Giving away everything in search of something more I tossed my backpack into the back and climbed into the passenger seat. It was a little after 10pm in South Dakota, and I was the only person waiting outside the regional airport. “Where’s your luggage?” the driver asked. “This is my luggage.” My carry-on contained my laptop, a couple rolled shirts, pants, and some socks. I wore a pair of jeans, a shirt, hoodie, and tennis shoes. I had everything I needed, so it was all I had. Anything else would’ve been excessive. Anything more would be waste. Materialism’s undergone intense cultural scrutiny in recent years. Concepts like downsizing and minimalism are migrating from the fringe and becoming — dare I say? — trendy. Trinkets and things litter our planet and pollute our self-worth. Is there validation in knickknacks? Do my Facebook friends like my latest toy? At best we have a conversation piece for the mantle. At worst we’re paying for trash before it ends up in a dumpster. Break and Build I had a mental breakdown in 2018, and shortly afterwards I sold or donated most of my stuff. I was 26 years old with a respectable career, low rent, plenty of excess income, and a massive library of books, music, and movies. I also had a drinking problem, some bad memories, and a closet full of skeletons. I’d get drunk and look at the accolades, service medals, and certificates I earned in the army. It wasn’t a happy drunk. It’s too easy to attribute all my struggles to trauma. While there’s definitely a correlation, there was something more. I never enjoyed being a soldier — I fantasized about going AWOL all the time — but at least the uniform meant a sense of purpose; an intention. As infantry, I trained with the expectation of going to war. As a paratrooper, I was expected to be anywhere on the planet within 18 hours. As a combatives instructor, I had to equip my fellow soldiers with the tools necessary to survive a nightmare. It was a mean life filled with all the drama and chaos that you’d expect from the army — but at least there was purpose. Set Adrift After 5 years of service and an Afghanistan deployment, I got my Honorable Discharge and was finally set free. Or rather, set adrift. I think that’s what most people end up doing. Drifting. I don’t know how many are aware they’re drifting, or if they’re content, but it was killing me. I woke up hung-over, suffered through a shift at my new factory job, then went home and drank. Rinse and repeat. During the rare weekend off, I’d go shopping for things I didn’t need to justify my shipwrecked life. “I can’t quit. I won’t be able to afford all this crap.” It’s no wonder I snapped. Just like resetting a mangled limb, sometimes you gotta break before you can heal. The day I quit my job, I packed up most of my stuff so I could get rid of it later. At the time, I didn’t know why I had to get rid of everything, but it was an impulse I was happy to oblige. I wasn’t proud of anything I owned. Pride comes from purpose — intent — and my existence offered none. But with the clutter cleared, I finally found it. Seeking Purpose I’m a writer, and I’ve always wanted to be a writer since before I could even read. Prose is power. Stories connect us — they remind us we’re human. Parables enlighten, fables offer caution; myths entertain and legends inspire. But tales don’t tell themselves, and the best come from first-hand experience, from life. My path to happiness had never been clearer: travel, experience, and write. I had the talent; I’d been published a couple of times by then; it was just a matter of doing the damn thing. I tossed everything into my rucksack, bought a ticket to Alaska, and began a journey filled with adventure, travel, friendship, and romance, the likes of which I never even dared to dream. After an incredible summer in Alaska, I went home to Ohio for about a month, during which I had a falling-out with my mother that was over twenty years in the making. Afterwards, I went to Colorado for the winter, working with some friends from Alaska and making many more. From there, I went on to spend nine months working just outside the Grand Canyon in Arizona. Severing ties with a parent, no matter how toxic the relationship, is a traumatizing experience, but distance from my friends helped me get through it alright in the end. They mean more to me than every cent I’ve ever earned, and I am forever grateful for them and my decision to become a minimalist nomad. Misfit Traveler In late 2019 I moved to Mexico to be with my girlfriend and write full time. Gigs came easy at first, then COVID happened. Work disappeared and I couldn’t contribute to the household funds — which is how I ended up bartending in South Dakota; another mistake made in pursuit of money. I missed my girlfriend more than I can say. Managers were incompetent, I wasn’t happy, I wasn’t making enough money to justify sticking around, and I wasn’t writing. I had to get back to Mexico. With so little to pack, I decided to turn it into an adventure. Trains passed through town several times a day, and there was usually at least one waiting in the yard. I’d never hopped a train before, but I was obsessed with hobo and travel literature; Jack London, Kerouac, Louis L’Amour; “Beggars of Life” by Jim Tully, and “You Can’t Win” by Jack Black (no relation to the film star). I thought of those stories as I scoured the train yard for a rideable car. I found one, climbed aboard, found a hiding spot, and a few hours later the train left town. I made it about 100 miles, accidentally going in the wrong direction, then hitchhiked over 1,200 miles from Wolsey, South Dakota to Juarez, Mexico. It took exactly three weeks, and every mile was better than the last. The things I saw and the people I met changed me for the better, and I learned more about myself over the course of 21 days than I did in over five years in the military. Afterwards — back in Mexico — cuddling in bed with Sara and our dogs, I felt a wave of love, happiness, and purpose the likes of which I’d never known. You can’t put a price on that. You can’t put a price on what matters. So stop trying to buy it; you never will.

And several important lessons it taught me. 2020 was one of the most challenging years we’ve ever faced not only here in the UK, but worldwide. Yet, I’ve managed to find many valuable lessons and heal in more ways than ever before. While many have found this year to be brutal on their mental health, I’ve found it to be largely the opposite. Leaving behind grief and beginning to heal. At the beginning of 2020, I was in a dark place. My partner and I were at breaking point and my mental health was beginning to decline again. The previous year had all but broken me, and I was dragging myself into the next decade held together only by hope. In fact, things were so bad I fear that had COVID not happened, I would not only be single but quite likely dead. I was, for lack of a better word, suicidal. Still, there was a part of me that expected 2020 to be ‘my year’. It was meant to be the year that I beat anorexia nervosa for good, would begin to travel more, and generally enjoy my life. Although my travel plans didn’t make it past my driveway, and I’m still very much in recovery, I somehow managed to find a part of myself that I’ve not seen in over sixteen years. In the face of a worldwide pandemic, I was forced to slow down and was able to find my way back to a girl (now woman) that I had been missing for the majority of my adult life. Now, as I write this secure in 2021, I’m able to reflect on all the lessons COVID-19 has taught me. The years leading up to 2020 were, for lack of a better term, a write-off. I’d been living with depression, anxiety, and anorexia nervosa for the majority of my adult life, and it all came to head in late 2018. During intensive recovery in the years following, I was able to rediscover my passion for creativity and not only start writing again but also illustrating. Now I’ve been writing for over two years and have managed to secure freelance work through my personal blog. Not only that, but after rediscovering my love for drawing, I’ve opened an online store and successfully secured a job illustrating a variety of children’s books. 10 Important Lessons Learned from the pandemic. Your health is your wealth. Last year I was taught that I shouldn’t be embarrassed for wanting to protect my own health. This includes both mental and physical health. I’ve canceled plans, stayed indoors more, and even (begrudgingly) took six months of isolation just to protect myself and my family. The old me would have felt embarrassed and guilty, and don’t get me wrong, I did. But as time went on and it became apparent just how serious this all was, I saw it as a necessary step rather than something to be ashamed of. But what has this taught me in the long run? It taught me that even when COVID-19 is a distant memory, it’s still important to look after your own health and wellbeing. There’s no shame in taking medication, nor is there shame in taking a day or two to cope with personal health issues. We should also be more understanding of each other and any hidden ailments others could be going through. Remember, all struggles aren’t necessarily visible. You can do a lot more when you slow down than when you’re overworked. I’m just as shocked as you to hear that we can actually achieve a lot more by taking the time to slow down. There is such a thing as moderation and the harder we push ourselves, the closer to burnout we get. It’s important to take time to relax, unwind and simply do nothing every once in a while. Without downtime, we run the risk of not only increased levels of stress but all the side effects that can come with it which can hinder our productivity in the long run. When you’re off work, be off work. That includes putting down the phone or laptop and taking time to do the things you enjoy. If work is something you enjoy, find something else to fill the gap. Appreciate