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The common practice within the current mental health system when people are distressed is to diagnose them (to find the category in the DSM or ICD which best fits them) and to treat them accordingly.

In the previous post I said a lot about why people who are suffering might want to embrace a diagnosis of a mental health problem. In the next post I will say more about why practitioners may be wedded to this way of working with distress. Here I will outline some problems with diagnosis in general.

As I mentioned, for people who are struggling, diagnosis is often seen as the only option other than seeing themselves as totally 'to blame' for their own distress. Also, it may be the only way to access support and community, and to be taken seriously by employers and others whose understanding they may need as they are struggling. Given that this is the world we currently live in, it is important for those who are critical of diagnosis not to impose that on others. Rather we might explore, with them, the potential losses and gains of taking on a diagnostic label (something explored in the Open University counselling module). Common losses which people express are that no label fits them perfectly, that – if they do embrace a label - they feel trapped by it (that this is all that they are are all that they'll ever be), and that they are treated differently by other people.

Irving Yalom points out this problem with diagnosis, that it easily fixes people (the way that a kiln fixes a pot) and can prevent us from treating people as whole, complex human beings. Rather, it is easy for professionals to see people as a 'bipolar' for example, or as a 'borderline personality disorder' (assuming that that category is all that they are, and that this person will be the same as other people in that category). Actually there can be multiple diverse meanings for people who fall into the same category which it is vital to explore. Take agoraphobia, for example, which involves fear of being outside the home. This could be about a fear of social contact, a sense of shame about oneself, an oversensitivity to noise, a genuine concern around violent attack (racist or homophobic, for example), an inflated concern over the risk of crime, superstitious fear of an accident happening, worry over one's own capacity for anger and violence with others, or many other things (and combinations of things).

The point about fixing people is supported by the famous Rosenhan study 'on being sane in insane places' which was conducted in the 1970s. He got a group of people to present to psychiatrists. They didn't wash for three days and said that they heard the word 'thud'. All were admitted to hospital and all were diagnosed with schizophrenia (except one who presented to a private clinic who was diagnosed as manic depressive, which is telling about class and diagnosis). Once admitted, the people said that they were fine and didn't report any further symptoms. Nonetheless they were kept in for weeks at least and their behaviours were still read as ill or disordered. For example, queuing up for lunch early because they were bored was labelled 'oral acquisitive syndrome' and making notes was labelled 'compulsive writing behaviour'. Science writer, Lauren Slater, repeated the study in the early 2000s herself. She didn't get admitted, but was diagnosed and medicated by everyone she presented to, reflecting shifts in understanding and treating mental health problems.

Clinical psychologist, Richard Bentall, has pointed out the incoherence of many diagnostic categories: It is possible for two people, categorised in the same way, to have completely different clusters of symptoms. Some symptoms which are generally seen as signs of mental illness, such as hearing voices, are experienced by many people and are not always viewed as problematic.

Also, there are issues with the cultural and historical specificity of diagnosis. The classic example of this is the fact that homosexuality was included as a disorder in the DSM until 1973 and in the ICD until 1992. Other consensual sexual behaviours which are considered 'outside the norm' (such as fetishes, sadomasochism and transvestism) are still listed despite lack of evidence linking them to distress and calls for them to be removed.

This raises the question of to what extent diagnosis of disorder represents individuals being in conflict with the norms of society rather than a genuine pathology. There are many other examples of this. For example, the 'sexual dysfunctions' are categories for people who don't have the amount, or type, of sex that they are expected to have by wider society. Categories of 'premature ejaculation' and 'vaginismus' suggest that 'proper sex' involves penile-vaginal penetration.

We might also think about what things are classified as addictions and what are not (in relation to what is socially acceptable), or what forms of self-harming are pathologised (cutting and burning oneself, but generally not smoking, drinking to excess, risky sports or driving, or cosmetic surgery).

Many have argued that the high levels of diagnosis of depression in women (and the greater likelihood that distressed men will be criminalised as 'bad' whilst women will be pathologised as 'mad') are related to cultural expectations around femininity and masculinity. Also, black and minority ethnic people are more likely than white people to be diagnosed with 'severe' mental health problems and to be hospitalised and treated with drugs, arguably due to the western norms inherent in the diagnostic categories, as well as experiences of racism and social injustice.

