In a world where one-third of households could struggle to meet the rising cost of living, it can be stressful to make the right decisions, whilst still monitoring our impact on the environment. Today more than ever, buying cheap products to cut costs is becoming increasingly more appealing. My name is Lea and I have newly joined Inspire The Mind. As a new graduate from Gen Z, it seems that we are living through so-called ‘once-in-a-lifetime’ moments, one after the other. I write this piece from the perspective of someone who feels that they are constantly threatened by the ongoing responsibilities that they have learned to juggle, including my ecological footprint, and understanding my effects on our blue planet. But in today’s world, how can people afford to be concerned about the environment? The ‘Net Zero’ Plan vs. The rise in costs Many countries across the globe have finally started to consider the pressing matter, and governments are slowly increasing their efforts to become Net zero by 2050. Ultimately, ‘Net Zero’ is a plan and commitment by governments across the world, to extract as much carbon as their countries emit into the atmosphere. However, many households in the U.K. are facing the largest spike in cost-of-living prices in over 30 years. Due to Brexit, Covid-19, and current socio-political issues, we have now entered a recession and have started seeing food supply shortages, panic buying, and fuel price increases, among other issues. If you’re interested in reading more about the ongoing fuel crisis and the interventions that could improve health and wellbeing outcomes, check out this blog. Ultimately, lower disposable income will mean people will start considering immediate impact before long-term issues, by choosing cheaper options such as less organic or free-range products, which usually have a lower environmental impact. According to Donvan, manager of ‘Everyday Green’, an alternative to non-sustainable products, people may avoid spending more on reusable items as they require more upfront investments than a cheap disposable alternative. Therefore, there is a real fear that pollution and emissions will increase. ‘Sustainable living’ has become somewhat of a luxurious trend, as organic and sustainable food, clothing, and other products are often more expensive. But what if I told you that living more eco-friendly is possible even during times of hardship, and it might even help you save money in the long term? Being better for the environment to save money In the short term, the rising costs will inevitably affect our environment, however, there are some long-term silver linings. Currently, the rise in costs will provoke consumers to seek cheaper, less sustainable options that will allow them to save money immediately. Yet, in a couple of months’ time, the constant financial pressure will lead many people to seek more sustainable ways of living. When looking at the issue from a business perspective, other than following trends, consumers are becoming increasingly aware of their personal environmental impacts and use that judgement to make purchase decisions. From this shift in priorities, many businesses are having to include Corporate Social Responsibilities in their mission statements. However, despite the efforts, most companies will be seeing their own internal costs increase and will try to save where they can. Unfortunately, this may lead to a compromise in their eco-friendly processes and material sourcing. Williams, founder of Greenpark, thinks that “whilst the companies that are already using sustainable practices are unlikely to reverse, as they would risk losing a loyal customer base, companies that have not yet started would be discouraged and are unlikely to start prioritizing sustainability”. You may have often thought “But I am only one person, I am not going to make a difference”. However, what if I told you that every little thing you did brings us one step closer to a greener planet? Any positive action you can take, big or small can drastically improve your carbon footprint. Here are a few of the things you can do as of today to save money and the planet: Shop locally. Find the best prices for the least amount of travel. Shop cheap and sustainably at food stores that have been ranked as top in sustainability: Lidl, Hello-Fresh, ASDA Eco, the Waitrose sale section, among many others. If you want take-out, think about your footprint at: Leon, Wahaca, Dishoom, Honest Burgers, Cajuu and Chipotle. If you’re thinking about your washing products, check out: Persil Bio, Smol, EcoVert refill, M&S Gently Does It, among others. Decrease your food waste and store your food correctly. Invest in tupperware! Ditch individually wrapped goods. Buy reusable wraps and covers for £5! Decrease the use of single-use and disposable plastic. Buy a reusable water bottle and make it your own! If you’re thinking of long-term solutions, consider: Insulating your home Controlling your fuel systems and heating methods Using transport alternatives such as public transport, cycling or car sharing Decreasing your food waste and storing your food correctly Start planting and make your own compost Checking your order’s delivery journey and tick the eco-friendly option before buying — it can even be cheaper Getting paid and be green: Return plastic/glass, make money from recycling plastic bottles, sell unwanted items such as clothes, create new habitats and get involved in woodlands, wetlands, and grasslands. For more inspiration, read: Everyday Green. Overall, there is no doubt that short-term emissions will increase as people find ways to deal with the everyday complexities of rising costs. Whilst there will be hard months ahead, and fewer and fewer people will be able to afford to be concerned about the environment… just remember: any step, no matter how small, can add up to a long and positive chain in securing the longevity of our planet and all who live on it. Header image: Photo by Noah Buscher on Unsplash

From the 1st of October, most people residing in the U.K. would have seen an increase in their bills, and approximately one in four adults plan to keep their heating off this winter. This has been long discussed, and different policies have been put in place to reduce the concerns of many. I am Gargi Mandal, a research assistant at the Stress, Psychiatry and Immunology lab, and I am keen to understand the impact of the energy crisis in the upcoming months. In this blog, I am going to briefly summarise the ongoing fuel debacle and explore energy efficiency interventions that have had a positive outcome in small-scale studies. This situation will not only pose financial challenges, but it will also be physically and mentally excruciating for many. There is a strong relationship between cold temperatures and cardiovascular and respiratory diseases. Also, a review published in the Public Health Journal also highlighted the relationship between living in cold or damp conditions and decreased mental wellbeing. More than 1 in 4 adolescents living in cold housing are at risk of multiple mental health problems compared to 1 in 20 adolescents who have always lived in warm housing. What has happened thus far? In 2021, as the country started to come out of the pandemic, the demand for gas increased exponentially. Subsequently, there was a shortage in supply which led to an increase in price. Many smaller energy providers collapsed, and Ofgem, the energy regulator, moved their customers to other companies, which were often more expensive than their previous suppliers. A total of 31 companies went bust and Bulb, a 2-million customer renewable energy supplier, has been under special administration, which is designed to protect customers’ credit balance, and during this time, the company can still operate as usual, but could be sold to another suitable company at any time. Moreover, the ongoing war in Ukraine added to this dire situation. Prior to the war, Nord Stream 1, the Russian pipeline, supplied 35% of Europe’s energy requirements, therefore, the prohibition of Russian gas has exacerbated the energy crisis. Additionally, the political uncertainty, until recently, regarding the next UK Prime Minister has significantly staggered the proposal and implementation of an energy plan for the upcoming months. From the 1st of October, the energy price cap has been set to £2,500, however, this is just an estimated measure and people will pay more if they use more. The cost per unit for gas and electricity has been fixed and is currently set to 10.30p from 7.4p per kWh for gas, and 34.00p from 28.3p per kWh for electricity. This is in addition to the increase in standing charges, which is a fixed charge for gas and electricity line costs per day. Furthermore, the cost of energy has affected different sectors. It has driven up the cost of production, transportation of goods, businesses and has negatively impacted the hospitality industry. These costs will ultimately need to be borne by the consumers, an additional expense at a crucial time. How can this situation improve? The current PM, Liz Truss, has promised to freeze energy bills at an average of £2,500 a year for the next two years, and a combination of government schemes has helped alleviate some of the stress. In addition to the means-tested schemes, former chancellor Rishi Sunak had put in place a £400 discount on energy bills, the Energy Bills Support Scheme, which started in October. Under this scheme, all households will receive a deduction on their energy bills until March 2023. Subsequently, many families are going to feel the real pinch in April, and the Energy Saving Trust is campaigning to provide additional support and to remove the Value-Added Tax on energy which can save around £90 for every household. In terms of future plans, better urban planning with higher energy efficiency could have a positive effect. A study published in 2017 investigated the short-term health and psychosocial impacts of a domestic energy efficiency programme in low-income areas in Wales between 2013–2015. The data from surveys indicated that the programme increased subjective wellbeing, improved psychosocial outcomes and reduced social isolation. Similarly, in Northern Ireland, as a part of a fuel poverty programme, energy efficiency measures, including some central heating systems, were installed in 54 homes. The intervention improved health and wellbeing, increased comfort levels in the home and reduced the use of health services, therefore having potential cost savings for the NHS. With these studies in mind, a large-scale study consisting of the WELLBASE urban intervention programme will be conducted in 6 European countries with 875 participants over 12 months. This intervention aims to reduce the effect of energy poverty (the inability to afford basic energy services to guarantee a decent standard of living) on peoples’ health and to provide new insights into the effectiveness of a comprehensive urban programme. What can we do on a personal level? Approximately £65 a year can be saved by turning appliances off standby mode. Additionally, draught-proofing of windows, doors and blocking any cracks in the floors can significantly reduce heat loss. In the kitchen, using a full dishwasher and not overfilling the kettle can help reduce costs. In terms of washing, 30-degree washes instead of higher temperatures and avoiding the tumble dryer can be beneficial. These are just a few simple yet effective steps that can help many in the upcoming winter. Furthermore, if you are interested in tips to save money and the planet, this blog from another Inspire the Mind writer is the one to read. For additional advice on everything, Citizen’s advice can help. This is a time of crisis, and it requires support on various different levels. The Government must support those who are most vulnerable. Future energy efficiency programs should be implemented. And each of us can do our own part in saving energy and reducing the costs.

