...but everything has changed this week An interview with Zarghona Rassa, the Chair of the British Afghan Women Society In the middle of the Afghan catastrophe unfolding live in front of our eyes and affecting thousands of people of every age and sex — among the scenes of crowds fleeing in chaos, people falling from planes, and armed soldiers parading — as a perinatal psychiatrist and an advocate for the rights of women and children, my first thought went out to Afghan pregnant women, and their soon to be born children. These incredibly vulnerable people, vulnerable even in the best of circumstances, are now once again exposed to the possibility of a new civil war and a ruler known for its past cruelty. The last time the Taliban were in charge, they allowed women to deliver in compounds full of girls and babies, giving birth on a cloth over a dung heap, because it absorbs the blood, and using a polluted stream as a source of water. Or simply they barred women going to hospitals, except for one establishment that had no running water or electricity, and only 45 beds for the whole of Kabul — a situation that was later partially reversed thanks to pressing from the International Red Cross. Undoubtedly the health situation — across the board, but for women and children in particular — has greatly improved over the last 20 years since the end of the Taliban ruling. According to a 2015 World Health Organisation report on Afghanistan, the maternal mortality ratio has declined by 70% between 1990 and 2015 (from 1340 to 396 per 100 000 live births), and the under-5 mortality rate has decreased by 50% (from 181 to 91 deaths per 1000 live births). Of course, these numbers are still incredibly high: the equivalent figures in the UK, for example, are 8–10 for maternal mortality ratio and 4–5 for under -5 mortality. NGOs (Non-Governmental Organisations) in Afghanistan have trained over 4,000 community midwives, but they have been a target of terrorist attacks within the country even before the events of this week. Nevertheless, there had been incredible progress, until now. And now we are already seeing the first reports of women’s health clinics being shut down. Zarghona Rassa is the Chair of the British Afghan Women Society (BAWS), a charity that was started to provide support to Afghan refugee women and children in the UK so that they could integrate into the British Society, but that has subsequently expanded its activities to help women and children in Afghanistan. Born in Kandahar, Zarghona lived in Afghanistan until 1994, when she took asylum in the UK with her family. She has been travelling back and forth to Afghanistan since 2004, involved in humanitarian activity, organising the delivery of donated material (clothes, baby formulas, medical and obstetric equipment, stationery for schools) and supporting health and education initiatives for women and girls. I managed to reach her on the phone, in between her interviews on The Times of India, BBC 5 Live, and Instagram Live. I started by asking her what was her perception of the situation on the ground in Afghanistan. It is very difficult to get in touch with anybody at the moment in Afghanistan, but we know that women are too scared to go out. The country is in a lawless situation, and we are watching a humanitarian crisis unfolding in front of our eyes. And we can only watch. It is very difficult to understand what is happening at the higher government level. And there are no systems or procedures in place at present. At ground level, the Taliban may behave differently than what they have been telling the press. There have been great improvements in health and education in Afghanistan in the last 20 years. What do you think will happen with the new regime? During the last 20 years, women had become much more confident in Afghanistan. [In the aforementioned interview in Times of India, Zarghona also said: We had female lawyers, 27% of parliament were women, as well as ministers and women journalists. It was inspirational for me to watch women journalists having strong opinions. We had many businesswomen too. Women could go out on their own and drive.] But everything has changed this week. What have your main activities been since you founded this charity? We started as a small group of Afghan women in 1999, then we became a charity in 2001. We still do not have any paid staff, and only rely on volunteers. We helped fundraising in the UK and supporting the transport of humanitarian material and deliveries to all areas of Afghanistan, and especially Kabul and Kandahar. We also supported internally displaced people within Afghanistan, and in particular women and children. [It is worth noticing that the United Nations Refugees Agency already said at the end of 2020 that there were almost 3 million internally displaced Afghans, because of ongoing fighting in most of the provinces. Nearly 400,000 have been forced from their homes since the beginning of 2021, with nearly 120,000 who have fled from rural areas and provincial towns to Kabul province. This was before the Taliban took over.] We brought food, warm clothes, and blankets, to children who were freezing because of particularly cold winters. [Here Zarghona is referring to episodes where freezing winters in Afghanistan were also in the international news: in 2012 (“the coldest winter in 15 years”), when 41 deaths from freezing, mostly children, were recorded in the three provinces of Kabul, Ghor and Badakhshan; and at the end of 2020, when, according to an appeal from the NGO, Save the Children, 300,000 children were at risk of facing illness and death from Afghanistan’s freezing winter conditions. Again, this was before the Taliban took over.] And how can we help people in Afghanistan from the UK? We are planning to support women and children in Afghanistan, by reaching out to local community leaders, when it will be possible. And we also want to prepare for the arrival of Afghan refugees in the UK. We are also reaching out to the Home Office, the Foreign Office and the Refugee Council to offer our help and advice. In the past, we have offered cultural advice on how to facilitate the integration of Afghan people in the UK and worked with the Refugee Council. We will also assist with emergency accommodation and translation. We are preparing a specific fundraising programme to support our activities. We talked for 10 minutes, this was the only time she had. She is preparing to support the arrival of Afghan refugees in the UK. And so are many other generous volunteers, hurrying to sort donations for Afghans escaping the Taliban. We, at Inspire the Mind, will continue to provide a platform for these traumatised, vulnerable people, and to offer an opportunity to hear their voices and their stories. As Dr Ayesha Ahmad says in her recent blog on Afghanistan on this platform: “We cannot let the blood of Afghan women be in vain. Theirs is a story that needs to continue.” — DR AYESHA AHMAD Follow the British Afghan Women Society on Twitter and Facebook to become aware of their fundraising and volunteering initiatives. Header image source: British Afghan Women Society (BAWS)

What comes to mind when you hear the terms ADHD (Attention Deficit Hyperactivity Disorder) or ADD (Attention Deficit Disorder)? Most people would imagine restless children not being able to sit still, running around recklessly in class, causing disruption and generally wreaking havoc. Until recently, this was how I too perceived this condition; but this all changed last year in my second year at university as a biomedical science student, when I realised that I myself might have ADD. Disabilities in the functioning of the neurological system and the brain that affect an individual’s behaviour, memory, and/or ability to learn, are termed Neurodevelopmental Disorders. These include dyslexia, autism, and ADHD. ADHD is the most common Neurodevelopmental Disorder in children, and whilst it has mostly been considered a childhood disorder, impairing symptoms in adults are increasingly being recognised. In the past, most research in ADHD was conducted on young boys, and research focusing on adults with the condition has only been undertaken in the past six to seven years. The exact cause of ADHD remains unknown, though it is thought to result from a combination of genetics, environment and problems with the central nervous system (brain and spinal cord) during development. The common symptoms of ADHD include impulsivity, fidgeting, emotional turmoil, lack of focus, lack of organisation and poor time management. ADD or ‘inattentive’ ADHD is one type of ADHD, most common in girls, where the person’s symptoms of ADHD transpires through inattention (for example, difficulty in focusing, finishing tasks, and following instructions), without hyperactivity or impulsivity. It is thought that children with this type of ADHD aren’t identified and diagnosed at a young age because they aren’t disruptive in the classroom. I have always just accepted that for me, accomplishing daily tasks, including school and university work, takes a lot longer and requires a lot more focus than for my peers. I only began to realise how abnormal it was that all my life I had been setting aside more than double the time my peers would, to complete my school and university work, and how unusual it was to spend hours (yes, hours) staring into the abyss, unable to concentrate, whilst at the same time being cripplingly stressed by the enormous amount of work I had to do when I got to my second year at University. The diagnosis I had suspected something was different with me in terms of my ability to focus and order my thoughts from a young age, but there was a particular moment when I decided to do something about it and arrange to see a psychiatrist. I was sitting at my desk with a mountain of work to do for university, and before I knew it, the whole day had passed and I had completed a tiny fraction of what I needed to do. Despite my desperation to progress, there was something going on in my brain which just did not let that happen. I became anxious and distressed thinking about all the work my flatmates had been able to get through in less than half the time I was at my desk, and anxious thinking about how much of my life I had been wasting. I felt further distress and anxiety thinking about the fact that there may be something wrong with me and that I have failed to do anything about it for 20 years. It felt like there were a million tabs open in my brain and all I wanted to do was shut them all to be able to focus on just one, to be able to get stuff done. I discussed my feelings and worries with a friend who recognised some of what I was describing as possible symptoms of ADD, and who advised me to see a Psychiatrist. The Psychiatrist ran through a lot of questions, many of which I never even thought would be relevant to ADHD/ADD. Aspects of my personality which I never thought could be explained by this condition started to make sense as he was going through the questions. Things like frequently having to come back after leaving the house because I had forgotten something, feeling very overwhelmed and unable to cope in stressful situations, accidentally interrupting a teacher even though I had always been a polite and non-disruptive student. The diagnosis suddenly explained all the frustration I had experienced throughout my primary and secondary school years- frustration at taking so long to complete homework, frustration at the length of time it always took me to study for exams; frustration at not being able to enjoy my weekends because I was catching up on work I hadn’t completed during the school week. Suddenly it all fell into place. The Outcome The frustration after receiving the diagnosis however was different. I almost felt like I was mourning the person I could have been had I been diagnosed when I was younger. I do not wish to suggest that I suffered greatly by not being diagnosed early. But thinking of all those hours I could have saved where I was staring into space, all those friends I annoyed by arriving late for arrangements, even exams in which I could have achieved my full potential, had I only known and received appropriate treatment… Thinking about how all that might have been different is terribly frustrating. The ‘what if’ road that I went down for a short while was tormentingly distressing and exhausting. But then came a wave of relief and reassurance. Relief to know that there was something going on in my brain that could explain those aspects of my personality that I had always thought of as flaws, which now suddenly made sense. I began to see what I always thought of as my faults, which I always felt embarrassed about, as quirks that I could embrace. It wasn’t just that I was just ‘slower’ or less focused than my peers. I began to see new opportunities to grow and excel with my newfound diagnosis, I felt determined to channel my frustrations into feelings of understanding and positivity. There was also a very tangible outcome from the diagnosis, namely my psychiatrist’s recommendation for me to take medication to help me focus and accomplish tasks more efficiently, during those periods when I particularly needed to concentrate and stay focused, for example during university term time. While it did take some time to find the correct medication and dosage that worked for me, once I found what worked, it made such a difference. They’re not magic pills, as I know many people may think- they don’t create a top achieving student from a bottom one, but they allow me, personally, to delete most of those tabs open in my brain, enabling me to focus and accomplish tasks without feeling so chaotic. Looking forward The diagnosis has been a turning point for me. I have gained new insight into myself, which I have started to use positively, as a step towards identifying and understanding behaviours which until now have hindered my achieving goals or even accomplishing simple daily tasks, allowing me to develop solutions and strategies to better myself. I hope this piece has shown that it’s not too late to overcome behaviours that have proved obstacles throughout one’s childhood and teenage years, by gaining psychological insight and seeking help.

