Social media platforms are constantly growing and becoming a central part of people’s lives, especially for the younger generations. While adults can also be negatively affected by social media, in this blog I will focus on adolescence, as this problem has attracted so much media attention recently. Social media is, at its core, simply a tool. It is how we interact and use social media that evolves this tool into a weapon. Whether this be through exacerbating peer feedback, causing detrimental effects on sleep, or providing a constant stream of images photoshopped to meet unrealistic standards of perfection, social media is unwittingly impacting our mental well-being. One example of this can be seen in the image above. Grazia magazine photoshopped out the natural hair of actress Lupita Nyong’o for her magazine cover shoot, as it seemed this would fit their ‘ideal’ of what hair should look like. However, it’s not just magazines that are doing this. Apps such as Facetune and FaceApp provide a means for anyone, regardless of age or skill, to edit and retouch their photographs before being posted onto social media. Since Facebook’s emergence into the public sphere in 2006, the online space rapidly expanded to include other platforms like Twitter, Instagram and Snapchat. The surge in popularity of these social media sites has raised concerns about their role and effect on adolescent wellbeing, mental health and cognitive development. Personally — and I am 21 years old — I frequently experience my friends using various apps to ‘Photoshop’ themselves before posting onto Instagram; making their waist smaller or thighs thinner due to pressure to look more like the celebrities they see on social media. For my friends and I, Instagram only became popular when we were about 16 years old. However nowadays 11-year-olds are creating accounts — and, in the last year there has been an increase in Instagram use from 14% to 23% by 12–15- year- olds. So I can only imagine the impact it is having for these children. I’ve seen the damaging effect it can have on self-esteem and anxiety, which is now going to start from a younger age if not controlled. So I wanted to ask, why are adolescents specifically so affected by social media? The social inclusion We know that adolescence is a crucial period for the development of our brains and our cognitive function. Many hormonal changes occur, which trigger structural remodelling and plasticity of the brain, providing a possible explanation for adolescents’ sensitivity to their social environment. Alongside this, parental influence decreases and peer opinion becomes more important — reports have shown that social and personal worth is predominantly impacted by peer evaluation, and rejection can reflect unworthiness. Thus, it is unsurprising that there is an increased vulnerability to mental health problems, such as low self-esteem, anxiety and depression, during this period. This led me to question, how does social media contribute to, or exacerbate, these already heightened emotions? Social media provides a way in which rejection and acceptance are constantly being highlighted and emphasised. In adolescent studies, regular contact with friends over messaging platforms created feelings of being loved and popular, increasing self-esteem. Those that do not conform with this standard feel excluded, and pressured to comply. For example, in one study the online game Cyberball was used to evaluate these emotions. Participants excluded within the game reported a having lowered mood and heightened anxiety when compared with those included, even compared with adults who were excluded. View fullsize In the group of the adolescents excluded by their peers, increased activity in brain regions was seen, specifically the anterior cortex and insula. These regions of the brain are involved in functions such as socio-emotional processing and decision making. These same regions are often implicated in depression, and healthy individuals who showed the increased activity also had an increased risk of developing depression. This may suggest there is increased vulnerability to social rejection during adolescence. The impact on sleep This need for inclusion, which is being exacerbated by social media platforms, also has detrimental effects on sleep quality. The sleepless nature of social media results in a perpetual stream of notifications 24 hours a day, creating pressure to be available constantly throughout this time. The demand for availability with the fear of exclusion leads to heightened anxiety and night-time use of phones. Additionally, blue light from screen exposure suppresses melatonin production and interferes with circadian rhythm. Therefore, this use before bed creates a direct pathway to sleep disruption that did not previously exist. This is of growing importance as the number of adolescent social media users who take their phones to bed with them continues to increase. In 2018, an OfCom report showed that 69% of 12–15 -year-olds have social media profiles, and 71% of them take their phones to bed with them. However, with regards to sleep, it doesn’t end here. As explained, there is an increasing need for availability. Availability, and the fear of missing out on new content, is facilitated by leaving one’s phone on at all times, and restricted access has been seen to increase anxiety levels. Incoming alerts can lead to sleep disruption throughout the night, and many adolescents feel obligated to return texts as soon as they are received to avoid guilt and misunderstanding. A downward spiral occurs, initiated by the need to be available. This interruption in sleep becomes even more of an issue when we consider that poor sleep in adolescents is associated with increased anxiety, low self-esteem and depressive symptoms. And we have recently discussed in another blog on this platform that disrupted sleep also increases the risk of obesity, with further risk for mental health and self-esteem. Peer feedback We have seen the effect of social rejection on adolescent mental health, so what are the effects of peer feedback, and how does this relate to social media? Social media acts as a source that provides carefully selected and often highly edited photographs of friends and celebrities. As previously mentioned with reference to even my own friends, this then becomes the norm when using apps such as Instagram and Facebook, and leads to the bombardment of photographs portraying the media’s ‘thin-body ideal’ and ‘perfect’ appearance. Multiple studies show that adolescents may internalize these ‘ideals’ and socially compare themselves, thus leading to increased body dissatisfaction. Furthermore, social media use increases dependency on personal pictures for social validation, due to the immediate reward of visible, quantifiable ‘likes’. This also increases body dissatisfaction due to the pressure felt to be and look perfect, to gain the largest number of likes. Increased body dissatisfaction is a danger to wellbeing; the internalization of these ideals and consequent body dissatisfaction increases depressive symptoms in adolescents. Social media thus provides a constant exposure to ideals and ‘norms’ that are decided by the media, which teenagers would not previously have been exposed to. The issue isn’t just constrained to body ideals. Another example where damage can occur is in relation to drugs and alcohol, which are often ‘glamorized’ by celebrities. Constant exposure to these activities on social media normalises them, encouraging adolescents to partake in the same activities. However, the issues surrounding social media have also gone beyond peer pressure and self-image concerns. It was just this weekend that a 17-year olds death was exploited via social media sites such as Instagram, Twitter and Discord. Graphic images of her death were posted and spread quickly before these sites could intervene. This is just one of many examples of how social media can be weaponised. And worryingly, this is just one example out of many I could use. Current and future perspectives There is increasing evidence of the link between a bad use of social media and low self-esteem, depression, body dissatisfaction and poor sleep quality. Thus, one needs to ask what can be done to prevent the decline of adolescent mental health in accordance with social media use. Throughout the last 5 years, I have seen multiple friends negatively affected by what they are constantly exposed to on social media, and a pressure to keep up with the ‘norms’ created by those with more followers than themselves. However, the multiple benefits social media provides should not be ignored. It provides a platform which allows connectivity regardless of location, and allows for the integration of different cultures. It acts as a tool for education and awareness, and can act as a creative outlet or source of inspiration. Therefore, the question moving forward is, how can we balance out the negatives with the positives in a constructive, non-damaging way? As a starting point, it should be noted that family or other environmental factors can protect children from the potentially deleterious effects of social media. For example, a positive mother-adolescent relationship decreases the association between social media use and body dissatisfaction. When a child is secure in their current relationships, their self-worth is less dependent on social validation and comparison with others. They feel less pressure to conform to the ideals represented by social media to gain acceptance. More research is needed to understand this relationship’s exact dynamic, however moving forward mothers could be informed of the importance of this role. Furthermore, phones now have features which tell you how many hours a day you use an app, and allow you to restrict the number of hours the app is used. This awareness may encourage users to decrease time spent on the apps, and restriction of hours may help prevent night-time use. Eventually, this could decrease pressure to be available at all hours. Additionally, major phone companies have introduced a ‘night shift’ mode for their phones, which claim to give off less blue light, in turn reducing the negative side-effects of this light. People are slowly becoming more aware of this rising problem, and taking steps to adapt to this new world which revolves around social media and the internet. Let’s hope that my friends notice too! header image souce: Yahoo Lifestyle Grazia magazine photoshopped out the natural hair of actress Lupita Nyong’o for her magazine cover shoot, as it seemed this would fit their ‘ideal’ of what hair should look like.