Dealing with Mental Illness on the Road (How the Beats Inspired Me to Live a Life of Purpose and Fulfillment) For me, Jack Kerouac was a hero who became an eccentric but distant alcoholic. Early inspiration in my life ultimately came from the Beat writers of America. It had been the first movement in the country associated with hippies, dropouts, burnouts, druggies, artists, and malcontents. This was a literary movement that inspired a generation. My name is Bryan, and I’m a published author. Previously, I worked as an audio engineer, traveling with a Beatles impersonation band. Then I switched to working as a copywriter and began tutoring and teaching English to ESL (English as a Second Language) students. In 2018, I left the U.S. for Italy and then made my way to Southeast Asia. The following year, I traveled to 12 countries. I spent the last two years living in Da Nang, Vietnam (mostly) while working remotely during the pandemic. I’ve also self-published 15 books. I wrote about Allen Ginsberg’s impact on my life for a literary magazine dedicated to the Beats. His famous poem Howl astounded me with its ferocious opening stanza that begins with, “I saw the best minds of my generation destroyed by madness…” The poem had been dedicated to a friend in an insane asylum. (Ginsberg’s mother had experienced the same.) Mental illness was at the heart of the world’s most important literary movement of the 20th century. Kerouac read his poetry while binge drinking from a jug of wine. On the Road was published a year after Howl. Like Ginsberg, Kerouac’s masterpiece became the voice of a generation. In his letters to his family and friends, he was somewhat manic when it came to developing his work routines. Sometimes he even asked his agent to help him get speed (or one of its derivatives) so he could write his next book. I followed in Kerouac’s footsteps like many boyish, middle-20s, flannel-wearing dudes across America. That led to broken relationships, switching jobs constantly, and never really finding my place under the sun. Kerouac did his best to stay at home with his mother, but Ginsberg preached his views through public appearances and lectures. He implied that the materialism and conformity of modern America often acted as precursors to addiction and mental illness. That dichotomy lived within me. Between poet and madman, shouting from the rooftops by way of my actions, a rebellion I saw in myself and others around me. I had to escape the ordinariness of American modernity. It seemed to be leading us toward the precipice of a disaster. Today, On the Road is taught at Yale University. (Where I recently submitted my second full-length play to their Drama Series contest.) And where is America now? Traveling the World (Which is My Home) Before the pandemic began, which initiated a noticeable rise in anxiety and depression, I was traveling the world. My journey began back in October 2018 when I took a one-way flight from Newark, New Jersey to Rome, Italy. I remember distinctly being on the plane during a turbulent patch when it felt like the whole world was ending as the plane tossed and writhed through dark gray storm clouds and intermittent flashes of lightning. A girl in the seat across the aisle, terrified, curled up into a ball on her seat, clutching her knees in sheer terror. Traveling the world brings to the surface some things you might have kept hidden in normal, everyday life. Like, for instance, being afraid of death. So, the worldwide COVID-19 pandemic felt like a rude awakening that still hasn’t gone away. Finding My Place in This World I ended my traveling after visiting 12 countries in 2019. After a failed relationship with a beautiful Chinese girl, we separated in Malaysia. I came back to Vietnam. Before I get to that, another thing most people don’t realize about themselves is finding their place in the world. That is the whole point of defeating mental illness or at least being able to overcome it. The best part of being a human being is that we get to observe the world. And through that, we get to know ourselves. That change came to me (or it rose to the surface) when I was mid-way through traveling to 12 countries in one year. I was walking along the streets of a neighborhood on the outskirts of Istanbul. Looking up at the bright blue sky with wispy white cotton clouds, I felt that the Earth, finally, was my home. I had that feeling for a bit when I was in Rome. But I also felt that way when I got back to Vietnam. It was my third time in the country. I had truly missed Da Nang, which is a gorgeous beach city alongside the central highlands. A big Buddha statue (Lady Buddha) oversees those dangling cotton swabs misting over a twinkling, crystal clear, blue-green sea. Arriving in January 2020, the mellow, vibrant streets came back to life as the rainy season waned in the rearview mirror and tourists abounded for the start of the Chinese New Year/Tet holiday. Little did we all know our lives would soon be turned upside down for the next 20 months. The Road Ended in Da Nang, Vietnam Da Nang escaped the pandemic for most of 2020. I met lots of people who had left their worlds filled with malaise, cloudiness, and despair for their place under the sun. Literally. Then the next summer came, in 2021, and the Delta variant finally arrived in Vietnam. Dealing with mental illness on the road during a pandemic became a lot harder when you were forced into a seven-week lockdown. I spent the whole first day of a new lockdown with a Vietnamese girl I’d been seeing. We shared the same birthday. Through the big windows of a beachfront hotel, the sea glistened. Birds hovered, scattered, and soared. Fishermen baked in the relentless sunshine. Dystopia began to appear. The local government shut down businesses, set up checkpoints, and then forced the entire city of 1.1 million people to remain indoors for three weeks. I got stuck in a 25-floor hotel with only two other guests. Some of the staff moved in during the stay-at-home order. I had room service. Soon, mental illness reared its ugly head. Suddenly, I had to rebel. There were barricades put up between neighborhoods. I wanted to knock them down. But really all I could do was to follow orders. Vietnamese are some of the warmest, friendliest, kindest, and most generous people you could ever meet. Mental illness in their country is taboo. And nobody questions the government. I saw everything differently, again. Da Nang began to look ugly in a brutal lockdown, and America to me seemed to be one of the greatest places in the world. After somewhat of a mental breakdown, I knew I had to get out of living each day as a prisoner. I told the girl I’d been seeing that the lockdown felt inhumane. She thought that was a bit harsh. Foreigners were not able to renew their tourist visas any longer. I joined a Facebook group of others looking to take a bus to one of only two international airports in operation. I could no longer handle sitting inside for weeks at a time with no end in sight. So, I made my escape. What I Learned from the Pandemic and Traveling the World The pandemic and traveling the world taught me that it doesn’t really matter where you are, but what you make of your life is what really counts. Some people prefer their cage. In a strange way, it helps them to feel safe. Others prefer freedom. The Beats spoke to that sentiment through their art. Writing becomes a form of escape when there isn’t any. What’s yours? Stray cat in Istanbul, Turkey. Author’s photo. (July 2019)Stray cat in Istanbul, Turkey. Author’s photo. (July 2019)

Gene-Environment Interplay in Depression and Body Inflammation: How do our genes interact with our childhood experiences? I am a researcher in Psychobiology and Epidemiology at University College London trying to understand the pathways through which psychosocial factors (e.g., stressful life events) influence our mental and physical health. I have been fascinated by the nature vs nurture debate surrounding the origins of depression since the beginning of my scientific career. I’m pleased that this debate has finally been solved, and it is now recognised that both the environment in which we grow up and our genes may contribute to depression and its underlying biology. But how does this happen? How do nature and nurture work together to shape our mental health? I’m very excited to share with you some new insights into the mechanisms by which our genes and early-life experiences may interact with each other and affect our risk of experiencing depression and body inflammation later in life. The role of early-life experiences in depression and body inflammation As discussed in an earlier blog, depression is a common mental health problem characterised by varying and sometimes opposing psychological and physical symptoms (e.g. depressed mood, feelings of guilt and worthlessness, loss of energy and fatigue, restlessness, decreased or increased sleep and appetite), which can have a devastating impact on our daily lives. Depression negatively affects the way we feel, think, and behave, influencing our relationships with people, productivity, and ability to work, and it can also lead to chronic physical diseases such as cardiovascular disease and diabetes. Unfortunately, many people affected by depression do not respond well to current antidepressant treatments, and the reasons for this variability are not clearly understood. Several environmental and biological factors are thought to contribute to depression, as no single mechanism can fully explain all aspects of this complex, multifactorial disorder. Childhood experiences, for example, are particularly important in shaping our mental health throughout the course of our life. Many studies have found a strong connection between exposure to adverse childhood experiences (ACEs), such as abuse, neglect, and family conflict, and the risk of depression in both children and adults. Our brain undergoes many changes during childhood, and for this reason, it is particularly vulnerable to the neurobiological effects of early-life stress. The immune system is an important pathway through which ACEs may become “biologically embedded” and affect our susceptibility to depression. When we experience high levels of stress our immune system acts as if there was an infection (even if it’s not actually there!) and produces more immune signals (i.e. cytokines), leading to high levels of inflammation in the body. In turn, elevated body inflammation can affect the way in which our brain works and predispose us to the psychological and behavioural symptoms of depression. Indeed, many studies suggest that individuals with ACEs, as well as people affected by depression, often have increased levels of inflammation in their bodies. A recent study has also found that adults who experienced traumatic events during childhood have elevated body inflammation, which in turn is related to a higher risk of future depressive symptoms. This suggests that early-life stress may affect depression through its long-term negative effects on the immune system. What about the role of genes? At this point, you are probably wondering how our genes are involved in all this. It is worth noting that not everyone experiencing high levels of stress will necessarily manifest body inflammation and develop depression later in life. Our genes could help us understand why some of us respond more negatively to stressful environments than others. Thanks to recent advances in the field of genetics, researchers have been able to identify specific genetic variants found across all genes carried by an individual that are associated with their susceptibility to specific diseases. These variants can then be combined into a polygenic score that represents our genetic risk of developing a particular disorder, as explained in a previous blog. An important finding of this research is that both depression and body inflammation are associated with several genetic variants, which means that many genes could affect the development of these disorders. However, these polygenic influences only explain a small proportion of our overall likelihood of experiencing depression and body inflammation (around 10%). This result is perhaps not surprising if we consider the multitude of environmental factors associated with these disorders (e.g. stress and unhealthy lifestyles). How are our genes and early-life experiences linked together? It is thus apparent that both ACEs and genetic factors can increase our susceptibility to depression and body inflammation. But it’s not exactly clear whether and how these two factors might interact with each other to shape our mental health. Some researchers have suggested that our genetic make-up can make us more or less sensitive to the impact of early-life stress on mental health. In other words, the chances of developing depression following the experience of traumatic events might be much greater for a person who is at high genetic risk for depression than for someone at low genetic risk for depression — in science, this is known as a ‘gene-environment (GxE) interaction’. So, our genes could explain why not all people affected by ACEs will become depressed later