently estimated that London Met officers spend >10,000 hrs each month responding to mental health concerns, which they consider to be health-related matters. A report in 2017 said that, in half of these cases, due to ambulance shortages, police end up transporting patients to a ‘place of safety’, usually A&E departments, for further assessment or care; however, mental health patients, and the police accompanying them, can experience extensive waiting time. Indeed, in London, police report that it takes on average 14.2 hours from police arriving with a patient to medical staff taking over their care. As a result of this, figures from the recent National Police Chiefs Council (NPCC) Productivity Review showed that police officers are spending ~1 million hours per year with mental health patients in hospitals whilst waiting for them to be assessed. One case, that occurred last year and was described by police as “unlawful”, demonstrates how police are having to deal with overflow from oversubscribed psychiatric services, as a child detained under the Mental Health Act stayed in a police station for 2 days due to a national lack of psychiatric beds. Police have been arguing for years that they are not best equipped to attend mental health callouts, given the need of people in crises for expert support. Indeed, an extensive 2018 report titled ‘Policing and Mental Health: Picking Up The Pieces’ expressed “grave concerns” over the level of police involvement for both staff and patient welfare, stating that “other services need to stop relying on the 24/7 availability of the police”. Police argue that, “health services must take primacy for caring for the mentally ill”. The Right Care, Right Person model (RCRP) Model: A New Approach to Mental Health Callouts The RCRP model was developed by Humberside Police, and it aims to ensure that the right agency deals with health-related calls instead of police being the default first responders. Following the Met’s initiative in London, on 26th July 2023 a National Partnership Agreement between police and health partners was reached, stating that the RCRP will be implemented across the UK, at the discretion of local forces. Based on the RCRP, in the case of 999 calls for a mental health crisis, police will no longer attend if the threshold for police involvement is not met. Police will conti nue to attend calls to investigate a crime that has occurred or is occurring, or when there is a real and immediate risk to life or of serious harm. In Humberside, in place of police, a new dedicated response vehicle with mental health staff on board has been attending calls and providing support, alongside other community-based mental health services. A similar Mental Health Joint Response vehicle service has been implemented in Manchester in 2022, and staff subsequently reported 1,260 A&E visit avoidances and 1,014 section 136 avoidances. This success has been attributed to the ability of the onboard mental health specialist to provide immediate support and referral to specialist services, thus minimising patient admittance to A&E departments. This immediate response is not something police are equipped to do. From a policing perspective, Humberside force found RCRP to be successful, with an internal evaluation showing that more than 46,000 officer hours were saved between May 2020 and December 2022 as a result of RCRP. How Will RCRP be Implemented in London? Many mental health organisations reacted with alarm to the May announcement, and there was uncertainty in the news about the timing and extent of police ‘banning’ any involvement with mental health calls. We at ITM shared these concerns and wanted to put together the facts, understanding the perspectives of key stakeholders in this decision. At the onset of our investigation, we wanted to speak directly with Met Police representatives to further understand the practicalities of how RCRP will be implemented. Following our request to speak with a representative, ITM received a press release, and further involvement was declined. Indeed, despite extensive efforts to reach out to police officers, superintendents, and the press office at the Met, we were unable to speak directly with anyone; police officers and 999 handlers we approached also declined to respond. Reflecting the decision between Police and London Health partners to cooperate, the press release came in the form of a joint statement. The statement referred to the 31st October as the “first key milestone” for RCRP in London, when 999 handlers answering calls will receive a new prompt to determine if police attendance is required. The plans to implement RCRP, from a police perspective, have been meticulously laid out in the RCRP toolkit. We found some description of how London Health Partners are preparing for this change, but it is unclear what were already existing plans to improve mental health services that have been fast-tracked, as opposed to new initiatives, and also how the workload will be taken over, by whom, and with what funding. What we do know, is that the plan includes the national launch of NHS 111 First for Mental Health. This scheme (which has been shown to reduce A&E visits and overdoses, and save millions of pounds in Peterborough and Cambridge) provides people phoning 111 with a specific ‘mental health help’ option to provide support and ensure that people have access to the best care for them. Secondly, there will be an increase in “joint response cars” (which have been operating across London since 2018 and combine mental health professionals’ skills with paramedics’) to redirect the workload. The government have also previously committed to investing at least £2.3 billion of additional funding a year, by March 2024, to expand and transform NHS mental health services and support an additional 2 million people per year. £7 million of this funding will go towards mental health ambulances and other schemes, such as improved crisis lines. Whether this will be sufficient to cover the changes required for the RCRP, is up for debate. So, is there cause for concern? In Part 2 of this piece, published tomorrow, we will discuss the responses of different stakeholders to present you with a balanced overview of this significant change. In the meantime, you can also: Read the recent BMJ News article: https://www.bmj.com/content/382/bmj.p2208.long Watch the recent Channel 4 News segment: https://www.channel4.com/news/inside-the-police-scheme-helping-people-get-mental-health-support