the time you have with loved ones. It’s not always guaranteed. This lesson actually came to me from a combination of both 2019 and 2020 when I lost three very important people to me within the space of 18 months. Now, more than ever before in our lives, we should be reminded of the fragility of human life. While many of us are lucky to see another day, it’s never a guarantee. When hugging becomes legal and spending time with loved ones isn’t risky, I personally can’t wait to gather with friends that I haven’t seen in well over a year. Nor can I wait to finally hug my grandmother without the fear of making her ill. Life is about the little things. Never mind the big houses and fancy cars, life is about the small things. It’s about the things we take for granted, the flowers we don’t stop long enough to see and even the time spent cuddling with a pet. Sometimes it’s just about that extra-long lie-in on new year’s day, with a cup of coffee and a cat for comfort. As I’ve said on numerous occasions throughout, slow down and take time to just be. You can’t control everything, everyone, or every situation: Let it go. I’m a type-A personality. I like to know what’s going on, when, and how I can control it. Even when my grandparents were dying I was on the phone or by their bedside asking what I could do. What more can the doctors do? Have they tried this, this, or this? Despite not being even remotely qualified, surely Grey’s Anatomy counted for something, right? Although I’m able to handle my controlling nature more, I still find myself itching to take control of things my husband isn’t doing fast enough (or at all). If you’re like me and find yourself rising to every occasion, even the ones that aren’t meant for you; Let it go. It serves us no good to try and control the world or the people around us. If anything, it leaves us with more stress and frustration and, ultimately, an uncomfortable life. Boundaries, boundaries, boundaries. It’s taken me until now to not only learn what boundaries are but to learn how to implement them. I’ve watched as generational boundaries have been broken again and again in my family. As a daughter, I was expected to continue the tradition of ‘boundaries, what boundaries?’. But this year, with the help of COVID-19, I was able to begin to build boundaries not only for myself but for future generations. It’s okay to say NO when you don’t want to do something or go somewhere. Equally, it’s okay to say YES when everyone else is saying NO. Understand? Boundaries are all about protecting ourselves, whether that be from other people, from opinions, or from events that may trigger a harmful emotional response. Although it won’t happen overnight, working to build your boundaries can start by simply saying NO, and progressing from there. Sometimes you have to be the bigger person. Much like boundaries, sometimes it’s up to us to be the bigger person. It’s important that we take responsibility for any wrong actions on our part, but it’s also important to step away from those who no longer serve us. Many of us struggle with saying sorry or taking accountability. It’s human nature. But it takes a mature person to admit fault, apologies, and make up or cut off a relationship. You can make do with a lot less than you think you can. 2020 was the year of lockdowns. A year when we could no longer simply nip into town to do our shopping, or spend haphazardly. Some of us were made redundant, others were furloughed and some worked night and day to keep the world turning. No matter who you are, you have to do more with less. Less money, less freedom, less time with extended family, less food, etc. Although difficult for many, my husband and I learned that we can do more with the little food we have left. Instead of letting things go bad, we made soup and obscure dishes to keep us going. Instead of throwing things away, we started to think about what else they could be used for who else would benefit? Healing takes longer than you think. Healing is a journey. It’s not a destination, nor is there a timeframe on healing. It takes as long as it takes, and that might be different for every person and circumstance. Last year I took more time to heal and less time spent stressing over the little things. Although I’ve still got a ways to go, I’m able to see the distinct difference between past me and the woman I’m becoming. I am stronger than I ever imagined. Finally, I think I’m not alone in saying that 2020 taught me that I can withstand and overcome far more than I ever could have imagined. Visit my blog on: www.nyxiesnook.com

On the road to reframing the narrative on mental health following the COVID-19 outbreak When I started writing this, it was mental health awareness week. Having worked in mental health for over fifteen years (in both clinical and academic settings), over the last two years I have started to notice a shift in the narratives around mental health, especially following the COVID-19 outbreak. A trip down memory lane Following the de-institutionalization of mental health in the 1960’s (where mental health care transitioned from asylums to community services), the narrative around mental health has been one of fear and division. During my psychology undergraduate years, I clearly remember being examined on the prevalence of mental illnesses —  some of the figures still echo in my head —  one in four people will experience a common mental health problem, such as depression or anxiety. However, the underlying tone I heard was that mental health problems will not affect everyone. Furthermore, the image of patients acting dangerously or in a violent manner as a result of their mental health has created a stigma that has been especially hard to shake. Although we know that some mental health symptoms are associated with an increased risk for violence, what we also now know is that mental health patients are significantly more likely to experience victimisation (victimisation is defined by the World Health Organisation as any person against who violence is used). There is evidence to support both- that an experience of victimisation can lead to worsening of mental health, but also that having mental health problems can increase the risk for experiencing victimisation. Furthermore, looking at the literature on mental illness recovery and remission, although we have quite clear guides on what they look like in relation to medication prescribing, when we think about the person’s everyday functioning, recovery and remission have remained rather illusive. As someone who conducts research using anonymised electronic health records, I know first-hand that it is much easier to determine what medication someone is taking than their level of functioning and wellbeing at a given point in time. The latter would require a combination of subjective and objective measures of personal experience. This raises some important questions about how we see and discuss mental health wellbeing in clinical settings as well as in our everyday lives. Change is coming As we begin to see glimpses of post-COVID-19 life, we are now beginning to emerge from something, which has been termed ‘collective trauma’. The definition of collective trauma is a psychological reaction to a traumatic event shared by a group of people. The harsh consequences of COVID-19, bereavement, social isolation, shielding, stress due to change in circumstances just to name a few, are emerging rapidly, with rates of depression, anxiety and other mental health problems expected to hit a record high as the year unfolds alongside the relaxation of lockdown measures. We are finding ourselves in uncharted territory, on a global level where almost all of us have been affected psychologically by the pandemic. This collective experience has precipitated a shift in how we talk about mental health. Mental health problems are no longer seen as something only few would experience in their lifetime. As we open up to share our experiences of the pandemic so has the conversation about mental health. Social media has provided a platform where people can share their experiences and how these have affected their mental health. A further poignant moment for me has been the shift in public perception and talking about having a mental health problem as a yes or no narrative, to talking about our mental health as having good and bad days. Furthermore, we have begun to shift our view of recovery from a destination that only few will reach, to a journey that we all go on — some parts of this road are freshly paved and easy to walk, others are full of potholes. Ultimately, what each and every one of us needs is to develop tools and strategies for whatever the road brings. The journey ahead I have really enjoyed reading the Metro edit on mental health awareness week and it is so refreshing to see such a diverse coverage of mental health on scale. One message that particularly stuck with me was about the need to keep the conversation going so we can turn this momentum into action. There are several initiatives, which I believe are instrumental to achieve this. For example, I am especially excited to hear mental health being spoken about in schools, with campaigns from charities such as Mentally Healthy Schools by the Anna Freud National Centre for Children and Families, which aim to promote mental health and wellbeing. A number of children’s charities have also developed resources and toolkits for mindfulness, breathing and relaxation. We need to educate the young generation on the value of maintaining good mental health and equip them with practical tools and strategies for how to do this. Leveling up mental health care on par with physical health is essential, just like taking our daily supplements, eating a healthy diet and exercising, we all need to be talking about having strategies and tools to maintain good mental health. Collectively we all play a part in changing this narrative. Let’s keep the conversation going.