Going back to Rosenhan's study we may regard the world that we currently live in as rather an 'insane place' (particularly given the current economic and ecological situation) and question what it means to respond 'sanely' to this. Winnicott famously said, of depression: 'The capacity to become depressed, to have reactive depression, to mourn loss, is something that is not inborn nor is it an illness; it comes as an achievement of healthy emotional growth...the fact is that life itself is difficult...probably the greatest suffering in the human world is the suffering of normal or health or mature persons...this is not generally recognised.' In recent goals for everybody to be 'happy' there is a danger that we pathologise, even more, quite reasonable forms of distress.

A friend of mine recently posted a cartoon on Facebook which had Sigmund Freud saying 'before you diagnose yourself with depression or low self-esteem, first make sure that you are not, in fact, surrounded by assholes'. I responded that I thought this said something rather profound about mental health at the moment. Could it in fact be said that a key aspect of many experiences of suffering is the problem of being 'surrounded by assholes' or - to be more generous - being surrounded by damaging cultural messages perpetuated by those around us?

When I first started counselling I became very aware that virtually everybody I saw was convinced that there was something wrong with them that needed fixing, mostly based on the fact that - when they looked around themselves - nobody else seemed to be struggling the way they were. Conversations with close friends, and self-reflection, suggest that this is an extremely common feeling: that everybody else is managing fine so there must be something wrong with me. Of course, when I asked clients how they thought they appeared to other people they recognised that they generally put on a 'happy, managing everything fine mask' which probably gave off the impression that they weren't struggling either.

It strikes me that many experiences of depression, anxiety and other common mental health problems have a strong element of self-scrutiny and comparison to others in them (whilst, of course, I am wary of proposing any universal explanation because these experiences mean many different things to different people and at different times). Michel Foucault used Jeremy Bentham's Panopticon to explain how people self-police in contemporary society. In the Panopticon prison there is a tower in the middle and cells all around an outer circle, such that a guard in the centre could – at any time – be looking into your cell. Because of this, prisoners begin to monitor their own behaviour rather than having to have huge numbers of guards. This idea has been linked to the high degree of surveillance that we now have, meaning that we could – most of the time – be being watched or recorded.

Foucault suggested that contemporary culture worked in this way more broadly. People are encouraged to scrutinise and judge themselves at all times, with advocations to self-improve, to work on themselves, and to present a positive and successful self to the world. This is linked to consumerism which is all about seeing ourselves as lacking and needing something to fill that lack. Advertising, and many other forms of media, create fears (e.g. we might look bad, be out of date, or be a failure) and then offer products to allay those fears (e.g. beauty products, the latest fashion, recipes for success in various arenas).

Within such a culture it is no wonder that people would be particularly driven to constant self-scrutiny, comparison to others, and presentation of themselves as happy, satisfied and successful (even when they may not be any of these things). This shores up the 'us and them' that I wrote about in my second post. Rather than distress and suffering being an inevitable part of everyday life, it is seen as a problematic lack which must be addressed, and is probably outside of the power of the person who is suffering to address.

Perhaps the major challenge for mental health practitioners, counsellors and psychotherapists is the danger that our work can perpetuate this perception: creating new diagnoses and categories and offering an ever-increasing menu of products to fix these (at a price). Even the one-to-one therapy situation is at risk of exacerbating this sense that people are wrong and need fixing, given that one person (the client) is encouraged to express their distress to another person (the therapist) who is generally fairly quiet and certainly not expressing any of their own problems. This is not to say that therapists and counsellors should be inappropriately burdening clients with all their difficulties. But we need to find ways to challenge the idea that the client's struggles mean that there is something wrong with them, and the perception (which most clients have, even when they are therapists themselves) that the therapist has no struggles, or deals with them all perfectly.