Are you someone who worries about things that haven’t happened yet? Things that might not happen? But, what if it does happen? And, if it does, what if it leads to something even worse? Not just something worse, but THE worst possible outcome. No, it’s not happened before. But, what if this time, it does? If so, you might be experiencing catastrophic thinking, or "catastrophising" as it is more commonly known. A thought process that feels like being trapped in a downward spiral of endless "what ifs". For some people the what ifs might not even be a question — it might feel more certain. If you are someone who can relate, you’re certainly not alone. The phrase “I’m spiralling” doesn’t come from nowhere. Many of us have and do from time-to-time experience this way of thinking. So today, we’re here to learn the basics of catastrophising. The what, why, and who of the ‘what if’ spiral. So, let’s start with what. What does it mean to catastrophise? In case you haven’t already guessed by the name, we are referring to a thought process whereby the mind jumps to the worst-case scenario. Making something of concern, yep, you guessed it — into a catastrophe. The actual probability of the catastrophe occurring? Well, that’s largely insignificant. If we take the analogy of the spiral, in mathematical terms, we might describe a spiral as a curve that gets further and further away from the point. And that’s really the best way to explain the catastrophising thought process. The concept was given its name back in 1957 by a Psychologist, Dr Albert Ellis, when he was working to develop a form of therapy. It was then when it was labelled as a type of cognitive distortion, and it is reported that Dr Ellis described catastrophising as an "irrationally negative forecast of future events". Catastrophising can be about current concerns, which we may then refer to it as "magnifying", or future events. What is clear is that being stuck in the "what if"-catastrophising-headspace can be extremely frustrating. When not in that place, we can often rationally see that these worries are just that: worries. The "what ifs" are just "what ifs". Questions that might not even come to fruition. Why then, if we can have this hindsight, is the spiral so all-consuming. Why do we catastrophise in the first place? From my research so far, it appears that there is no single answer to this question. It is not clear what causes catastrophic thinking. It could be many different reasons and for different people. What strikes me as interesting though, is that it may be rooted in our evolution. Catastrophic thinking may be linked with survival mechanisms that have ingrained a "negativity bias", in us. As human beings, we are naturally more inclined to acknowledge the negative. While previously adapted to give us more awareness of threats and predators, our brains are essentially hardwired to be on high alert for such dangers. One area of the brain in particular, the amygdala, has a key role in detecting threats and quickly priming us to elicit stress responses by informing other important areas of the brain (the hypothalamus) which subsequently informs our nervous systems, preparing us to deal with the danger. You might know of this as the "fight or flight" response. For the most part, in 21st Century life, the amygdala needs to worry less about the imminent attack of a wild animal, for example, but that doesn’t mean that this value of learning from negative information or situations is no longer needed. It can be helpful when we haven’t got learned information about potentially stressful stimuli (we haven’t faced a particular situation so don’t know how to respond), but this hardwiring of our brains is certainly not as useful as it used to be. So, perhaps this is why we jump to the negative? In a similar spirit, it has been suggested that catastrophic thinking might be a type of coping mechanism. By picturing the worst-case scenario, we feel more prepared to deal with it. And most of the time, the worst-case scenario doesn’t become the reality, and thus, anything less than that is easier to deal with, ultimately avoiding disappointment. Who experiences catastrophic thinking? What I really want to highlight is that catastrophising is not a mental health illness itself. However, your mental health might increase the likelihood of it happening. Years of research have shown that catastrophic beliefs are associated with a number of psychological disorders such as health anxiety, obsessive compulsive disorder (OCD), and posttraumatic stress disorder (PTSD) to name a few. Some of the strongest evidence has demonstrated that there are also associations between the thought process and anxiety disorders and depression. In a piece of work bringing together the results of lots of different research studies (something we call a meta-analysis), researchers demonstrated links between anxiety, depression, and catastrophising (specifically catastrophising relating to pain) even as early as in childhood. Interestingly, there are also some personality traits which might make us more inclined to lead toward the "what ifs". If you’ve read some of my other Inspire the Mind articles, you might recall I have explored the ins and outs of perfectionism — so guess whose ears pricked up when they read that perfectionism can make us more likely to catastrophise. A big part of perfectionism comes down to worrying about making mistakes, which as you can imagine provides the ideal environment for catastrophic thoughts to explore all the possible consequences of a mistake. There are also some similar research findings that suggest that we might also be more likely to catastrophise if we have low self-esteem. There are also times or situations which might make it more likely for our thinking to head toward the spiral, such as negative mood states or periods of increased stress in particular. Despite these various associations and speculations, it is important to note that most of us experience catastrophic thinking in one way or another, it may just be to varied extents. There is something comforting in knowing that what can feel like an isolated experience is something that is relatively normal and, for many of us, extremely relatable. Catastrophising might ultimately stem from somewhere beneficial, but that doesn’t mean it cannot lead to a lot of stress and discomfort and so it is important to look after yourself and understand why your thoughts are heading in this direction. Perhaps it wouldn’t hurt to occasionally question, what if it all works out ok?