in life. Earlier research testing the interplay between genetic and environmental factors in depression has provided us with inconsistent results. Some studies found evidence for the proposed GxE interactions, but many others failed to replicate these effects. The main issue here is that most studies to date have focused on individual genetic variants linked to depression, rather than considering individual differences in polygenic scores. Polygenic scores capture the cumulative effects of several genetic variants, and therefore they are better indicators of our genetic risk for a particular disease, compared with the effects of individual genetic variants. We also don’t know yet whether GxE interactions might contribute to our inflammatory responses to early-life stress, as very limited research has looked at this. For instance, the impact of stressful events on the immune system could be greater in people with a high genetic risk for body inflammation than in those at low genetic risk. What did my research show? During my PhD in Psychobiology & Epidemiology at University College London, I carried out a study focusing on the interplay between ACEs and polygenic scores in depression and body inflammation, which is now published in Psychological Medicine. I analysed data from a large cohort study of older adults living in England, known as ELSA (English Longitudinal Study of Ageing). This dataset is well suited to study the role of genetic, environmental, and biological factors in depression because it includes many assessments of depressive symptoms and blood concentrations of C-reactive protein (CRP; an inflammatory marker) over time, polygenic scores (PGSs) of depression and inflammation, and data regarding the participants’ childhood experiences. First, I wanted to understand whether the PGSs and different types of ACEs, including threat-related adversities (sexual or physical abuse), experiences of household dysfunction (parent arguments, parent mental illness/substance abuse, parent separation/divorce), loss-related adversities (separation from mother, parent death, foster care/adoption), and poor child-parent relationships, were independently associated with depression and low-grade inflammation (i.e. CRP levels above 3mg/L). Second, I was interested in knowing whether the relationship of ACEs with depression and inflammation varied according to the participants’ genetic susceptibility to these conditions (i.e. low vs high PGSs), as suggested by the GxE theory discussed above. My first finding was that all types of ACEs and the PGSs were independently associated with depression and increased body inflammation in this sample of older adults. The second finding was that the associations of ACEs with depression and inflammation were larger in participants with higher PGSs than for those with lower PGSs — yes, I did find some evidence for GxE interactions! Let’s now try to make sense of these interactions by considering some examples… For instance, the odds of severe depressive symptoms for participants reporting at least three ACEs and with a high PGS of depression were almost 4 times larger than the odds for those with the same number of ACEs but a low PGS of depression. I also found similar but smaller differences for body inflammation. Among participants with multiple ACEs, the odds of low-grade inflammation were about 1.5 times larger for participants with a high PGS of inflammation compared with those who had a low PGS (see figure below). The graph on the left-hand side shows the estimated odds of depression according to the total number of ACEs and the value of the PGS of major depressive disorder (MDD); the graph on the right-hand side shows the estimated odds of low-grade inflammation according to the total number of ACEs and the value of the PGS of C-reactive protein (CRP). How can we use this knowledge to improve mental health interventions? To wrap it up, my research shows that both our genes and early-life experiences can have a long-lasting impact on our mental and physical health. Another striking result is that people with a high genetic risk for depression and body inflammation are more likely to manifest these disorders if they experienced traumatic events during childhood, compared with people who were also affected by childhood trauma but are at low genetic risk. So, our genes might, at least in part, determine whether or not we will develop body inflammation and depression when we experience high levels of stress. Besides offering us new insights into the mechanisms influencing depression and body inflammation, these findings have relevant implications for mental health interventions. In particular, they highlight the importance of improving the detection of childhood trauma and the potential value of using genetic risk scores of stress-related disorders as clinical tools to design personalised treatment approaches for depression. For example, some research suggests that GxE interactions could affect not only the development of depression but also the way in which depressed people respond to psychotherapy and pharmacological treatment. Therefore, the adoption of personalised approaches that take into account the patient’s history of traumatic events, genetic risk, and biological alterations can be useful for tailoring depression treatments and enhancing their effectiveness. Although we still have a long road ahead of us, I hope that these results will stimulate more research into the role of GxE interactions in depression and body inflammation, which will ultimately help researchers and clinicians to develop new personalised interventions for depression. Header image source: Hans-Peter Gauster on Unsplash

Disclaimer In this blog, addiction psychiatrist Dr. Rebecca Lawrence discusses the topic of substance abuse and addiction, which may be triggering for some readers. The last eighteen months have been hard for many, not least for those who use alcohol or drugs to alleviate their pain. I am an addiction psychiatrist in Scotland, where we have been lucky enough to retain addictions as a popular sub-specialty of general adult psychiatry, although training numbers are worryingly low in England. We try to provide the best care we can, but sadly the pandemic has not treated our patients well, and drug-related deaths and alcohol-specific deaths have risen to a new high during 2020. These figures may appal us, but they are likely to be the tip of the iceberg, and it is important to also remember the many other alcohol-attributable deaths and all the suffering that we cannot measure. I work in an eight bedded specialist in-patient unit, where most of our patients are admitted for detoxification, often physically ravaged by the effects of alcohol, and levels of harm have risen, possibly due to a reduction in bed numbers. The Scottish Government has committed money to reduce drug deaths, and this is to be lauded; but the announcement of the alcohol-specific deaths received notably less press, and this is puzzling. Alcohol causes a lot of problems for people and is no respecter of anyone. It is responsible for many admissions to general hospitals and is one of the commonest comorbidities in those with psychiatric disorders, but often it remains hidden until it has caused irreversible damage. How to speak with patients about their alcohol consumption I am sometimes asked to see or discuss patients in general psychiatry wards, and it is becoming obvious to me that we are not always comfortable asking too much about alcohol. I use the word ‘We’ deliberately, as I remember that when I was a junior doctor, alcohol consumption was one of the sections of the patient history that I was most often guilty of forgetting. Indeed, this was one of the reasons that I decided to work in addictions, when I realised just how important it was. But why is this? Is it just forgotten, or not seen as important in the context of acute mental illness? Is it hard to ask about, given an assumption that people may be offended or feel stigmatised? For some, it may be that their own drinking is something they do not like to think about, and it can be easier to avoid that of others. There is a fine line between social and heavy drinking for all of us, and the numbers and units can be very blurred. We need to teach the skills of enquiry, so that alcohol consumption can be raised without embarrassment, and patients feel safe disclosing. An example might be when the junior doctor asks the patient (let us say the patient is also a doctor): ‘You don’t drink more than fourteen units weekly, do you?’ The patient, condemned and shamed, cannot disclose that they actually drink fourteen units in a morning alone. It has become impossible. It is my belief that the gentle art of motivational interviewing is underused. Its principles, particularly that of non-confrontation, can be applied to all psychiatric history taking — and, indeed, to life in general. Effects of the pandemic Returning from the individual to the terrible issue of the deaths — what can we do? The picture had been improving in Scotland, likely due to Minimum Unit Pricing, which was finally introduced in May 2018. Unfortunately, the pandemic then intervened, and the problem appears to be that many of those who were already drinking at risky levels may have increased their consumption, leading to harm. Others have reduced their drinking, such that overall consumption may be the same or less, but this has not prevented an overall increase in harm. During the pandemic, when few patients were being seen by services, there was a necessary move to harm reduction by phone, and patients were encouraged to keep drinking, rather than run the risk of seizures or delirium tremens (altered mental state and nervous response characterised by tremor, anxiety, nausea, vomiting, and insomnia) with few if any detoxifications being provided. Some excellent guidance was put together for both staff and patients, but it was ultimately one more situation where staff were unable to do what they felt was right, given that they were having to encourage patients to keep drinking, even when potentially harmful. Even though the risk of stopping drinking at home without support was potentially worse, staff suffered the psychological effects of making decisions that they would not have made in normal circumstances, described by Professor Greenberg and others as moral injury. Current service provision for alcohol addiction This opens up the knotty issue of services generally, and how we help people. I think this can usefully be summed up in terms of resources and connection; in other words, we need sufficient resources to be able to treat people, offering the full range of interventions, and we need to connect our services, so that however people present, they will get the right help. I’m not convinced this is always happening just now, despite the best efforts of many. I would like to justify this by touching on the complexity of alcohol use disorders. As I said earlier, many of our patients have some other psychiatric disorder as well as their alcohol use, and many have a wide range of significant physical health problems. Much of the psychosocial support required can be effectively delivered by third sector workers, but this can easily become the default in times of austerity. These workers cannot be expected to identify or treat such issues, or indeed to supply medication for relapse prevention. The latter should be available to all who need it and requires monitoring, which may not be possible in primary care, which is more stretched than ever. We should be aspiring to provide the best quality, evidence-based treatments for our patients, in a timely fashion. What the ideal service would look like I think, to sum up, I will outline my ideal service. We have some bits of it, in some places, but not all. All patients, wherever they present, will be asked about alcohol, in an empathetic fashion (I know not all will engage). If they disclose a problem, they will be directed, quickly, to the right level of help, which will include high quality screening of physical and mental health and monitoring and treatment where necessary. This will include disclosure in primary and secondary care, prisons, educational institutions, workplace — anywhere. If they are alcohol dependent, and require and wish detoxification, this will occur within 3 weeks (community or in-patient), with intensive follow-up and support. People will not be excluded from services because they don’t drink enough — they may do so in a few years’ time if they are. Rehabilitation (residential if required) will be available for anyone who needs it and will not be a last ditch offer. Some of this may be carried out by health professionals and some by third sector workers, but there will also be easy access to social work, occupational therapy, and psychology where required. There will be excellent community and in-patient services to support those with alcohol related brain damage — who will be far fewer in number due to the effectiveness of the services. It all sounds rather expensive, but I think we might actually save some money. And we would definitely save some lives.