Existential therapy includes the idea, not only that all people will inevitably suffer, but also that all responses to this suffering are sensible so long as we properly understand the person who is responding in this way. This, to me, is a very useful counter to the common assumption of something being 'wrong' and the person being flawed and lacking in some way if they do not respond in ways that are deemed culturally acceptable.

Self-Care

This week is depression awareness week (11-17 April). The most important thing I have to say in relation to depression is about self-care.

Towards the end of this week I'm going to an event about which asks, among other things, how people can nurture practices of 'self-care'. Towards the end of last year I ran a weekly workshop on self-care practices, and I'm running a day for therapists on the same topic this Autumn. The first chapter of the book I've recently written about relationships focuses on self-care. Here I want to look at why I think self-care is so important, what it is, and how we can build it into our lives (both when we are depressed and when we aren't).

Why Self-Care?

There's something wrong with me that needs fixing.

The most striking thing, for me, after several years of working as a psychotherapist, has been that virtually every person who comes for counselling or therapy believes that there is something wrong with them which needs fixing. A big part of this is the sense that everyone around them is managing life fine, whilst they are really struggling. There must be some lack or flaw in them in comparison with the rest of the world and they are desperate to put it right. Why can't they just be normal? What is wrong with them? Why aren't they like everyone else?

Sound familiar? I was certainly extremely grateful for this experience of person after person expressing sentiments that I had felt myself so many times. I now try to imbue therapy sessions with this sense that what is normal is to feel abnormal and wrong in this kind of way.

Reading about this sense of lack I've recognised that much of it is down to the difference between the image we present to others and our own inner experiences. The reason that people feel that there must be something wrong with them is that they are comparing themselves against the perfect, shiny people they see every day at work, on television, in the shopping mall, on facebook. But of course they themselves are likely also presenting a similar image to other people. When someone asks how we are we generally say 'fine' and accentuate the positive. Recent research has found that we write about the good stuff in our lives on social networking sites far more than what we are finding difficult. We know the messy, ugly and frightening stuff of our own selves because we live in them, but our point of comparison is a bunch of people who are unlikely to reveal that similar stuff to us unless we are very close to them indeed, or perhaps their therapist!

There may have been an element of this kind of comparison through history, but it is certainly exacerbated at the time we currently live in. Just think about the number of times each day that you receive the explicit or implicit message that there is something wrong with you which needs fixing. Maybe try counting for just one day. The explicit messages are easiest, although we don't often think about them. Every billboard advert and commercial on television, radio, or at the cinema, tells us that we need to be younger, more attractive, more successful and happier by owning more products or have more experiences of the kind that they are offering. This is also an implicit message in many newspaper articles, Hollywood movies, and reality television stories which tell accounts of the achievement of happiness, success or beauty through doing certain things, or sometimes of failure to achieve because of not having done such things as going on a diet, buying a lottery ticket, starting up a business or appearing on a television show. And we are certainly encouraged to compare ourselves to the airbrushed images in magazines, the snapshots of people we get in a brief news story, or to the characters who are being acted out by professional performers. We become used to comparing against a selective version of somebody's life rather the full warts-and-all picture. We could also think more widely about educational systems and organisational processes which are about comparing people against each other and striving for 'excellence' rather than being good enough.

Clearly there are important political conversations to have about this socioeconomic situation which underlies a good deal of current human misery. This is something that is frequently ignored by solutions which focus entirely upon the individual, including many forms of therapy, drug treatments, and people suggesting that we 'pull our socks up' (not that these things can't be helpful in their place, but if they obscure the wider context then there is a danger that they reinforce the idea that there is just something wrong with the individual person). In addition to addressing the wider context, what can we do as individuals to protect against this kind of toxicity, to help us to see these process as they operate through us, and to support each other better?

One suggestion is self-care.

What is Self-care?

It could be argued that, at the same time that society has become so consumer-oriented and focused on individual improvement, we have also lost some of the means we had in the past for caring for ourselves and for reflecting on our lives. It is very easy now to go through days and weeks without ever having a moment of quiet alone. We can easily fill our lives with noise, work and distraction such that we are always playing games on our phone, listing to podcasts, emailing, watching television, meeting people, getting tasks done, or socialising. When we do this it often gets increasingly frightening to be alone with ourselves. We can be anxious about what we will find. If we are struggling this means that it can often reach a crisis point before we do anything about it.