This is the second blog about the 114 days I spent at the National Institute of Mental Health and Neuro Sciences (NIMHANS) in Bangalore, India. My previous blog focused on the Perinatal Psychiatry work in outpatient clinics, the mother and baby unit and several inpatient wards. In this blog, I want to tell you about another Department where I spent a lot of my time: the Integrative Medicine Department (I’ll call it IMD from now on), which focuses on the use of traditional Indian practices such as Yoga therapy (the clinical application of Yoga for treatments) and Ayurveda (a traditional Indian medicine system) with inpatient and outpatient services to treat mental health and neurological issues. In fact, this was my primary purpose in coming to NIMHANS; I want to develop a prenatal Yoga module for women at risk of postnatal depression with the expertise of Yoga academics, clinical Yoga therapists, and psychiatrists. The Yoga and Ayurveda buildings are tucked away from the street noise at the back of the campus, and one of the first things that I noticed is that you leave your shoes at the door; everyone is barefoot, which helps to be more grounded to the earth — this I found particularly beautiful! One of the most impressive things about IMD is the emphasis on patient empowerment, where the patient is consulted and given a very active voice in the treatment process. Patients were encouraged to take an active role in the decisions relating to their treatment plan, with staff members providing education and resources to help them make informed decisions about their health. This focus on patient-centred personalised care was refreshing, a departure from short consultations focused simply on medication prescriptions or medication reviews. In the IMD, patients undergo treatments incorporating Yoga, Ayurveda, and Western Medicine in perfect harmony, made possible by the treatment teams, including psychiatrists, psychologists, Yoga therapists, and Ayurvedic doctors. Every day, Monday to Saturday, in the Hatha Yoga Hall or the Patanjali Hall, groups of patients came in for Yoga modules, validated and published in peer-reviewed journals, that had proven benefits for psychiatric and neurological conditions. These applications ranged from clinical depression, Attention deficit hyperactivity disorder (ADHD), migraines, schizophrenia, substance abuse, and general wellbeing, to name a few. In addition to in-person "batch" (group) classes, classes were also delivered online (one of the batches has been going on for over three years!) and on a one-to-one basis. How are these modules developed, you ask? The IMD prides itself on being very stringent in its scientific research methods. The Yoga modules are designed based on traditional and contemporary Yoga literature and qualitative inputs from experienced Yoga therapists, and then undergo expert validation. The finalised Yoga modules comprise elements from Hatha Yoga (the modern yoga that is practised through physical postures and other physical practices), usually including slow movements with breathing awareness, loosening exercises, asana (poses), pranayama (breathwork or breathing exercises), and relaxation. Finally, an open-label clinical trial evaluates this Yoga module’s effectiveness. Once peer-reviewed and published, the module is incorporated into clinical practice at NIMHANS. I mostly attended the depression and anxiety classes, accessible from a physical exercise point of view, and where my presence was less disruptive — in other classes with patients with more severe symptoms, my presence was more destabilising, which I recognised pretty early on. In the modules I attended, I particularly enjoyed the emphasis on chanting and pranayama, which I don’t get to practice much in Yoga classes in studios in the UK. I was also a part of clinical case discussions and the academic program of the IMD. Every patient on the ward was introduced, discussed, and reviewed in a boardroom with Ayurvedic doctors, psychiatrists, a Yoga professor, and several Yoga therapists. Patients were viewed as physical, mental, emotional, spiritual, and social beings, with each facet considered in the management plan — which incorporated pharmacology, psychology (as in therapy but sometimes also psychoeducation of family members), Yoga therapy, and Ayurveda. I was particularly in awe of how the Ayurvedic medical system explains mental illness, its manifestations in the body, and how yogic anatomy (the panchakosha model — the different layers of existence) can be addressed for a holistic recovery. For example, according to Ayurveda, many mental health issues fall within the vata dosha imbalance, vata being related to the air element. Imbalances in the vata element manifest in insomnia, fear, excess fear or worries, sadness, digestion, and appetite issues — common symptoms of depression and anxiety. Moreover, in a very crude way (and apologies for my limited knowledge of Ayurveda), the main site of accumulation of the vata dosha is the intestine, making it a primary treatment site. When I first heard this, I immediately thought, "The gut-brain axis!" There were specific lifestyle measures (sleep, diet, routine, even relationship advice!), along with Ayurvedic treatments (that may include therapies and medication), that were advised to patients, alongside conventional (Western medicine) treatments such as psychotherapy and psychotropic medication. This harmonious dance between the two medical systems aligns with my view of holistic care. Before I go, I wanted to share a beautiful moment I witnessed at NIMHANS. On the 26th of January, Republic Day (that celebrates the date on which the Constitution of India came into effect), early in the morning, under the canopy of tall trees, the Integrative Medicine Department performed a Yoga dance, a mix of Yoga poses and dancing to traditional Indian music. This was prepared in secret, and I was so surprised and proud to see the academics and students that carved time from their busy schedule (have I mentioned they work six days a week, 12 hours per day?) to perform for NIMHANS staff and patients. That same morning, for the best part of two hours, groups of patients, staff, and sometimes mixed groups performed songs, played instruments and danced. The performances were truly spectacular, from a patient playing original ragas (melodic framework for improvisation) in a veena (a traditional Indian musical instrument) to staff re-enacting the challenges of being a working mother using contemporary dance, patients singing solos, all in beautiful traditional clothing, and using thousands of flower petals and confetti for added dramatic effect. I felt very emotional during the performances; seeing Arts in Health in action (do you remember my work on the community arts for mental health projects, SHAPER program, and Brain Waves study over the last 3.5 years?) made me long for Western societies where singing, dancing, and performing are part of everyday life (at work, too!) and not just an artistic pursuit for those considered exceptionally gifted. This amazing opportunity to live and work in India for just over three months was supported by the Hannah Steinberg Award, by the British Association for Psychopharmacology, and was only possible with the mentorship and guidance of Professor Carmine Pariante (your ITM Editor-in-Chief) and the incredible professionals at NIMHANS.