Have you ever experienced an emotion so strong it felt as if you were losing touch with your own self? Did you feel like these emotions took control over you, creating a sense of instability? I am confident that most, if not all, of us have experienced this, but the crucial part is this: how did you react? Did you succumb to your own thoughts, or did you consciously take a moment to notice what exactly was going on? Realizing that that decision is yours to make is both liberating and incredibly powerful. As a PhD student researching the epigenetics of post-traumatic stress disorders, I have always been intrigued by the biological underpinnings of stress-related disorders and the central roles of associated thoughts and emotions. Looking back, I realize that that curiosity stems from my own personal experiences in struggling with emotions. I used to get overwhelmed easily by emotions such as fear. To me, fear felt mentally paralyzing, and for years I was lacking the strength and coping mechanisms needed to deal with it, but deep down I knew there was more to me than fear. So I started to wonder: if I am not fear, who am I and how can I empower my true self to conquer fear? Little by little, I started to truly understand that what matters is not the sensation of my emotions, it is how I consciously decide to react to those feelings. Ever since, I like to visualize arising emotions. Whenever I feel anxiety taking over, I imagine that emotion as being a large, round, dark structure stuck in my stomach or throat, depending on what feels more accurate at that time. Whenever this happens, I actively try not to judge whatever is arising, and I provide the space needed to reflect upon how it is making me feel. I ask myself a variety of questions: what triggered this emotion? Is it related to any prior experience? If so, how was I impacted by that experience? Was this harmful cloud of negativity ever constructive or helpful? You guessed it — the answer is always no. Although emotions can guide us through external circumstances, discerning the origin and purpose of each emotion is crucial. I visualize fear differently. Although I used to lose all sense of self-control when fear was arising, fear now resembles a small ghost that lives in a house inside my chest. Whenever fear is coming out of its house and is looking up at me, whenever it is gaining confidence and tries to claim ownership over me, I stop whatever I’m doing. I reflect. At this point, remember you have a choice to make; are you going to give it the space it needs to take control or are you going to put it aside? Now that you’ve taken the time to notice how you feel, you can choose to gently guide fear back into its house and close the door behind it. I’m stressing “gently” here. The key in all this is to remain filled with compassion and love not only toward yourself but also toward these external emotions. Be patient with yourself. My visualization of fear ready to take over, accurately represented by Olivier Snijders. The more you try to carefully reveal underlying patterns and experiences, the more, over time, the complex network of intertwined emotions will become more distinct from your true self. The more you develop a deeper understanding for it, the more you can start to deconstruct it. The house of fear then becomes smaller and calmer. That is exactly what you want; regain control over yourself and not let these external emotions take over and guide you through life. Little by little, you will start to understand that these emotions are not you. You are the awareness that has the power to decide what to do with them at any point of time. You are in charge. And yes, that is scary. For those among us who have never had the opportunity to fully exist, who have always been shut down by others or who have been traumatized at some point in their lives, claiming control of their own self is far from straightforward. You are facing the unknown and that is terrifying. Don’t expect to figure it all out overnight, but slowly start to accept and understand that there is more to you than emotional instability and uncertainty. Although I am nowhere close to claiming myself to be an expert on this matter and I am still learning daily, here is my piece of advice for anyone who can relate to the first few sentences I put down on this page. From now on, make an active commitment to mindfully acknowledge and recognize emotions as the begin to arise. Let your feelings temporarily resonate and allow them to just be. Take a step back, be the observer of your own feelings and gently distance yourself from this stream of emotions. Breathe. Remind yourself to remain patient. Then, try to understand their origin and start to deconstruct them. Where are these emotions coming from? How are they making you feel? Is it possible you are giving them too much credit? Do not be afraid of seeking professional help to guide you through this process if needed. However you decide to go through it, remember that this process is one to be continually practiced and requires patience. Remain loving toward yourself and step by step, you will build the strength needed to face whatever is coming up, acknowledge it, put it aside and allow your true self to fully exist. You will then finally realize that you are not your emotions. NOTE FROM THE EDITORS: We are so excited to have Clara Snijders writing for InSPIre the Mind. Clara is a PhD student in Neuroepigenetics at the University of Maastricht in The Netherlands. We are very pleased that she wanted to share her account on the importance of taking control of emotions with our readers. header image source: Clara snijders

Just last month, I was chatting to a friend, who happens to be a doctor, about my research. She asked me: “So, really? You would classify obesity as a disease?” I sighed. The kind of sigh that said: I’m not annoyed, just frustrated… how have you completed five years of medical school and not learnt about obesity in the context of disease rather than personal choice? I replied: “Yes of course, it is one of the most complex diseases currently facing the population and modern science”. As a researcher working in the field of obesity, I often find myself in these types of conversations, arguing against the belief that all individuals who live with obesity are overweight and remain overweight because they are lazy, weak-willed and less disciplined than individuals of a healthy weight. Sadly, this viewpoint is highly prevalent, even in medical professionals who are in regular contact with patients living with obesity. Over the last century, obesity has been viewed and addressed by health professionals, policy makers and the general public as a result of how calories are processed. That is, that continuous weight gain in individuals with obesity can be predicted by this simple equation: CALORIES IN-CALORIES OUT = BODY FAT Governments all over the world have pumped millions of pounds into policies and campaigns based on this idea, which places 100% of the responsibility of obesity on the individual. There is an intuitive appeal to this theory. ‘Individuals live with obesity because they have eaten too much and exercised too little for too long.’ Simple. Yes, it is true that diet and exercise are drivers of weight gain, no-one is denying this. But this theory is overly simplistic. This theory does not explain why we all have that friend who eats a lot, yet never gains weight, or why another person may have a lower calorie intake and put on weight, despite being reasonably active. The obesity epidemic cannot be down to calories alone. There is more to this story. As highlighted in the UK Government’s Foresight Report, weight is influenced by over 100 complex factors which include genetic, environmental, psychological, social, economic and political factors. These interact in varying degrees to promote the development of obesity. I aim to use this article to highlight some of the factors that have contributed to the obesity epidemic that are rarely given mainstream attention. I will then go on to discuss the robust link between obesity, stigmatisation and it’s mental health consequences. The food environment The food environment has changed in ways that promote overeating. Highly caloric and fatty foods are not only affordable but they are also very easily accessible. High streets are now homes to multiple fast-food outlets. Grimsby in Lincolnshire recently topped the table as Britain’s unhealthiest high street, and the same study found that the number of fast food outlets in the UK increased by 4,000 between 2014 and 2017, with the most deprived areas now occupying five times more than the most affluent areas. Furthermore, most offices, schools and hospitals have multiple vending machines somewhere on their grounds. These types of highly palatable foods are frequently available in large portions, which contribute to increased daily caloric intake. In addition, the number of processed food items (foods high in sugar, fat, and salt) available in supermarkets, petrol stations, and corner shops has rapidly increased. These products are heavily marketed to both adults and, perhaps more dangerously, to children. Convenient, easy to prep, and cheap, these high calorie products are frequently consumed by millions of families who are struggling to meet the economic and time demands of today’s fast paced lifestyle. However, even with changes to the food environment, there will be diversity of body weight and size, in the same way that there is a spectrum of height and shoe size. By linking the food environment to obesity without considering additional influences, the inaccurate assumption that individuals simply gain weight by eating the ‘wrong’ foods, and that thinner people are healthy and less susceptible to ‘junk food’ marketing, will be fueled. Hormones Hormones are chemical messengers that regulate processes in our body. The hormones leptin and insulin, along with sex hormones, influence our appetite, our metabolism (the rate at which our body burns food for energy), and how body fat is distributed in our bodies. Leptin is produced by fat cells and then enters our bloodstream. It reduces our appetite by acting on specific parts of the brain to reduce our urge to eat. Because leptin is produced by fat cells, their levels tend to be higher in people with obesity than in people of normal weight. I know what you’re thinking… surely, if individuals with obesity have higher levels of leptin, then they should have more regulated appetites? But, what research actually finds is that individuals with obesity aren’t as sensitive to the effects of leptin and, as a result, tend not to feel full during and after a meal. Ongoing research is investigating why leptin’s messages aren’t getting through to the brain in people with obesity. Another hormone that is important in the development of obesity is Insulin. Commonly discussed in the context of diabetes, Insulin is important for our regulation of carbohydrates and the breakdown of fat after a meal. Insulin causes glucose (sugar) to move from our bloodstream into our tissues, to make sure that we have enough energy for everyday functioning and to ensure we have normal levels of sugar pumping around our body. Research suggests that, in individuals with obesity, insulin signals are sometimes lost, which causes higher levels of sugar in the blood. This can lead to development of obesity because the body’s cells cannot access blood sugar for energy, which can lead to an increase in thirst and hunger, as well as feeling drowsy and tired. Lastly, changes in sex hormone levels of both men and women over the lifespan are associated with changes in body fat distribution. For example, in women, increased testosterone and decreased estrogen contributes to an increase in abdominal fat and may help explain the weight gain commonly experienced during menopause. Genetics Just over a decade ago despite huge efforts, no gene had been clearly associated with body weight and risk of obesity. In recent years, however, more advanced scientific methods in the field of genetics have succeeded. The first obesity-susceptibility gene was detected by researchers in 2007 (the FTO gene). A variant in the FTO gene predisposes individuals to type 2 diabetes through an effect on body weight. This genetic variant is thought to contribute to approximately 22% of common obesity in society today. Exactly how the FTO gene causes obesity is still not entirely clear. FTO appears to regulate ghrelin, a hormone produced in the gut that alters appetite and food intake. When ghrelin is increased, reduced fullness and increased food intake occur. Different studies have found that FTO is linked to increased intake of fat and protein, increased appetite, reduced fullness, poor food choices and eating habits, and also a loss of control over eating. Researchers have also found that increased levels of ghrelin occur after diet-induced weight loss, so this may explain why we see such high rates of weight regain after successful diets in this population. Furthermore, genes can directly cause obesity in disorders such as Prader-Willi syndrome. In