I'm not saying that those kinds of activities can't be done in caring ways (see my last blog entry on mindfulness), but I'm arguing that it is useful to ensure that we have some time in our daily lives devoted to being quiet, to looking after ourselves and to tuning in to where we are at. Otherwise it becomes increasingly difficult to tune into our needs (are we getting enough rest, food, support, activity, etc.) and also to tune outwards towards other people and the wider world.

Self-care is not just another form of monitoring ourselves and finding ourselves lacking, although we are so used to doing this that we need to watch out for it ('damn I haven't built any self-care into today – bad me!'). Similarly it isn't about just giving up on ourselves and thinking we may as well do comfortable nice stuff because we are no good anyway.

People's biggest block to doing self-care is often the idea that it is a selfish or self-absorbed thing to do. My own view is quite the opposite. Constant self-monitoring and self-improvement is self-absorbed because it is so internally focused that it often prevents us from seeing the fullness and struggles of other people. It also exhausts us to the point that we have very little to give to anyone else.

Caring for ourselves means that we are more aware of the kind of painful processes going on for us that make us despondent or fearful. This means that we can tune in better to the fact that other people likely have those same processes, so we can be more compassionate with their snappiness, withdrawal or neediness. We are less likely to just feel hurt and betrayed when others treat us poorly, because we understand it better. Also, when we have looked after ourselves we generally have more energy and patience for looking after others and for engaging with the world more broadly. We are more able to open up because we are less fearful of showing the fact we are lacking and imperfect: we know that everybody is.

What kind of self-care, and how to build it in, is up to each person. Different things work for different people at different times. I'd suggest making space for two things: kindness and reflection. Kind self-care is a way of demonstrating to ourselves that we are as deserving of kindness as anyone else (even when we don't quite feel that we are). Reflective self-care is a way of checking in with ourselves, tuning into our body and our emotions, asking ourselves how we are, thinking through any issues we are currently dealing with, making sense of why we are finding something difficult.

Examples of kind self-care that work for some people include: having a hot bath, giving yourself a treat, taking half an hour in a cafe, spending time with friends, being in the garden or park, sharing a hug with a friend or pet, and watching your favourite programme. Example of reflective self-care include writing in a journal, having a session with a close friend where you both have time to talk through whatever is on your mind, going for a walk, and meditating.

It seems to be really hard to build these into our everyday life. Our tendency is often to leave them till last (if we get everything else done) rather than prioritising them. When things get tough we are often even less likely to do these things because we feel that we don't deserve it, and we are often scared to be quiet or to tune into ourselves because we fear that we really will find something terribly wrong with us. Gently trying to build in a daily kind act towards ourselves is often a good first step at such times, followed later by also taking some time to kindly listen and reflect upon what is going on in our minds and bodies.

Given the world that we live in it is likely that we will keep forgetting self-care and needing to remind ourselves, and that we will easily slip into beating ourselves up about it or doing it with the secret hope that it will make us all 'better' or stop us from ever struggling again. When those things happen it is just another reminder of our imperfect humanness, and of the messages that surround us and others that make this so hard.

Suggestions for Fear and Sadness

My main job at the Open University since I started working here in late 2008 was to produce and present a module called Counselling: Exploring Fear and Sadness. As part of that process my colleagues Darren Langdridge, Andreas Vossler and I edited a textbook which brought together experts on all different types of counselling to say how their approaches would work with fear and sadness.

When we wrote the book I thought that it would be great to do another book covering the same areas, for people who are not interested in studying counselling themselves but who just want to know about what different kinds of counselling suggest. As Mick Cooper and John McLeod have recently pointed out: different things work for different people at different times, whereas most books on the market cover just one approach in detail. Maybe I'll write that book one day, but meanwhile here are what I personally think are the top suggestions from each chapter of the book we did write. If you find them useful of course you can always do the whole module (D240) through the OU.