Content warning: This article includes brief mentions of suicide. I mentioned back when I did my article on Shirley Jackson that before I teach about a particular author, I like to study their background with my students so that they can gain a better understanding of the thought processes behind the author’s works. Sylvia Plath is no exception, and like Jackson, there is a long discussion to be had on their life before anything can be said about their writing. Whenever I teach Sylvia Plath to my students, I ask them to look for markers of resilience in her poems. I ask them to really look, because it's there. The strength of mages in "Lady Lazarus." The resolve of the abandoned but still living daughter in "Daddy." The passionate, hopeful lover of "A Mad Girl’s Love Song." I don’t want to be one of those English teachers responsible for Plath’s unfortunate reputation as "the depressed poet." History tends to forget the full richness of her sensitive, adventurous spirit that kept bees, rode horses, travelled abroad, and swam like a siren in freezing waters just to feel alive. I cannot, with an unburdened conscience, allow my students to exit class with the idea that the same person who wrote "I rise with my red hair, and I eat men like air" was just "the depressed poet." Nevertheless, the inevitable conversation cannot be avoided or even delayed, which is that Sylvia Plath not only suffered from severe clinical depression but also died of suicide in 1963 at the age of thirty. And when students ask me why she did it, I have to tell them the truth. "Things were different back then than they are now. She didn’t get the help she needed." What she got instead, if she was telling the complete truth in her autobiographical novel The Bell Jar, was ignored, electrocuted, and given ineffective medications. By men she really should have eaten. Now consider my reaction, while preparing my lesson plans beforehand, when I discovered that there is a whole psychological condition named after her: the "Sylvia Plath Effect". I can’t say that I was particularly surprised by this new knowledge. Congratulations to the psychologist who would not have to awkwardly name his findings after himself, thanks to the convenient death of a famous mentally ill poet. The opportunity was there, and he took it. This invention was the work of James C. Kaufman, Professor of Educational Psychology at the University of Connecticut, back in 2001; around forty years past Plath’s death, and three years too late for Plath’s famously prickly husband Ted Hughes to potentially sue (Hughes died in 1998). The thesis of Kaufman’s “Sylvia Plath Effect” is that people with artistic ambitions, especially poets, are more vulnerable to mental illness than others who do not share the same drive to write and to channel their emotions through writing. In 2011, Kaufman conducted a study where 1,629 writers were psychoanalysed for signs of distress or derangement related to their profession and concluded that female poets were especially the most susceptible. A second study brought in a further 520 women of different but still intellectually demanding professions so that their states of mind could be compared to lady poets. Again, the same conclusion. The Wikipedia page for the Sylvia Plath Effect features lists of writers, both female and male, who might have had this ambigious disorder, on the basis that they were writers and were mentally unwell in their lifetimes (Anne Sexton is there, along with Virginia Woolf, Ernest Hemingway, and Dylan Thomas, who was Sylvia Plath’s literary hero). But there are too many factors with each individual case for an official stamp. It’s mostly speculation. Now, there is something of common sense at work here. Yes, it does piece together that writers, more in tune with their conscience and more sensitive to the world’s many injustices, would be more likely prone to depressive periods. And for women the lack of respect and recognition they often receive for their efforts can be a staggering blow (as a female writer myself, this is something I'm familiar with). But, and I really have to ask this, did this phenomenon have to be named after Sylvia Plath? Don't get me wrong, I have nothing against advancements in psychological research. But I just can’t shake off the feeling that naming this mysterious disorder after Sylvia Plath is something of an insult to her memory. It commodifies her, overrides her individuality, and her right to be remembered as a full human being rather than as a condition. I think Plath’s still-living daughter Frieda Hughes probably shares my sentiments. Hughes was not particularly impressed with how her mother was portrayed in the 2003 biographical film Sylvia and would later describe the film’s appropriation or romanticisation of Plath’s predicament in her own poem as “their Sylvia Suicide Doll.” Like Barbie, it seems like Plath’s name has become synonymous with ideas and stances rather than personhood. And then there’s the secondary factor that makes my relationship with the Sylvia Plath Effect unpalatable. I know that by doing my own extensive research on this I put myself at risk for going down the very same rabbit hole I went down when I thought I had (and was proven wrong in having) pink eye, heart disease, oral thrush, eczema, and at one point a tumour in my bladder. I am a chronic offender of the dangerous, jeopardising self-diagnosis. There have been too many times where a doctor’s take on things is one opinion, and Google’s is another. I know it’s wrong, but I keep on doing it. Traversing the Sylvia Plath Effect is far beyond just scholarly curiosity; it’s an off-the-beaten-track pathway in my ongoing adventure in determining "what on God’s burning Earth is wrong with me." Like Sylvia Plath was in her lifetime, I am infected with a constant, overbearing urge to write that itches so fiercely that it might as well be eczema. It’s my curse, my poltergeist. It gives me no peace. At night I lie in bed, trying to sleep, and my brain clears its throat, "Ahem. Now that you are