Consider processing and strengthening your mental health by letting your creativity flourish Once upon a time in a land far away — also known as 1999, a book titled Speak was released. About four years later, it found its way into my thirteen-year-old hands while browsing at my local library. If you’re not familiar with the title, Speak is a fiction book that details a young girl’s experience in high school after being raped by a classmate over the summer. Throughout the book, she struggles with depression, isolation, and re-traumatization when she confides in a friend about what happened and isn’t believed. I hadn’t thought about this book in years, and I’m talking like 18 years, until a few weeks ago. I took my daughters to a book shop, and lo-and-behold guess what title was sitting as a featured read front and center on the shelf? Rereading it now means something entirely different to me than it did back then. The mental health themes speak to me loud and clear. I got to thinking, what if I wrote fiction with mental health themes? … I’m a mom, a sister, a daughter, a tia, and a friend, among many other things. But when it comes to the role I choose for myself, I am a proud mental health advocate and a writer. Mental health is health — full stop. My work won’t be done until we’ve ended the stigma around these discussions. I struggled with mental health for as long as I can remember — long before it was openly discussed. I can’t help but wonder how my life may have been different if I received help for mental illnesses before the age of 30. While I can’t rewrite the past, I’m determined to advocate and contribute to rewriting the narrative around mental health. As a person who actively manages anxiety, depression, and PTSD, there is nothing like a good fiction read to give me somewhere to escape. But what about the other side of the coin? Let’s talk about how writing fiction can help you manage your mental health. … Processing Your Struggles Via Your Characters How often do we hear mental illnesses thrown around by people without understanding the weight they carry? “Quit acting so bipolar.” “Come on. Your vibe is so depressing.” “You are just being crazy!” What if you were able to educate your audience about what it really feels like to be bipolar? What if you could explain the different ways a depressive episode can actually manifest. By allowing your characters to show what life really looks like living with a mental illness, you contribute to a more realistic understanding of what some people write off as “crazy” behaviour. … In a short fiction piece that I’m currently working on, my main character manages PTSD and anxiety attacks. As someone who struggles with both these mental health conditions, it’s important I accurately represent the experiences of so many through my writing. By doing this, I can use my fiction writing to benefit my reader in two different ways. First, help educate those who have not personally experienced these mental illnesses. By giving them a first-hand view of challenges that come with managing mental health, so they can better support those in their life who do. Second, by having my character’s character arc include managing her mental health, I hope to validate my reader’s feelings toward their own mental health. In preparation for this piece, I reread some of my current fiction drafts that I hadn’t picked up for a while. I never critically read my work through a mental health lens. Clearly, I can find defined mental health themes or elements throughout my words. Sometimes, it’s historical fiction involving Catherine Medici and her processing trauma when Florence was sieged. Other times, it’s in new adult fiction involving a toxic relationship. Which leads me to the second way writing fiction has helped me manage my mental health. … Rewriting Your Narrative About Past and Future Experiences How many times have we said things would be different if we knew then what we know now? I don’t know about you, but there are plenty of scenarios in my 30-something years I wish I could rewrite. Maybe, the moment I realized anxiety was running my life. I struggled, silently, shamefully, for many years trying to outwork, out achieve, anything to outrun my anxiety. I wish a character in my favourite book would have experienced this and had a positive outcome. Sure, it’s messy and hard and shrouded in stigma, but seeing someone navigate that successfully would have meant the world to me. The beautiful thing about fiction is that as the author, you determine what happens in their story. The good, the bad, and ultimately the ending. While we can’t go back and change the narrative of our own lives, we can give our characters better situations. … At the same time, there is a responsibility that comes with heavy, real-life narratives. For example, there is a highly popular YA (Young Adult) fiction series, The After Series by Anna Todd, made into films. In these books, mental health is secondary to the character’s love for each other. Love that is problematic at best but, truthfully, incredibly toxic. I have no doubt Todd did not intend to reinforce a potentially harmful narrative. But when it involves emotional abuse, gaslighting, and excessive alcohol abuse used to self-medicate by a character who suffers from PTSD, it can get sticky. And it is being consumed by millions of readers, many of which are young adults. The problem with this work of fiction isn’t depicting real-life mental health struggles. The problem is the narrative that (potentially) young readers are getting. But, Holly, this is fiction, with fictional characters who have fictional problems. While this is true, the fictional characters can be modelled after real people living this reality. And when the story ends with the exception (not the rule), it can reinforce unrealistic expectations. It also may send the message that these harmful coping mechanisms and toxic behaviours in relationships are normal. Final Word As someone who has made questionable choices when it comes to boundaries and how my mental health has been affected, it’s a priority to write about them realistically in my fiction. The best part is giving my readers an alternate ending, a happier and healthier resolution to potential real-life conflicts. Because sometimes we are so conditioned by what society expects us to accept, we forget we have other choices. By writing that ending for them, I hope to empower them to accept nothing less than what they deserve. … I’d like to encourage you, whether you are a reader or a writer, to critically think about the narratives you are consuming or creating. How does the narrative depict mental health and mental illness? How does that depiction make you feel? Are the takeaways in your book trending with a typical trope, or are they empowering you to be like the characters within the pages? When we accurately talk about and represent mental health and healthy relationships that support mental health, we all win. Together we can end the stigma around mental health and rewrite the narrative.

This article is a double debut, both in discussing my OCD as a journalist, and writing about the disorder in relation to my poetry. Creative writing has eased the traffic of my congested mind when Pure ‘O’ feels overwhelming, and I hope this piece shows how writing poems can be both a joy and an effective coping mechanism. I remember the day as clear as glass — well smudged glass —  because it’s hard to remember some things clearly when one of my OCD symptoms is ‘false memory’. Overused examples of someone with this symptom tend to fall on the obsessive worry of not locking a door. However, false memories expand to all kinds of situations, where events or conversations replay like fuzzy recordings, always keeping you guessing. I was walking back from a day at Sixth Form, the sun stinging my eyes, my mind dark with thoughts, going over situations in class, with friends, and family, trying to remember what I’d said and done. Slumped on the sofa when I got home, I trawled through online advice with no luck, but I eventually found a forum with people discussing unwanted images, thoughts, and how they related to their personhood. I don’t remember details, but I’ll never forget how my smile stretched to reach the edges of hope. I would never recommend informal online discussion as the only form of help, and it can be really harmful and counterproductive if seeking reassurance or hoping for a ‘quick fix’ or simple diagnosis. However, as a teen struggling with endless worry, I realised in the short snippets of feeling on the forum, both the potential of writing and that I had what I didn’t yet know was termed Pure ‘O’. Now at 25, poetry lets me extract my thoughts, helping me as a journalist, and encouraging me to pursue a PhD in Creative Writing. More broadly, OCD is defined by the National Institute of Mental Health as “a common, chronic, and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and/or behaviors (compulsions)”. However, Pure OCD (or Pure ‘O’) is a type where the person predominantly (but not exclusively) experiences mental obsessions or mental compulsions (e.g. intrusive thoughts or checking and repeating thoughts). This past pandemic-stricken year has placed my Pure O symptoms in fast-forward mode. With the claustrophobia of multiple lockdowns, the daily time-loop of repeated routines and places has recharged my symptoms in the morning and night. However, writing has helped me accept the feelings, and being in a private space has let me see poetry not as a measure of success, but as an achievement for myself. As Anna Maria Di Brina writes, poetry in a pandemic can bring different meanings to what we think we know. Poetry and OCD blend into one another. They are both a mix of the real and the imaginary, often seeming absurd or outlandish. With OCD, you can have different ‘categories and themes’; for example, contamination or intrusive thoughts are categories, and themes such as harm or perfectionism can cross over between categories. There is a lot of stigma around what OCD is, which can prevent people from getting the help they need. This is similar to the expectations around writing, where curated school anthologies teach you to dissect poetry in a quantifiable way. For me, poetry is like music, it helps create a timeline of feelings that show you things can change. Similar to when you listen to a song that evokes nostalgia or bittersweetness so strongly it kneads into your skin, writing a poem lets you weave through multiple feelings. It is therapeutic to be able to travel back in time to poems written in distress, and look at them from above, knowing your future self could feel better. OCD organisation Made of Millions says “When a Pure-O sufferer’s brain lands on a thought or question that is unacceptable to the person having the thought, the