The Mosaic Edges of an Afghanistan in Trauma The sense of time has stopped. The monumental images of Taliban standing where hopes, dreams, and visions of peace had danced just a sun and a moon away shattered any conceptualisation of a brighter tomorrow or a future free from the mesmerisation of trauma. I am a Senior Lecturer in Global Health at St Georges’ University of London with a PhD in Medical Ethics, and co-editor of Humanitarian Action and Ethics. My research is situated in Afghanistan as well as Kashmir, Turkey, Pakistan, Iraq Kurdistan, and South Africa. The world often feels beautifully embroidered with the tapestry of lands through such spaces. Two weeks ago, even, my research team and I were still finalising plans for interviewing mothers and daughters to help inform our developing of a mental health care package for women survivors of violence. Danger is unequivocally draped over every decision and a darkness that does not ever escape even when there is hope. Over the last few days, though, the world’s distance shrunk to an irrelevant portal. The tears and fears uncontrollably raining into our phone-call conversation travelled through such different lands and terrains. Our a-part-ness was illusory. Rather, it was just one jagged edge of a mosaic piece that had lost its corner. We shared so much yet the gulf between us meant that we could not build our solidarity side by side. The faith in being asked to help someone, the voices I spoke to, the words I read, the sounds that stayed silent from fear, these are all the mosaic edges of an Afghanistan in a traumatised state that is so poignantly palpable yet at the same time is elusiveness and ethereal. There is also the shock. The betrayed trusts and enflamed memories of an existence that had never really ceased and is now resurrected. When I reflect on the suffering of Afghanistan, a land-locked mountainous region, with a historical legacy of travellers, bringing forth the essence of storytellers to find poems or songs or stories in a personified land, a land that perhaps was born in the wrong place. On my visit to Kabul to analyse the meaning of suffering and the role of storytelling in the trauma therapeutic response to gender-based violence, one of the first sentences that greeted me was “here, in Afghanistan, even a tree has a story”. Yet, here we are now. The trauma of war is such that creativity is mirrored with destruction, and imagination is murdered by bearing witness to violence. Against this literary and sentimental reflection of Afghanistan, there is an imminent humanitarian crisis. The journeys of tribes and nomads have been strictly determined by the direction of war. Since the beginning of 2021, an estimated 550,000 and rising, Afghans have been internally displaced within the country and between the 1st July and 15 August 2021, 17,600 internally displaced persons (IDPs) entered Kabul, and a significant number of these have serious health concerns and health needs. Some are staying with relatives but there is an urgent immediate need for shelter especially since Kabul is in the hands of the Taliban. Many of these IDPs who came to Kabul have significant reasons to fear identification by the Taliban and expected that the province would be a sanctuary from Taliban power. There are those who are left behind with unaddressed humanitarian needs, and there are those who are screaming to the world that the story their efforts tried to create for Afghanistan’s future is now being condemned to end along with their life. Many of us who have friends and colleagues in Afghanistan have needed to battle over the last few days, and continue to do so, to find ways to honour their pleas for help. In my area of global health, I specialise in psychological trauma from gender-based violence during conflict and ethical issues in humanitarian action. From my experience in the United Kingdom responding as an expert witness to the mental health and gender-based violence that Afghan asylum seekers have endured, I have learnt that the global and humanitarian community must do more than to know the words that are being spoken, or, rather, the words that are being silenced. We can create spaces for voices to speak and to tell expressions of the self and the surrounding world as it is experienced by those we seek to listen to. But in these moments when there are those with the leverage to speak and those with the perilous curse of silencing, to prioritise breath over words, we need to reflect on our own landscapes. How are we creating and designing spaces so that the mosaic edges of Afghanistan in trauma do not have to conform or fit into a space, but for the land to find its own shape, and for voices to be heard. So, the worn-down edges of a mosaic corner are seen as complete. Unless the academic community can ensure that we extend our spaces to where Afghan women can no longer tread, then Afghanistan will be the graveyard of Afghan women who never slept whilst threading their dreams through the hearts of the new generation of Afghan girls. Selay Ghaffar, a political and women’s rights activist, after the murder of Farkhunda in 2015, sponsored the construction of a memorial [pictured below]. We cannot let the blood of Afghan women be in vain. Theirs is a story that needs to continue. Afghan women are bleeding, bleeding stories. Their words are their own, but to speak, we must focus our efforts on giving safe sanctuaries to Afghan women who are dying for their words, the mosaic obliteration of a land born on stone. May these stones be their platform, not on their grave.