1 - Introduction

Remember that everyone gets frightened or sad, and everyone also has times in their life when this becomes overwhelming. There is not really an 'us' (the professionals) and a 'them' (the clients or patients) because all people will find themselves both in the position of struggling and of helping others who are struggling.

2 – Diagnosis

We used the words 'fear and sadness' rather than 'anxiety and depression' for the module because there are pluses and minuses to the more diagnostic categories. It can be useful to think about what is gained, and what might be lost, from taking on such labels. For example, they can make it easier to find others who are in a similar situation, to access support, and to feel legitimate in what you're experiencing. But they can also mean being stigmatised by others or feeling as if you are stuck this way for good. Diagnosis can also be more or less useful for different people at different times, and doesn't have to be the way you see yourself forever.

3 – Drug treatments and the biopsychosocial approach

People often link diagnosis and medication. It can feel like either you have an illness, you take drugs and therefore it is not your fault that you are struggling, or you don't have an illness, you don't take drugs and therefore it is your fault and you should 'pull your socks up'. That's a really unhelpful (but sadly common) way of looking at it. We become overwhelmed by fear and sadness for all kinds of complex reasons involving our bodies, our background, things going on in our lives, and the world we live in. Drugs can certainly help some people at some times, but taking them doesn't mean you can't do anything for yourself as well. And deciding that you don't want to take drugs doesn't mean you are struggling any less or don't need support.

Interestingly the one thing that everybody we interviewed for this module agreed on (including celebrities like Trisha Godard and Stephen Fry) was that some form of physical activity had helped them immensely. It can be really hard to do when you're feeling bad, but well worth keeping in mind just how beneficial it can be.

4 – Psychoanalysis

I'm not a great fan of psychoanalysis myself, but the chapter that Ian Parker wrote on this topic for the book was a real eye-opener about the starting points of the 'talking cure' of counselling. I loved Freud's metaphor that we are like those 'magic slate' toys which kids have.

When things happen to us it is like writing on the front layer of plastic. Then that gets wiped clean, but there are still traces of the writing on the wax behind that will have an impact on whatever we try to draw next (the lines will get a bit broken and distorted). Freud believed in the value of exploring what there is back there on the wax layer which is affecting us now. And I think that is valuable as we often find ourselves responding to current events in ways that are hugely influenced by what has happened in the past. Making sense of that can help it to feel more manageable and understandable.

5 – Humanistic counselling

A key concept here is empathy. Can we cultivate empathy for ourselves and for other people? Carl Rogers proposed a challenge where each time you speak – in an argument or discussion – you first have to restate the ideas and feelings of the previous speaker accurately and to their satisfaction, before you get to have your say. This might seem a long way from fear and sadness, but many authors are now seeing compassion as centrally important in these areas. If we can learn to be more understanding and kind in our interactions with others we end up feeling less alienated from them, and it also helps us to recognise that it makes sense when we struggle as well, and that we also deserve kindness. When people are feeling really distressed one of the best things they can do is just to make sure that they do one kind thing for themselves every day. It helps to remind them that they are as worthy of kindness as everyone else.

6 – Existential counselling

Existential counselling challenges our common idea that there are good emotions (joy, pride, happiness, etc.) and bad emotions (fear, sadness, anger, etc.) Rather it sees all emotions as important parts of human existence. When we have to make choices we often experience deep anxiety but that is part of embracing our freedom and really living. Similarly there are inevitably points when it all feels too much and we give up and retreat from the world. Existential therapist Emmy Van Deurzen suggests that emotions are on a kind of compass, from happiness (North) through anger (East), down to sadness (South), and back up through hope (West) to happiness again. We move endlessly around that circle – like it or not – so it is worth understanding all those states, and what we get from them as well as what is difficult about them, rather than trying hard to avoid some of them which means we might well get stuck in one place.

7 – Cognitive-behavioural therapy (CBT)

When we find something frightening or depressing we tend to avoid it, but often that leads to it becoming more scary or saddening rather than less so, and we can then become quite paralysed. Our world narrows as more and more things seem difficult. A very basic CBT idea would be to gradually approach the things that scare us rather than avoiding them (starting small and working our way up). Another useful CBT technique is to pay attention to the little negative thoughts we have throughout the day – like an ongoing commentary – maybe noting them down as we are aware of them and challenging each of them. Is it really realistic? What alternative explanations are there? Is it useful? How might I think about this differently?