fear network of the brain is alerted that something is wrong and needs to be done about it IMMEDIATELY”. This sense of immediacy has been exacerbated by delays in therapy and a lack of access to support systems this past year. The feeling like something is ‘wrong’ and needs to be made ‘right’ affects many OCD sufferers, but presents itself in different ways. For me, it feels like there is something sticky in my brain, like when you have jam on your fingers that you can’t rub off. The gooeyness of writing about feelings always put me off, but when the ‘stickiness’ of OCD developed, I found that letting the thoughts and feelings stretch onto the page made the imagery of something ‘wrong’ slightly fade, particularly when this year has been marked by so many things actually going ‘wrong’. Research has shown that those with OCD tend to have a high response to ‘error’ and too few ‘stop signals’. So even if you know what you’re doing or thinking makes little sense, you do it anyway. Reading poetry has let my emotions bump into those of others, diluting this idea of ‘wrong’. In the poem “The Visitor” from a collection called The Carrying, poet Ada Limón writes: “This might be what growing older is. My problem: I see all the angles of what could go wrong so I never know what side to be on”. — ADA LIMÓN, THE VISITOR This felt like it was written for me, and showed me how poems move off the page. At times when I feel like work or study seems pointless and tasks feel arbitrary, instead of poetry being just another task, it has let me move through the different types of feelings. I can now see how poetry and OCD are intertwined, and this has given me both a coping strategy and a life-long passion. Here is a poem of mine called “writer’s block”: “I can only write along the lines of my mind’s fissures when I let a splinter of sunlight fall into the whites of the pages eyes bloodshot and heavy with the day’s discontents”

Understanding Long Covid: The need to challenge stigma at its root I’m a philosopher. For the last few years, I have been working on philosophical issues around Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. When the Covid-19 pandemic struck, I was unsurprised to see the emergence of the phenomena we are calling “Long Covid”. Everybody recognises that finding solutions to Long Covid will require scientific ingenuity. What is less recognised, but equally true, is that finding solutions to Long Covid will also require that we do some philosophical work. In the UK and across the world, Long Covid rates are high, and there are lots of questions being asked: What kind of illness is it? How do we define it? How do we treat it? We are far from being able to answer these questions fully. Doing so requires scrutinising and dismantling deeply entrenched, long-standing dynamics of stigmatisation against other illnesses. The debate so far has shown resistance to accept parallels between Long Covid and other existing conditions, or more specifically, existing conditions which have historically been subject to stigma. Resisting the association of Long Covid with particular sets of stigmatised illnesses has at least two undesirable potential consequences. One risks not only endorsing the stigma associated with the existing conditions, but one also creates high stakes whereby the emergence of scientific reasons to accept parallels between Long Covid and stigmatised conditions delegitimises the suffering of those with Long Covid. So, what has been said so far? Last winter, a blog was published by the British Medical Journal, promoting use of the term “Long Covid”. This blog was authored by medical professionals and other academics who have suffered long-lasting effects from SARS-Cov-2. The authors encourage medical professionals to continue to embrace the patient-made term “Long Covid” on the grounds that it is better able to navigate socio-political and clinical challenges than alternative labels. “Long Covid”, they argue, “side-steps” words “post, “chronic” and “syndrome” which delegitimise suffering as a consequence of being associated with stigmatised groups. Contested illnesses There’s something of an elephant in the room here. Who are the stigmatised groups in question? The obvious candidate is those who suffer from so-called contested illnesses. This term is often used as a catch-all to refer to illnesses for which there is poor biological-level understanding, such that whether they are legitimate illnesses of their own is contested by some. Most obviously in the firing line here is Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME), and so it will be my focus. CFS/ME has heterogeneous symptomatology, but is typically characterised by disabling fatigue, lasting six months or longer that is not eased with rest; post-exertional malaise (worsening of symptoms following exertion); sleep problems; pain; headaches; cognitive problems; flu-like symptoms; feeling dizzy, sick, or having heart palpitations. Other complex and poorly understood illnesses such as Post-Viral Fatigue Syndrome (PVFS), Fibromyalgia and Functional Neurological Disorders (FND) are also relevant. We might also include Medically Unexplained Symptoms (MUIs). Almost everybody who is familiar with CFS/ME will know that it is a heavily stigmatised illness. An important aspect of this stigma is the lack of scientific consensus about it: its aetiology, its nosology, and the efficacy of its diagnosis and treatment. What causes it? What kind of specialist do we send patients to? How many distinct new or existing conditions are captured by the existing diagnostic label? How can we prove that they’re really ill? The lack of scientific knowledge about CFS/ME leads to stigmatisation by way of exploiting that uncertainty. The formula is the same for the other conditions. Lack of reliable biological markers and diagnostic tests can be taken as evidence that the illness is somehow less “real”, with its place “in one’s head”. This can delay diagnosis, treatment, and lead to undermining interactions both in the clinical encounter and wider society. Psychiatric illness Pejorative descriptions of ill-health predicaments as “all in one’s head” are pejorative as a result of their association with yet another set of stigmatised illnesses: psychiatric, or mental, illnesses. The stigmatisation of psychiatric illness has a long and complicated history. Here I will mention only a small aspect of it: available causal explanation. With the aforementioned contested illnesses as a case in point, the perceived legitimacy of an illness can be affected by the specificity of the story that can be told about its aetiology. Telling such stories about psychiatric illnesses has historically been difficult, where diagnoses typically do not carry as much explanatory power as in more obviously bodily illness. Continued difficulty pinning down clear aetiology at the biological level for psychiatric illness sustains, and partially contributes to, a long-standing attitude that those with psychiatric illnesses are suffering from something less real, less medically legitimate, than those with more obviously bodily diseases. With varying levels of subtlety, psychiatric illnesses continue to be often described as predicaments “all in one’s head”, in contrast to “real” bodily disease. From one extreme to the other, psychiatric predicaments are then seen as reducible down to personality traits such as laziness and weakness of character, in stark contrast to bodily disease. The relationship The association between CFS/ME and psychiatric illness is a highly controversial one. Lazily made assumptions that people with CFS/ME are “just” suffering from a psychiatric illness can cause great harm. Indeed, some with CFS/ME have reported such assumptions to be detrimental to the standard of care they received, such that it motivates resistance to the inclusion of a psychiatric perspective in their care. Despite rapidly emerging parallels, the motivations for resisting associations between Long Covid and conditions such as CFS/ME now become clearer. To resist terms like “post”, “chronic” and “syndrome” is, at its foundation, to resist the stigma associated with psychiatric illness. It is imperative to tease apart two grounds for resisting the inclusion of a psychiatric perspective: social grounds (the avoidance of stigma), and medical grounds. So long as the powerful stigmatisation of psychiatric illnesses persists, the social grounds risk superseding medical grounds. Where psychiatric illness is associated with laziness and weak character, how could it be anything but harmful when a medical professional suggests you might benefit from seeing a psychiatrist? This is concerning, as ignoring medical grounds in favour exploring scientific hypotheses can obfuscate potentially illuminating lines of enquiry. Are there good scientific grounds for resisting the inclusion of a psychiatric perspective on the relevant conditions? It’s not entirely clear. Though we must tread carefully here, the view that psychiatry might be relevant to these conditions (at least in some cases; recognising heterogeneity is important) does not appear scientifically misguided, as Professor Carmine Pariante has recently argued. Moreover, recent brilliant advances in branches of psychiatry such as immunopsychiatry challenge the distinction between psychiatric and somatic (or mental and bodily) illness that much of this problem survives on. I am not claiming here that we are in a position to say that these conditions are psychiatric conditions, in poignant words, “whatever that means, though it is rarely something good”. Rather, it is true that we are not in a sufficiently strong epistemic position to rule out that psychiatric research and treatment can help improve the lives of patients. For that reason, we should remain open minded. Moving forward The task at hand, then, need not necessarily be to resist the association between Long Covid, CFS/ME, and psychiatric illness, but to challenge that which negatively affects the perceived legitimacy of the conditions in question. How? By recognising and dismantling the stigmatisation of psychiatric illness. Human suffering should not be stigmatised, whether it is treated by a psychiatrist, neurologist, immunologist or an endocrinologist. We should therefore embrace scientific research into Long Covid with an open mind. We should also remain vigilant, on the look-out for deep-rooted stigma which risks stifling scientific progress and harming patients. This is hard work, but it is crucial. It is vital for both social and scientific progress that we recognise and challenge these stigmatising dynamics. Then, and possibly only then, can we make good progress in both individual and collective understanding of all such implicated conditions. This way we can tackle Long Covid, without leaving others behind.