When I think about the word optimism, the first word that often comes to my mind is ‘positivity’. I conjure up an idea of someone who sees the world through rose-tinted glasses and thinks positively 24/7. I often see Instagram posts filled with images such as “a negative mind will never give a positive life” and #goodvibesonly, leading to this idea that we should be positive 24/7. As a medical student interested in mental health, I started thinking about the impact these posts have, and what being positive really means in relation to ‘good’ mental health. On the surface, the purpose of these posts is to make people feel better and be more ‘positive’ — and for many they do, which is great! However, I have had many discussions with friends about social media — in fact, I wrote a piece on the effects of social media on adolescents — and how in excess these posts and comments can create a pressure that we should be having a fun, positive time all the time. In reality, being positive all the time is a completely unrealistic idea. As humans, we’re made to experience the full range of emotions whether it be sadness and stress, or happiness and gratitude. Research has shown repressing our negative emotions has negative effects on both our mental and physical health, highlighting the importance of accepting the full spectrum of our emotions. The last 18 months have been filled with uncertainty and change due to various COVID-19 restrictions and their repercussions. Throughout, I have personally experienced people responding to these situations with hyper-positive statements and have seen many similarly positive posts on TikTok and Instagram. For example, posts of encouragement to ‘make the best of a bad situation’ or telling someone who’s lost a loved one to ‘try to stay positive’. These statements could be interpreted as a type of positive reframing, a process where a situation or event that was initially viewed as negative, is viewed through a positive lens, reframing the negative into positive. As recent research studies show, positive reframing has been linked to increased mental wellbeing and fewer depressive episodes, and therefore can be highly beneficial. However, while positive reframing is a hugely valuable technique, if it is misinterpreted or exaggerated, it can turn into what is known as toxic positivity: the exaggerated and overgeneralization of a think positive state no matter the situation. Just like anything done in excess, if positivity is used excessively or to deny our emotions, it can become ‘toxic’. For example, continuously hearing phrases such as ‘just look at the bright side’ or ‘it could be worse’ can invalidate negative emotions that one may feel. This suppression of negative emotions has been associated with decreased self-esteem and an increased risk of depressive symptoms, thus has negative consequences to short and long term mental health. Additionally, if positivity is used to dismiss grief or silence negative emotions, people may feel shame about these emotions and pressure to be happy. Shame impacts feelings of acceptance and belonging, and thus can be an isolating experience. Therefore, in times of anxiety, loss or bereavement, being insincere with or invalidating our negative emotions is often counterproductive and can lead to worse mental health outcomes. Interestingly, a 2018 study looked into the link between emotional acceptance and psychological health. It found emotional acceptance — accepting emotions and thoughts without judging them — was related to a decreased negative emotional response to stressors. Perhaps emotional acceptance should go hand in hand with positive reframing to avoid slipping into this idea of ‘toxic positivity’. Can we also use optimism to avoid toxic positivity? I was recently listening to a podcast with Dr Deepika Chopra (known as the Optimism Doctor), a clinical psychologist who did her PhD on the topic of optimism. Interestingly, Dr Chopra does not use the word positivity to define optimism; instead, her 2 keywords are resiliency and curiosity. By this she means: 1. Resiliency: overcoming and persevering through life’s challenges — knowing we have the power to lean into these moments and push through them. Resilience plays a positive role in coping with adversity and thus reduces the risk of anxiety and stress reactions. It has even been shown to predict life satisfaction as we age. 2. Curiosity: being able to be curious about one’s own experience and emotional experience. For example, you might be going through a difficult time, feeling emotions of anger, worry or sadness. However, even when something seems difficult, you can say to yourself: “I am curious how I will grow from this”. Therefore, for Dr Chopra ‘an optimist is someone who is very aware and mindful of their setbacks or less than ideal situations, however, sees them as temporary, recognizing their ability to overcome them, even if they don’t know exactly how or when’. She explains that by embracing the challenges and the things that make us feel uncomfortable, we can practice these behaviours and become more optimistic throughout our lives. In this way, we also avoid the toxic positivity mindset. How do we practice resiliency and optimism? Recognize all emotions as a normal, valid, and important part of being human Seek out news that has a positive impact on you, and content you find inspiring — which doesn’t discourage emotional acceptance! Practice mindfulness, which encourages us to give our emotions ‘space’ to exist. I like to use Headspace, but other popular apps include Calm and Insight Timer Practice gratitude e.g. through journaling The bottom line is: optimism and “good” mental health are not about never having negative emotions or going through challenging times. Instead, it’s about remembering it’s OK to feel our emotions, while still looking forward to the possibilities of the future. Header Image Source: Blackburne House

In 2012, one year after the London riots, I wrote a blog for the Huffington Post UK, and longer academic paper, where I tried to interpret the terrible events of 2011 London’s burning through a psychosocial perspective. As you will read in the blog, republished below, I lamented that, one year on at that time, there had been no attempt to understand the youth’s suffering that had led to the protest, and that all the events were brushed under the carpet as a public order problem. Unfortunately, 10 years on and the situation has not changed: lessons have still not been learned, and there is a clear concern that the same factors operating then can make the same events happen again today. In the meantime, it has also become apparent that the response of the courts was unduly harsh, with custodial sentences given to people, often kids or youth, even if some had never committed a crime before. These included a student jailed for six months after pleading guilty to stealing bottles of water worth £3.50, and two men jailed for four years for inciting riots on Facebook, although no disorder occurred. Nothing has changed since Victor Hugo’s Les Misérables: Jean Valjean went to prison for five years for stealing a loaf of bread to feed his starving family. Exactly a year ago, hundreds of kids misbehaved really badly, so why has nobody asked the question? Have we — society, government, family — done something wrong? Why the loud silence? Oh, sorry, I forgot — they are they just nasty little rioters, and should go to prison. There is nothing else to ask. Where is the reflection, the understanding, the questions? Those arrested during the riots mainly came from deprived areas and had the poorest educational backgrounds. They set fire to their own communities, and looted consumerist goods − plasma TVs, “branded” fashionable electronics and expensive shoes. Why did they do what they did? Parents in a bedroom When our kids misbehave badly, we reprimand them. Sometimes we even punish them. We give them time-out, we ground them, we take away toys and gadgets — just temporarily. Then, we go back to our bedrooms, and we ask ourselves: what have we done wrong? Every time, we ask. The more serious the misbehaviour, the more serious the asking. Was it something in the way we educate them when they were toddlers? Were we too harsh? Were we too liberal? Were we not affectionate enough yesterday? Were we not affectionate enough 10 years ago? Exactly a year ago, hundreds of kids misbehaved really badly, so why has nobody asked the question? Have we — society, government, family — done something wrong? Why the loud silence? Oh, sorry, I forgot — they are they just nasty little rioters, and should go to prison. There is nothing else to ask. Please don’t take me wrong. I am not implying that illegal and violent behaviour should go unpunished, or that we should have a soft approach and send everybody back home with a gentle rebuke. Some of the actions were terrible: widespread rioting, arson and looting occurred, along with injuries to the public and police, and the death of five members of the public. But why the silence? Where is the reflection, the understanding, the bedroom questions? Those arrested during the riots mainly came from deprived areas and had the poorest educational backgrounds. They set fire to their own communities, and looted consumerist goods − plasma TVs, “branded” fashionable electronics and expensive shoes. Why did they do what they did? Many have discussed the role of social and economic factors in the origins of the riots. We would like to contribute to this debate by proposing a formulation of these terrible events from a psychosocial point of view. We believe that psychiatrists, as “specialists of the mind”, may help understanding what has been repeatedly described as “mindless” violence. At the margins of society, at the margins of emotions We would like to propose that two mechanisms were operating in the rioters’ minds during those terrible nights: a lack of social identity, and a lack of inner understanding of their emotions and of what their emotions meant. The lack of social identity led to frustration and anger, and the lack of inner understanding led to the violent expression. One thing these riots were not: they were not a politicized form of protest. A defining feature of politicised protest is that participants are able to identify with a cohesive social group, to argue a political position, and to express clearly their needs and their requests to the rest of the society. In contrast, the peculiarity of the English riots lies in their confused and disorganised nature, and in the absence of any attempt not only from the rioters to express a common social message, but also from the commentators to identify one. The riots started as a social protest against the police, but ended up as a spontaneous, collective robbery — a highly disarticulated form of social protest with a message to society that was very contradictory and difficult to decrypt. We would like to propose that this indicates a failure of the English rioters to see themselves as a social group, and as having a “social identity”. Perhaps because of a lack of ideological background, these young people — living in areas of high unemployment and in a country with the lowest level of social mobility in Europe — failed to understand their position in society, in relation to either the people around them or to their own past. Additionally, we would like to propose that the stealing of consumerist goods — shoes, clothes, electronics, mobile phones — constituted an attempt to obtain such a social identity. Marcuse got it all wrong The American philosopher, Marcuse, believed that the most marginalised members of the American society (such as immigrants and students) were the last revolutionary force, able to counteract a consumerist society. The English riots highlight, to the contrary, that the most marginalised members of the society aspire to consumerist goods: to the flamboyant ostentation of branded accessories — the “bling-bling” of the hip-hop culture. However, this creates tension and confusion: on the one hand, the “socially excluded” would like to share the goods (the “symbols” of the community) and, on the other hand, they know that they will never be part of the community that can afford those goods. This desire, constantly unfulfilled, leads to a sense of frustration and resentment. On this occasion, unable to understand these inner emotions, people just turned into violent looters. Perhaps even more tragically, by destroying shops and stealing goods in order to “belong”, the rioters confirmed that they were not part of the society, and thus increased their social exclusion. How can we break this vicious circle? What can we do? Our psychotherapy training teaches that a good and successful therapist should show himself to the patient as “present, involved and invulnerable”. We would like to propose that a healthy community, which tries to integrate its marginalised members, should try to show these same characteristics: “present”, meaning knowledgeable of the community members in difficulty; “involved”, meaning interested in helping the pursuit of the individual and social goals of the community; and “invulnerable”, meaning trustworthy, and morally coherent, in how we deliver on our promises of equal opportunities, personal development, social mobility, and respect of the law. But showing concern is not enough — although it is a start. Practical steps can be delivered to improve social inclusion. For example, recent research in the USA has shown that social and psychological intervention can improve social belonging in ethnic minorities. The results of these studies show a positive association between an increasing sense of belonging and improving academic achievements in the Afro-American population. These interventions are focused specifically on a student population, and so perhaps this is when and where we need to start: in our schools. Social belonging is a primary requirement to allow people to live a meaningful life in the community, and this — not sending kids to prison — is the major deterrent that a civilized and emancipated society can offer to prevent violence and riots.