Like any Ukrainian, I spend a lot of time thinking about my mental health and that of our whole nation in these times of war. As rockets keep falling on our homes and families are sent to the frontlines, we must find balance in ourselves to withstand the current events. Which mental health solutions can help us cope? In this blog, I have spoken to Illia Poludonnyi — a psychotherapist with 10 years of experience in Gestalt therapy (i.e. a person-centered form of psychotherapy that is focused on a person’s present life and challenges rather than delving into past experiences and taking responsibility rather than placing blame). I have supplemented it with the illustrations of Ukrainian artists, reflecting on how they are feeling. The interview was taken on April 25th, 2022. In 2015, with his co-founder, Illia created the first online platform for psychotherapy sessions in the post-Soviet segment of the Internet, Treatfield, and his clients come from over 50 countries today. Illia shares: “All of the psychotherapists we work with are our partners, not employees. Therefore, our pool is quite small — about 60 therapists. We feel very confident about who we are working with and, in all the years of our existence, we only had two negative reviews.” In the first days of the war, Illia created a chat called “How are you?”, managed by the psychotherapists on her platform. This is the story of that chat. Note: as I chatted with Illia, air raid sirens went off where he was, and he moved into safer spaces, never interrupting our interview. I had left mentions throughout the text of when this happened during our chat. What did you do in the first days of the war? For the first 4 days, I was busy evacuating my family. We took a car and drove to the west of Ukraine. My therapeutic specialization is crisis management and trauma, so it was a fascinating experience to understand the dynamics of the situation while going through it myself. As my hands were still busy with the wheel, I started thinking about what I could do to help. I knew the protocol for working with a traumatic shock. It is a dissociating experience; the person gets out of touch with their body, the world outside, society, family, and friends. People often lose all of their communicative skills and report feeling like they are floating around, totally detached from everything else. As this was happening to me, it had to be happening to others; war is a collective traumatic experience. *The air raid siren interrupts the interview, and Illia goes to his corridor, as there are no windows that could explode and hurt him.* See, those go off every couple of minutes; how is one supposed to feel safe? In this first phase of trauma, people are not ready to engage in therapy. When a rocket hits a house next to you, it is purely about survival. In this initial state of affect, it is essential to stabilize the person, bring them back in touch with reality, and just let them talk about their experience. To respond to this immediate need, I created a chat called “How are you?”, managed by the psychotherapists from our pool. In Ukraine, we say that “How are you?” became a form of saying, “I care about you.” So how did this chat work exactly? You mentioned that psychotherapists administered it. Could they provide care to others while themselves going through the crisis? The chat was a place of collective support, straightforward, and reflected the needs of the situation. People were encouraged not to give advice but to share their current state: to express empathy towards each other, to provide care and support. We had a core team of eight therapists who had experience with trauma and crisis management, moderating the chat. Additionally, the therapists had a curator looking after their needs and checking for the signs of burnout and a supervisor providing support and releasing the therapists’ tensions. Everyone had to be in a green or yellow zone (i.e. In Ukraine, green and yellow zones are the territories with the least military action), so in the west of Ukraine, or abroad, because if a therapist is also afraid of a rocket flying into his house, they cannot exude a sense of calm. It was like a pyramid of professionals that could withstand the tension. Chat participants in the red zones (i.e. zones in an active phase of the war) could also refer to a chatbot for contacting a therapist one-on-one. Again, the format was only “keep in touch”, not working with trauma. I was involved in this project, too, and I kept in touch with many people: a woman from Kharkiv leaving town under the shelling, someone living under occupation in the Chernihiv region. People told me that it gave them the power to feel like they were not alone. Someone is thinking about me, remembering me so I can go on. You mentioned that you do not think that therapy is an effective solution at this time. Why so? Many of our Western colleagues were trying to help, but often people were naive to the severity of the situation. When you are on a call with a therapist, he recommends a breathing technique. Still, this person is sitting in a bathtub because their bathroom has no windows that could explode and hurt them, or they have been in a bomb shelter for days; it is a solution that is not matching their reality. It is a different context, and no in-depth work can be done within it. *Air raid siren is over.* Do these chat and chatbot exist now? I am about to delete the “How are you?” chat and chatbot because I think they have served their purpose, and now it is time for different solutions, otherwise, the therapists will burn out. At its peak, the chat had four thousand participants and about a thousand messages per hour. After one month, people started to leave the chat. People started to understand where is the active zone, where is relative safety, and which direction their life should take. To go forward, we would need a different structure. For a few months, it was ok for people to volunteer as they received social gratitude, good feedback, and a feeling of doing meaningful work — a sufficient exchange but not sustainable long-term. What do you think will happen after the war, and which mental health solutions will be relevant then? I think after the war, once people recover from the shock and start processing their trauma, is when they will seek therapy. We will witness a massive growth in demand for Ukrainian-speaking specialists. People will also have financial difficulties, so creating some platforms will be very relevant, offering free mental health support. I think it is essential to monitor the work/life balance and mental health of specialists involved in crisis management and ensure that we put as much work into building sustainable management systems and training as we would in more peaceful times. Since this interview was taken, the situation in Ukraine has escalated again. As the Ukrainian army is de-occupying more and more territories in the East, horrible crimes against humanity committed by the Russian army are coming to light. In the city of Izyum alone, over 400 bodies with signs of rape and torture were found. Hopefully, justice will be served to those who are guilty. Like Ilya, I believe that checking in on each other and providing care and support will be a significant grounding factor, helping a lot of us to be able to engage in the day-to-day. Give a call to your Ukrainian friend, give a call to a Ukrainian mental health worker you know, and do not talk; just listen. This is the best way to support us now.

As a student of psychology, and an aspiring mental health practitioner, one of my key areas of interest involves understanding new forms of interventions and uncovering their evidence base (my previous blog on play therapy can be found here). For my MSc dissertation, I’ve been investigating the efficacy of both pharmaceutical and non-pharmaceutical interventions for Attention Deficit Hyperactivity Disorder (ADHD) in childhood. ADHD is a neurodevelopmental disorder marked by inattention, hyperactivity, and impulsivity, causing significant impairment in daily functioning, and is one of the most common mental health conditions affecting children. Over the past few months, identifying studies relevant to my project has sparked my curiosity to learn more about the novel, contemporary approaches to treating childhood ADHD. As I attempted to sift through 4,200 odd studies, I began to discover and better understand the application and efficacy of mindfulness-based interventions (MBI) among children with ADHD symptomatology. Through this blog, I will attempt to understand the current research base on this topic, and where we can go from here. Can Mindfulness be linked with ADHD? The concept of mindfulness was something I came across during the peak of lockdowns in India, in 2020. Mindfulness refers to having the knowledge of what we’re feeling, and accepting that feeling as it occurs, in the present moment. Through this process, we give ourselves the chance to freely accept all thoughts and feelings, be it something that makes us happy, or something that’s uncomfortable. Reading books such as The Miracle of Mindfulness by Thich Nhat Hanh, and The Little Book of Hygge by Meik Wiking made me understand this concept, and appreciate the diverse forms it took. Flash forward to June 2022, when I began to ask myself why we aren’t talking about integrating mindfulness-based interventions for ADHD, especially among children enough (trust my “psychology-mode” brain to find every little connection such as this!). I noticed myself picking at the most basic aspects of mindfulness, such as having the knowledge of what goes on within ourselves and reconnecting our mind and body to the current moment. While this concept is assumed to be one practised and understood only by adults, there are a number of mindfulness exercises that have been adapted to be made more understandable by children. One example is my favourite, called the Hot Chocolate Breathing exercise. It’s easy to follow, and you can take a moment right now, and do it yourself! Start by holding an imaginary, warm cup of hot chocolate in your hands. Take a deep breath in, and imagine the smell of the warm chocolate entering through your nose. To cool the hot chocolate, breathe out, with your mouth, for four counts. Through the concept of imagery, this simple, but fulfilling, exercise awakens all the senses within the child, with the thought of something we all love: chocolate. This exercise, though so simple, was meaningful and stuck with me, and I myself have found that it calms me down during moments of anxiety. Mindful breathing exercises such as this, have benefits over and above feeling relaxed. For example, they can reduce heart rate and blood pressure. Keeping ADHD in mind, studies have shown that rhythmic breathing also helps regulate the autonomic nervous system, which provides both, an increase in attention levels as well as relaxation. ADHD is one such neurodevelopmental disorder that has multiple aspects, from hyperactivity to inattention and impulsivity. Mindfulness, at its core, can help to better manage these symptoms for children in environments such as at school, or when playing at home. Through mindfulness exercises, mental health practitioners can provide children with a mindfulness “toolkit” of sorts, equipping them with the skills necessary to focus on the present moment (further information can be found here). What are the current MBIs, and do they have an evidence base? Given that a core principle of mindfulness is being in the ‘here and now’, I sought to understand if, and how, MBIs can be especially fruitful to reduce inattention-related symptomology in the spectrum of ADHD. While most studies I’ve come across in ADHD literature focus on medication-based intervention, the past few years have witnessed an increase in literature on MBI, especially as individuals in the field aim to integrate non-pharmaceutical interventions into the treatment of ADHD. A popular 2008 study was a catalyst in understanding MBIs for adolescents and adults, but the question I asked myself was if, and how we can integrate similar approaches among school-aged children. Twenty-four adults and 8 adolescents participated in an 8-week-long mindfulness training programme, following a format consisting of opening meditations, discussions, and practice exercises. The programme was well received by both age groups and found improvements in self-reported ADHD symptoms. What I find particularly interesting is the fact that there is no one approach to mindfulness. Researchers and practitioners have developed various programmes, either