Prader-Willi syndrome, certain genes are either missing or not functioning correctly, which changes how the hypothalamus works (a part of the brain that controls thirst and hunger). Sleep debt Sleep deprivation is typically considered getting less than 7 hours of sleep per night. There are numerous studies which suggest that sleep deprivation can indirectly cause weight gain. One study recruited 83,377 older adults and followed them over 7 years, concluded that sleep duration of less than 5 hours, compared with 7–8 hours, increased the likelihood of developing obesity by 40%. This is concerning, given that in 2017, 74% of the UK population got less than 7 hours sleep a night, and 12% got less than 5 hours. Experimental studies have shown that sleep restriction can influence hormones, like those described in the section above, that regulate the breakdown of food in the body and influence our feelings of hunger and fullness. Other authors suggest simply that individuals who sleep less have more opportunities to eat food because they are awake for longer, and that short sleepers experience more tiredness which reduces the likelihood of exercising. These researchers ran a study with 225 study volunteers; for five nights, half of the group had their sleep restricted to just four hours, whilst the other half were free to sleep as long as they wanted. And what did they find? Sleep restriction is not good for your waistline. Everyone in the restricted sleep group gained weight, on average 1kg over the course of one week. Drug-induced weight gain Weight gain is associated with several medications, and the recognition that some of the most widely prescribed classes of drugs can cause significant weight gain supports the hypothesis that drug-induced weight gain may be contributing to the current obesity epidemic. Certain antipsychotic drugs (such as clozapine, olanzapine, risperidone and quetiapine) are known to cause weight gain. Antidepressants too, such as amitriptyline, mirtazapine and some serotonin reuptake inhibitors (SSRIs), may promote weight gain that cannot be explained solely by the individual not feeling depressed any more. Furthermore, a common side effect of certain anti-diabetic drugs is weight gain, which is obviously very problematic in clinic as many diabetic patients live with obesity and further weight gain is hence undesirable. Some individuals are fortunate enough to be able to switch to a different brand of medication if they notice significant weight gain. We see this happen a lot with contraceptives. There are hundreds of different contraceptives available, meaning an individual can try several different ones to find the one that works for their mental and physical health But what about the individual with bipolar disorder or schizophrenia whose medication has done wonders for curbing their symptoms of psychosis yet has caused them to gain weight? What is more important for that individual? Their mental health or their body size? They should not have to choose. Obesity, stigma and mental health Every year there are a substantial number of media articles published that stigmatise and discriminate against people with obesity. These articles are easily accessible and can be read by millions of people. Recently, the very important medical journal, The Lancet, has published a call for developing collaborative work with the media in order to reduce the weight stigma and discrimination evidenced across society. The call highlighted the following examples from popular UK newspapers: Individuals with obesity face stereotypical attitudes from employers and disadvantages in hiring, wages, promotions, and job termination. They are also more likely to be prescribed weight loss interventions when presenting with worrying symptoms at their GP, and hence experience delays in alternative interventions because their issues are commonly assumed to be weight-related. Ironically, weight stigma is also prevalent in anti-obesity campaigns. The USA’s ‘Strong4Life’ campaign is one such example. Started in 2012 by a hospital in Atlanta, the campaign featured billboard adverts with unflattering photos of visibly unhappy children living with obesity. The adverts were accompanied by warning banners stating messages such as: “Chubby isn’t cute if it leads to type two diabetes”; and “Being fat takes the fun out of being a kid”. It has been said that the ‘Strong4Life’ adverts were partly modeled on a successful anti-methamphetamine campaign in the states, and the hospital behind the billboards defended the campaign by stating that “it raised awareness of the dangers of obesity”. Another more recent example is the recent cancer research UK campaign that you may have seen advertised on your local high street. Its focus on weight as a leading cause of cancer is misleading. Weight is a crude indicator of health and while there is a link between higher weight and cancer, the reasons for this are unclear. Implying that individuals are totally in control of their weight (and therefore cancer) supports a culture of blame and drives marginalisation and inequality of an already stigmatised population. Not only this, but the evidence is crystal clear that obesity stigma does not motivate individuals with obesity to lose weight. People with obesity who experience weight-related stigmatisation participate less in physical activity and the stress associated with weight stigma can trigger eating and contribute to further weight gain. This negative view is contributing to and perpetuating a cycle of weight gain. Moreover, a recently published study that analysed data on more than 17,000 children born across the UK in 2000–2001 (The Millennium Cohort Study), found that high body weight and poor mental health go hand in hand from early childhood. The author of the study commented that: “People think it’s as simple as eating less and exercising more — but it’s much more complex than that” Unfortunately, largely because of this lack of understanding of the complex web of factors that contribute to causing and maintaining obesity, weight-related stigmatisation (weight stigma) is very common in society. So where do we go from here? Journalists reporting obesity-related topics can use balanced and sensitive visual content, depicting non-stigmatising portrayals of individuals with obesity. The European Association for the Study of Obesity has set up an Obesity Image Bank specifically for the media to view and make use of in future articles. Furthermore, anti-obesity campaigns are likely to be more productive if they focused on respectful care for all bodies, empowering people to make health promoting changes, no matter what their weight. As a society, if we are to successfully tackle the complex and growing issue of obesity and the mental health problems that come with it, we must move away from viewing weight gain as a personal failure. Instead, we need to view obesity as a consequence of dealing with a complex condition, and we need to view individual responsibility in the context of uncontrollable factors. header image source:the women journal

In recent years, more and more attention has been placed on the concept that the psychological development of a child is the result of a combination of genetics and environmental factors, dating back from previous generations. This means that the mental health of women in its entirety, not just during pregnancy or post-natal periods, is relevant to the future of the children. In this blog, I explore the role of maternal stress, and especially of maternal experience of maltreatment, on the development of their offspring. Typically, the word ‘maltreatment’ is associated with physical or sexual violence, however, the term also includes psychological violence and neglect. Recent studies, including from our own research group, have shown that a history of such abuse and maltreatment in a mother can affect the offspring by increasing their risk of developing mental health problems as children and adolescents. There are many mechanisms that could explain this transmission of risk from one generation to the next. One explanation could be epigenetic modifications of DNA. Epigenetic modifications are changes of the DNA chain determined by the environment. These modifications alter the expression of the genetic makeup of an individual, so that some piece of DNA, leading to specific proteins, tend to be produced in a more or less abundant way. Epigenetic changes induced by the experience of maltreatment in mothers could be transmitted to the offspring by changes in the ‘utero’ environment. For example, a history of child maltreatment can lead to permanently increased levels of stress hormones in the mothers’ body, subsequently affecting the intrauterine environment, where the fetus grows. The change in the intrauterine environment, through such epigenetic mechanisms, can modify brain development, and therefore increase the child’s exposure to mental illness later in life. Other studies show that children of abused mothers present an unsafe style of attachment, which could also explain the increased susceptibility to mental health problems. But what is attachment? Attachment theory is the result of work carried out between the 1960s and 1980s by psychoanalyst, John Bowlby. Bowlby argued that “attachment is an integral part of cradle-to-grave human behavior”. The capacity of the human being to develop a harmonious personality depends mainly on having an adequate attachment to a mother figure (or to a similarly important figure). A secure attachment style is therefore a reflection of a present and sensitive mother (or caregiver) who is able to respond to the needs of the child. A child with a secure attachment style uses his or her parents as a base to explore the environment. Children appear stressed by separation and are reassured when reunited. On the other hand, a child with an unsafe attachment style (technically defined as ‘anxious-avoidant, ambivalent or disorganized type’), is not able to use the caregiver as a basis for exploration, and shows less adaptive ability at the time of separation and reunion An insecure style of attachment could make relationships in adolescence and adulthood harder. Difficulties with self-esteem, self-reflection and trusting peers, maybe at the heart of this issue. Studies have shown that the style of attachment that most closely correlates with the history of maternal child maltreatment is the disorganized type. Mothers with childhood abuse and a history of neglect have less ability to elaborate traumatic experiences and their own emotional experiences. This may results in an inability to respond to the child’s requests, and to attend to the child’s needs. As a consequence, the child may also develop an ‘unsafe attachment style’. These factors may contribute to the development of mental health problems in the child, such as conduct disorder or depression in adolescence and early adulthood, and also to perpetuating the problem from one generation to next. Biological studies have explained this phenomenon by demonstrating that mothers who are exposed to maltreatment during childhood, especially if they later developed post-partum depression, show altered levels of oxytocin. Oxytocin is the hormone that is naturally produced during the postpartum, determining the mother’s ability to bond with her baby. How can we help mothers who have suffered from childhood maltreatment? In light of what we have discussed, it is clear that early identification of mothers with a history of maltreatment could be helpful in order to identify this vulnerability, and for putting in place a support framework for the mothers and for the mother-infant dyads. This could be fundamental not only for the well-being of the woman, but also for her child. Maternal and mental health clinical services should aim to identify women at risk before, or at the beginning, of pregnancy. This would allow professionals to provide the necessary care and assistance early on, involving the whole family where possible. Social support (a heathy network of family and friends) is essential, and, in the more severe cases, cognitive behavioural psychotherapies or family supportive psychotherapies are recommended. As we said before in a previous blog, in many countries psychological therapies are rarely available in the public health services — but in the UK, luckily, they are. By embracing the psychological and social needs of mothers who have suffered from childhood maltreatment, we will able to stop this vicious cycle of transmission of mental health problems from one generation to the next, and from a mother to their children. header image source: Valeria Zoncoll on Unsplash