How Anxiety Can Stop You Getting an Accurate Health Assessment “I can’t tell if she’s really unwell or if her anxiety is causing it,” I told the nurse over the phone. “That’s the problem with anxiety,” she explained gently. “It often mimics other symptoms.” My 10-year-old daughter sat on the couch with her hand pressed against her chest. She tried to describe the sharp pain but, as it came and went, she was struggling to explain it. She’d had a week of flu-like symptoms. “Will I be okay?” she asked every night, afraid to die in her sleep. After her flu symptoms ended, the chest pain and worrying carried on. “Do kids get heart attacks?” she asked me. “It’s very unlikely,” I reassured her. The more she worried about it, the worse it became. I decided we needed to check it out properly. If I’ve learnt anything over the years about anxiety, it’s that writing off symptoms as “all in your head” is never a helpful thing to do. My sister and I both struggled with anxiety disorders from a young age and also both have Crohn’s Disease, an inflammatory bowel disease. Crohn’s is often diagnosed in your early to mid-20s and my sister was the first to experience severe symptoms. When she ended up in the hospital, her family doctor had an unexpected response to the specialist’s Crohn’s diagnosis. He refused to believe it. “I know her like the back of my hand,” he replied to the specialist in writing. “This isn’t Crohn’s. It’s her anxiety.” My sister is a qualified nurse and knew he was wrong. She wasn’t able to hold down food or fluids. She was rapidly losing weight and had severe stomach pain, but her doctor was convinced. It was all in her head. Thankfully, the specialist disagreed and treated my sister for Crohn’s which, later tests confirmed, she did in fact have. Many medical professionals now understand the importance of listening to all of their patients’ concerns. The old approach of dismissing ‘the worried well’, as patients with anxiety were sometimes called, is being challenged. Still, it’s difficult to separate anxiety symptoms and other symptoms. It’s hard for those of us with anxiety too. As someone with a chronic disease, I experience odd and troubling symptoms all the time. In winter especially, I’m constantly in the doctor’s office. After a while, you start to doubt yourself. No one wants to waste anyone’s time worrying about symptoms that are “all in your head”. But that’s the key: anxiety itself is not all in our heads. It’s very much in our bodies. Our mental and physical health are interlinked. Crohn’s Disease can triple the risk of anxiety disorders, and stress increases the chance of a Crohn’s flare-up. Other diseases are linked in similar ways. Can we really separate our minds from our bodies? When my daughter described her chest pain, I decided it was important I didn’t write off her symptoms as just in her head either. Whether it was caused by anxiety or not, it didn’t change the real physical pain she was experiencing. We took a trip to the doctor’s office. The first doctor was dismissive and raced us through the appointment. “No children get heart attacks,” he told her. He listened to her chest quickly and told her she was fine. She felt reassured for a few days, but the pain wouldn’t go away. I asked her what she wanted to do. “I’d like to talk to another doctor,” she said. I was pretty sure by this point the chest pain was a mild panic attack. It only happened at night before bed, when she got most anxious about dying in her sleep. “You can tell doctors anything, you know,” I told her. “You can talk about feeling worried.” “Can you talk about stuff like that?” she said, amazed. I nodded. “Of course!” In the doctor’s office, I sat quietly and let my daughter do the talking. I wanted her to feel confident explaining what she thought was going on for her. “It’s your body,” I told her in the car. “You’re the only one who really knows what’s going on.” She described her chest pain as the new doctor listened attentively. He asked questions and did a thorough check-up. “What do you think is wrong?” he asked her at one point. “I think it might be because I’m feeling anxious at night,” she said. I stayed silent, wondering how the doctor would respond. “That’s very self-aware,” the doctor said. He waited while she explained more, and how she thought seeing her play therapist might be helpful. He nodded and spoke to her about how the mind and body are connected, and things that might help her chest feel better at night. “That was really helpful!” she said in the car afterwards. Her shoulders lifted with confidence, and she beamed up at me. “I’m proud of you for talking about what you needed,” I told her. “Me too,” she said. We implemented the different things the doctor suggested and, over a few weeks, the chest pain disappeared and she slept better and for longer. My daughter’s first doctor hadn’t been wrong: it wasn’t a heart attack, but we already suspected that. He didn’t take her physical anxiety symptoms seriously or address them in any way. Anxiety is not “all in our heads”, it’s very much in our bodies too and that’s important to acknowledge and treat, as her second doctor did. Anxiety and panic attacks can cause severe, very real physical symptoms, including heart problems, chest and stomach pain, headaches, dizziness and numb tingly limbs. Other times our anxiety masks physical problems with different underlying causes, like my sister’s Crohn’s disease. Becoming self-aware can help us decide what to do with our symptoms. Understanding how a panic attack feels and how anxiety manifests in our bodies is a useful place to start. Then we can be better advocates for ourselves and our health. We can ask for what we need and get a second opinion when we know medical professionals haven’t listened well. Importantly, we can push for further investigation when we feel something else is underlying our symptoms.

Animals to the Rescue — Assisted Therapy & Unconditional Love Over the years, I relocated several times for education and work in India. On every street, I found a dog who became a companion. They knew my schedule and would wait at their spot with wagging tongues and tails. One would climb the stairs to my house because why not! At times, they weren’t looking for food, just petting. Once, a cat came to live on the balcony with her two kittens. The landlord wasn’t happy. I was. It was a riot with those two little munchkins. Cat mom would often take a nap, asking me to keep an eye on them. All these strays were and still are, my doses of instant happiness. Turns out, science agrees. Petting an animal promotes the release of serotonin, prolactin and oxytocin — all mood-elevating hormones. I have always believed in the healing power of nature and by extension, animals too. While my spiritual side believes in their omens and symbolism, my human side knows that healing works in combination with medications as prescribed. History of Animal-assisted therapy It is not a new discovery that having animals can be an important part of the mental healing process for humans in therapy. Animal-assisted therapy (AAT) dates back to ancient Greece, where they used horses to lift the spirits of severely ill patients. No other documented mention of AAT occurred until the 1600s, when physicians again turned to horses to improve their patients' mental health. Sigmund Freud, a highly influential neurologist and psychologist, in the later part of his life, around the 1920s, provided canine-assisted therapy with his Chinese Chow, Jofi, and believed that dogs have a calming effect on people. In the 1940s, the American Red Cross, a non-profit humanitarian organization that provides emergency assistance and disaster relief, used farm animals to help war veterans with post-traumatic stress disorder (PTSD) and other war-related traumas. In the early 1960s, Boris Levinson, a child psychologist, presented a paper at an American Psychological Association meeting based on his clinical experience. Levinson went on to author Pet-Oriented Child Psychotherapy and became ‘the father of AAT’. Numerous studies have shown that pets and animal-assisted therapies have a positive effect on our physical and mental health. For example, animal-assisted therapies have been shown to ease aggression in patients with Alzheimer’s, improve the response of kids on the autism spectrum, and help the elderly struggling with loneliness. Animal-assisted therapy has also been shown to improve physical health by reducing blood pressure and stress hormones along with improving mental health by reducing symptoms of anxiety and depression. A study at American Heart Association’s Scientific Sessions, 2005, concluded that even short-term exposure to dogs has beneficial physiological and psychosocial effects on patients. Healing Stories Animal-assisted therapy has just begun to gain popularity in metro cities in India, partly because mental health itself was rather an obscure concept, in small towns and even cities, not so long ago. I remember getting discouraged when I expressed interest in studying psychology in the early 2000s, hearing “There is hardly any scope…” If I had only known animals were involved, I would have protested with much more determination regarding this choice of career. Recently, I connected with Radhika Nair, who co-founded the ‘Animal Angels Foundation’ in Mumbai, India, a non-profit organization that has introduced the field of Animal Assisted Interventions in India. She and Rohini Fernandes, both clinical psychologists and certified AAT practitioners, launched the foundation in 2005 and have since worked with numerous non-governmental organizations (NGOs), rehabs, schools for children with autism, the elderly, people with physical disabilities, and child sexual assault survivors. They mostly train dogs for their therapies but had a rescue cat too, who was equally purr-fect in healing her human patients. Radhika had a bag full of heartwarming healing stories. One child who had previously suffered abuse was not able to trust adults. A therapy dog had helped by being the one whom he could rely on. Later, the trust circle embraced an adult with the dog and slowly, the circle expanded to other adults too. In the US, many states allow specially trained dogs in court to help calm child abuse survivors while testifying. There is something innate about the bond between pets and children. A 2017 study by Cambridge found that a child’s bond with their dog is even stronger than with their siblings. Radhika also told me about one of her clients, aged 22, who lost his ability to walk after an accident due to a spinal injury. His mental