at an individual, or a family level. Two techniques — Mindfulness-based stress reduction (MBSR) training, and Mindfulness-based Cognitive Therapy (MBCT) — have been discussed in emerging literature surrounding this topic. MBSR is an 8-step stress reduction programme that allows individuals to gain awareness about their behaviour in relation to stressful situations. MBCT combines mindfulness and cognitive behavioural therapy practices and consists of learning meditation techniques. MBSR techniques were originally developed in the 1970s to effectively manage pain and stress, but recent studies have diversified this technique among children with ADHD and their parents. For example, a 2020 study found that an adapted MBSR intervention (delivered to parents and children) led to significant reductions in ADHD symptomology, especially those relating to hyperactivity. Interestingly, MBSR techniques involve practices such as yoga and meditation, and while the image of a young child sitting in a meditative position might seem absurd, emerging literature has indeed attempted to portray just the opposite. Though these interventions might require adaptations such as smaller groups and the usage of child-friendly imagery, evidence (as portrayed in a 2018 systematic review) found that yoga, meditation, and MBIs had statistically significant effects on ADHD symptoms. In addition, these interventions also found effects on outcomes such as the parent-child relationship. Among the types of current non-pharmaceutical interventions, parenting interventions have been of great importance in the context of childhood ADHD. More specifically, the past few years have seen ‘mindful parenting’ gaining popularity in this sphere. This concept consists of dimensions such as self-regulating the parenting relationship, listening with full attention, and accepting oneself and the child in a non-judgemental manner, by being present in everyday parent-child interactions. Research, being innovative as it is, has adapted mindful parenting into specific interventions for childhood ADHD as well. A randomized controlled trial conducted in Iran found that 8 sessions of ‘mindful parenting’ showed a reduction of not only ADHD scores but also parental distress from baseline (before the sessions) to follow-up (8 weeks later), as compared to a control group receiving medication only. MyMind is an MBI, though originally meant for children on the autism spectrum and their parents, which has been adapted for ADHD. This is an 8-week treatment, based on a group format for children, while their parents parallelly receive mindful parenting training for the same duration. Each session consists of meditation exercises, and homework, and parents are trained to practice meditation exercises with their child. The mindful child training aspect consists of activities centred around enhancing attention, and children are taught to apply techniques learnt in difficult situations. A 2011 study evaluated MyMind’s efficacy and found that parent-rated ADHD behaviour significantly reduced, along with parental stress. A recent study evaluating the same program found similar results, with parents reporting reductions in inattention problems as well as parenting stress. To conclude, the interventions and studies I’ve discussed are only the tip of the iceberg in this field, and their results have definitely signposted us in the right direction. While the current evidence base seems to indicate that pharmaceutical intervention might be the most effective, MBIs can be a valuable tool that children can add to their “coping kit”, equipping them with simple, but meaningful exercises that they can make use of in daily life, and social situations. Involving parents and making them play an active role can go a long way in improving the parent-child relationship.

I had never paid much attention to depression, anxiety, eating disorders or sleep deprivation, that is, until I had my second baby. She was born sick and went through a number of surgeries in her early life, requiring a stay in the Newborn Intensive Care Unit for a few months. I thought I am a strong mother and I can handle all the problems being thrown at me. I was wrong. During this time, I began to realise that I was eating excessively, getting angry at the baby and becoming annoyed very quickly; my first child was totally neglected. Negative emotions were experienced throughout my whole family, something that has been shown to affect the quality of the care of children (Kong et al. 2013). I was shocked to see that my mental health was deteriorating and that my mood was constantly shifting. The Research College of Midwives has published an article reporting that 80% of parents who have a sick baby in hospitals suffer from mental illness after the experience. Why do we only pay attention at these mothers after they suffer from mental illness? Why do we not care for them before they cross this line? 30% of Neonatal care units in the UK agree that parents do not have any psychological support during their babies’ stay in hospital. I don’t even know how many parents, besides me, would ask for help; to me, this is the scariest part. How do the parents know if they are going through psychological turmoil? Even though I was not aware of what my symptoms were, my gut feeling was that I should talk to my GP about what I was experiencing. I also decided to research this myself. This thought made a big difference to my life as my attention shifted in a different direction. I began to watch films, read books, meditate, and use the internet to research what was happening in the field. It helped me to think it all through, and to find different answers. It helped me to make myself comfortable and find a solution, to keep me engaged with my whole family. Because I identified the need of speaking out, I was able to get counselling. Without knowing about the psychological impact of having a sick infant, you may not necessarily know that you need to reach out. The problem may not be recognised until it is at the very worst point. During this period, I was referred to counselling sessions for 10 days. Even though it gave me some relief by being able to talk to this amazing person who takes on other folks’ horrible experiences, I didn’t get that much help. This is not to say I had no improvement as it helped me realise the changes I needed to make, but rather I felt that they didn’t explain to me what was happening and why. Instead, the counsellor recommended treatment with anti-depressants. Even though I was not diagnosed as a depressed person, the counsellor might have figured out that I was heading that way. I still can remember my exact feelings when I was offered antidepressants: Nooooooooo….. My instinctual response was to refuse to take antidepressants. Instead, I said to the counsellor, “I am sure I can manage it and I will go the GP again if I need any help.” I did now know what antidepressants are, but personally, I hate taking any pills. So much so, that I didn’t even bother to ask the pros and cons of the antidepressant. Antidepressant pills can be prescribed to patients with moderate to severe depression, however, NHS website says that ‘how it works is unknown’. On the internet, the effect of antidepressants always comes with mixed feelings. Some feel that they may help with symptoms such as sleeping problems, anxiety and sadness, whereas others have doubts about it. Personally, I haven’t got much experience about it, except for the information available on the internet or from the NHS. I am still a bit confused about the facts available to the general public about antidepressants. However, antidepressants are helpful in people with clinically significant depression. I didn’t worry too much about it, because I knew I was not so depressed. Instead, I started walking around the park, and I was so gutted to feel that I was breathing heavily like a dog. Only then, I realised how much my health had declined, and that I was overweight as well. So, I have realised that it doesn’t matter how fast or slow you walk, what matters is that you walk and take as much fresh air as you can into your body. This made me feel so much more relaxed and comfortable. Research has shown that exercise and outdoor activities improves the signs of stress. I also did light exercise, cycled around the park, read many self-help books and practicied meditation. Without even realising, my sleeping pattern improved; I started eating more mindfully — reducing the quantity I used to eat. Because of all of this, I started turning back towards my family, and I was once again helpful to my children. I was calmer than before and started thinking very clearly. Therefore, while I am not speaking for everyone, and I know that antidepressants are very helpful for some people, it is true that there are also other methods of combatting depressive-like symptoms, not just pills. While as I said I was not diagnosed with depression, the counsellor could see that I was heading that way. It may not be the sole answer for someone with more severe depression, however the beneficial effects of fresh air, exercise and diet have been proven to help for some people who are experiencing depressive symptoms. That being said, if that you feel you are experiencing depressive symptoms, it is vitally important to talk to your GP. If we all go outdoors as much as possible, connect with nature and distract our minds from thinking about the complicated lives we have, it can make us feel much more relaxed and comfortable. It effects both our mental and physical health. When I did these things, it helped me to get rid of the awful feelings I had, without the need to take antidepressants. A few years on and I am feeling so much better, and I am pleased to say that my daughter is doing so much better too. NOTE FROM THE EDITOR: At InSPIre the Mind we have created a new anonymous account to allow writers with more personal experience, to tell their stories as honestly and openly as they would like. The aim of this account is to allow writers to feel most comfortable and to remove any pressure when sharing stories they may not have spoken out about before. Of course we know who the anonymous writer is, and, while respecting their editorial freedom, we ensure that what they say is not against current medical and scientific evidence. NOTE FROM THE WRITER: I have decided to write this blog to let parents going through similar situations know that they should get help, from their GP or the NHS, if they experience symptoms like this, before it’s too late. This is important so that precautions can be taken to prevent going down the line of depression or anxiety. But, they should also help themselves through changes in their lifestyle and activities. If they don’t fight for their mental and physical health, no one else will do it for them. header image source: Tim Bish on Unsplash