8 – Mindfulness

Make a little time every day just to sit somewhere peaceful and breathe. The idea is to be comfortable without distractions and just focus on the sensation of the breath going in and out of your body. You will find that you keep getting carried off on thought processes and distracted by sensations and that is absolutely fine. Just notice that it has happened and bring your attention gently back to the breath. Notice how the thoughts and feelings bubble up and then pass away again eventually if you don't get too stuck to them. The idea in mindfulness is that if we practice doing this regularly we will start to be able to bring the same accepting awareness to whatever is going on in the rest of our lives.

9 – Systemic counselling

The fear and sadness we experience feels like it is inside us and that there is something that we need to do individually to change it. Systemic counselling proposes that actually much fear and sadness is really in between people, in families, relationships, and groups of work colleagues. Think about your own dynamics with people you are close to: do you tend to bounce off each other sometimes in ways that leave one or more of you feeling bad? A nice exercise from systemic counselling is to take some different shaped stones or modelling clay and make a model of your family or group, representing each person as an object, and where they are in relation to each other, by the way you position them. Then you can move it around to show how you would rather it was. This can help you to be aware of how the dynamics in relationships can get stuck and also how they might shift.

10 – Sociocultural issues

Similar to systemic counselling, sociocultural approaches remind us that a great deal of our fear and sadness are about the culture surrounding us and how we are viewed within it. Being marginalised is strongly linked to experiences of distress, and we all occupy multiple sociocultural positions (in relation to race, gender, sexuality, age, class, (dis)ability and so on). It can be useful to reflect on which position you are in on all of these dimensions and what the assumptions are 'out there' about people like you. Do your experiences of fear and sadness relate to those assumptions at all? Are there ways of sharing these with other people who are in a similar position?

11- Context and setting

This chapter was all about counselling over the phone and online. One idea from it was to write about a time when you were feeling particularly sad or frightened – noting down what was going on and how you felt about it – without thinking about it too much. This was really an exercise to think about how people express their emotions online or over email, but actually researchers like Pennebaker have found strong evidence that writing regularly about our feelings is hugely beneficial. Private blogs and personal journals can be a helpful way of doing this.

12 – The therapeutic relationship

This chapter explored how different types of counselling involve different relationships between the client and the counsellor. Many people who decide to go for counselling don't realise how many different types of counselling there are, and how they will all involve very different kinds of relationship and quite different focuses. I wrote a bit about the different counselling approaches here. It is definitely worth thinking about what would work for you and asking counsellors about their qualifications and approaches before committing to it. You should always make sure that they are accredited with one of the major bodies (e.g. BACP, UKCP, BPS). If in doubt, ask.

13 – Outcome research

As well as finding out about what approach might suit you, it is also worth checking out the research that has been done into the kind of counselling you're thinking of going to. Mick Cooper's book on this topic is very accessible if you are interested, and even online searches can give you some idea of whether the kind of counselling you're considering has been found to be helpful for the kinds of issues you have. However...

14 – Process research

...perhaps the main research finding about counselling is that all of the main approaches (covered in this book) are generally about equally effective (with some exceptions like CBT being particularly good for simple phobias). According to the research, a good relationship between client and counsellor is one of the main things which predicts how useful counselling will be. So it is worth shopping around for someone you have a good rapport with. If you are accessing free counselling it is still okay to ask for a different counsellor if you don't feel a good relationship with the one you have.

15 - Conclusions

There is always a risk with going to a counsellor that this will reinforce the idea that many of us already have that there is something wrong with us that needs fixing. Our commercial culture is very good at giving us a sense of anxiety about the things that we lack, and selling us products to relieve this anxiety. In this culture it is all too easy to think that we are not good enough. Therefore it is important to remember that going to get some support or talk through what's happening doesn't mean there is anything inherently wrong with you, and also remembering that counselling is just one of many ways of thinking things through, looking after ourselves, and getting support.