We all experience stress. Whether garden-variety stressors (the task that was due last week, the pile of laundry that keeps growing, the traffic jam when you’re running late), more serious ones (living through a natural disaster like a hurricane or flood, experiencing an assault) or chronic ones (caring for an ill relative, being unemployed, living with someone who is abusive), each of us faces stress from time to time. Depending on the stressor’s severity, how we experience it, and how long it lasts, it can affect our bodies and brains differently. A short-term stressor, like getting caught in traffic, might increase your blood pressure and have you feeling frustrated or annoyed for a few minutes. A more chronic stressor that lasts weeks or months can impair your immune function or result in symptoms of clinical depression or anxiety. But do we ever stop to think about how stress might affect our guts? Not the stomach-in-knots feeling that you might get when you’re stressed. But the actual bacteria inhabiting our bowels. Your intestines are home to trillions of bacteria, that together weigh in at around three pounds! These bountiful bugs that make up the gut microbiome may be sensitive to stress, too. In rodents, even brief mild stress changes the composition of gut bacteria, as does chronic stress. However, there is less research on stress impact on gut microbiome in humans. The gut microbiome is the collection of microbes (bacteria, archaea, viruses, plus their genetic material) in the gut. Normally, there is a balance of different bacteria types (or taxa, e.g. genera, species, subspecies), in the human gut. Based on the animal research, scientists wonder whether stress also alters the balance of gut bacteria in humans. Adults with major depression, a common companion of stress, have altered gut microbiome composition. However, in healthy adults, stress levels are not associated with gut microbiome composition, suggesting that we need to learn more about how the type, timing and severity of stress impacts the gut microbiome in humans. One particularly pernicious form of stress is early life stress (also referred to as adverse childhood experiences or “ACEs”). This includes abuse, neglect, or a chaotic home environment during childhood or teenage years. In the past decades, we’ve learned that such early life stress can increase risk for everything from depression to heart disease, even if the person has overcome the stressful environment of their youth. This is likely because the stress has occurred during a sensitive period of brain and body development, when our stress response axis is developing — disruptions here can set us up for vulnerability to stress down the road. But is the same true for the gut? If our bowel bacteria are sensitive to stress, does the stress we experienced early in life leave an imprint in our guts? This is the sort of question that I am interested in answering in my research. In rodents, early life stress changes the composition of the gut bacteria, which lasts through adulthood. I was interested in whether the same were true in humans. In our laboratory at the University of Pennsylvania, we focus on how stress impacts the body and brain, and are interested in how different types of stress, such as early life stress, might increase risk for mental health issues. We recruited healthy women to our laboratory to look at whether their early life experiences had left a signature, decades later, in their gut microbiota. These women, who were pregnant at the time of the study, were otherwise physically and psychiatrically healthy. Half of them had experienced multiple childhood stressors, and half had not. We found that the women who had multiple stresses in early life have a different looking gut microbiome than women without such experiences. Specifically, the women with high levels of early life stress have elevated gut Prevotella compared with women without early life stress. This is interesting, as studies by other research teams have shown that this type of bacteria is associated with inflammation and differences in emotional processing in the brain. (Specifically, researchers found elevated Prevotella in people with rheumatoid arthritis, a disease in which the joints are inflamed, and in people with lower activity in a brain region called the hippocampus when viewing negative images). We also found that specific gut taxa, including Prevotella and Dialister, are associated with cortisol and inflammatory response to an acute stress administered in the lab, in both groups of women. To examine this, we asked a subgroup of our participants to perform a stressful public speaking exercise, and measured levels of cortisol (a stress hormone) and proinflammatory cytokines (substances secreted by immune cells that cause inflammation) in their blood. We were interested in this because elevated levels of cortisol or proinflammatory cytokines, over months or years, can have negative impacts on our health. Also, we and other researchers have found that adults with a history of early life stress have an altered stress response system (including cortisol and cytokine output), but no one had looked at this in the context of the gut microbiome. Why is this important? This is the first study to show that stress experienced early in life may impact adulthood gut microbiome in humans, and the first to find that a more intense response to stress is associated with abundance of particular microbes in the gut. While these are exciting initial results, more studies are needed in this area. As luck would have it, another study came out on the heels of ours that added more detail to the picture. This study looked at shorter-term effects of childhood stress on the gut microbiome, that is, when subjects were adolescents rather than adults. Dr. Bridget Callaghan examined the microbiota of teens who had lived in an orphanage in early life (a form of severe chronic stress) and compared it with the microbiota of children who had been raised in a stable family environment. The children were raised in orphanages were on average from birth to roughly age 3, although some remained in institutional care through age 7. When these children were studied a few years later, at around age 10–15 years, they had altered gut microbiota compared with the children who had spent their entire lives in a stable family environment. Together, these results indicate that early life stress can impact the gut microbiota during childhood, which can persist through adolescence and into adulthood. These initial results need to be replicated by other researchers, and there are many related questions that need to be addressed. For instance, if early life stress does leave a permanent mark on the gut microbiome, does this translate to health or mental health risk in adulthood? If so, what role does the gut microbiome play in the link between early life stress and adulthood health risks? Are there ways we might intervene at the gut microbiome level, via diet or other factors, to help offset some of the impact of early life stress? Finally, do factors such as resilience or having a supportive adult present buffer some of the effects of early life stress on the body and brain? NOTE FROM THE EDITORS: We are so excited to have Dr Liisa Hantsoo writing for InSPIre the Mind. Liisa is an Assistant Professor at the Department of Psychiatry, Penn Center for Women’s Behavioural Wellness at The University of Pennsylvania School of Medicine. We are so pleased that Liisa wanted to share an insight into her work in childhood adversity, the gut microbiome and inflammation with us. header image source: Jukan Tateisi on Unsplash

The period following childbirth represents a very delicate phase of settling and redefinition of personal and relational identity for new mothers. As Kristi Sawyer wrote in her blog, ‘matrescence’, the time of ‘mother-becoming’ is a critical transition period involving shifts in hormones and identity, during which we often expect women to be happy and excited for the upcoming arrival. The experience of childbirth has a positive connotation, but at the same time it contains elements of concern. Many women, when they are about to give birth, experience a strange mix of feelings: joy — because it is generating a life — but at the same time distress, fear, pain and threat. When these two groups of emotions coexist, there is a tendency to only show positive emotions, and to feel ashamed of showing the negative emotions and talking about the negative aspects of childbirth, also because of the social and cultural pressure. The negative aspects related to the experience of childbirth should be recognised by the women, in terms of both remembering, and talking about this aspect of the experience. Instead, memories are pushed back and ignored, and the mother is unable to translate the traumatic and negative experience into words. And when these experiences don’t find a way to express themselves in words they can cause emotional difficulties. Generally, the postpartum period is a critical and vulnerable phase, in which the risk of postnatal depression and post-traumatic stress disorder (PTSD) is very high. It is often thought that only women experiencing complicated childbirth (prematurity, or other health problems in mother and/or the child), can be affected by PTSD. However, this is not always the case: new mothers with normal childbirth, can experience symptoms of PTSD, even in the absence of psychopathological risk factors or complications. Recent studies in post-partum PTSD have shown that childbirth is a stressful and traumatic event per se, not only due to the physical pain, anxiety, fears, worries and uncertainties associated with childbirth, but also because the negative aspects of childbirth are not mentally processed as a social and personal experience: they are not verbalized, nor verbalizable. The personal, social, and family beliefs around childbirth, often conveyed by narrative on maternity, lead mothers to openly express only the positive aspects of childbirth — not the negative. The Expressive Writing paradigm: As I have said, new mothers may tend to avoid communicating and elaborating on negative effects and thoughts related to childbirth, because of personal, social, and family beliefs, often conveyed by the general shared view on maternity, which could lead them to express only the positive aspects of childbirth. Doctor James W. Pennebaker, an American social psychologist, clearly defines avoidance as central symptom of PTSD, and underlines how negative or upsetting events that are kept secret or silent are more likely to result in health problems. According to inhibitory theory, the failure to express emotions and traumatic experiences affects physical and psychological health negatively. People usually try to avoid or inhibit depression symptoms, frightening thoughts and flash backs, sleep problems, and other posttraumatic symptoms induced by stressful and traumatic experiences. The efforts spent to avoid these unexpressed thoughts and feelings may increase psychological distress and psychosomatic symptoms. Instead, negative thoughts and emotions should be spoken about more openly. Even better is to express negative thoughts and emotions in writing, which demands more integration and structure than spoken language. Bringing out emotions and thoughts through writing can deactivate avoidance mechanism and enable the elaboration of distress. Expressive writing thus helps emotional regulation and promotes a new stronger sense of efficacy and mastery. The expressive writing is a form of writing therapy developed primarily by Doctor Pennebaker in the late 1980s. The seminal expressive writing study instructed participants in the experimental group to write about a ‘past trauma’, expressing their very deepest thoughts and feelings surrounding it. In contrast, control participants were asked to write as objectively and factually as possible about neutral topics (e.g. a particular room or their plans for the day), without revealing their emotions or opinions. People in the experimental group, as compared with controls, were shown to have reductions in negative effects of stress and made significantly fewer visits to a physician in the following months, demonstrating the value of expressive writing. Furthermore, other studies have shown that expressive writing may have the potential to actually provide a ‘boost’ to the immune system, perhaps explaining the reduction in physician visits. The importance of avoidance symptoms in PTSD following childbirth has been supported by various studies, showing for example that negative subjective childbirth experiences lead to avoidance symptoms and psychological maladjustment, and even to a clear PTSD diagnosis in the first year following childbirth. How did I know about Expressive Writing? Many variations of the expressive writing procedure have been implemented, all similarly showing that it benefits a significant proportion of those who participate. I would like to talk about a particular research study that one of my psychology teachers, Professor Paola Di Blasio, presented during her teaching for my Masters Degree in Developmental Psychology in Milan. The study investigated whether an expressive writing intervention decreases depression and posttraumatic stress symptoms after childbirth. 113 women were recruited when pregnant with their first child and then randomized to either expressive writing or to neutral writing. For the expressive writing, they were asked to write about ‘their deepest thoughts and feelings experienced during labour and childbirth’, while for neutral writing, they were asked to write about ‘what you have done and what has happened in the days of and after childbirth’. Women were assessed in the first few days after child birth, and again after 3 months. The study showed that, after 3 months, PTSD and depressive symptoms were lower in women who had performed the expressive writing task compared with those who had not. Interestingly, the writing intervention reduced PTSD symptoms in all mothers, even those with minimal initial symptoms. This was the first study to indicate that expressive writing can be a helpful, low-cost, early universal intervention to prevent postpartum distress for women. Moreover, this evidence is consistent with the experience of women described in our previous blog on the ‘Maternal Journal’, a group-based intervention also aimed at using journaling as a path to prevention of, or recovery from, mental distress in the perinatal period. All together, these activities point to the powerful effects of writing about the emotions of childbirth as a tool to promote mental wellbeing, either as private experience or as part of a group, based on women’s preferences. The message is always the same: do not avoid negative emotions and thoughts, instead, share them with yourself and others. header image source: rocknwool on Unsplash