I was born a few months after the Columbine shooting. I always lived in a world where school shootings were normal Disclaimer: This blog discusses a topic which some readers may find distressing. Last week, 21 people, including 19 children, died in a mass shooting at Robb Elementary School in Uvalde, Texas. The shooter acquired his weapon legally. The gun he used can be ordered online for $1870 with free click and collect shipping. There was even an instalment plan. It’s clear that America has a problem with mass shootings, to the point that firearm-related injuries are the number one cause of death for children. An eleven-year-old survived last week’s shooting. One moment, she was watching Lilo and Stitch with her fourth-grade class. The next, her teacher and several of her classmates had been shot. Her friend bled to death in front of her. Fearing the gunman’s return, she put her hands in the open wound of her dead friend and spread the drying blood on her own clothes, so that she might look convincingly dead. It worked. She survived. I can’t imagine she’ll ever forget. At my school, shooting drills were just as routine as fire drills. I was born a few months after the Columbine shooting, so I always lived in a world where school shootings were tragically normal. Even in the liberal state of California, it was still something we feared growing up. I don’t remember the first school shooting I heard about. They all blur together, to the point where people ask “which one?” when the topic comes up. Americans treat school shootings as inevitable, like earthquakes or forest fires. There is this pervasive notion that they simply cannot be prevented, only stopped by higher fences, barricaded doors, or “a good guy with a gun.” My mom works as a teacher’s assistant. Her class is the youngest in the school, with the oldest kids being only six years old. During shooting drills, she tells them there’s a big angry dog outside, in an attempt to shield them from the truth for as long as she can. But too many of them already understand. They’re not hiding from a dog. When we talked about the news over the weekend, as we typically do, there was a lingering devastation in her voice, the kind that only comes from seeing the same tragedy over and over again. “Why is your right to own a gun more important than my right to life? These children have had their right to life taken away,” she told me. “What are we expected to do? Turn schools into prisons? Having one locked door just doesn’t work in a school.” Arming teachers is often proposed as a potential solution to the school shooting epidemic. No teacher I have ever spoken to wants a gun in the classroom. “It will get worse if there’s a gun in the room already. I have the right to feel safe at my job, and children have a right to feel safe at school. For some kids, school is the only place where they feel safe, and we’re taking that away from them,” my mom told me. Texas Governor Greg Abbott made a statement after the shooting, saying “We as a state, we as a society, need to do a better job with mental health.” But just a few months ago, in April of 2022, Abbott cut $211,000,000 from the Texas Health and Human Services Department, which provides mental health care to Texans. The mental illness narrative is a misinformed and stigmatizing idea that perpetuates negative stereotypes about people with mental health issues. “People with mental illness are more likely to be victims of mass shootings than perpetrators of mass shootings. Less than 10 percent of shootings involved a suspect who had mental health issues,” says Greg Hansch, head of the Texas chapter of the National Alliance on Mental Illness. I marched for gun control nearly five years ago. I have never seen so many young people marching before or since. The youngest person I saw at the March for Our Lives was a student in an after-school class that I taught on Friday afternoons. I remember thinking “She’s too young to be fighting for this.” She couldn’t have been older than seven. It’s not supposed to be children’s responsibility to protect themselves, but when we teach kids to hide below the windowsill, lest bullets break the glass, we put that responsibility on them. If our children grow up suffering as we did, then we’ve failed them. America is the only developed country where this still happens. It isn’t inevitable. I marched for gun control as a teenager, but as an adult, nothing has changed. When will it end? When will we have gun control?

The Proof is in the Pudding: How Western diets increase our risk for cognitive decline and Alzheimer’s disease The food we eat can directly change the way our brain functions. And, depending on what that food is, these changes can be detrimental to our short-term and long-term brain health, even increasing the risk for Alzheimer’s disease, which is a disease characterized by the death of neurons in the brain, leading to impairments in memory and overall cognitive function. I received my doctoral degree in neuroscience and am currently a postdoctoral researcher at The Ohio State University in the United States. My research focuses on how nutrition impacts the communication between the immune system and the nervous system, and what this means for brain function. More specifically, I look at how different diets impact brain inflammation, learning, and memory in multiple biological models, including ageing and Alzheimer’s disease. Over the years, this area of research has become more personal for me as I have lost several family members to Alzheimer’s disease and have witnessed how devastating this illness can be, not just for the patient, but also for the caregivers. I believe the chances of developing Alzheimer’s can be greatly reduced, and in this blog, I will tell you more about it. Understanding the disease is critical for informing medical professionals and, more importantly, the general public, on how to best reduce our risk. Luckily, there is exciting work being done on these topics and this article will discuss one very important factor: diet. Western Diets and Brain Function So, what is a “Western diet”? This is a term that is often used to describe the typical diet consumed in the United States and some countries in Western Europe. This diet is high in saturated fats, added sugar, and simple carbohydrates, and very low in fibre. These foods, such as white bread, pizza, ice cream, and packaged foods, are cheap, tasty, and heavily processed to extend shelf-life and limit trips to the grocery store. Unfortunately, overconsumption of these foods can also lead to metabolic dysfunctions (changes in metabolism that are harmful to the organism) such as type 2 diabetes (insulin resistance), hypertension (high blood pressure), and obesity (high body mass index). Obesity and metabolic syndrome (a term used to describe some combination of the metabolic dysfunctions mentioned above) are major risk factors for cognitive decline and Alzheimer’s disease later in life. However, several clinical studies have shown that, even in the absence of these other metabolic changes, the single factor of consuming a Western diet (even for a short period!) is associated with cognitive decline and shrinkage of the hippocampus, which is a brain region involved in learning and memory function and Alzheimer’s disease. Ok, but how can the food I eat, damage my brain? This is a question that does not have a straightforward answer because it can happen in several different ways. For this article, I am choosing to focus on my area of expertise, which is the immune-to-brain connection. In pre-clinical research (laboratory research that is before research is done on humans) it has been shown that overconsumption of saturated fats and sugar can increase inflammation in the gut and even impact the function of circulating immune cells. These immune cells can release inflammatory molecules that send signals to the brain that “activate” inflammation in the brain. If this brain inflammation is prolonged, then it can damage neurons and other cells in the brain, which can lead to changes in behaviour or cognitive issues. Besides, there is some evidence, based on magnetic resonance imaging (MRI), that obesity is also associated with brain inflammation in humans. In studies done on humans, research has shown that consuming a Western diet can lead to increased inflammatory molecules in the blood. Again, these inflammatory signals are likely communicated to the brain, resulting in brain inflammation and potential damage to neurons, which can lead to the development of Alzheimer’s disease. Ageing Increases Vulnerability I mentioned above that ageing is one of the variables I study regarding nutrition, the brain, and the immune system. This is an important variable because older individuals seem to be more vulnerable to inflammatory triggers (such as an unhealthy diet). This is because aged mammals display chronic, low-grade inflammation, even in the absence of disease. Because of this higher inflammatory level, additional inflammatory stimuli can trigger an even greater, more dangerous inflammatory response. Is there a solution in sight? Well, there are several things we can do to help lessen the toll that inflammatory stimuli take on our brains. Potential Tools to Lessen Inflammation First, we should all try to limit the intake of these inflammatory, processed foods