Overlooked and Downplayed: The Difficulty in Getting an Emotionally Unstable Personality Disorder (EUPD) Diagnosis It took me years to finally get an EUPD (Emotionally Unstable Personality Disorder) diagnosis. Years I can’t get back. Explaining what EUPD is like isn’t easy. To simply refer to it as a personality disorder doesn’t give the depth and diversity of this mental illness; yes, it affects your personality, but it’s more than that. All your emotions are amplified. It feels like you’re an exposed nerve. Your moods fluctuate throughout the day, you’re anxious all the time, relationships are challenging and difficult to maintain, and knowing who you are feels nigh on impossible because you lack a solid sense of self. Not everyone’s experience will mirror mine, but those contrasts we all have don’t diminish the struggle that EUPD presents. This post is but a window into my personal experiences. From an early age, I knew what I felt wasn’t normal. I was so different from my peers; I lacked the genuine enthusiasm they had for life. I’d experience short bursts similar to theirs, but I’d always rapidly come down from that high and enter into a depressive state. To be diagnosed, you need at least five of the below nine traits: Fear of abandonment. Unstable relationships. Unclear or shifting self-image. Impulsive, self-destructive behaviours. Self-harm. Extreme emotional swings. Chronic feelings of emptiness. Explosive anger. Feeling suspicious or out of touch with reality. I meet all of them, in one form or another. However, the most notable symptoms for me are the fear of abandonment, the instability of relationships, impulsivity, extreme mood swings, and uncontrollable anger. Any one of those symptoms is tough to handle, but several of them? It’s a powder keg waiting to explode. The only problem is, it’s waiting to go off every single day. Life can be a rough enough ride on its own without EUPD added into the mix. As I grew older, and my behaviour became more erratic, I found myself desperately needing answers — I couldn’t go on like this. So, in 2015, I pushed for my GP to refer me to a specialist. I wish the process was as simple as it sounds, but it was one of the most stressful experiences I’ve gone through. Right from the beginning, I was met with a tone that shouldn’t belong in mental health services; there was this air about them, as if I was an issue they’d rather not deal with. At first, I wondered if I was taking their words too personally, falling back on my old habit of reading between the lines and coming to the wrong conclusion. But as the sessions with my assigned community mental health nurse progressed, I realised it wasn’t in my imagination. It wasn’t that my mental health nurse didn’t offer a safe space, but rather that they did so in a way that made me uncomfortable. When I tried to express the issues I was having, they acknowledged them but never really listened. Eventually, I found excuses not to attend my sessions, soon followed by me asking to speak to someone else. I needed someone to be invested and care about my welfare. It took a lot of persistence, both from me and my partner, but I was finally referred to a new mental health nurse. And for me, they were even worse. Forced into a corner, I asked for a psychological assessment. I wanted them to tell me what was going on, was this generalised anxiety and depression or was it something more, as I suspected. That appointment was heartbreaking, mostly because they immediately approached my case as just another statistic. Even when I asked about the possibility of EUPD (also known as BPD, Borderline Personality Disorder), they said I was “slightly borderline, but nothing more”. I walked out of that room and into four extremely difficult years, ones where, at times, I didn’t think I would survive. Not only was I a danger to myself, but I was damaging my relationship too; my partner couldn’t handle how unpredictable I was. Luckily, we made it through, and even decided to buy a home together, however, a lot of damage had been done during this time. “When I initially went in 2019, I was completely dismissed.” Shares Eleanor Noyce, a freelance journalist who’s currently seeking diagnosis. “Granted I did bring it up in a mental health appointment allocated to discuss my progression with sertraline, but I felt that I was silenced in the name of saving time and/or money. I returned to the doctors in 2021 as I realised that the problem was not going to go away, and I’d been suffering for years.” Her story is similar to many others, such as Amy, who also experienced a lack of empathy as well as misdiagnosis. “I was wrongly diagnosed in 2013 with bipolar and even though I stressed many times to my GP and psych that I didn’t feel like I fit that diagnosis, I researched a lot of my symptoms and feelings but was never listened to.” This need for answers is what drives us and is the reason why I soon contacted my new GP after I’d settled into my new home. Similar to both Eleanor and Amy, I went in armed with extensive research into the disorder. My doctor sat there and listened to my experiences, quickly agreeing that it sounded like I did have EUPD, “I can’t clinically diagnose you, but you sound like you have it”. Those were his words, words that made me feel like I was finally being taken seriously. When I received the call to arrange my first appointment with the specialist a few weeks later, I was met with startling news: I’d been diagnosed with EUPD four years prior. That “slightly borderline” remark that was treated as insignificant, had meant that I never got told the truth about my mental health. A new referral now in hand, I went to an appointment at the same mental health hospital which had proven so problematic previously. Inside the enclosed office, I explained my situation. The answer? To question my need for labels; my new nurse insisted that diagnosis often did more harm than good, without actually giving me the chance to make that decision for myself. It bears a striking similarity to a conversation I had with another person living with BPD, who wishes to only be credited to their online name. When @SchrimpBoy contacted their doctor begging for help, their doctor asked what they were meant to do — the disorder isn’t curable, so knowing what it is won’t change anything. Although I too voiced my concerns and my need for answers, I kept running into the same hurdles. Even when I mentioned how I’d recently been informed that I was given a diagnosis four years ago, my care coordinator’s response was that it was a lot of paperwork to go through to confirm this. My struggles were a tedious ad hoc task to her, one she wanted to avoid. Only when I was at my third session with this woman, when I told her that she could either help me or I would go private, did she finally relent. Although I’m grateful that she did change her mind, I regret feeling forced into giving such an ultimatum. It took two weeks before I heard anything further, but a letter confirming my diagnosis did eventually arrive; there, in black and white, was my validation. The moment I’d been waiting for. I should have felt relieved, and while a part of me did, the other part of me was angry. Nobody should have to go through so much turmoil to get answers for their mental health. My feelings, based on the experience I have had, is that far too many within the medical profession simply don’t understand mental illness, they can say they empathise but I’ve yet to see much genuine emotion there. For one genuinely invested GP, there’s 10 more who treat you in a clinical manner, which often only exaggerates our self-hating internal monologue. I know this isn’t the universal experience but that doesn’t take detract from the difficulties I, and many others, have faced. I feel, if mental health services are to improve, better training is needed to ensure that more care is taken when talking to such vulnerable people. Although medical professionals may not mean to appear disinterested, their demeanour can come across otherwise. Such an impact stays with us, we remember it long after they’ve forgotten. EUPD is far from unknown, so there’s no reasonable excuse as to why it keeps getting overlooked and downplayed. We shouldn’t have to be at crisis point to be taken seriously.

Why Mental Health Starts Before We Are Born: The Importance of Mental Wellbeing in Pregnancy Mental health is a growing topic in the media and features prominently in modern conversations. We are improving in our ability to talk about mental wellbeing and understand what measures to take to keep ourselves mentally healthy. However, it is becoming increasingly apparent that if mothers suffer with mental health problems while they are pregnant, their children are more likely to develop poorer mental health themselves, later in life. Perhaps we need to start considering the mental wellbeing of a child even before he or she is born. A commonly discussed disorder in this area is antenatal depression, that is, depression during pregnancy. Although not as well-known as postnatal depression (depression after the baby is born), it is almost as common, with estimates ranging from 7–20% for antenatal depression versus 7–30% for postnatal depression. These figures may vary depending on the mental health services offered to women in different geographical areas, not just in terms of the treatment on offer which might help to reduce the rates, but also depending on how well the services routinely ask women about their mental health and therefore identify those women who need support. As with other mental health problems, babies born to mothers suffering with antenatal depression show poorer mental wellbeing as they develop. You may think the explanation to this is obvious: surely it is because they have shared genes? Or perhaps a mother who is depressed may care for her baby slightly differently? These two things are likely to play a role, but what is often less considered is the specific impact that antenatal depression might have on the developing foetus. We call this ‘foetal programming’, a fairly new area in which we are trying to understand how the biological environment of the mother might ‘program’ the growing baby while in the womb, in preparation for the outside world after birth. For example, a mother who is pregnant during a time of famine might give birth to a baby ‘programmed’ to expect an environment with low food availability, which in turn might shape how the baby’s body absorbs calories from food. We are now starting to understand how the psychological environment in which a foetus develops in the womb may impact the development of that person’s mind, brain and body throughout their life. Our recent paper, published in Molecular Psychiatry, compiles the results of a vast body of literature to explore what effects all these factors may have when brought together. It is thought that this ‘foetal programming’ mechanism, in the context of mothers with mental health problems, might be a reason why we observe higher rates of mental health problems in their children. The more we can understand about how this ‘transmission’ of poor mental health occurs, the better-equipped we are to identify those most in need, as well as offer the most effective support. In our review article, we identified a number of studies which showed, for example, differences in the birthing process in mothers suffering from antenatal depression, whose babies are more likely to be born earlier and with a lower birth weight. From a psychological point of view, studies also show that these children may show difficulties with emotional regulation and behaviour in early life, and are more likely to be diagnosed with a mental health disorder in adolescence or later. There are also clear biological differences found when comparing the children of depressed and healthy women, such as our own study which finds increased response of the stress system to the pain of vaccination in the babies of depressed women. Of course, these studies also have to take into account the wider environment in which these children are raised, for example, it is often observed that mothers with depression have lower levels of social support, which might be indicative of a more unstable family environment. Furthermore, statistically they are often lesser educated and of a lower socioeconomic background, which might shape the learning and enrichment opportunities available to the children as they grow and develop. However, even when we take these factors into account, there still seems to be a specific effect that antenatal depression is having on the child’s development, which supports our idea that ‘foetal programming’ is an important mechanism that we need to understand more about, if we want to offer the best interventions to women and their unborn children. But, it is important to stress that not all stories are the same; not all children born from mothers who were depressed in pregnancy (or postnatally) go on to develop physical or mental health problems. What was very striking when looking at all of this research overall, was how the results varied across studies, sometimes with one study directly contradicting another. When we looked into this in more detail, we were able to find many aspects of a child’s environment which may help to protect against any negative consequences a mother’s depression might have. For example, the presence of a supportive father figure, a pleasant mother-baby bond, and good childhood education, were all factors which helped to improve outcomes for the child. It is important that we remember this, so that women who suffer with antenatal depression do not feel guilty about any potential impact their condition might have had on their child. Instead, the focus should be on the things that mothers can do to ensure that the impact of antenatal depression is reduced. And we, not only as mental health professionals but also as a whole society, need to be providing psychological and social support to these women at the right times, which might even include pre-conception, as well as during pregnancy and motherhood. Where possible, these initiatives should also include other family members, or the father of the child. If we can do this, we can improve the emotional wellbeing of the whole family, leading to better outcomes for all.