Disclaimer: The intention with this blog is to discuss some of the ways that myself and others have noticed that brands use times like Mental Health Awareness Month as a platform to promote themselves and their products. Often, this results in shifting the focus (and profit) towards themselves rather than for the causes the brand seems to be advocating. Of course, I support the campaigns in themselves — as long as the causes are getting the backing they need, then the means which they get the social visibility and funding isn’t important, given of course it is harmless. Over the years, brands have figured out that appealing to our emotions and morality, rather than just our desires, is especially profitable. Under the guise of a mental health awareness campaign, several brands have recently taken to social media in the hopes of strategically using the occasion to sell more product. One memorable and recent example is Burger King’s ‘Real Meals’. In their press release on May 1st, Burger King announced their partnership with Mental Health America; a show of their support in “addressing the needs of those living with mental illness and to promoting the overall mental health of all Americans”. The idea of the ‘Real Meals’ line is to acknowledge that “No one is happy all the time. And that’s ok”. With the ‘Pissed Meal, Blue Meal, Salty Meal, Yaaas Meal and DGAF (Don’t Give a F — -) Meal’, customers are encouraged to embrace how they feel in ways that apparently Burger King felt that they couldn’t before. And, of course, nothing shows well-intentioned support of self-care like an international fast-food chain trying to sell burgers and fries. Ah, the epitome of promoting well-being! Though only a limited time release, in a few select restaurants in the US, the attention that this campaign received was huge. Quickly the internet responded to the alleged mental health campaign with equal parts enthusiasm and disgust. We have seen this before with mental health campaigns which have completely missed the mark. One example — which just might be the most memorable and strange — was when ‘Sunny D’s’ social media team decided to take to Twitter to express their ‘feelings of hopelessness’. This odd attempt to seem relatable by simply tweeting “I can’t do this anymore” sparked quite the conversation. In fact, even more bizarrely, other brands decided to jump on the bandwagon and continue this strange role-play. From the back and forth, discussions emerged, questioning what is fair game in the world of advertising; are there topics which cannot be moulded into a marketing strategy? Although an oversimplification, all advertising is manipulation and exploitation at its core, and so how are these campaigns any different? It’s hardly foreign knowledge that sex sells. Practically every other advert somehow manages to link their product to sex, but since these types of adverts have over-saturated the media, brands have had to evolve to keep customer attention. It seems that appealing to our morals and social identities is now the way forward in corporate marketing. Sex sells and now ‘morals’ do too. It’s not hard to recognise that Sunny D’s depression tweet was a calculated, quick, and free way of getting some attention. These somewhat weird attempts by brands to appear relatable and personal on social media (as if they aren’t corporations just trying to sell you their product) end up coming off as, at best, funny, and at worst, incredibly insulting. But it’s important to recognise that Burger King and Sunny D are not the only ones to do so, these are simply some examples that I think are the most memorable. Brands commodifying the need to be seen and heard that marginalised and ill-represented groups have is nothing new. In fact, in the heart of Pride Month, it’s hard to miss the minimum effort attempts by big name brands to appear supportive of the LGBTQ+ community. While a growing number of brands — including but not short of Harry’s, Converse, Levi’s, Absolut, and B_ND — are making use of this increased attention to donate a percentage of profits (or all profits from select products) to charities supporting the LGBTQ+ community, we still too often see support and ally-ship at face value only. Brands will plaster a general statement on a rainbow logo, and maybe a promotional video that goes viral, and then the other 11 months of the year is radio silence. The rise of brands using social media to present themselves as an individual with morals, hopes, and feelings is strange enough in itself. But what really takes it to the next level of buck-wild for me, is the way people interact with these tweets and videos. Some people love it — swearing allegiance to the brand, somehow inspired by the fictitious bravery of a multi-million-dollar corporation sticking up for the marginalised (in the most low-risk, bare-minimum way). Others hate it — their misplaced passion shown in tweets about how they will be boycotting said brand, maybe accompanied by a video of them destroying their own property (as if that does anything other than destroying their own property… they’ve already got your money, just don’t give them any more…). All this boils down to one simple idea: creating controversy. Unfortunately, none of us are immune to the charm of advertising, hence why it works so well and why in the UK alone, 2018 yielded an advertising spend of £19.9 billion. Commodification of social justice — be it in the form of mental health awareness, LGBTQ+ rights, recognising and fighting racism, or advocating women’s right — has proven to be a lucrative market to corporations. Naturally, these companies continue to make use of this opportunity. Whenever there’s controversy surrounding a company or an individual, what we consistently see is a massive increase in conversation about said company. Marketing teams which recognised this pattern quickly understood that controversy is synonymous with marketing; and potentially free marketing at that. Suddenly, hundreds of thousands of people were interacting with the Sunny D twitter account; memes were being shared, think pieces and blogs were being written, video essays, podcasts, and radio shows were talking about them. This account, which typically gets around 20 replies/few hundred likes per tweet was suddenly getting all this attention and free advertising. With Burger King, we see the same thing. Here the original tweet was far less seen but the articles, blogs, videos it generated were still abundant. Arguably the most recognisable example of a company recognising this trend in social media marketing is the Nike campaign from September last year. The ad itself is actually really great, with a powerful message; the ad features predominantly black athletes and their success, narrated by Colin Kaepernick, and supportive of his activism. However, the response to this campaign is the truly important part to Nike; the accumulated 29 million views to date is only the cherry on top. As expected, there was a distinct divide in reaction to the ad. On one end of the spectrum, you had people applauding Nike, thanking the brand for standing beside these genuinely great individuals. On the other end, people stormed to the internet to bombard anyone who would listen with tweets about how this was disgusting of Nike to do, filming videos of them burning their expensive Nike shoes, ripping the logo off of socks and shirts. How did this affect Nike? Well, people were certainly talking about them! Share prices increased 7.47% in the weeks following the ad, to the highest in the company’s history until April this year, and the endorsement gave way to Nike’s market value rising by $6 billion. When we see companies like Burger King make these attempts to appear accepting, supportive, and relatable, what should be clear is that more often than not, we are only seen as potential customers, rather than an individual to related to, with regards to our mental health. Now, perhaps this is all unwarranted cynicism, but it really is quite difficult to react in any other way in the face of poetic irony as exhausting as an international fast food brand meekly preaching self-care whilst trying to sell burgers of all things, especially since research has extensively linked junk food and poor diet to poor mental health. As I’ve written in my previous blogs, discussing how we interact with the movies and shows that we watch, we must be just as, if not more conscientious about the social media we interact with. As hard as it is, if we’re more aware of how we read these supposed mental health awareness campaigns, we can be better about what we do in response. It’s all well and good to support a brand being supportive of Mental Health Awareness or Pride or any form of activism but what is even better is to support those causes you care about directly.

‘The Wounded Healer’ — Harnessing the Power of the Performing Arts to Reduce Mental Health Related Stigma in Healthcare Professionals and Students Not so invincible after all… “Why am I as I am? To understand that of any person, his whole life, from birth must be reviewed. All of our experiences fuse into our personality. Everything that ever happened to us is an ingredient.” The Autobiography of Malcolm X I want to begin by sharing my own personal story with you which, I hope, will provide an insight into who I am, what I stand for and why I feel so passionate about harnessing the power of the performing arts to challenge mental health related stigma. I left my family behind me in Lebanon when I was 17 years old. The brutal and bloody civil war in the Lebanon in the 1980s had far-reaching ramifications so much so that even decades after the conflict was over prospects in the country were not looking favourable. So I packed my bags and took a one-way flight to England with high hopes for a better future. It’s not easy saying goodbye to your parents and I will never forget the sombre look on my mother’s face as I was bidding her farewell in Beirut International Airport. This may very well shatter my masculine bravado but I’d be lying if I said that I didn’t shed a tear or two… Almost immediately after my arrival on British shores, I started working as a janitor cleaning floors. The callouses on my hands were testament to the toil of my labour. I worked 70 hours a week on minimum wage to sustain myself. Being far removed from my family meant that I could not derive comfort from their immediate presence. Naturally I felt melancholic when I saw other teenagers my age living with their parents preparing for the A-Level exams to gain entry into medical school without having to work full-time. These were trying times no doubt but I never gave up hope that one day I would realise my dream of qualifying as a doctor, no matter how far fetched it seemed. The subsequent year I enrolled into a Sixth Form College and continued to work full-time hours. I remember when the Head of the Sixth Form at the time laughed at my face after I told her that my intention was to apply to read medicine at university. ‘It’s too competitive’ she instantly retorted ‘you’ll never receive an offer’. She had this ability to make me feel like I was this dirty little immigrant with delusions of grandeur and that I would never amount to anything in life. I refused to allow her to diminish my resolve however. I dug deep and, somehow, managed to secure the A-Level grades necessary to matriculate into Manchester Medical School despite working full-time hours. It seemed that my dream to one day qualify as a doctor was starting to become true… In 2006, when I was a third year medical student, I woke up one morning to discover that my hometown in Lebanon was bombed and that hundreds of people were killed overnight. I saw live footage of bombs being dropped on buildings and horrifying images of dismembered civilian