health was in shambles. Severe depression led him to have no interest in his physiotherapy sessions or even personal hygiene. Radhika and her team used to visit the hospital he was admitted to for therapy sessions. At first, the young man showed no interest in the pets. He used to gaze with a blank stare when Angel, a Golden retriever, played tug of war with other patients as a part of therapy. Gradually, he opened up to play with her. His muscles were extremely weak, and Angel won every time. One morning when Angel reported for her duty, she was pleasantly surprised. This human was eagerly waiting for her after an early shower and his physiotherapy session. Apparently, he wanted to win in today’s tug of war. It was a moment full of happy tears and the start of a healing journey. Angel has passed over the rainbow bridge since then but the name lives on forever in their organization. Aren’t all pets therapy animals? Though the animals don’t care for that label and continue to bring joy to our lives, therapy animals are specifically trained with positive reinforcement and sensitized to help patients in different age groups and with different types of difficulties. Not every animal has the temperament to work in this way. It is crucial to match the temperament of the animal with the patient. Without training, a pet might qualify as an emotional support animal if prescribed by a licensed mental health practitioner in some countries. Emotional support animals provide therapeutic benefits by companionship, unlike trained therapy dogs who are trained to socially adjust to various people and provide calming, psychological and physiological healing. It might be argued that there is not enough evidence to support the claim that these therapies work. Some experts have raised concerns that using emotional support animals might harm both the animal and the person undergoing therapy. For example, the person undergoing treatment for anxiety or phobias might work well with emotional support animals in the short term, but if the dependency isn’t controlled, it might cause harm in the long run. Radhika raises a valid point against these concerns: “It is a complementary therapy — you use it in congruence with other therapies. Recommendations and results are dependent on the skills of the therapist too” Regarding concerns on whether animals, particularly our canine friends, are under stress doing this healing job, a study reported in Applied Animal Behaviour Science in 2018 measured salivary cortisol of 26 dogs in animal-assisted interventions across five different hospitals, involving hundreds of patients, and found that therapy dogs aren’t stressed by their work and might actually enjoy it. Just for humans? You might be surprised to know that some conservation zoos calm cheetahs’ anxiety by giving them support dogs. The San Diego zoo has been doing this for three decades. It is remarkable how our furry friends can heal us in ways we never anticipate. We all break and heal multiple times in our lives. I’ve often found nature and animal companionship to be intensely cathartic. Maybe because love exists there in its purest form. “Until one has loved an animal, a part of one’s soul remains unawakened.” — ANATOLE FRANCE Header Image by Turgay Yıldız from Pexels

An Insider’s View on Mental Health in the Legal Profession Law is a high-stress profession; there’s almost no doubt about it. Having been deemed the second most stressed profession with a ‘toxic, cut-throat’ work environment, it doesn’t take long before one starts to wonder why this is, and wonder what the driving forces behind it are. A survey conducted by the Junior Lawyers Division of The Law Society of England and Wales found that 14% of junior lawyers having experienced suicidal thoughts, and 48% of respondents reported mental ill-health. As someone who is considering going into the profession, it’s hard for me not to feel anxious about how I will fit in with my existing mental health issues that I’ve talked about in a previous blog. Although I am still at the study stage and undertaking a law degree at university, I am already starting to feel the pressures taking hold. Between balancing deadlines, expectations, and trying to sufficiently take care of myself, the different aspects sometimes feel incompatible. I often wonder if the working world will provide more support — but that doesn’t appear to be the case. The issues and shocking statistics are particularly pertinent for workers entering the profession right now. Speaking to a practising lawyer, they mentioned that one of the main barriers for those who take on law as a first job, is the transition into working in a new sector — an issue faced by many new employees, not just within the legal profession. Successful transition involves having sufficient supervision and creating a workplace environment conducive to asking questions and learning. Such an environment is crucial for someone who has just started out, as it permits rapport-building, understanding the methods and behaviours in which people work, and seeing the inner workings of the organisation. Bringing in some personal experience, a lawyer mentioned how they ‘learned so much from being sat in the same room as the partner I was working for, just listening to how they spoke to clients on phone calls, how they manage their day, how they behaved in the office…you can see everything that’s going on’. Besides the barriers posed by the working environment for newly qualified lawyers, another major source of stress comes from the profession’s demands to bill clients by the hour. When a price tag is placed upon the seconds and hours that you are working, it inevitably creates pressure to work more hours and can generate an environment where people feel trapped within the work cycle. Despite best intentions and motivations to generate a healthy work-balance for oneself, the reality is difficult to ignore and there will always be the temptation to forsake your own wellbeing for a bit of extra time in the office, and thereby extra income. This is particularly acute for those entering the profession, who are yet to feel completely secure within their positions and may feel a need to ‘prove’ themselves — only to create prime conditions for burning out and perpetuating the stress cycle that currently dominates the legal world. A further issue arises in the pressurised environment created from the nature of the work and client expectations. The work being done by lawyers can often have impacts beyond the client themselves, such as when the businessman Simon Dolan brought a case challenging the legality of lockdown restrictions. On the face of it, the client is Mr Dolan, but the outcomes of the case had an effect extending far beyond the singular individual and could have impacted the whole nation. There are always stakes at play in a legal case, and frequently with outcomes that may not be favourable for clients, despite best efforts. This creates unspoken expectations that can easily push the more junior end of the profession into a perfectionist mindset, as they try to mitigate some of the inevitable disappointments that will arise. In the words of a lawyer that I spoke to, lawyers are generally expected to be problem-solvers. Dealing with such pressure is never easy, and when it becomes integrated with the work that you are doing, it can lead to work-induced stress about circumstances beyond any individual’s control. Compounded by the expectations being pushed by clients, it can create an illusion for more inexperienced lawyers to feel that they are responsible for things beyond their control, and for them to then feel like they’re ‘failing’ when, in reality, it is impossible for them to act in the way envisioned. Understandably, all of these challenges were exacerbated in recent times by the advent of remote working in the age of COVID-19. The structural support that would otherwise be there to help new workers transition ended up collapsing on itself, and an already stressed-out profession came under greater strain with an increasing fear of burnout. However, it wasn’t all bad; it did create an opening for legal professionals to begin talking more about wellbeing concerns and empathise with the difficulties that employees may be personally going through. It also appeared to fall in line with wider governmental recognition of the mental health problems that could arise from the pandemic, and ways that we could mitigate this impact. For a profession that traditionally holds a stigma of having a ‘stiff upper lip’ and never talking about the stress induced by billable hours and client expectations, it was a welcome shift as more workplaces became receptive to the idea of running webinars and events addressing such issues. One lawyer told me that when she first started working, stress management and self-support was never discussed and people were just expected to hit the ground running when they entered the profession. Contrasting that to the support that is being established now in the form of having mental health champions in workplaces, and non-profit support organisations such as LawCare, it’s a welcome move away from the previous lack of discourse. The aim of these initiatives is to help create a more welcoming environment in which people feel comfortable to discuss their issues and to challenge pre-existing stigma, which has been perpetuated by the idea that lawyers should be helping others with their issues instead of bringing their own. Being able to see more authoritative figures address mental health and wellbeing, including Simon Davis, the President of the Law Society of England and Wales, appears to grant permission for employees to bring their own issues to light, instead of struggling with it alone and continuing the cycle of silence. Furthermore, such mental health advocates often have personal experience, and so can empathise beyond a superficial manner and also provide practical advice for coping with difficult times. While this work is great, it remains clear that there are still structural issues as noted by respondents in the Junior Lawyers Division 2019 Survey, who commented that many of the actions being taken felt more performative as opposed to helpful. However, by gaining a better sense of the underlying issues, we can begin addressing root causes to hopefully make some changes for the better. The momentum has been kicked off now, and it feels like there is a new generation of lawyers trickling in who are bringing the topic of mental health and wellbeing to the agenda, to drive more change as we head towards the future.