and replace them with healthier options. Just like certain nutrients can be inflammatory, other foods can be anti-inflammatory! One of the more prominent anti-inflammatory nutrients is omega-3 fatty acids, the main component of fish oil supplements that you can buy at almost any grocery store. They are also abundant in fish such as salmon, cod, and sardines. There is an overwhelming amount of pre-clinical data showing beneficial effects of omega-3s on brain health, including reducing inflammation. There is also some promising data in human clinical studies suggesting omega-3 supplementation can slow cognitive decline in ageing. For more information on how healthy diets can help your brain, you can check out other articles from our blog, here and here. Other tools can be used to mitigate inflammatory insults and improve the quality of life as we age. These include activities such as a consistent exercise routine and even intermittent fasting, which involves consuming all of your daily calories during an 8–10 hour window so that your body is in a fasted state for 14–16 hours a day. While things like exercise and eating healthy foods is a good idea at any stage in life, the earlier we can start living a healthy lifestyle, the better. There is now evidence from human studies that the earliest brain changes related to cognitive decline and Alzheimer’s disease can be detected during your 40s. I will close by saying there is no “magic bullet” that will guarantee the prevention of something as complex as Alzheimer’s disease, but there are tools we can employ now to reduce our risk. So I want to ask anyone who reads this to consider how your diet impacts your brain. Whatever this looks like for you if you avoid heavily processed foods and stick to healthy whole foods (like salmon, fruits and vegetables, dark leafy greens, nuts and berries, etc) and get regular exercise, your brain, your immune system, and your future self will thank you. Header image by happy_lark on Adobe Stock

Dialectical Behavior Therapy (DBT) Coach App: Relief comes at your fingertips In early 2020, at age 38, I was diagnosed with Borderline Personality Disorder. The diagnosis came as a relief because I suffered from symptoms that were often confused with depression and anxiety for years, such as suicidal ideation, mood instability, ruminant thoughts, and exaggerated fear of abandonment. However, even with the drug treatment (started in 2010), the pain I felt didn’t seem to stop. The emptiness I felt (and still feel at times), seemed to never end. It was like watching a movie in slow motion, and wondering what you’re doing inside it. No medicine or therapy was able to alleviate my pain and fear. Until, on my psychiatrist’s recommendation, I started treatment with “Dialectical Behavior Therapy” and suddenly everything started to make more sense. After all, it is an approach aimed at patients with high emotional dysregulation. The only problem is that I developed such a strong bond of dependency with my psychologist. It became increasingly difficult for me to get assistance just once a week in our sessions. That’s when she referred me to the DBT Coach app so that I could learn and practice the skills several times a day, without having to turn to her at every moment of crisis. I am willing to share my experience with the DBT coach app and say how much the tool contributes to my autonomy in problem-solving. The DBT trainer app is a kind of digital diary, and in it, the patient can record mood, skills, and activities that are carried out during the day. To give you an idea, the daily card check-in starts with the small (but complex) question, “how are you today?” The screen has a small circle with an emoticon in the center, which changes color according to your daily mood. And that’s where it gets interesting: recording humor is not an easy task. There’s a big difference between someone telling you’re not okay just judging by your appearance. On the other hand, when you recognize that you are not ok, it goes beyond appearances: it requires self-knowledge and an understanding of your own emotions. In this sense, the app has already gained my trust because recording mood requires a daily exercise of self-knowledge. DBT Coach is a tool that invites people to take a daily dive into the ocean of emotions that guide behaviors, attitudes, and skills. And speaking of skills, these are divided in the app (as in DBT) into 4 modules: mindfulness, interpersonal effectiveness, emotion regulation, and tolerance to discomfort. The application suggests that we do a self-assessment of whether each of these skills was helpful when implemented in everyday life. The good thing about having the application at hand is the accessibility to review the lessons applied in DBT. The more I accessed and reviewed skills training videos, the more confident I was in applying them to my daily life. There is an exercise, for example, called “daily reflection”. For me, it’s one of the richest exercises in the app, as it makes me remember and reflect on situations in which I felt peaceful and open. Putting good experiences into words develops feelings of joy and gratitude, especially in times of so many comparisons on social media. We get so fixated on other people’s lives, whether it be on Facebook or Instagram, that we even forget to appreciate what’s good in our own. It is also worth noting the importance of mindfulness activities in DBT skills training. I learned in my sessions that mindfulness is living intentionally in the present moment, without judgment, doing one thing at a time, with openness and curiosity. In a world so full of stimuli, we have acquired the habit (without realizing it) of eating without tasting, hearing without listening, looking without observing, and living without feeling. Mindfulness skills exist to remind us that it is not enough to live, it is necessary to experience. It’s like learning to ride a bike! You have to pay attention to your balance, feel the pedals little by little, and adjust your body as you move the handlebars. This is just an example of a mindfulness activity-one skill at a time. DBT coach app also guides the practice in other everyday situations, such as washing the dishes, tasting a piece of chocolate, and listening to the sounds of nature while walking. It’s about observing, describing, and participating, putting words to each experience. In DBT, we usually talk about the 3 states of mind, termed by Dr. Marsha Linehan, creator of Dialectical Behavior Therapy. According to Linehan, a wise mind is the combination of our emotional and rational minds. Having a wise mind means using the logical part (of the rational mind) and sensitivity (of the emotional mind) in a crisis or problem situation. In the wise mind exercises, you learn to observe your thinking (instead of acting impulsively); describe the situation that upset you emotionally; learn to use skillful means to solve a problem, rather than doing what you think is right. Practice leads to excellence. From practicing this skill so much, today I can notice the change in my thoughts and emoticons, mainly in the ability to interact with other people. By the way, here’s another valuable skill worked on in the DBT coach app: interpersonal effectiveness skills. Interpersonal effectiveness skills are intended to help a person develop self-control, balance, and self-respect. The exercises encourage the patient to discover more effective ways to achieve goals with other people, without being rude or aggressive. A technique widely used for this in DBT is DEAR MAN. It is an acronym for Describe (D), Express (E), Assert (A), Reinforce (R), Mindful (M), Assertive (A), and Negotiate (N). By scripting (DEARMAN) activity, I was able to understand the difference between describing facts and expressing opinions about a situation. When we express an opinion, it is charged with emotion and feelings. On the other hand, when describing a problem, we limit ourselves to observable facts, without making value judgments. In the activity, it is possible to reflect on how the way we communicate can reduce discussions, and increase mutual understanding. I particularly could see the difference that this skill makes in my relationships, especially with my family. We cannot expect someone to guess what we want or expect from a situation, it is necessary to say it clearly. In view of all this experience with the app, what I can say is that the exercises significantly contributed to the reduction of my anguish, as well as to the development of my autonomy. With each task completed, I felt more and more confident and less insecure about my feelings, thoughts, and attitudes. It is important to remember that none of this happened overnight. DBT trainer activities were shared with my psychologist and discussed in our weekly sessions. There are always skills to improve, so making use of the wise mind, balancing reason and emotion, is the key to a more harmonious and peaceful life. That’s why mindfulness skills help a lot, as it’s about getting in touch with what you think and feel, without judgment. In no way does the DBT coach app replaces psychotherapy, but it does act as a great ally in the therapeutic process. Therapists and patients can review the app’s lessons and work more efficiently on improving skills for a better quality of life. A life worth living.