The Covid-19 pandemic has made life unpredictable, and accordingly, mental health concerns have grown exponentially. In fact, 13% of the population of 5 Western countries reported trauma linked with the pandemic. Trauma is one of the primary symptoms of post-traumatic stress disorder (PTSD), which develops upon experiencing a subjectively traumatic event. Through Covid -19 related phenomena such as quarantine, supply shortages, and death, many people have felt exactly this. Eye Movement Desensitization and Reprocessing (EMDR) is a widely used intervention for PTSD and during the pandemic, as many services and therapies have been, this treatment has been delivered online as remote EMDR (eEMDR). As a researcher who’s keen on studying different psychotherapeutic approaches, the uniqueness of EMDR caught my eye. As part of my postgraduate degree in Clinical Psychology, I have been introduced to several psychotherapeutic approaches, most of which revolve around themes like feelings, thoughts, childhood, etc. EMDR on the other hand, is based on the concepts of recollection and desensitisation, which are discussed below. While a relatively new approach, it is gaining popularity rapidly, and with this blog, I want to explore what PTSD is and how EMDR can improve one’s experience with the same. Moving on, the differences between the standard EMDR therapy and its online variant are discussed, alongside the strengths and weaknesses of eEMDR. Symptoms of PTSD include intrusive memories of the traumatic event, hypervigilance, sleep disturbances, emotional withdrawal, irritability, and lowered concentration. Thoughts of the traumatic event happen in the form of recurring nightmares, flashbacks, and dreams, and must last for at least a month for diagnosis. These unprocessed memories elicit other distressing thoughts, emotions, somatic (bodily) sensations, and beliefs that occurred on originally experiencing the traumatic event. Recognized as an effective treatment for PTSD by the World Health Organization and the National Institute for Health and Clinical Excellence, EMDR is aimed at altering the way the traumatic event memory is retained in the brain, in order to change the feelings, thoughts, and sensations these memories elicit. Standard (in person, and on-site) EMDR is typically a 6–12 week long intervention, with one or two 60–90 minutes sessions per week, divided into eight phases. eEMDR (online) follows a similar pattern, with the exception of a different way of delivering “bilateral stimulation”, and there being a heavier emphasis on “grounding techniques”. Let’s take a closer look at these eight phases and how each compare between in-person and online EMDR. Phase 1: Client History This is when history-taking, diagnosis, the establishment of treatment goals, and the development of the therapeutic alliance take place. History-taking in standard EMDR is done using observation and direct questioning; in the remote variant, questionnaires are administered online. Extending into phase 2, a successful therapeutic alliance is when the therapist is able to adapt themselves to the client’s needs and understand the client’s tolerance when re-experiencing their traumatic event. In the process, a case conceptualization (the clinicians detailed and combined understanding of the patient’s biological, psychological, and social contexts) that is Adaptive Information Processing (AIP) informed, is created. The AIP model suggests that memories of recurrent or typical events are stored adaptively, and those of traumatic events are stored maladaptively, and recommends that PTSD is caused by dysfunctional storage of memories that haven’t been fully processed. Overall, the main aim of Phase 1 is to understand the client’s memory network of their experiences underlying their current difficulties. Phase 2: Preparation The goals here include strengthening the therapeutic alliance and introducing and preparing the client for the unique power and speed of EMDR. The process of EMDR is introduced while grounding techniques, which help clients understand that their memory and reality are not the same, are being taught. This is done by reorienting oneself to the present by stimulating ones senses (vision, hearing, smell, touch, and taste). One of several grounding exercises is “butterfly hug”. This technique is elaborated in Phase 4. Phase 3: Assessment During this phase, clients work to identify which moment of the traumatic event is most distressing for them. Once identified by the client, the distress caused by it is rated on a Subjective Units of Disturbance Likert scale, varying between “no disturbance” and “worst possible disturbance”. Phase 4: Desensitization This phase marks the beginning of ‘reprocessing’, where clients recall the traumatic event memory to a degree that they are comfortable with and which causes the least possible level of disturbance. The client is expected to focus on the cognitive, somatic, and emotional outcomes of the traumatic event memory while being bilaterally stimulated (being stimulated physically from an external source) during an on-site session. One way this is done is with a “butterfly hug” in its online variant. “Butterfly hug” is a method in which the client is bilaterally stimulated by orating positive words while the client wraps themselves in a hug by placing their arms on alternate sides of their bodies. It is hypothesized that since the client simultaneously focusses on the traumatic event and utilizes their therapeutic resources with, for example, side to side eye movements, sounds, or taps, the client becomes desensitized to the negative sensations evoked by remembering the traumatic event, thereby making remembering a manageable process. Phase 5: Installation During Phase 5, the therapist helps the client establish and strengthen connections between their new, more adaptive thoughts (thoughts via which one is able to ground themselves), and their pre-existing helpful thoughts, via bilateral stimulation — in other words, help them “install” the new positive beliefs to replace the previous negative ones. While phases 1 to 4 can be conducted in groups, Phase 5 has to be conducted one-on-one since the desired positive and helpful self-beliefs may vary from person to person. Phase 6: Body Scan Body scan, which refers to mentally scanning one’s body for any lingering signals, is conducted in Phase 6. The client is assisted by the clinician to find any somatic symptoms, like pain, stiffness, or heavy breathing that arise in their body upon recalling their traumatic event for complete processing. Grounding techniques are especially relevant in Phases 4–6 as the ‘reprocessing’ phases, for self-soothing, and are more relevant to eEMDR due to the absence of the therapist to provide calming tactile stimulation. Phase 7: Closure For clients, Phases 4 to 6 in particular can be difficult due to the recalling of the traumatic event, and so in the penultimate step, clients are given the opportunity to indulge in their choice of self-soothing activity and have a chance to share what they have gone through on reprocessing their traumatic experience, to help them calm back down. Clients will not progress to the next stage until they are able to recall the traumatic event and feel completely emotionally and physically neutral about it. Phase 8: Re-evaluation In the final and 8th phase, clients who do not present an adequate level of improvement are given individual attention. The nature and severity of their PTSD symptoms are identified and are scanned for comorbid (other simultaneously occuring) mental health issues, using their Phase 2 data. Evidence that eEMDR therapy is approximately as effective as its standard on-site variant is imperative as it differs from other treatments for PTSD. This online method does not involve exposure to a traumatic event in a verbal manner since the clients do not need to report verbally what they experienced to a therapist. Instead, feelings, thoughts, and sensations that imagining the traumatic events elicit are worked with internally, eliminating the subjectivity of interpretation of the event by the client as, when recalling, clients may unconsciously emphasise certain aspects of the event or may be unable to recall certain others. Another benefit is that one can undergo therapy from the comfort of their home. In fact, clients who underwent eEMDR expressed over 60% reduction in distress when purposefully remembering their traumatic experience. However, despite being convenient, and cost-effective in terms of negating travelling to and from appointments, eEMDR has several pitfalls, including the potential for re-traumatization on re-exposure, which is one risk of eEMDR. While this is a possibility even in EMDR, the presence of a therapist acts as a buffer. Clients are also often in environments with distractions which can be an inconvenience as this approach requires focus and concentration. Furthermore, there is a risk of having one’s privacy violated, during eEMDR, due to a lack of encryption of several sites and applications. Moreover, in comparison to other effective interventions, eEMDR is expensive for those seeking therapy for their trauma, as several insurances do not cover it due to its specialization. Overall, both EMDR and eEMDR are equally effective and is best suited for licensed therapists who have educated clients on the potential positive and negative outcomes of the therapy. It’s my hope that there might be a surge in professionals mastering this technique as research suggests that the treatment has desirable results regardless of the therapist’s experience. In the long run, the accessibility of remote EMDR therapy will play a major role in propagating use among those who need help dealing with PTSD and their trauma. Header Photo by Marina Vitale on Unsplash