corpses (including babies) strewn on the streets. I remember feeling utterly powerless as the death toll continued the rise and the destruction continued to spread. Fearing that my family were among the dead, I frantically tried to call them however I wasn’t able to get through (unbeknown to me at the time, my family were evacuated by the British Government). The stress from the war in Lebanon precipitated an episode of psychological distress. My world had turned upside down and, in my despair, I contemplated suicide. I would stare at the buses speeding past me and think about which one I would throw myself under. I, however, resisted the urge to act upon these thoughts since I was a practising Muslim and suicide is forbidden in Islam. Between 1,100 to 1,300 Lebanese people and 165 Israelis are believed to have been killed in the 2006 Lebanon war. The conflict severely damaged Lebanese civil infrastructure (opposite are buildings in Beirut that were reduced to rubble during the war). Debilitating though the symptoms of mental illness were, I soon discovered that the stigma of mental illness was far worse. I was ostracised, dehumanised and shunned by the very people who, at the time, I thought were my closest companions. I was rendered impoverished and homeless and my mental health rapidly deteriorated. These were the darkest days of my life. I look back and think how on earth did I manage to emerge from that seemingly bottomless abyss? What made the situation even worse was that I was in complete denial that I had developed a mental illness. ‘Going mad’ is not something that happens to people who are robust enough to study medicine, but to other people, or so at least I thought. This state of denial was one of the main reasons why I did not seek help. Also, I did not find the thought of taking psychiatric medication (or ‘chemical cosh’ as it is referred to by members of the anti-psychiatry community) too appealing. What I did gravitate towards, however, was the power of film, literature and poetry. I remember how deeply therapeutic and profoundly cathartic it was for me to watch movies at the cinema (hence the term, ‘cinematherapy’ has been coined to reflect this), read novels (mostly fiction of the magical realism variety from Gabriel Garcia Marquez) and recite verses conceived by Dylan Thomas and Rudyard Kipling. Moreover, there were no ‘adverse effects’ associated with these activities. I started to exercise more and I noticed that slowly, but surely, my mental health started to improve without the help of psychotropic medication or therapy. Prayer, the power of the performing arts and exercise were all factors that played crucial roles in my recovery from mental illness. These factors continue to contribute to my resilience. Recovery and discovery… I gradually recovered and resumed medical school with a renewed resilience and determination. There was a ‘fire burning in my belly’ and a ‘thunder in my heart’ to realise my potential and to make meaningful and important contributions to our world. I had been dis-empowered for so long and ridiculed and rejected by society and so redemption became my driving force. When I qualified as a doctor, I felt that it was incumbent upon me to challenge the stigma attached to mental illness in medical students, indeed I felt like this was ‘my calling’. After all, a recent systematic review and meta-analysis on the prevalence of depression, depressive symptoms and suicidal ideation in medical students published in JAMA in 2016 revealed that 27% of the 120,000 respondents reported depressive symptoms and 11% experienced suicidal ideation. I was clearly not alone. However, although effective treatment is available, stigma and ‘a culture of shame’ are formidable barriers to mental health services. My ‘mission’ therefore, was to break down those barriers so that medical students and doctors with mental health difficulties could access and receive the treatment they need and no longer continue to suffer in silence. Despite the perception that medical students and doctors should be ‘invincible’ the reality is that we are human beings and are vulnerable to developing psychological distress like everyone else. Picture taken at a Mental Health Fight Club event in Dragon Café, London. Genesis of the Wounded Healer In 2014, I responded to my calling and pioneered the Wounded Healer under the direct supervision of my mentor Dr Rashid Zaman FRCPsych, a Consultant Psychiatrist based at Cambridge University and Director of the International Conference on Mental Health at Cambridge University. I must take this opportunity to pay tribute to Dr Zaman. It is no exaggeration to state that he is truly one of a kind. Never, throughout the 10 years that I have been fortunate to know him, has Dr Zaman EVER uttered a single negative word towards me. Dr Zaman has been with me every step of the way, the highs and lows, the failures and successes and he provided me (and continues to provide me) with unwavering support. I would never have achieved my goals if it wasn’t for him. Simply put, Dr Zaman is the ultimate mentor and I am so blessed to have him in my life. The Wounded Healer is an innovative method of teaching that blends the performing arts with psychiatry. The main aims of the Wounded Healer are to engage, entertain, enthral and to educate to debunk myths about mental illness, encourage care-seeking and challenge mental health relate stigma. The Wounded Healer also harnesses the power of storytelling; it traces my recovery journey from homeless and impoverished ‘service-user’ to receiving the 2013 Royal College of Psychiatrists Foundation Doctor of the Year Award and, later, the 2018 RCPsych Core Psychiatric Trainee of the Year Award (the RCPsych Awards mark the highest level of achievement in psychiatry in the UK — not bad for a ‘madman’ even if I say so myself!). I was inspired to conceive the Wounded Healer because not only did I believe that the mental health of medical students is not spoken about as often as it should be but also most (if not all) the talks that were given on this topic were soporific. My argument was, and remains, that in order to educate an audience you must first be able to engage them. The Wounded Healer is a highly theatrical intervention that disrupts conventional educational approaches and seldom elicits indifference. In the Wounded Healer, I re-enact scenes from famous films and recite poetry to engage audiences and, once engaged, I educate them with the facts. If Ezekial 25:17 from Pulp Fiction does not galvanise audiences, I don’t know what will! I also find delivering the Wounded Healer empowering and that it continues to contribute to my resilience. In the Wounded Healer I re-enact scenes from famous films to engage audiences. The above picture was taken when I was delivering the Wounded Healer to 1000 medical students in Lisbon, Portugal. ‘Nothing about us without us: Experts by Experience as Educators…’ I had so much faith in the Wounded Healer that I took three years out of my clinical training to promote it. I initially reached out to medical school psychiatry societies in the UK and have since expanded operations internationally. Since its inception in 2014, I have been fortunate to deliver the Wounded Healer to over 75,000 people in 15 countries in five continents worldwide. The Wounded Healer has also been integrated into the medical school curriculum of four UK universities. In recognition for my services to public engagement and education, I was honoured to be a Finalist of the 2015 and 2017 Royal College of Psychiatrists Psychiatric Communicator of the Year Award. The Wounded Healer: Evidence, not just Anecdote The Wounded Healer is data-driven and evidence-based; it contains all six key ingredients of effective anti-stigma programmes targeting healthcare providers as identified by Stephanie Knaak and colleagues at the University of Calgary. The main strength of the Wounded Healer is that it is delivered by an Expert by Experience. We know from the results of multiple meta-analyses that the most effective way of reducing mental health related stigma in adults is through social contact with someone who has recovered from mental illness. We conducted a pilot study with King’s College London Undergraduate Psychiatry Society to assess the effectiveness of the Wounded Healer at reducing mental health related stigma in healthcare students (this was a single-arm, pre- post comparison study). We administered validated psychometric stigma scales on participants before and after exposure to the programme and the results of our study showed statistically significant reductions in stigma variables (knowledge, attitude and behaviour). Leveraging the power of film and digital technology to challenge mental health related stigma I was extremely fortunate to receive invitations to deliver the Wounded Healer to audiences nationally and internationally however there were only so many talks that I could give (and only so much time, energy and resources that I had). In 2015, like a manna from the heavens, filmmakers from the London College of Communication approached me and offered to commission the production of the Wounded Healer film. We know from multiples studies on healthcare providers that virtual (i.e. video) contact with an Expert by Lived Experience is effective at reducing mental health related stigma so I embraced this opportunity. The Wounded Healer film has since been screened at the Psychiatry and Arts Section of the World Psychiatry Association World Congress in Berlin and the Australasian Physician’s Health Conference in Sydney. The results of a pilot study conducted by University College London Psychiatry Society on the effectiveness of the Wounded Healer film at reducing mental health related stigma in medical students were also encouraging. The Wounded Healer Film Screening at the London College of Communication, London. Afterthought… Despite the perception that medical students and doctors should be ‘invincible’ the reality is that we are human beings and so we are vulnerable to developing mental illness just like everyone else is. Many medical students and doctors with mental illness continue to suffer in silence even though effective treatment is available and the consequences of this can be fatal. Indeed, Dr Daksha Emson, a multi-award winning psychiatrist with bipolar affective disorder, tragically killed herself and her three month old baby daughter during a psychotic episode. An independent inquiry into Dr Emson’s death concluded that she was the victim of stigma in the National Health Service. Succinctly put: stigma is killing people. I have learned, through lived experience, that stigma and a ‘culture of shame’ are formidable barriers to mental health services. The Canadian Psychiatry Association reported that conventional education alone will not reduce mental health related stigma in medical students. We must pioneer innovative programmes that break down the barriers to mental health services for medical students and doctors who urgently need them. We must embrace our vulnerability, be honest and open about our mental health and instigate a cultural revolution. According to Professor Brian Hurwitz, an eminent scholar in the health humanities based at King’s College London, there is a growing perception that science alone provides overall insufficient foundation for the holistic understanding of the interaction between health, illness and disease. The health humanities, therefore, emerged as a distinct entity in attempts to ameliorate the limitations in the provision of healthcare services and can be broadly described as the application of art and literature to medicine. The performing arts and storytelling both possess an extraordinary power and must be utilised to reduce mental health related stigma and as a tool to promote recovery from mental illness. The evidence is clear, Experts by Experience have the power to reduce mental health related stigma and must operate at the vanguard of any anti-stigma initiative. The Wounded Healer is an innovative anti-stigma programme that blends the performing arts with psychiatry that is delivered by an expert by both personal and professional experience and has been shown to reduce mental health related stigma in medical students. More research in this area must be conducted (and resources allocated) if we are serious about improving the mental health of medical students and doctors. For those of you experiencing psychological distress in any of its many forms, I know that the world can be a dark and lonely place, believe me I know. But please, don’t give up hope. Effective treatment is available and recovery can be a reality for the many, not for the few. If I can recover and realise my dreams, other people out there with mental health difficulties can realise their dreams too… Twitter: Dr Hankir Tweets as, ‘The Wounded Healer’ @ahmedhankir NOTE FROM THE EDITORS: We are so excited to have Dr Ahmed Hankir writing for InSPIre the Mind. Ahmed has used his lived experience and channelled performing arts to challenge stigma and we are very thankful that he was willing to share his story with us.