Art & Mental Health in Conversation: An interview with Ukrainian Artist Margo Sarkisova The Art Unit x Inspire the Mind This interview was conducted before the start of the Russian invasion of Ukraine. Margo Sarkisova had to flee her home in Kharkiv. She keeps producing art and reflecting on the current situation in a ‘war diary’. The Art Unit is an online gallery selling and promoting works by emerging artists. The Art Unit launched in spring 2021 with a release of works by over 20 Ukrainian artists. We believe it is vital to support artists at the start of their career, as it becomes increasingly hard to maintain a career as an artist in the global art market. Emerging artists face various obstacles on their path, and I believe in helping them to speak up and share their stories. Margo Sarkisova is one of the artists from The Art Unit’s first release. Based in Kharkiv, Ukraine, Margo produces beautiful original works that are full of personal messages from the artist. This interview gave me a chance to start a deeper conversation with Margo about her art practice, her mental health and more. I began our conversation by asking Margo if she could tell me about her development as an artist. What influenced her, and what, on the contrary, interfered? This is a very good question! I can point out several factors that influenced me as a person, and that subsequently forced me to turn my attention to the topics that I work with as an artist now. First of all — my family, and that I am the middle daughter in the family. According to my observations, middle children have a rather interesting place in the family system: a kind of link between the older and younger child. The middle ones are often overlooked while the older one is scolded and the younger one is praised. Therefore, I had many opportunities to reflect, to invent my own world, while all the adults were busy and did not take my various hobbies and thoughts seriously. The second important factor that is deriving from the first one is the cultural background of my family. By nationality, I am an Assyrian (Assyrian people are an ethnic group indigenous to the Middle East, Assyrian religion was heavily influenced by its Mesopotamian predecessors and its culture is famous for elaborate stone carvings) on my father’s side and Ukrainian on my mother’s side. This polarity of two cultures has always created a certain conflict and contradiction during my growing up. Despite the fact that I was born in Ukraine, I was brought up according to Assyrian traditions and cultural codes. This created a certain “vacuum”, in which I was in the circle of my family and left it in a completely different Ukrainian environment, where those around me lived by completely different principles. I have always wondered: why is that? Why are the traditions and laws of my family arranged in this way? And this gave me an impetus, after studying at the Academy of Arts, to study my family tree, Assyrian traditions, and the place of a woman in the Assyrian value system. The same things interfered with the development of my art, only in a different polarity: attitudes acquired from an upbringing in a closed patriarchal culture, obstacles in the form of my father’s beliefs that my sisters and I do not need to receive higher education, as well as the political situation in eastern Ukraine (In 2014, Russia annexed Crimea and invaded the Eastern part of Ukraine, an area called Donbas, many people left their home in Donetsk, Luhansk and other towns and cities due to military actions in the region; on the 24th of February in 2022, Russia started a full-scale invasion of Ukraine). I already had to leave the art school in the first year due to the political situation, and be transferred to the free hearing (a form of education, in which one can attend lectures, but does not identify as a student) in Kharkiv where I still live after 8 years (Kharkiv is a big city in eastern Ukraine, Kharkiv is one of the cities that is heavily bombed and shelled in the full-scale invasion by Russia, Margo had to leave her home for the second time and now resides in the Western part of Ukraine, which is safer). Do you think mental health affects art? Does it affect your work? I believe that mental health directly affects the art that an artist creates. For me, art is the most honest portrait of the one who creates it. Here, of course, you can also deceive yourself or the viewer, but this fact is always felt on an intuitive level. Therefore, looking at the work of one author, we can feel a connection with him, we experience feelings and emotions. And from others, we may feel only indifference and coldness. It’s all about the truth. And the truth is always bitter because one must, first of all, admit it to oneself — that is, the artist must, first of all, see the truth himself: himself, the world, and all their imperfections. And in order to withstand such difficult experiences, it is important to have inner stability. And this is possible only if you devote a lot of time to your mental health, otherwise, you can very quickly go into addiction, self-destruction and waste precious energy, without which you cannot realize all your ideas and projects. Do you think that art can help people? If so, how? Art can really help people, but it has no such task. Art is not salvation or a solution to problems. It’s all about perception. The artist creates what excites him, but to think that it can help someone or change the world is very naive, I think. People can be helped not by art itself, but by the ability to perceive it, the ability to be sensitive, and attentive and develop the skill of interpreting the symbols that the form carries. For me, art is a mirror of the one who looks at it, so I would not endow it with the role and responsibility of being an aid in helping someone. People can help themselves, and art is only a tool. You use a lot of symbols in your work, tell us why and what do they mean to you? Smithsonian Education define symbolism as usually a solid, recognizable thing — an animal, a plant, an object, etc. — that stands for something that would be hard to show in a picture or a sculpture. I really love symbols and they play a big role in what I create. I have formed a certain system of symbols through which I express my thoughts. The first important symbol was ‘Garden’, as the device of the world and life. Later, a gardener appeared who works on the garden every day — his little universe; he puts things in order in the garden, thereby warning the world from chaos. And in the future, images began to come from these concepts: poisonous seeds are what a person who commits evil plants, fruit trees are a symbol of life and prosperity, the connection between the external world and the internal, and so on (about Margo’s works). For me, symbols are the inhabitants of my world structure, codes that can be interpreted in different ways. Though for me, they have a certain meaning that forms the message that I carry through my work. How do you feel about criticism, does it help you or, on the contrary, make you stop? Criticism can be very different, and at this stage of my life, I accept it only if I ask for it myself from a specific person. Otherwise, the unsolicited criticism and advice only violates my boundaries and has no value for me. Things like this should only be given upon request. What art formats do you like the most? Why? By my education as an artist I specialize in printing, so for myself, I highlight the importance of working with paper. But lately, my horizons have expanded and I try different techniques and combine them with each other. These include beadwork, patchwork and pen-on-canvas painting. I would also like to note that art has no boundaries and materials, the main thing is how much this material helps to express an idea. and at the same time, an art form can express nothing and be only a form, and that is enough. I would like to say thank you to Margo for having this conversation with me, which took place before the start of the full-scale invasion of Ukraine on the 24th of February. Margo continues creating artworks during the war. As Margo said, art is a tool that can help people, it could be used for easing anxiety, level of stress and more. It is important to reflect on how professional artists are impacted by their craft and how it can help others. Header Image by Margo Sarkisova

Postpartum (or puerperal) psychosis is a rare — occurring in just 1–2 women per 1000 deliveries in the general population — but extremely severe postnatal mental illness. So severe, in fact, it is considered a psychiatric emergency requiring specialist care and/or hospitalisation. Indeed, if left untreated postpartum psychosis can have devastating consequences for a woman and her family, and in rare but tragic cases can lead to suicide and/or infanticide. Beginning soon after childbirth, typically within days or weeks of the delivery, postpartum psychosis can develop without warning, escalate very quickly and soon become severe. Symptoms include elation, depression, or rapid fluctuations between elated and depressed mood. As the name suggests, women also experience psychotic symptoms in the form of delusions (unusual thoughts or beliefs), such as paranoia, and hallucinations (seeing, hearing, smelling or feeling things that are not there). Confusion is also a common symptom, and women may appear not to know who or where they are. Understandably, episodes of postpartum psychosis can be extremely frightening for the woman, her partner and her wider family. While postpartum psychosis is among the most severe psychiatric disorders, with treatment and support, women will go on to make a full recovery. Nevertheless, understanding the causes of the illness could help prevent women from developing an episode of postpartum psychosis in the first place. And this is where my work comes in. I am a postdoctoral researcher in the Stress, Psychiatry and Immunology Lab (the team who brings you the InSPIre the Mind blog), working in the field of perinatal mental health. I have a keen interest in advancing our understanding of risk and resilience factors for maternal perinatal mental illness, with the aim of developing targeted treatments and interventions for women most at risk. In this blog, I would like to tell you about the work we have been doing examining risk factors for postpartum relapse in women at increased risk of postpartum psychosis. The exact causes of postpartum psychosis are currently unknown. Several factors have been proposed, including becoming a mother for the first time (primiparity), sleep disturbance, and the dramatic fluctuation in hormones that occurs during pregnancy and the early postnatal period. However, more research is required to better understand the factors underlying the illness. One thing we do know is that women with a diagnosis of bipolar disorder or schizoaffective disorder and those who have experienced an episode of postpartum psychosis following a previous delivery are at much higher risk of experiencing an episode of the illness after giving birth. In fact, research has shown that up to 50% of women with bipolar disorder or schizoaffective disorder and those that have had a previous episode of postpartum psychosis will develop symptoms following the delivery. But why do some women at risk become unwell after they give birth, while others stay well? Last year we published an article in the scientific journal Psychoneuroendocrinology, which demonstrated that stress might be one of the key factors that make women already at increased risk of postpartum psychosis more susceptible to becoming unwell in the early postnatal period. Specifically, our research found that postpartum women who had an episode of postpartum psychosis experienced more stressful life events and higher perceived stress, as well as showing biological changes. Indeed, we found higher levels of two main biological markers: cortisol, our main stress hormone, and high sensitivity C-reactive protein (hsCRP), an overall measure of inflammation throughout the body. But could these measures of stress already be present before the illness even begins? And, if so, could they help to predict in advance which women at high risk will go on to become unwell in the postnatal period? It is this question that