unoccupied and I have your full attention, I have fourteen new ideas that I am going to run by you. Firstly, a complete rewrite of that sloppy paragraph you just slap-dashed together in your book review for The Monitor. Secondly, a letter of complaint to The Globe and Mail about the faulty lights at that one intersection you strategically avoid while you’re driving. Thirdly, a complete first draft of that fantasy short story you’re thinking of writing about that myth with Loki and the horse…" Periods of not writing, not producing, not making good on my promises to the literary world sometimes send me spiralling into these black voids of depression that can only be alleviated by, what else, writing. Could this be the Sylvia Plath Effect in effect? As a creative, am I doomed to be always anxious, stressed, sleep-deprived and depressed because of my calling’s disproportionate power over me? And by telling my students, many of whom are aspiring writers, about this, am I putting them at risk for fretting over the exact same thing? What I'm saying is, contrary to my disapproval over the name of the Sylvia Plath Effect, I may need more developments to be made on this. For both professional and personal purposes.

Interview with Dr Graziana D’Addabbo by Yuri Milaneschi You’re a couple, ‘specially when your body’s doubled. Massive Attack, Karmacoma These cryptic lyrics from one of the most iconic Massive Attack’s tracks (I came of musical age in the ‘90s) often made me think about a specific aspect of my experience as a psychotherapist. In the (short) stretch of my career spent in clinic, before dedicating myself completely to research, I provided individual psychotherapy for anxiety and depression. In this context, you sit together with a single client, but the clinical setting is inevitably inhabited by a multitude of others. The relational life of the subjects, especially with the closest partners, emerges in any part of the therapeutic work. Often, in exploring hidden thoughts fuelling discomforting emotions, the client sees images of the (allegedly accusatory, resentful, detached) gaze of the partner, producing painful feelings of shame, worthlessness, abandonment, anger or rage. Relations disruptions may be signs of personality difficulties and almost invariably a detrimental consequence of unaddressed psychological distress. Here is the question triggered by the Massive Attack’s lyrics: what if the client in front of me doubles? What if I face the actual relationship rather than its internal representation in a single person? What would this change in the therapeutic work? I never had the occasion to experience this directly. Thus, I decided to ask Dr. Graziana D’Addabbo, an experienced clinical psychologist, who made the transition from individual to couple’s psychotherapist. Could you describe your professional background and history? I am a clinical psychologist and board-certified psychotherapist coming from Italy, where I worked for 10 years in different settings: hospital, schools and private practice. After moving to Amsterdam, I earned a research master’s in Clinical and Developmental Psychopathology and I had specific training in Emotionally Focused Couples Therapy (EFT), an evidence-based approach developed by Sue Johnson that was revealing for me. Why did you decide to delve into couple’s therapy? After years of delivering only individual psychotherapy, I felt the need to expand my area of expertise with specific training in couple’s therapy. Two reasons drove my motivation at that time. The first one was clinical: more and more often I was facing some kind of limitations. Clients were hardly trying to solve their relational difficulties, talking with me over and over about a third person who was absent but at the same time so present in our room. Since most of the time the problems in a couple are negative patterns in which both partners play a role, the impact of individual therapy was limited. The second reason was more personal. After struggling in my most important relationship and undergoing a couple’s therapy, I have realised how important it is to repair the bond. How important is to deeply understand our interactions and to change them. What are the main differences you found moving from individual to couple’s psychotherapy? Of course, the change in the setting is significant. You deal at the same time and in the same space with two persons, two internal worlds. This can sometimes be intense, almost overwhelming. In particular, when partners fight, you may find yourself in a really dangerous territory where it is extremely important to validate what happens to both of them, without taking sides with one of the two and leaving the other one desperate and alone. It is extremely important to remember that your client is their relationship and that everything that happens has to be read as a relational problem or resource. This has some practical implications. First of all, it changes how you evaluate and assess problems. Although as a clinician I recognise individual limitations or even potential psychological disorders (referring clients to individual therapies and psychiatric evaluation), the main focus is how those persons are connected or disconnected, what they do when they are triggered, how they feel and “how they dance” (S. Johnson) in their attachment bond. The real “enemy” is the dysfunctional relational pattern and the different roles of the partners in their disharmonic dance. For example, one can play the role of a pursuer protesting and asking for connection, while the other one may withdraw. Remaining focused on this aspect helps to avoid the risk of being absorbed by the specific content of a fight. Instead, the core issue is the way the partners found to ask each other important questions (“Are you there for me if I need you?” “Can I trust you?”), beyond the obvious topics of conflict that are triggering distress. What would you consider the core of couple’s psychotherapy? The core is attachment, an innate survival instinct present from the beginning of our