How everyday activities can allow our brains to be flexible and adaptive across the lifespan Often, people report that their cognitive abilities change as they age, including worsening memory. Like many others, I used to think of cognitive ageing as synonymous with cognitive decline. However, recently I learned that the ageing process is far more complex and nuanced. The past academic year, I also delved into research on cognitive reserve for my undergraduate dissertation in Psychology. Put simply, cognitive reserve describes an individual’s ability to compensate for brain damage or degeneration. Through engaging with this topic, and by learning how the brain develops throughout the lifespan, my understanding of cognitive ageing has shifted. It turns out that the mechanisms involved in our cognition — that is the processes involved in our learning, experiencing, and thinking about the world — age differently. Whilst some cognitive abilities do decline across the lifespan, others are preserved or indeed improved. Most importantly, I learned that engaging in everyday activities, such as socialising, working, and exercising, contributes to having a greater cognitive reserve. This, in turn, allows our brains to be more flexible and adaptive in the face of declining cognitive abilities, and brain damage. As we age, it is normal for some brain areas to shrink in volume. In addition to this process, some of us will experience age-related disorders, such as Alzheimer’s disease (the most common type of dementia), which lead to further shrinkage or degeneration of brain tissue. Thus, knowing that there is such a thing as a cognitive reserve, and that everyday activities contribute to it, made me feel hopeful. Indeed, discussing this topic with my research participants highlighted that many of us, regardless of our age, are focussed on — and discouraged by — the decline of cognitive abilities across the lifespan. In this blog, I would like to shift some of our attention to the abilities that are preserved or improved throughout the ageing process, so that we might acquire a more complete and comforting perspective. This seems particularly worthwhile, considering that we live in an ageing society. According to a 2019 report by the United Nations, roughly 25% of North Americans and Europeans will be aged at least 65 by 2050. So, what actually is cognitive ageing? Cognitive ageing — a complex process Throughout normal cognitive ageing — an ageing process, which does not involve brain damage or age-related disorders — we undergo a decline in so-called fluid abilities, especially from the age of 60 onwards. The umbrella term ‘fluid abilities’ encompasses various cognitive functions allowing us to process information or knowledge quickly, and in a goal-directed manner. For example, we use fluid abilities to make plans, decisions, or to react to changing environments. If we want to do these things successfully, we have to select appropriate behaviours and relevant pieces of information, whilst suppressing their inappropriate counterparts. For instance, when making plans to see a friend later on in the day, it is important to consider today’s weather forecast, workload, and transport options, but not so much where you first met your friend. In a different context, accessing the latter piece of information or other details of your friendship may be crucial. To engage in these processes, we rely on general control mechanisms referred to as executive functions, such as the ability to selectively attend to a relevant piece of information. Various brain areas are involved in executive functions. However, the frontal lobes, located right behind your forehead, and in particular an area known as the prefrontal cortex, are typically associated with executive functioning. As part of normal ageing, our prefrontal cortex shrinks in volume from around the age of 25 onwards. As such, it has been proposed that declines in executive abilities in later life are related to declines in prefrontal cortex volume. In contrast to fluid abilities, crystallised abilities are preserved across normal ageing. These include our general or semantic knowledge of the world (e.g., facts, and concepts). As we age, we continue to grow our store of semantic knowledge, for example by encountering new people, and places, or by reading books. To acquire new semantic knowledge, we use a brain region referred to as the medial temporal lobes. This area is located at the centre of the brain, and, compared to the prefrontal cortex, it remains quite stable in volume throughout the ageing process. Whilst this is only a brief overview of some of the processes involved in cognitive ageing, it shows that both declines and improvements in cognitive abilities accompany our development across the lifespan. Whereas younger adults are able to use their fluid abilities when engaging in cognitively demanding tasks, older adults may need to rely on their advantage in crystallised abilities. So, how does cognitive reserve come into play? Cognitive reserve and its protective outcomes The term cognitive reserve describes a hypothesis developed to explain why two people experiencing the same brain pathology (e.g., brain damage associated with an injury or with disease), do not necessarily also experience the same symptoms. For example, cognitive reserve is proposed to account for the finding that a sizeable proportion of older adults (roughly 25%-67% across different studies) who pass away without having experienced cognitive impairments, did actually suffer from Alzheimer’s disease or other types of dementia. One of the most famous research projects on this topic is known as the Nun Study. Here, 678 U.S. American School Sisters of Notre Dame took part in cognitive assessments throughout their lifetime and agreed to have their brains studied after death. When analysing the nuns’ brains, researchers found that some of the nuns who were deemed cognitively ‘normal’ before their death, actually presented with levels of brain damage sufficient for a diagnosis of dementia. Thus, the Nun Study exemplified that older adults can suffer from brain pathologies meeting clinical criteria of dementia, whilst showing none of the typical symptoms. First discussed in the context of Alzheimer’s disease, cognitive reserve has since been associated with protective outcomes across various clinical and healthy populations — but what exactly is it? People who benefit from higher cognitive reserve tend to score higher on standardised assessments of intelligence (i.e., IQ tests), have higher occupational and educational attainments, and engage frequently in cognitively stimulating leisure activities. In particular, taking part in physically demanding, and complex activities, with high levels of interpersonal skills, seems to be crucial in giving rise to these protective outcomes. Since we cannot measure cognitive reserve directly, researchers use IQ and lifestyle components of cognitive reserve as proxy measures. Interestingly, childhood intelligence is a strong predictor of many later life outcomes, including education, occupation, and a healthy lifestyle. Nevertheless, Opdebeeck and colleagues have reported that each lifestyle proxy uniquely contributes to the protective outcomes of cognitive reserve. This is good news as it illustrates that engaging in stimulating physical or social activities may still be associated with protective outcomes, even if you did not benefit from access to high-quality education growing up. How does cognitive reserve work at the level of the brain? The exact mechanisms underlying cognitive reserve remain to be uncovered. However, it seems likely that a combination of active and passive pathways are responsible for the flexibility and efficiency with which people with higher cognitive reserve complete tasks. For instance, a passive factor contributing to cognitive reserve would be individual differences in brain size. Put simply, a person with a larger brain will be able to tolerate slightly more damage without showing symptoms, than a person with a smaller brain. Active pathways tend to be separated into two mechanisms: neural reserve and neural compensation. Having a greater neural reserve involves being able to use neural networks efficiently and flexibly, whilst engaging in neural compensation describes the recruitment of alternative neural networks. Neural compensation would be crucial when the networks typically used for a specific task are damaged or unavailable. In the context of normal ageing, this can be observed when older adults successfully engage in tasks putting high demands on their fluid abilities. Our brain is separated into two connected halves or hemispheres, each of which contains a prefrontal cortex — the right and the left. As I mentioned earlier, our prefrontal cortex volume shrinks as we age. Since younger adults benefit from having a larger prefrontal cortex, they are able to complete fluid tasks by using either the right or left prefrontal cortex. In contrast, older adults activate both hemispheres to complete the same task, illustrating the recruitment of an extra area to compensate for the normal decline in prefrontal cortex volume. Looking into the future The reason I enjoy studying cognitive reserve is that it gives me hope for and comfort about my own future — and that of my family and friends. The types of activities seemingly contributing to greater cognitive reserve, are the ones we typically engage in on an everyday basis — being part of social networks, carrying out physically demanding tasks, such as exercising or putting an IKEA shelf together, looking after loved ones, or managing one’s finances and household. Although cognitive reserve will not prevent you from getting Alzheimer’s disease, or any other brain pathology for that matter, it may well contribute to your brain’s ability to compensate for the brain damage caused for a little longer. This insight has changed how I view some of the (tedious) everyday activities I engage in, and hopefully, it will do the same for you. Header image by Jaddy Liu on Unsplash

Psychology in the education system I was 10 years old when my first crush died. In an instant, my carefree innocent life was never the same. After experiencing trauma in my childhood and going through years of on-and-off grief, I discovered that writing about my thoughts helped me to better understand what I was feeling, and consequently, to process my grief. My crush was slightly older than I was. Consequently, we had very few interactions since we didn’t share any classes or extracurricular activities. It was a regular innocent childhood crush and I’m pretty sure it would not have amounted to anything. But when I learnt of the car crash and his passing, I was violently thrust into a deep well of grief. I was a nervous wreck. My emotions overwhelmed me, and I fumbled and blundered trying to deal with them. The pandemic last year left me unemployed and with a lot of time to explore my mind. Nearly 15 years later, as a young adult woman, I can now see the coping mechanisms I developed to deal with my grief and how they persisted into my adulthood. Growing up I had a morbid fascination with death, which led me to want to become a doctor — I can now confirm after dropping out of med school two years into it, that I in fact do not want to be a doctor. I was terribly afraid of change, especially the one that comes with some form of uncertainty — like changing schools or meeting new people. I struggled (and still do) with commitment and opening up to even my closest family and friends. The most unfortunate part was because I did not have the tools to deal with grief, I was unable to process this trauma in a healthy way. In our society, we’re not educated on the workings of our minds, and so I had absolutely no idea what was going on with me. I didn’t know how to start asking for help and regardless, I don’t think my parents and teachers would have known what to do; they were not equipped with the skills and knowledge either. This lack of education might be one of the biggest failings of our society. It’s remarkable to me that we spend so much time and effort ensuring that children can count to a million or write cursive. Yet the study of our own minds — how to process and make sense of our feelings, thoughts, actions, and detrimental behaviour patterns — is not even part of the curriculum in mainstream education. Sadly, these skills are not acquired intrinsically just because one becomes an adult. Further, in our society, feelings and emotions are frequently given a negative connotation; they are viewed as outbursts experienced by people who don’t have control over their own minds. As a result, many children take the leap into adulthood not even being aware of why they think and act the way they do, and how any childhood trauma they faced might have shaped their life’s trajectory, as I recognize that my trauma shaped me. Unfortunately, children who have faced traumatic experiences usually end up with poorer school performance, and their interpersonal relationships as well as their growth and development are negatively impacted. They have also been shown to exhibit higher rates of depression, anxiety, distorted cognition and personality deficits as adults. With all these glaringly negative effects that extend into adulthood, stress and trauma should be appropriately addressed instead of waiting for children to “get over it” in adulthood. Most likely, they will only develop unhealthy coping mechanisms if left to deal with it themselves, just as I did. Where is the educational system failing? When I was in school, there were no classes or lessons that taught students about their emotional and mental health. Fortunately in the UK, such a programme exists — it is the personal, social, health and economic (PSHE) education, which covers emotional health and wellbeing in addition to physical wellness. While the programme has been in existence for two decades now, it is only in 2020 that it was incorporated into part of the mandatory curriculum. To me, this highlights that the current adult population in the UK, in all likelihood, has not taken PSHE or psychology as part of their learning subjects when they were in school. It is therefore unlikely that they are equipped to handle their own mental wellbeing, let alone pass those skills onto the younger generation. According to the Office for National Statistics, the death rate by suicide across England rose by 21% between 2009 and 2019. And while there can be many contributing factors to suicide, the top 10 most common themes among people who died by suicide include abuse and neglect, bereavement, bullying, and social isolation. These are all signs of unaddressed stress and/or trauma. What can be done right now? In my opinion, schools across the globe should redesign their psychology programmes with cutting-edge expert knowledge that comprehensively covers psychology in practical terms. Teachers should also undergo rigorous training prior to engaging with children on these topics, as they themselves most likely did not acquire the necessary education either. The programmes could discuss the various types of emotions, how to process emotions, how to de-stress during stressful periods, as well as a list of people and bodies to reach out to in the case of overwhelming distress. I believe that in guiding children to better understand themselves and others, we can help them to better cope with life’s stresses so that they do not feel as alone and confused as I did.