In her TED talk Dr. Sacks explains that, just like adolescence, ‘matrescence’ is a time of feeling “hormonal and moody…skin breaking out…body growing in strange places and very fast, and at the same time people…expecting you to be grown-up in this new way.” Both adolescence and matrescence are times when substantial hormonal and physical changes are occurring in a person’s body. In adolescence, at least, people are often quite considerate of the mood swings and behavioural changes that occur as the young person is learning how to navigate this large upheaval in their lives. Perhaps less often do we make these same allowances for pregnant women, often expecting women to be happy and excited for the upcoming arrival of their ‘bundle of joy’. In their PSHE (Personal, Social, Health and Economic Education) lessons at school, teenagers are taught not just what bodily changes to expect, but how to control and manage their new emotions as they develop from a child into a young adult. Antenatal classes, however, focus almost exclusively on the (albeit very important) medical aspects of being pregnant and giving birth, but lack time dedicated to the discussion of the psychological transition in identity from woman to mother, or the incorporation of the ‘mother’ role into a woman’s identity. This concept was one of the major take-home messages and largest discussion points from the Maternal Journal workshops. Maternal Journal has been described in detail in a previous InSPIre the Mind blog. In short, it is a programme of workshops set-up by Laura Godfrey-Isaacs, an artist and midwife, in collaboration with our lab’s Perinatal Psychiatry section. I and colleagues were fortunate enough to be invited to attend these sessions, aimed at supporting the mental wellbeing of pregnant women and mothers with a history of mild or moderate mental health problems. Unlike traditional antenatal classes, the aim of these journaling workshops, which explore self-expression and sharing through a variety of artistic modalities, is to discuss and reflect upon the psychological aspects of motherhood. Prominently-included in these discussions, although not termed such, is this concept of ‘matrescence’. In the launch event, one of the most positive aspects highlighted at the launch of the Maternal Journal workshop series was the focus of discussions on mothers as individuals, rather than ‘bodies carrying babies’ in the medical sense. The artistic aspect of the journals allowed women to share their feelings in an abstract form which made them feel more comfortable to open up. The conversations were open, honest and intimate. Attention was paid to ensure that a variety of different artistic methods were covered in a structured way, which removed the “I’m not creative” barrier that may prevent some individuals from participating. The activities ranged from collage to cartoons, and from poetry to exploring the history of female journaling. The focus was not on the quality of the art, but the art as a form of self-expression, or a way for the women to share their experiences. As Carmine Pariante said in the panel discussion, the use of art “created a sharing experience, which fostered a social connection that is often lost in modern Western culture”. “being listened-to is as important as speaking”.— Fran Burden, an artist involved in the project The practice of sharing excerpts from their own journals at the start of each session was very powerful, as it gave the women the freedom to express themselves to an audience who are truly and intently listening and, to some extent, understanding. The launch event was a true celebration of the success of this project. In my eyes, it is no great surprise that the project has received such great interest. Women have been journaling for hundreds of years and some female journals such as those of Fanny Burney and Anne Frank have been key political and social commentaries of their time. The word “radical” was used many times during the launch to describe this project, as women feel empowered to take time out for themselves prior to the birth of their baby, and beyond. Women have a lot to say about the social aspects of mothering and the political environment in which mothering is occurring in this country and further afield. This space to reflect on the upcoming life change, carved out prior to birth, is important for all women but particularly those who have a history of mental health problems. It allows them to feel, as Mo Ade said, that they are an “active participant in their own care”, where their feelings are not clinical, medical or made to seem like an illness. It allows women to take ownership of their own situation, and to understand that in many cases, their feelings, whether positive or negative, are largely understandable and even expected in the face of such a life upheaval and transition period, in the same way as we expect mood swings of teenagers going through adolescence. Perhaps we should be acknowledging ‘matrescence’ as a life stage for women, and perhaps even ‘patrescence’ for men, and be providing more reflective spaces, like this Maternal Journal, to allow people to explore and share their feelings during such an upheaval in their emotional and practical lives as new parents. Note from author: Alexandra Sacks has also blogged on Medium about Matrescence, see links below: Matrescence — what is it? Why we NEED the word “Matrescence” header image Source: Mom loves best

Adolescent depression is on stage in London: at the KILN Theatre, in ‘The Son’ by Florian Zeller, and at the Royal Society of Medicine, in a timely conference. I went to see ‘The Son’ by Florian Zeller at the KILN Theatre in London a few weeks ago. It’s the final part of a trilogy — the preceding parts being ‘The Mother’ (focused on a woman’s depression when her children leave the family home) and ‘The Father’ (focused on old-age dementia). I knew that this play was about adolescent mental health, but I didn’t expect it to be quite so moving. It was as though all of a sudden somebody had taken me back to my days as a trainee in the Psychiatry ward. “He’s not like he was before. Believe me, I don’t know what’s happened, but something has. He’s changed. He … And I’m wondering if … to be absolutely honest with you … I’m even wondering if …” Anne (played by Amanda Abbington) has just discovered that Nicolas, her son (Laurie Kynaston), has been skipping school for months, so she asks for help from her ex-husband and Nicolas’ father, Pierre (John Light). Anne explains that Nicolas is not the same smiling boy that he was just two years before, before their divorce. Something has changed. Nicolas’ solution is to attempt a fresh start by moving to his father’s house, where he lives with his new lover, Sofia (Amaka Okafor), and their baby son. But, in the new home, Nicolas feels unwanted. He is not able to explain what’s happening to him, the reason for his self-harming or why he keeps skipping school. When his depression deepens, we find ourselves wondering what could really help him, until a moving and tense dialogue with a psychiatrist puts Nicolas’ parents in the position of making a critical decision about his wellbeing. At the end of the play I found myself joining in with the standing ovation and clapping as loud as I could. I will try to describe my response to the play, without spoiling it too much for those of you who still want to watch it (it will transfer to the West End in August). The play brilliantly depicted the family interaction: the impossibility of communication between adolescent and parent. We could see clearly Pierre’s frustration and Nicolas’ desperation, but despite their efforts, my impression was that father and son were not listening to each other. There are harrowing moments in the play. For example, when Pierre finds out that Nicolas is secretly self-harming. On one hand, Nicolas does not ask for help and does not share with his father his inner feelings. He is completely absorbed in his own pain, his energy is sapped, and he can barely speak. He rarely smiles or relaxes and looks every bit an outsider — even when surrounded by people who love him. Nicolas, as I soon realized with my clinical hat on, is deeply depressed. On the other hand, Pierre’s genuine interest in understanding Nicolas soon gives way to his own feelings and concerns. He is in pain as well, the pain of a father who realises that his son is self-harming, but doesn’t know what to do. From a certain moment in the play, the characters seemed to decide to ‘close in’ rather than reaching out to the other; we could feel their loneliness with heaviness in our heart. Anne, for her part, looks frozen, as if she is too scared to know what’s really going on. She seems lost, and she even says so. Overall, the pain takes shape in each character in very different ways, but my impression was that behind their pain there is a constant, overwhelming fear. When offered psychiatric help in the hospital, Nicolas reaction is “How do you think I’m going to get better if I’m surrounded by people who are much sicker than I am?” This scene reminded me of a doctor that used to work in the Psychiatry ward where I was a trainee. When people in A&E were refusing to be admitted because, in their own words, “there are people much sicker than me here”, she used to reply, “But you are the most severe in this moment, because you’ve just arrived, while the others have already started to recover”. Mental health problems are always real, even if they have different degrees of severity, and they are heart-consuming not only for patients but also for their relatives. Thus, nobody should feel ashamed of asking for help. Unfortunately, a lot of people, and especially adolescents, give in to the fear and refuse to seek or receive psychiatric help, or be admitted to a Psychiatric Unit even if it truly necessary. But, as I said in my previous article on treatment-resistant depression, fear comes from the unknown. Zeller himself, in a recent interview with the BBC about ‘The Son’, said that, “there is something taboo about mental health … there is a lot of shame and ignorance about these problems and I think there are many young people that suffer, and it is important to see that, show that and share that”. This is also important for parents, who often feel alone in these moments and don’t know how to deal with their children’s suffering. Early interventions for young people’s mental health. What can be done to identify and treat depression in adolescence? This was discussed just last week in a conference at the Royal Society of Medicine (RSM), on “Transforming Children’s Mental Health in Schools: targeted interventions”. This conference brought together medical and educational professionals and parents, to find new ways to take care of school children and young people with mental health needs. Do not worry if you missed it, as similar other events will follow! Today, one in eight (12.8%) 5–19 year olds have at least one mental disorder, according to a 2017 NHS survey. In particular, 2.6% of adolescents experience depression at any one time, with double the risk in females. The school might just be the safe and familiar environment where it might be possible to identify and treat these mental health problems. For example, a project led by Professor Shirley Reynolds (University of Reading) consists of administering a simple screening questionnaire for mood and feelings to school students, in order to identify possible difficulties, followed by the clear question: “Do you want help with that?”. Then, students and parents can choose to go ahead with trained therapists for a few sessions of a psychological therapy called ‘Brief Behavioural Activation Therapy’, which supports and encourages adolescents in “doing more of what is important to them”. This approach has shown some good results in terms of improved depression and increased well-being. Another exciting research study, currently ongoing at King’s College London, is the MQ’s IDEA project. This study is led by Dr Valeria Mondelli, also president of RSM Psychiatry section. It analyses cultural and family environment, stressful experiences, brain images and stress measurements of people aged 10–24 from the UK, Brazil, Nigeria and Nepal. The aim of the project is to identify global and context-specific risk factors for depression in adolescence, involving high- and low-middle-income countries around the world. Such risk factors (ranging from biological, to cultural and social ones) could then be integrated into health care services across the world, and could help to early identifying and treating depression in young people. For the general public, several online learning courses are now available to help parents and teachers to identify signs of depression in adolescence. These are just some of the initiatives that are ongoing to promote early intervention in adolescent depression. There is still a lot of work to do, but at least now it is the time that academics, clinicians, mental health professionals, teachers, parents and young people are all coming together: they are all working together to create preventative interventions. So that next time someone like Nicolas is depressed — in real life, not in a play — a parent or a teacher can realise what is going on, and can approach him in the most considerate way, encouraging him to see a mental health professional who can offer him a treatment that is meaningful and engaging. Let’s use what we see on stage to help us make real life better! header image source: The londonist