lives that shapes the way in which we structure relational bonds. Adult love is an attachment process and couple distress may be read as an insecure attachment, which can be described as the lack of availability, responsiveness and emotional engagement of the partner in moments in which the other one needs comfort and support. EFT is based on the evidence that adult lovers need a secure base and move in the same way as parents and children do in situations of distress. When a partner tries to connect and the other doesn’t respond, we can observe the same behavioural strategies we see in children: protest and desperation (anxious strategy), distancing and shutting down (avoidant strategy) or both (fearful avoidant strategy). What's interesting to underline is the universality of these behaviours, which allows me to work with couples from all over the world with extremely different cultural backgrounds but showing the same problematic patterns. The contents of the fights may be very different, but the emotions are the same. How can the understanding of the attachment theory guide you in better helping your couples? Using the lens of attachment allows me to understand and explore experiences, reactions, behaviours of the partners, without ever losing focus on why they need to move in certain ways that are causing them a lot of pain. Most of the time, a partner has their own way of interpreting what the other does or says, confirming preconceptions about the other (“He does that because he doesn’t care, he doesn't love me”). It can be extremely revealing to discover that there may be other reasons behind certain behaviours, even positive and unexpected (“He is angry with me not because he hates me but because he feels guilty” or “She is withdrawing not because she doesn’t care but because she is scared of ruining the relationship”). Knowing what is happening when triggered, what the other one is saying to himself, and why one may feel threatened and become defensive or aggressive, combined with the awareness of our own reactions and emotions, is the first step for the de-escalation of the negative pattern and for creating safety. A final suggestion for all the couples out there. When should they search for the kind of professional support you provide? What should they expect? Our physical and mental health depends on how secure or insecure our intimate relationships are. That’s why it is so important to help couples to repair and to create secure interactions. A professional support may be helpful when partners struggle to connect when the volume of their fights is higher and higher and the possibility of repairing is more and more difficult, when anger or silence are the only way to communicate, and when the partners are feeling lonely, even if they are together (that is worse than being alone). When it’s not too late and the possibility to repair - although small - is still there after all the pain and the partners are willing to work together, the couple’s psychotherapy can help them reach a common goal: to learn how to dance together in synchrony, trusting and following the partner, knowing that if one stumbles, he will not fall but will be supported by the arms of his beloved.

Think of the last time you had a cold sore, or the flu, or a bowel infection…I am sure you don’t have the fondest memories of that experience, as your mood must have been quite bad. We are inclined to think that having a low or irritable mood during sickness, as well as experiencing fatigue, disrupted sleep or decreased appetite, is a natural reaction to physical distress. In other words, it is obvious to feel low when your body is in pain. However, science has started to show that there is a precise biological mechanism explaining the connection between body and mind, physical illness and depressed-like behaviour. I am psychiatrist and a PhD student, and my research aims to study this connection. Indeed, sickness behaviour, which is the behavioural response to physical illness, is a complex reaction involving the immune system and its effects on the brain. The role of the immune system in mood regulation has been the focus of several blogs here on InSPIre the mind, but it can be studied in so many different ways, and some of you might not be our regular readers. So, I will summarise below what the immune system does, how it can affect the brain and why this is important for research in psychiatry. What is the role of the immune system? The immune system is a complex network of organs, tissues, cells (mainly the immune cells) and the substances that they produce. Its main role is to defend our body from infections, like an army of soldiers, with an overall defensive strategy called inflammation. How does the immune system affect the brain? When inflammation is triggered, a series of proteins — the inflammatory cytokines — are released in the blood stream and in the tissues, acting like messengers between different organs, with the aim of alerting the body to fight the infection. What has become clear in recent years, is that inflammatory cytokines can also reach the brain and affect some crucial cellular processes involved in mood and behaviour regulation. This has been suggested by animal studies, showing that cytokines can reach the brain via the blood-brain barrier (BBB), a border of cells protecting the brain against circulating toxins (like those in the picture below) and, at the same time, allowing vital nutrients and other substances to pass. These animal studies indicated that cytokines are among those substances that can go through! Once in the brain, inflammatory cytokines can alert the brain cells belonging to the immune system, like microglia and astrocytes. Once alerted, these cells go through changes in shape and dimension, in order to reach their activated state and produce more inflammatory mediators, leading to a general condition of brain inflammation. This, in turn, can have disruptive consequences on neuron generation and functioning in different brain areas, such as the hippocampus, involved