How can psychology help us to treat long covid? (Part two of two) You might have caught part one of this blog piece two days ago, where I introduced the subject of long covid. To recap, I am an Assistant Psychologist currently working in a long covid clinic in South East London and I wanted to share some of my experience in this new and challenging field. In my previous blog I did my best to portray what the long covid experience is like for some patients, without having personal experience of long covid myself. I touched on the importance of a multidisciplinary approach to treatment and introduced some of the ways that psychological interventions can be used to help. If you did catch my blog , thanks for returning! And if not, you can check out what you missed here. Part two today will focus on more of the psychological difficulties that are commonly experienced by long covid patients and the different ways we can support them. Managing Loss and Transition Many patients with long covid are forced to reduce their activity levels, give up much loved recreational activities and adjust to a totally new “them”. Significant feelings of grief can accompany this process as the patient temporarily loses aspects of themselves which were previously valued, such as their identity as a parent, employee and/or partner. Some patients I have met with describe how they suddenly feel like a spectator rather than an active part of family life. Family members may experience loss as well, as they are deprived of part of the companionship the patient used to provide, as well as their work around the house and possibly also their financial contributions. Family members also have to adjust their visions for the future and grieve their own losses. In clinic, techniques from Acceptance and Commitment Therapy (ACT) can be used to help patients and their families adjust to this “new normal”. An important part of psychological adjustment is acceptance, an acknowledgement that life has changed at least for now. Acceptance does not mean resignation, but instead a recognition that life has changed and a commitment to live the best life possible under the circumstances. ACT is a form of Cognitive Behavioural Therapy which can help individuals to have a clearer sense of purpose based on their own values and what is important to them, to learn to accept aspects of the situation that cannot currently be changed and to take committed action to change what can currently be changed. ACT can help to improve an individual’s quality of life by encouraging them to try different ways of doing things and to be less affected and controlled by unwanted thoughts and feelings that inevitably occur in such difficult circumstances. Patients can learn to stop avoiding, denying, and struggling with their inner emotions and, instead, accept that these deeper feelings are appropriate responses to certain situations that should not prevent them from moving forward in their lives. Counselling approaches and couples therapy can also be used in cases where long covid has put family relationships under strain. Managing Fatigue When we first meet a patient in clinic, we ask them to rate their top 3 most troubling symptoms. The majority include extreme fatigue in that list. Despite resting and a good night’s sleep, fatigue occurs for some long covid patients after very minimal effort. It is prolonged, limits their usual activity and can leave them feeling dull, unmotivated, and dealing with significant “brain fog”. The exhaustion patients experience after physical or mental exertion is termed “post exertional malaise” (PEM) and it is a key symptom of Myalgic Encephalomyelitis (ME)/Chronic Fatigue syndrome. An excellent account of PEM in long covid was provided by Dr. Paul Garner, professor at the Liverpool School of Tropical Medicine who after feeling a little better during his recovery from COVID-19 infection, took part in a high intensity exercise class and immediately relapsed. He didn’t leave his bed for 3 days and many of his symptoms returned. His account perfectly demonstrates the pattern of behaviour that we try to help patients to avoid, called the Boom and Bust cycle. As you can see in the diagram below, some patients wake up and feel great, so do a little more than usual, and then experience a big flare up of fatigue over the next few days. They then do less which leads to a good phase and the cycle repeats and gradually causes the individual to spiral down into less and less function over time. A recently published study of 3,762 long covid patients found that 89% reported experiencing PEM, with physical activity and stress reported as the most common triggers for energy crashes. The study also found that “pacing” was listed as the most common treatment that patients found helpful. Pacing involves a patient slowly building up their activity levels whilst monitoring their response to exertion and limiting their activities accordingly to prevent PEM. Patients are required to strike the right balance between activity and rest to ensure less variation in their activity levels over time. Pacing can be really challenging and frustrating, particularly for patients who were very active before long covid. There are a number of ways that psychology can support patients to pace effectively. We can encourage patients to keep an activity, rest and symptom diary to record what they have done during the day and how they feel after each activity. We can then review their diaries to help them spot unhelpful patterns of activity such as “boom and bust” behaviours. We can support patients to use their diaries and their reflections to plan a well-balanced week: prioritising what they need to get done and how they might realistically achieve this, for example by spreading things over a longer number of days and by scheduling regular rest breaks. Spoon theory is another helpful technique we can draw on to help patients explain and manage their energy levels. Patients are encouraged to imagine they have 12 spoons (energy units) to fuel their day. When they are feeling healthy, cooking a meal might take up 1/12 spoons, but during long covid it might take up more like 4/12. The metaphor can help patients to notice when they need to break up tasks into smaller parts or simplify them, when they need to take rest breaks, and when they might need to ask for help or delegate. Managing Depression Depression is very common in chronic illness and estimates suggest that it affects over 13% of individuals living with long covid. This should not be surprising, given the effects of ongoing symptoms as well as the disruptions and uncertainty created by illness. In addition, depression may be part of the illness, with real physical causes. For example, prolonged stress may alter cognition and biochemistry in the body, causing depression. Individuals with depression can feel sad or empty for much of the time and may become more tearful than usual. They may feel irritable or intolerant of other people and lose interest in activities they used to enjoy. In more severe cases, patients may have thoughts of harming themselves or that they would be better off dead. There are several psychological interventions that can be used to manage depression in long covid patients. Firstly, we can provide psychological education materials to help patients to understand the causes of their low mood and to normalise the symptoms they are experiencing. We can also explain how depression feeds on itself, whereby patient’s attitudes become a self-fulfilling prophecy. If patients believe they can get better, they will take actions that have a good chance of helping them. Cognitive restructuring can also be used to improve low mood. An example might be that a patient has the thought: “I am so tired today. I don’t think I will ever feel energetic again”. A psychologist might encourage the patient to test some alternative thoughts, such as “I am so tired today. However, thinking back to my past experience with fatigue, I know that I will feel good again after giving my body some rest”. Another example of cognitive reframing could see the thought “My pain is awful and it’s never going to get better” reframed as “Yes, the pain is strong today, but the last time it was this bad, it did get better.” For individuals experiencing social difficulties related to their depression, techniques from Interpersonal Psychotherapy (IPT) can be used to help. IPT is an evidence-based therapy established on the premise that there is a bidirectional relationship between depression and social difficulties. Attachment theory provides the theoretical basis for IPT and suggests that people are distressed when they experience disruptions in their relationships. IPT is based on the expectation that by improving interpersonal relationships and social support, depressive symptoms will improve. The psychologist and patient will gather information about the patient’s key relationships, and they will conceptualise how the patient’s difficulties have developed. Patients will identify problem areas to focus on, such as dispute, grief and loss, or role transitions, and the psychologist will support them to implement specific interpersonal strategies to resolve these difficulties. More research is needed Every professional currently working in long covid will tell you that we are learning huge amounts every day and in every consultation. Each patient has a unique experience in regard to the type and the degree of symptoms experienced, as well as the impact of long covid on their mental health and social life. More research is needed to better understand long covid and to raise awareness of its potential threat. One area that I find particularly fascinating from a psychological perspective and one in which I would like to uncover more about through research is the role of personality in an individual’s recovery from long covid. Personality is an individual’s biopsychosocial pattern of reactions and behaviours. It influences the habits we form, the behaviours we engage in, and our appraisals and experiences of stress. Personality itself is also influenced by genetics, experiences in early life, development, and social and cultural relationships across time. Each of these various pathways link to health outcomes. Anecdotally, a personality trait I have frequently observed in clinic is that of a perfectionist, athletic individual with a strong work ethic. For these individuals, their failure to rise to usually high standards of hard work might lead them to a feeling of lack of agency and low self-esteem. I believe that focusing on the links between personality and health will aid causal understanding and facilitate the most appropriate tailored psychological interventions for patients. Help is available Most people with long covid were not hospitalised and often struggle to access health services, which has been a cause of considerable distress. If you are struggling with physical, cognitive and/or psychological symptoms after being infected with COVID-19, I strongly recommend you book an appointment with your GP who can consider a referral for you to a specialist long covid clinic in your area. You can also find your local NHS psychological therapies service (IAPT) and self-refer yourself for free talking therapy via this link. Finally, remember that the current rising rates of COVID-19 will increase the number of individuals living with long covid in the future. It is just as important as ever to stick to the current government guidance and get your vaccine. Young people might feel invincible from COVID-19, but long covid poses a very serious threat. https://www.economist.com/leaders/2021/05/01/health-care-and-workplaces-must-adjust-for-long-covid