brings us to our current research and focus of this blog, describing a paper we published recently in Psychoneuroendocrinology. As part of the Psychiatry Research and Motherhood, or PRAM, Study, we recruited a group of women at increased risk of experiencing postpartum psychosis and followed them from the second trimester of pregnancy to 12-months post-delivery. This study design enabled us to collect information on various types of stress, including experience of psychosocial stress (childhood trauma and stressful life events during pregnancy) and markers of the biological stress system (cortisol and inflammation), before the onset of any postpartum symptoms. In this particular study, we focused on postpartum symptoms, including depression, mania (feeling elated/high) or psychosis (having unusual thoughts or seeing/hearing things that are not there), that started within 4 weeks of the delivery. So, what did we find? The impact of childhood trauma Firstly, we found that women at high risk of developing postpartum psychosis who had experienced severe childhood maltreatment, defined as experience of physical abuse, sexual abuse, antipathy (emotional abuse) and neglect prior to the age of 17 years, were almost five times more likely to have a psychiatric relapse in the first 4 weeks’ postpartum than women at risk who had not experienced maltreatment during childhood. This finding suggests that asking women at increased risk of postpartum psychosis about their experiences of childhood maltreatment during pregnancy (perhaps as part of their routine antenatal care) could be important in helping to identify those women most at risk of having a psychiatric relapse in the early postpartum. The impact of recent stressful life events While early life stress, in the form of severe childhood maltreatment, predicted postpartum relapse, the same was not true for stressful life events in later life. Indeed, we did not find a link between experiencing a stressful life event (e.g., death of a close family member or friend, marital difficulties or major financial crisis) during pregnancy and relapse in the postnatal period. We did, however, find that women at risk who relapsed were more likely to find the stressful life events distressing, in comparison to those who remained well. This suggests that it is not the experience of a stressful life event itself that increases the risk for postpartum relapse, but instead how distressing the individual perceives that life event to be. It is, therefore, possible that implementing interventions, such as problem-solving, self-calming or mindfulness techniques, which are aimed at lowering stress during pregnancy could help to reduce the risk of postpartum relapse in women at increased risk of postpartum psychosis. Changes to the biological stress system As I mentioned, we also looked at biological measures of stress during pregnancy. We were surprised to find, given our earlier findings that women with postpartum psychosis showed increased levels of hsCRP, that none of the inflammatory markers we investigated (including hsCRP) were increased during pregnancy in those who subsequently went on to have a psychiatric relapse in the postpartum period. This indicates that the measurement of inflammatory markers during pregnancy might not be able to provide an early indicator of which women at risk will become unwell after giving birth. On the other hand, we did find that daily cortisol levels were elevated in the third trimester of pregnancy in the women at risk of postpartum psychosis who relapsed in the early postpartum, when compared with women at risk who remained well after giving birth. This is important, as it suggests that elevated cortisol in the third trimester of pregnancy might be a biological marker that we could use to help identify which of the women at risk of postpartum psychosis are most likely to relapse following the delivery. It also further highlights the potential need for interventions aimed at reducing maternal stress during pregnancy. So, does stress play a role in postpartum relapse in women at risk of postpartum psychosis? Our findings suggest that psychosocial and biological stress do play a role in determining whether women at high risk of postpartum psychosis experience a psychiatric relapse in the early postnatal period. It is of course important to remember that we are still in the early stages of this work and much more research in similar prospective studies with larger samples of women at high risk of postpartum psychosis is needed before we can really answer this question. It is also important to highlight that many factors are likely to be involved in determining whether or not women will experience a relapse in the early postpartum period and that experience of stress (whether in the form of childhood trauma or stress during pregnancy) will not result in a postpartum relapse for every woman at increased risk of postpartum psychosis. Indeed, many women at risk who experience these stressors will remain well after giving birth. Nevertheless, my hope is that our research goes some way to improving our knowledge and understanding of the factors that might increase the risk of postpartum relapse in women most at risk of postpartum psychosis. Understanding the risk factors for postpartum relapse will provide an opportunity to better monitor and support women at risk and ultimately develop targeted treatments and interventions aimed at preventing maternal postpartum mental illness.

I can’t remember when I first started worrying about the idea of ‘going mad’, but by my late teens it had become such a deep-rooted fear that it helped to fuel a spiral of obsessive thoughts, anxiety and depression that I took years to recover fro m. However, although at times I thought I’d created a self-fulfilling prophecy, the reality was that I never actually endured the sort of experiences I associated with ‘madness’. I’m caveating ‘going mad’ and ‘madness’ with inverted commas because these are vague, nebulous terms that gesture towards a set of ideas and images rather than offering any tangible definition. If I was asked at the time what these concepts meant to m e, I would have probably resorted to other imprecise phrases such as ‘losing my mind’, or else invoked stereotypes of a caricatured ‘crazy’ person running amok. This illustrates the other reason I’m wary of employing these expressions — in popular usage they often carry such negative and stigmatising connotations. Some people with experience of mental health problems are reclaiming the word ‘mad’ as a subversive act of self-empowerment. But in wider society, such labels are often still used casually with the effect, intended or not, of reducing complex human experiences to a two-dimensional ‘otherness’. My own personal and professional journey has taken me from a similarly simplistic understanding, to a place of respect, curiosity and compassion. Looking back now, I think what I feared in my youth was some amalgamation of symptoms of severe mental health problems (voices, hallucinations, delusions) and the implications of danger and chaos these are imbued with by media and cultural representations. But in many ways, it was the ambiguity of the fear that gave it such power — the underlying sense of threat and dread that couldn’t be rationalised away. In fact, the very act of trying to control my anxiety through obsessive thoughts contributed to me becoming unwell. It might seem odd that, as someone so unsettled by these ideas, I’ve gone on to spend my career working on mental health in different capacities — mostly in social policy but more recently in frontline NHS services as a Social Worker. The truth is though that many people who have experienced mental health problems find themselves attracted by the idea of trying to help others who are struggling. For me, if I’m honest, there is also an allure to being close to the thing that I fear. Although my primary focus is always on trying to help the people I encounter as a mental health professional, I have also found it hugely enriching to learn and understand more about the reality of symptoms that previously provoked such unease in me. It has been a privilege to have people open up to me about what they are going through — it has allowed me to become more comfortable with the experiences being described, which in turn has made me better able to respond with effective support. None of this is to say that I was undaunted by my transition into frontline work. For all the training and shadowing I undertook before being able to see people alone, I was full of trepidation as I made the way up the steps of a huge council block to make my first solo home visit. This was mainly due to self-doubt about what I really had to offer the person, and how I would respond if I simply felt out of my depth. But there was undoubtedly also an element of fear — as much as I’d like to disown them, I know that tropes about severe mental health problems and dangerousness linger in my subconscious. My initial appointments were indeed challenging. I found some of the things people said and some of the ways they behaved unnerving, even disturbing at times, and I often felt unsure about how to respond. But what was most striking to me was how people’s underlying personality and humanity remained apparent, and how there would always be moments of connection, even when we were perceiving and experiencing the world in very different ways. In my simplistic and naïve conception of ‘madness’, I’d worried I might cross a line at some point and ‘lose myself’, but it was clear that what constitutes our ‘self’ is much more adaptable and resilient than this, and can manifest both through and around even the most severe mental health problems. In my mind, ‘madness’ had also been tied up with ideas of chaos and ‘losing control’. At first glance, the lives of some of the people I’ve been supporting may have seemed to conform to this preconception. But the better I have got to know people, the more I have understood the order and logic in how they respond to the world as they experience it. People try to find ways to cope with the circumstances they find themselves in. These strategies may not always seem positive and constructive to an outside observer, but an outside observer doesn’t have to live within the same circumstances. Similarly, people’s brains seem to try to find ways to cope with the stresses and strains they are put under. Experiences like hearing voices and developing unusual beliefs may be the brain’s ‘coping mechanism’ for extreme circumstances. Recurring themes within what different people hear, see and think in these situations certainly suggest these are not simply the random concoctions of malfunctioning minds. Getting past the initial strangeness of these phenomena also allowed me to see how they might connect to people’s pasts. It is often traumatic events in people’s lives that both precipitate and shape experiences such as voices or hallucinations. People will often hear the voice of someone significant from their past, or see things that relate to a formative event. Stories of abuse, discrimination and immense hardship are common among the people I have supported, often with poverty and isolation as the backdrop that enables and compounds such experiences. Through working in NHS mental health services, I feel I have developed a much more nuanced relationship with the idea of ‘madness’. I recognise and appreciate how far away I am, or have ever been, from the difficulties others face, but can also see more clearly how people end up in such a place. I see potential explanations where once I just saw disorder, but I also have a better sense of the depths of anguish that severe mental health problems, and the circumstances that contribute to them, can inflict. However, for all the knowledge and understanding I feel I have gained over the last few years, I am also aware of the dangers of making assumptions and generalisations about what are deeply personal and subjective experiences. I have shared here my observations and reflections on the situations I have encountered, but I recognise that these are shaped significantly by my perspective and I do not mean to claim that they are universally applicable or that I can truly understand what others have experienced.