in the modulation of emotions, motivation, learning and memory. Finally, this is followed by the development of depressive-like behaviour. The whole journey of inflammatory cytokines (like Interleukin-6 –[IL-6] and Tumor Necrosis Factor-alpha [TNF-a]) is illustrated in the picture below and is described more in detail in a recent scientific chapter that I have written. The good news is that today it is possible to study changes in the structure and functioning of brain cells of living humans (something we call ‘in vivo’), thanks to a technique called Positron Emission Tomography (PET). This is an imaging technique, involving a small dose of radiation, that can provide us with pictures of the human brain and information about changes in cells activity, including cells like microglia that are involved in brain inflammation. So, we can now explore whether humans have inflammation in their brain by using PET. Why is this important? If inflammation can go from the body to the brain and lead to the development of depressive symptoms, this could explain why, when we have an infection, we also feel so low! This would also explain why a high proportion of people with chronic inflammatory conditions (for example, Rheumatoid Arthritis) tend to suffer from comorbid depression. Therefore, in those circumstances, we could treat depressive symptoms with alternative strategies, like anti-inflammatories. Now, in order to support this hypothesis, imagine if it was possible to track the theory of sickness behaviour step by step, following inflammation in its journey from beginning to end, from the body to the brain, by recreating conditions “artificially”? Well, that’s were my research and my PhD come in. With the help of some healthy volunteers and of PET imaging, I had the opportunity to follow the journey of inflammation and discover what it really does to the brain. The FLAME project and the journey from the body to the brain In my study, called FLAME (because it involves inflammation), I recreated the conditions of inflammation in the bodies of 7 healthy male volunteers, by administering a drug called Interferon-alpha. This drug can challenge the immune system to produce a temporary state of inflammation, which lasts up to 72 hours. Don’t worry, Interferon-alpha is quite safe, and one injection can only cause some flu-like symptoms which can be easily treated with paracetamol (the study was approved by an ethical committee and all participants gave their consent to take part before starting. The study did not compromise their health in any possible way). After the injection of interferon-alpha, I measured the presence of body inflammation with blood tests. I also measured the development of brain inflammation with PET imaging and with an alternative technique called Magnetic Resonance Imaging (MRI). This is considered to be less specific than PET in detecting brain inflammation, but it is much cheaper and less invasive for participants (since there is no radiation involved), so I wanted to explore its potential too. Finally, I measured temporary mood changes with some clinical questionnaires. Overall, I wanted to test whether the temporary inflammation caused in the body by Interferon-alpha was associated with inflammation in the brain and with some temporary mood changes. A more detailed illustration of the different measurements is shown below. Just as in my favourite movies, research can have twists in the plot, like events or conclusions that I did not expect at the start. This was the case also for the FLAME study. I found that interferon-alpha was causing increased inflammation in the body of participants, as well as creating some temporary mood changes, like increased fatigue and low mood, from 4 to 24 hours after the injection. Overall, this reflected my initial expectations. However, PET imaging gave different results from what I anticipated. It looked like there was no inflammation in the brain as brain cells involved in inflammation did not show particular activity. I later realized, that there was a methodological limitation in the PET technique that was used. Indeed, PET was not sensitive enough to measure changes in the structure and functions of microglia, the most important brain immune cells, under these specific experimental conditions. So, I could not really tell whether the inflammation caused by Interferon-alpha was able to go from the body to the brain. This indicated that future studies using PET imaging should be using some precautions when interpreting their results. My data was published in a scientific journal that considered them useful for future research and you can read the full article here. Just as I was ready to think that perhaps inflammation did not reach the brain, I thought that perhaps the problem was the imaging approach. You know when you go to the theatre and, for some reason, the leading actor cannot perform that day? They send the understudy on stage. Well, sometimes the understudy performs even better than the leading actor, and you leave the theatre surprised and happy to have discovered a new talent. A similar thing might have happened to me in this experiment. The MRI technique, which I employed as the neuroimaging understudy to PET, might be able to show brain structure after Interferon-alpha, which could indicate the presence of brain inflammation. As soon as I have more data on this, I will write another blog! My PhD research showed that even if results are not exactly as expected, they can still provide new perspectives of study and make way for future work on the same topic, in this case involving either more precise PET techniques or also MRI, which is cheaper and safer, to study inflammation in the brain. You may wonder: how is this research useful for people? Well, this is the focus of another project that I conducted, regarding the possibility to treat depressive symptoms with anti-inflammatory drugs, which can have an effect on brain inflammation. But this is a story that I will tell you next time, and of course, there will be a twist!