13 Self-care Tips to Help You Achieve Good Mental Health Mental health has been an increasingly pressing problem in recent years. Depression, anxiety, and mood swings are just a few of the most commonly experienced mental illnesses. This is why, for many people, mental health self-care has become so crucial. I am a young woman devoted to helping other young people like myself to better understand the concept of mental health, and why it is important to take care of their mental health. I wrote this blog because I have gone through depression myself and I wanted to talk about some of what I implemented to help me overcome it. These may not all work for everyone, but I want to share with you some self-care tips that I found most helpful and easiest you can carry out in your daily life. 1. Take a social media break The reality that is depicted on social media is not always accurate. Using social media frequently can have devastating effects on people who are struggling with their mental health. For example, spending too much time on social media might make you feel like you’re falling short of your potential, when continually comparing yourself to others’ lives. Limiting your time on social media might assist you in focusing on other messages that encourage emotions of self-appreciation. 2. Try healthier eating Research has shown that the consumption of processed food can be detrimental to mental health. Sugar is abundant in processed meals. The amount of serotonin — known as the “happy” hormone — in a person’s system increases when they consume sugar. This causes us to become reliant on certain meals whenever we are down. According to nutritionists, your diet should include the following three foods for good mental health: Complex carbohydrates: These include brown rice, millet, and sweet potatoes. This type of carbohydrate will leave you feeling full for a longer time compared to the simple carbohydrates found in sugar and candy. Lean proteins: These provide energy that allows your body to think and react quickly. Sources of lean proteins include eggs, meat, chicken, soybeans, fish, nuts, and seeds. Fatty acids: Fatty acids help with the proper function of your brain and nervous system. They can be found in fish, eggs, meat, and flaxseeds. 3. Engage in your hobbies or explore a new one Hobbies are about more than just about passing the time or enjoying quality alone time. They are crucial for your mental health and general well-being. According to research, people with hobbies are less likely to suffer from depression, stress, and low moods. It is therefore important for your mental health that you find activities that will make you happier and feel more relaxed. Just a few hobbies that you can get into include painting, music, writing, gardening, fishing, and yoga. 4. Keep a journal When we were kids, I’m sure most of us maintained hidden journals in which we recorded our innermost thoughts and feelings. However, for some reason, as we got older, we stopped keeping our diaries. Journaling can help you improve your mental health in the following ways: It allows you to track stressors and symptoms associated with mental illnesses. This can help you discover recurring triggers and in turn, help you devise strategies to deal with them. Assisting you in prioritizing your issues, concerns, and anxieties. It’ll be easy to find out what’s bothering you the most and focus your attention where it’s needed. Creating a safe environment in which you may work through unpleasant ideas and actions. 5. Hang out with people you care about It can be really beneficial to your mental health to spend time with the people you care about — people who make you feel good and comfortable with yourself. At the same time, you should also cut off connections to people who are not good for you. Your spouse, children, parents, or your best friend might be among those who are beneficial. They are the ones who know the most about you. They can sense if you aren’t feeling well. When you talk to them about the difficulties that are upsetting you, they will not judge you. They may actually be able to assist you in dealing with your issues and will accompany you on your recovery path until you are able to stand on your own. 6. Create a schedule From the second your alarm clock goes off in the morning, you must begin making choices. Should you take a shower or eat breakfast first? Will you go for a run or check your inbox? So, what are your plans for the day? Most of these choices may appear simple, yet one after another, they can be stressful. These are decisions that you can make ahead of time if you follow a routine and stick to a plan. With a routine, you are able to complete the tasks that you set out to do, which makes you feel good about yourself. Sticking to a timetable also allows you to prioritize things and therefore help you to make time for relaxation. You may use that time to read a book, play video games, or paint, all of which are beneficial to your mental health. 7. Explore what you love — and do it! Maybe you are passionate about keeping the environment clean, or tree planting, or maybe you are passionate about rescuing animals off the street. You may join any of the organizations or charities in your area that are active in any of the topics you are passionate about. If your passion lies in saving the environment, you can choose to join environmental charities. Participating in activities that you like will significantly assist you in achieving excellent mental health. 8. Try online therapy It might be difficult to leave the house when you are suffering from depression, anxiety, or other mental health issues. This is where internet counselling comes into play. Despite the fact that many people are opposed to online therapy, it does have advantages, such as: Online treatment sessions are less expensive than physical therapy sessions. Some people may find it easier to share personal details in an online session. It can be less daunting to reach out to an online therapist if you experience social anxiety. 9. Get plenty of sleep Sleep is extremely important to our general well-being. It allows our bodies to repair themselves and our brains to merge our memories and process information. Poor sleep has been linked to mental health issues such as anxiety and depression, so it’s critical to enhance the quality of your sleep if you want to get adequate rest. Things like adjusting the light, noise, and temperature in your bedroom, as well as modifying your eating, drinking, and exercise habits, are some strategies that may help. 10. Spend time in nature According to psychotherapist Dr Stephanie Sarkis, being out in nature improves both your mental and physical wellbeing. It is recommended that you have at least a 50-minute walk in nature once or twice a week, according to Dr Benjamin Levy. Sunlight can make you feel good in both your body and mind. Being exposed to natural light can increase your mood and self-esteem. This further helps you decrease anxiety and negative feelings, while also helping you improve your working memory. Travelling to places you like spending time can also be great; both the change in your scenery and the chance to experience new things can positively support your mental wellbeing. 11. Practice gratitude Our minds are affected positively every time we practice gratitude. You can start practicing gratitude by keeping a gratitude journal to help you keep track of all the good things in your life. Some of the positive effects of practicing gratitude include: • Minimizing negative habits, patterns of thinking, and feelings • Helping us feel inspired and motivated • Preventing worry and frustration 12. Learn how to stop procrastination Studies have shown that procrastination is linked to poor mental health. When you procrastinate, you are faced with negative thoughts like “what’s the point?”. Procrastination becomes the norm when you are afraid to fail. Or continually think that you are not good enough for the task at hand. To achieve good mental health, you should make an effort to learn how to stop procrastinating. You can start by breaking down our tasks into smaller tasks and start doing them one by one until you are done — as I said before, routines can be incredibly helpful in more ways than one. 13. Value yourself Self-value is more behavioural than emotional, focusing on how you act toward the things you value, such as yourself, rather than how you feel about yourself in comparison to others. It’s imperative that self-care is included throughout the practice of all the other points on this list. It’s vital for our mental health that we value and respect ourselves; through strengthening our sense of self-worth, we cherish the time, energy, effort, and sacrifices we make. We should nurture all of ourselves, the good and the bad, while working to improve ourselves through taking care of our physical and mental health. This ends my list of the various popular and important self-care tips to help you achieve better mental health. Of course, these are not all of them but are some of the ones I have found to be very important. These may not work for everyone, but there is no reason not to try, right? Also, take your time when implementing them. You should strive to develop a strategy for how you intend to enhance your mental health by working on yourself. Your mental health is important, and you don’t have to rush through your journey. There are no deadlines when it comes to doing what is best for yourself.