Film has always been a powerful and stirring medium for storytelling, especially around the theme of mental health. Here, we reflect on the power of film in creating conversation around stigma and the complexity of the human condition — through the films shown at the MedFest film festival, “Inside Outside” last April. Wilson and WIT H IN drew out the taboo and difficulty around speaking out about struggles with our emotional state and mental health. John Ogunmuyiwa’s Wilson captures the superficiality of our modern social exchanges, where “How are you?“ skims across the surface of the true state of our being. Wilson, the main character, is caught in one such exchange when the cracks in his composed exterior break down — revealing him trapped in the bleak forest of his mind. Little does he know that his seemingly put-together colleague walks a similar path. In WIT H IN by Crowns & Owls, we see a man scramble on all fours, desperate, animalistic and primal, through a hostile landscape barren, with jagged rocks, sheer cliffs and fire — a volcano waiting to erupt. We sense his fear, his desperation, his struggle for survival. The suspense of what comes next is defused as we see him in a different room, smartly dressed. “That’s how it feels…”, he says to his psychiatrist — who responds with an empathetic nod. Coincidentally, the main characters in both films were young black men. With the festival panel, we discussed whether the films were positive and progressive — in encouraging and normalising help-seeking within this population, or whether it was problematic. Young black men are the most overrepresented within the mental health system and more likely to be sectioned under the mental health act. This raised the question of ethnocentricity and systemic bias within the NHS. The varied cinematic techniques used across the films presented the opportunity to talk about film as a versatile medium of expression and storytelling. We talked about how filmmaking requires empathy — knowing your audience and your actors as well as how to honour and respect people’s identities and stories, while not being patronising. In these two shorts we were taken on a journey across the spectrum of realism — with Wilson and WIT H IN set in live-action, but with increasing elements of fantasy. When we arrived at Eggand Wood, we were thrust into a fully animated, surreal world — which perhaps sets the backdrop for the telling of narratives which may be quite far removed from the reality that most of us encounter. Egg is told through black and white animation, stark geometric shapes and vivid imagery, a retelling of director Martina Scarpelli’s personal experience. The soundtrack is intense and enveloping. It depicts a woman locked within a cube with an egg. She simultaneously admires and fears the egg. Her daily routine is lived out through routine and ritual, especially when it comes to her struggles with food, citing “doctor’s orders”. She eventually eats the egg and destroys it. Wood, by Sean Sears and Tor Freeman is the eerie tale of a lonely dollmaker, passing his days in isolation, told through the disarmingly innocent visual feel of a fairy tale. The doll-maker’s loneliness is magnified by the happy lives of those around him. He decides to make a doll in the likeness of a person, whose picture he keeps with him in a locket. Initially, he lives in a fantasy world accompanied by the doll. Things take a dark turn when the doll seems to take on agency of its own, becomes a giant, evil creature and eventually pursues the dollmaker through the city. The dollmaker is forced to confront it and ultimately kills the doll. The film closes with him cradling the lifeless body of the person he once held dearly. These films offered the opportunity to think about the conscious and unconscious lenses and frames through which we viewed them. We wondered if the topic of race would have come up if Wilson and WIT H IN were shown separately, and not consecutively. Similarly, we talked about “showing, not telling” and to what extent a narrated voiceover helped with conveying the story within the film. This was particularly pertinent in Egg, where the voiceover specifically mentioned anorexia. For some, this had the effect of breaking the intrigue and tension within the narrative. Moving further inward, we took away different interpretations (and projections) from Wood, which was absent of any spoken word. These ranged from grief — and the confronting (and resolution) of grief, to thinking that the doll-maker might have been guilty of causing his loved one’s death. This was made especially interesting given that the makers of Wood had not intended it to be specifically about mental health. Ultimately, seeing is believing. For the past 10 years, MedFest has celebrated the power of film to move and inspire through bringing people together in conversation and reflection around themes related to mental health. The film screening and panel discussion hosted by KCL PsychSoc was (and will be) one of many happening around London, the UK and the rest of the world. If these themes have resonated with you in any way, don’t miss out on the chance to be part of upcoming MedFest screenings, especially the Keynote events at the IoPPN (3rd June 2019) and the RCPsych (5th June 2019) — where we will be joined by mental health campaigner Jonny Benjamin MBE as well as some of the filmmakers themselves! About the Festival Panel Chair: Dr Sotiris Posporelis, Neuropsychiatrist @Pospo Jonny Benjamin MBE @MrJonnyBenjamin: An award-winning mental health campaigner, film producer, vlogger and public speaker, bringing his powerful lived experience of mental illness to the fore. Dr Adnan Raja: Medical registrar and filmmaker @addyfilms, as well as committee member of MedFest. Psychiatrists and film enthusiasts Prof Carmine Pariante@ParianteSPILab and Dr Sally Marlow@drsallymarlow of @KingsIoPPN. Image Credits: All obtained from the MedFest website. header image: Graphic created by Mao Fong Lim

Maternal Mental Health Matters Awareness Week 2019 has just started, and we are going to celebrate it today with the launch of the Maternal Journal website. It’s Maternal Mental Health Awareness Week, dedicated to raising awareness about mental health problems in pregnancy and in the postpartum. Thus, today is the perfect time to celebrate the success of Maternal Journal, with its website launch today, and to tell the stories of Hannah and Laura. Laura, is an artist and midwife who has decided to use art to help women with mental health problems during the perinatal period. Laura’s successful initiative, Maternal Journal, promotes creative journaling as a way to explore thoughts, feelings and personal experiences around pregnancy, birth and mothering, with the aim of promoting mental health and well-being. It helped Hannah so much in September 2017, when she first met Laura. Hannah experienced mental health problems after the birth of her second child, and so during her third pregnancy this was a big concern for her. And this is why she attended the Maternal Journal project, and met Laura. Maternal Mental Health Matters Awareness Week is a global initiative, offering an opportunity to reflect on how society can protect mothers, and their babies, from mental health difficulties. Social support (information, advice, practical help and emotional reassurance) from partners, family, friends and the community is one of the strongest factors in protecting women from depression and anxiety, in both pregnancy and the postpartum, something we recently discussed alsoin another blog on InSPIre the Mind. It is not surprising that many traditional cultures advocate a ‘protective’ period around birth and for the first few weeks after delivery. During these periods, the mothers and babies are confined to their homes, discouraged from engaging in household chores or work activities, and surrounded by women in the extended family who help by preparing food and assisting with postnatalcare. While of course some of these restrictions can have their own negative consequences, they are at least a testimony to a time when motherhood was recognised as an experience that involves a large network of relatives, friends and local community. In 2017, Laura had a simple idea: to transform motherhood again into a collective, sharing experience, through a series of free creative workshops for pregnant women with a history of mental health problems. She called it Maternal Journal, because it focussed on exploring the history and practice of journaling. In the meantime, Hannah was going through her antenatal care, and finding that the preparation did not include much discussion of mental health. She had one extremely dissatisfactory counselling session that was difficult to organise, and antenatal courses that did not provide the space or support to explore her concerns. Her experience was not so different from that of Lynn, on whom I have written about before, who had previously developed severe postnatal depression, and who also participated in the Maternal Journal. When Hannah stumbled across the chance to participate in the Maternal Journal, she felt, in her own words: “like a door had been opened and the light flooded in” Hannah felt relieved that the focus of Maternal Journal was not just on the babies, but rather on the women mothering, as part of a long trajectory of collective female experiences, identities and voices. The group was mixed in terms of first-, second-, and third-time mothers: some had already given birth and others were at different stages of pregnancy. This made the sessions rich with a pool of experiences to share, reflect on, and gather support from. Hannah’s experience was further enhanced by seeing how the invited female artists, such as Holly McNish, Kate Evans, Rebecca Fortnum and Fran Burden, could channel their experience into acerbic comic creations, bringing relief and levity to a mother’s experience without undermining or downplaying it. Maternal Journal explores the tradition of women's diary and journal keeping as an expressive, creative and therapeutic practice for pregnant women with a history of mild to moderate mental health problems. Film-maker: Martim Ramos Maternal Journal is a collaboration between King's College London's Department of Psychological Medicine and Laura Godfrey-Isaacs, brokered and supported by the Cultural Institute at King's. The artists’ contributions encouraged all the participants to experiment with their own creative skills, and to value their own voice and experiences. All together during a Maternal Journal session: Laura (first from the left), Hannah (sixth from the left) and me (the only man) sitting on the left of ‘Cartoon Kate’ Evans. Photo: Martim Ramos. Furthermore, Hannah felt strengthened by this time to reflect, with other pregnant women, on the wider politics and history of motherhood, feminism and creativity. Maternal Journal explores the tradition of women's diary and journal keeping as an expressive, creative and therapeutic practice for pregnant women with a history of mild to moderate mental health problems. Film-maker: Martim Ramos Maternal Journal is a collaboration between King's College London's Department of Psychological Medicine and Laura Godfrey-Isaacs, brokered and supported by the Cultural Institute at King's. When Hannah had her 8-week postnatal check-up, she was given the widely-used Edinburgh Postnatal Depression Scale to complete. While reading its questions (has she been able to laugh and see the funny side of things? Anxious or worried for no good reason? So unhappy that has been crying?) she felt more equipped to maintain better mental health herself, through participating in a project that introduced her to the benefits of creative journaling, as well as a widened network of inspiring, supportive women. Maternal Journal featured in the Arts in Mind Festival in June last year, and today it launches its website. There are nine journaling guides, each produced by a different artist, introducing interested women to creative techniques and ways of using a journal. The guides are also designed to generate ideas and conversation around the tradition, history and culture of pregnancy, birth and parenting. Most importantly, Maternal Journal is described as an ‘inclusive project’. The websites says ‘We welcome all pregnant women*, mothers and people that birth, positively encouraging inclusion and diversity of experience. On this website, and in our promotional material, the use of the word ‘woman*’ is intended as inclusive and generic to cover any person who ‘births’, identifies as a ‘woman’, ‘mother’ or as a ‘gender non-conforming parent’. Which is a powerful reminder that pregnancy, and maternal health, is more than just ‘inclusive’: it’s everyone business. While maternal mortality (that is, mortality around the time of giving birth) fell by almost half between 1990 and 2015, it is still incredibly determined by social and economic factors, with rates that are 80 times higher in low income countries than in high income countries. In the meantime, maternal mortality is rising in the United States, and infant mortality is rising in the UK. This is at a time where the predominant view among (the current) political leaderships in these countries is that we should cut public services. But, if we — the citizens, all of us — do not think of mothers and of the future generations, and take responsibility for their health and wellbeing, who will? A previous version of this blog was published on The Mental Elf platform in 2018. header image source: Hannah Lamdin, with photo by Lara Peake