Neuralink is one of several neurotechnological companies currently developing implantable brain-computer interfaces. The company was founded by Elon Musk and a team of seven scientists and engineers in 2016, with current CEO Jaren Birchall. This year, after having been given official FDA approval, the company hired a clinical trial director, as it moves towards testing chip implants in humans. But when, and if human testing starts, what would this major step mean for brain implant science, and what ethical questions still need answers? After a culmination of breakthroughs by brain-machine interface (BMI) researchers, this landmark moment for the field of neurotechnology has generated widespread curiosity about the potential implications for future human-machine boundaries, medical treatments, and general understanding of the human brain. Approval by the U.S. Food and Drug Administration is no mean feat. The FDA doesn’t typically confirm approvals for human clinical trials but offered a statement: “The FDA acknowledges and understands that Neuralink has announced that its investigational device exemption … for its implant/R1 robot was approved by the FDA and that it may now begin conducting human clinical trials for its device,” an agency spokesperson said in a statement Friday. The chip itself is groundbreaking. Dr. Paul Nuyujukian, director of the Brain Interfacing Laboratory at Stanford's Wu Tsai Neurosciences Institute, states, in a 2022 interview with WIRED, that “for about 20 years now, academic research brain implants, up until this point, have been almost exclusively with wires. The difference that the N1 has with Neuralink, is that it is fully implantable, it's battery powered and wireless. All of this is being done over Bluetooth protocol”. This human-brain implant trial aims to address conditions such as paralysis, brain injuries and other neurological disorders (where the neural pathway from the brain to the target muscle is damaged) by developing a direct connection between the brain and external devices, using neuro-electrophysiological recordings. In paralysis, damage in the pathway from the brain to the muscle prevents signals from the brain from reaching the muscles, preventing voluntary movements. Dr. Paul Nuyujukian explains that, in many cases, the signals are still present in the brain, but it is simply the connection to the muscle that is lost. Therefore, if one was to reach in and listen to those neurons, researchers would know how the muscle reacts in real time and gain a better understanding of how these neurons affect body movement, which is ultimately the goal of a brain implant. The current aim of this is to allow quadriplegic individuals to control computers and mobile devices with their thoughts. Future goals include restoring speech, vision, and motor function, and eventually “expand how we see the world". Participants in the trial will undergo a careful screening process to ensure their eligibility. Once selected, they will have Neuralink’s brain implant surgically placed in their brain. The implant will consist of tiny, flexible threads known as the BMI devices. According to the company, these threads are thinner than human hair and can be inserted into the brain with minimal disruption. This chip, will allow direct communication between the human brain and external devices. These BCIs typically involve the implantation of electrodes or other sensors into the brain to record neural activity. The implanted electrodes are used to record electrical signals generated by neurons in the brain and carry information about a person's intentions, thoughts, and movements. Neuralink's technology involves sophisticated algorithms and machine learning techniques to decode and interpret neural signals. This allows the system to understand the user's intentions and translate them into specific actions or commands. According to the company, once the neural signals are decoded, they can be used to control external devices, such as computers, prosthetic limbs, or even robotic exoskeletons. For individuals with paralysis, this means they could potentially regain control over their limbs or interact with their environment using their thoughts. There are potential benefits to this new technology, such as the restoration of lost functions, which would help patients regain mobility and independence, and lead to an improved understanding of the brain, providing valuable data and insights into how the human brain functions, potentially advancing our understanding of neurological disorders. However, similar to any clinical trial, the development and use of brain implant technology also raises some important ethical considerations. As Courtney Worrell shares in her 'Transforming the future of Clinical Trials' article, clinical trials are research studies that test a medical, surgical, or behavioural intervention in people. So, whilst many clinical trials raise similar questions and concerns, this very new technology requires extra consideration in particular. Many of these include public concerns over data privacy, consent, and potential misuse. Even though Neuralink have expressed their commitment to address these issues and ensure the public on the responsible and ethical development of their technology, these issues remain complex and demand careful examination. One of the foremost concerns revolves around informed consent. Participants must fully understand the risks, benefits, and potential consequences of the procedure. Given the irreversible nature of the brain implant, ensuring informed consent is critical and it is therefore essential for the participants to enter this procedure willingly and with full comprehensive understanding of the technology, forcing the company to fully disseminate its methods and techniques. However, Neuralink are yet to comment on this concern and showcase its road forward. Another dominant concern relates to privacy and data security. Brain implants have the capability to record, transmit and store vast amounts of personal data. Therefore, ensuring the safekeeping of this sensitive information is paramount. Both researchers and companies conducting these trials will need to implement robust data protection measures and adhere to strict ethical standards regarding data access, sharing and storage, as mishandling of this data could have serious consequences for patients and their respective communities. There is a concern that access to advanced neurotechnology might worsen existing social and economic differences. If brain implants become available primarily to those with financial means, CNBC suggests it could lead to a two-tiered society where some have access to enhanced cognitive abilities, whilst others do not. Ethical guidelines must ensure that these technologies are kept within their legal ramifications and ensure they are accessible to a broader population, including those from disadvantaged backgrounds. Overall, Neuralink’s approval for human-brain implant trial recruitment represents a significant milestone in the field of neurotechnology. On one hand, it offers hope to individuals with neurological disorders and presents a glimpse into a future where humans and machines can interact together in unprecedented ways. However, as technology continues to develop and as we move forward, it is essential to consider the ethical implications of such developments and ensure that these technologies are developed in a responsible and transparent manner. The journey towards unlocking the full potential of the human brain has begun, but striking a balance between innovation and ethical responsibility is essential for all.