Mothers Who Make is an international initiative providing mothers and makers peer support. It has been a saving grace for me during the last five months. I have made connections with women I may never have met without lockdown. Women who understand the innate need to be creative. Women willing to listen. Women who are willing to share. Is there any more comfort than someone holding you and saying, ‘I hear you, I get you and yes, I feel this too’? I say hold, and I really do almost mean it. It’s so brilliantly uncomfortably British to recoil at the idea of hand gestures (just one of these hugely successful added extras), but they have become so second nature, I find myself having to sit on my hands so as not to look a complete idiot in other zoom meetings — watch out for such exuberance if you should meet me anytime soon! In this time, where so many of us desire to hold our friends and family, this group of women has found ways to make up for the 2D life that so many of us are living at present, make up for lack of body language and all those social nuances we take for granted in ‘real’ life. It’s funny to think that in the past months, while I’ve spent more time with some of these women than anyone beyond my husband and son, they’ve still never seen the back of my head and they don’t know how big my bum is. It is now no surprise that I have found myself merrily strolling in a different direction, to that which I was aiming, so soon into this blog — so I will attempt to reign myself in — but really I am just setting the scene for a question I was asked a few weeks ago by one of the founders of Mothers Who Make. Can you tell us more about your piece ‘180 Days’? It feels, at this still relatively early stage in my life as a visual artist - in my ‘other life’ I am a violinist - that this (along with I am not stupid — the springboard to an extensive set of works) is still one of my most important pieces. I have made it in fabric (several versions), in stencil, in print, hand coloured — and I would be surprised if that’s the end of its possibilities, I hear my brain cranking up as I type… 180 days started out as a simple table of my mood. It was 2014 and I had had a mental breakdown. I was diagnosed with GAD (Generalised Anxiety Disorder), although alongside that it would have been accurate to diagnose Endometriosis. Alas, at this point, I had another three long years to wait for that conclusion. Endometriosis is a chronic illness suffered by 1 in 10 women. Average diagnosis time 7 or 8 years. Often debilitating, regularly causing off-the-scale pain (in my experience, think labour). It is caused by cells, similar to those found in the womb, forming elsewhere in the body predominantly, but not exclusively, around the reproductive system, bladder and bowel. The cells behave as their counterparts and bleed every month and I was already beginning to twig that, or at least question whether, everything that was going on in my brain and body was cyclical. But, as I said, at this stage I had no idea this was what was going on so, I started a chart. Simply, was the day good or bad? Or a combination of both? I recorded it as G, B, or G/B. I did this for 6 months, or more precisely 180 days. Ironically, I never went back to check whether or not there were any patterns. Even to this day, I haven’t done that, but with a diagnosis of Endo it’s safe to assume they are there if you look hard enough. (Check out my blog Endometriosis and me) I put the first stitch into the centre of the original version of 180 Days, on November 5th, 2015. I know this because I was in a rehearsal for Monteverdi’s L’incoronazione di Poppea in Venice. It was an unusual place to do it, and the fabric was large and stiff (as cotton Aida is before it’s kicked around for months with me on my travels — or nowadays — on my sofa). It was on the verge of inappropriate rehearsal behaviour, but I was too excited to wait. The work was to take 18 months to complete, alas no more accurate than that, the last stitch must have felt hugely momentous — but I don’t remember it — maybe because I was hugely disappointed with the finished product, but I’ll come back to that. Designing the piece was a very lengthy process too. The colour palette was easy. I don’t know whether I am unusual in my decisive and instinctive emotional reaction to colour, but my response is so strong that every single room in our house is decorated, or accented with, the colour red. Almost my entire wardrobe was red until the day I dyed half my hair red. At this point, all my wardrobe became black or grey, as I couldn’t handle the disparity that might occur between my clothes and my hair. My shoes (almost exclusively boots actually) have remained red. I fully accept now that what we wear, or our appearance, bears no real connection to who we are (I’ve stopped wearing makeup or brushing my hair in lockdown — I wonder how quickly I will feel the need when ‘real-life’ eventually rears its head?), but it does still feel part of who I want people to think I am — is it just a mask? — or maybe it’s ok to just accept it genuinely makes me happy, fulfils a deep inner need, and that’s ok? Red, and the colours surrounding it on the colour wheel, feel warm to me. They signify contentment, safety, fulfilment. The other half of the wheel, the blues, and greens, do nothing for me. I’m indifferent about green, but blue represents cold harshness and meanders heavily into the grey palette towards black — a colour I have never used in any version of 180 days. Even my worst days, were not black. Black is finality. Black, in this context, is the end destination we all creep towards, at different, indistinguishable and unidentifiable speeds, from the day we are born. The range of colours, within the ‘red’ and ‘grey’ criteria, are non-hierarchical. While it might have made interesting art, and given me a further range of possibilities, to have scored my days out of ten— or better still twenty— at the time of recording, my only aim was to try to aide myself and understand… well, I was busy trying to normalize the reality, which was that I was living in constant pain. The design of the original is, on reflection, a lovely marker of how far I’ve come as an artist, as a designer, probably as a fulfilled person — knowing a whole lot more about who I am, who I want to be and how to get from one to the other. I free-hand drew my 180 segments onto graph-paper. I tried to make them look as equal as possible. I may have checked it was the same width as it was height. Don’t get me wrong, it wasn’t an easy task, even within those loose rules, but the lack of clarity and precision within those parameters was to cause me immense disappointment for many years to come. Sounds overdramatic? It is but the truth. I continued to cross those stitches for a full eighteen months, but in the course of that time, I developed as a visual artist much further than I could ever have imagined. I had art lessons covering a huge range of techniques and subsequently became a part-time student at Leeds College of Art (I got an NUS card — a student card allowing all sorts of discounts in a wide variety of shops — such excitement at forty-something!). These courses were an amazing resource — it is galling that the entire, extensive offering of part-time courses was wiped out as a requirement of Leeds College of Art becoming Leeds Arts University. Fortunately, my family and I were moving away from Leeds by that point, which considerably softened this blow. The disappointment, or maybe the process of acceptance needed, on finishing the piece, after so long, was considerable. My main issue with my work was its lack of symmetry and circularity. Why on earth hadn’t I started with a circle and worked inwards, rather than just winging it with the outside shape? Namely, because the me that started out had no experience of making art. I had no practice in designing something and knowing what the finished product would look like. I had no idea that my style was going to innately turn out to be incredibly neat and precise — nothing less is good enough. So I hated the completed work! I found it incredibly unpleasing to my eye. It didn’t make me happy. I had none of the fulfilment and buzz I now know can be produced by creating something I really believe in and love. Something I’m incredibly proud of. And then there was the BIG issue of the balance of colours. ‘Red’ meant a good day. ‘Grey’ meant a bad day. As I mentioned, I hadn’t looked at patterns, as was my entire reason for recording the data, I think I thought it would be a big ‘reveal’ at the end. A piece of art never really speaks until it’s completion. I learned early on, that if I reject work at the point when I think it looks rubbish I wouldn’t finish anything, moreover, I would have thrown away work I am dead proud of. Maybe the truth was I was very fearful of that reveal? And indeed, I felt the whole thing just looked too ‘red’. Like life, on balance, was fine, and therefore it diminished my experience of mental illness. It confirmed suspicions that I was making a huge fuss. I was an attention seeker. There was nothing wrong with me and now I’d made a piece of ‘art’ that confirmed to everyone. I was a fake. I still feel the need to justify this. However, taking a deep breath, since I’m being so honest, I will see it as not ‘justifying’, but as explaining the mental process I have had to go through to now love it. And I do love it. I love it enough to have replicated it in many other mediums — Admittedly, all a perfect circle! I started recording the data not immediately I had the breakdown — I was far from a mental place where ‘hey, why don’t I write down my mood’ would have occurred to me. Grey, dark grey, very dark grey, and more grey. At the time I just needed it to stop. I would have taken literally anything anybody gave me to make the darkness go away. To stop the constant and unending brain chatter. To take the noise away. To give me space for just one easy breath. I started recording about eight weeks after commencing anti-depressants. Citalopram to be more precise. Whenever I talk about anti-depressants with anyone, I always find us comparing drugs — so there — it was, and is still, Citalopram. I’m constantly searching for that moment when life looks a little easier and I might try coming off them. Unsurprisingly, with the world as it is, that moment seems to evaporate every time I think I see it on the horizon. I look back on those red and grey days and remember what the grey days looked like. The red days were days that were not grey days. But what did a grey day look like? It took a long time to realize that everybody’s good and bad days are relative. Not just to them, but to their lives. To what’s going on around them. To their family. To their health. To their financial situation. To their week, their year, their decade. It’s hard to pin-point just how my grey days of 2014 looked. But I know they were full of miscomprehension. Of irrational thoughts. Of panic. Of pain. Of exhaustion. And the red days weren’t empty of those things, I was just slightly more in control of them. No panic attacks. Red days definitely did not involve panic attacks. And now I conclude that this blog is getting dangerously close to self-indulgence. A plea for sympathy. Which it isn’t meant to be. I have always tried, in my writing, to juxtaposition my life and how I have learned to live with chronic illness, against other, inspiring artists’ lives and work. This is my first attempt at talking about my own artwork. Jumping between me and, oh, me, feels slightly cringeworthy and is a very fine balance! I have ended up, predominantly — at least for now — making hand coloured prints because, beyond the fact that I find them incredibly pleasing and enjoyable to make, they don’t take 18 months to produce! However, after a 2-year gap, last year (Easter, Edinburgh — another landmark and memorable moment in the life of 180 Days) I decided it was time to return to the cross stitch version and to make the pleasingly circular version the original could have been! Graph paper, and a friend’s baby bath bucket, and the next version was on its way. Not only a perfect circle but this time every single day, within a stitch or so, is exactly the same size. I can only hope that this time I love the finished product. Roll on 2021. Hand Coloured Prints of 180 Days can be purchased HERE. Originally published at http://rebeccajburman.com on June 19, 2020. NOTE FROM THE EDITORS: A massive ‘thank you!’ to Rebecca from all of us at InSPIre the Mind from sharing this lovely piece with us! Rebecca is a musician, writer, and visual artist, constantly striving to find ways to express what goes on inside her head in a way that she hopes may help others to understand their own. You can see more of her gallery of work and blogs here. Thank you, Rebecca!