It doesn't make it better if Jo Cox's killer was mentally ill

Yesterday one of our MPs was murdered, as everybody in Britain knows.

Jo Cox, MP, 1974-2016

There's been reports that the presumed murderer had mental health problems. For example, as I write, the Wikipedia page on her murder states "A 52-year-old former psychiatric patient was arrested in connection with Cox's death."

And the tone of a lot of the reaction to that is kind of "well that's ok then." I mean sadness about the loss but relief that it's not terrorism or racism or sectarianism or ...

No.

An oft quoted statistic is that about 25% of the population has a serious mental health problem sometime. So it's ok to paint a quarter of the population as potential murderers?

And just because somebody has had mental health problems, who says their actions yesterday were in any way related to their mental health? The police have - quite rightly - said nothing to indicate that, just as they have not indicated that it was related to the words the murderer supposedly shouted. We simply don't know the motive.

Let's say for a minute that the murder was in some way related to mental health. That is certainly a possibility.

Then what does that say about our society?

It says that we are completely failing to care for the mental health of our population, to the extent that they become murderers. Yes, there could always be an isolated incident where somebody snaps from nowhere, but then the rumour is that this person has had mental health problems. So where was the right drug treatment, the right talking therapy, the right care in the community, or if absolutely necessary the right hospitalisation? It wasn't there, was it?

So if it was mental health related, it doesn't make it better.

It makes it worse.

The sheer terror of self worth

My therapist and I have discovered that a good project for the rest of my life might be to get myself to … well … not love myself, necessarily, but like myself. See my own value. See me like my friends do.

Become a good friend to myself.

The mere concept fills me with terror: when we first talked about it, I started crying just trying to think about it as an abstract idea. Returning to it, I start crying as soon as we skirt near the idea of building up my sense of self-worth.

I have a suggestion to work with, have had for a week and a half now, and probably will carry for quite a bit longer before anything happens: make two lists.
One with all the things that have hurt me. All the hurtful slurs, shouts, names, attacks from my school mates.
One with all the things everyone tells me and show me now. All the things that I am, that are valuable, that make me as loved as I am.

The idea is to build up an alternative narrative, that can take up place in parallel to the one cemented through years and years of school harassment.

…

only

…

I didn't get as far as to writing, but trying to get to sleep tonight, I found myself thinking of document titles for the first list. “Sticks and stones” is a favorite, or reading it out further “Sticks and stones break bones that heal, but words tear me down and leave eternal scars”
And then thinking of things that go into the bad list.
Fat.
Disgusting.
“Micke Toansson” — something vaguely like Mike the Toilet, sounds silly now, hurt incredibly much back then. I still don't like the (incredibly common) nickname “Micke” to this day.
My classmate screaming and running away rather than open a door she had seen me touch.

And as I think about these things, not much happens. I'm comparably euthymic, so these ideas don't spin up a self-hating spiral right now — so not much happens. I'm indifferent to these old, ugly, hurtful words and thoughts.

Then I try to think of the second list. The one about me being good, me being lovable.
Lovable.
The very word brings me to tears. This is a word that terrifies me. I can't understand why, but even trying to think of myself as someone deserving of love sends me crashing down.
I'm surrounded, daily, by evidence to the contrary. People seek me out to spend time with me, to do research with me. I have friends that I love. I have a wonderful wife, whom I love. I love my family.

But the very idea that I could be lovable has me crying in front of the computer. Utterly terrified.

“You carry that bright blue really well — not everyone can do that, you really can.”
«The singer for Shpongle running up to give me a hug before their latest concert»
“We should find a new research project to continue with — I'll bribe you with daily St Louis frozen custard if I have to.”
«My survey article has gotten assigned as introductory reading for people getting into my field of research. At Oxford.»





I write down ways in which I was hurt as a child.
And I feel nothing.
I write down ways in which I am loved right now.
And I am crying onto my keyboard, my head is screaming on the inside.

New Year Blues

I've been low for four months now. Reactive, I think: a new course involving 8-9 hours preparation for every hour delivered, leaving me drained after each session, plus anxiety over persistent unwellness awaiting diagnosis, on top of winter and the general sense of getting older. So it goes...

Anyway, yesterday afternoon one of my undergraduate students came to see me about late coursework. I knew they'd been having difficulties but not the details. Unprompted, they hesitantly told me that they were chronically depressed, so I told them in outline of my 40 years of episodes. They immediately relaxed and said that I was the first grown up who'd ever come out as depressed: at last they had some sense that someone else knew what they were talking about.

I said that I thought depression was just another illness and that acknowledging it helped make it more ordinary and less stigmatising. And I said that because it's an illness, it's not an excuse, it's something that deserves support and compensation.

So, dear reader, why don't I generally tell my colleagues about my condition...?

More and more diagnoses… finally!

 140 characters don't really contain more complex ideas. Neither does 280 characters.

Srsly. "Used to not be a diagnosis" is not an argument against helping people now.

At best, it says we should try not to repeat history.

— michiexile (@michiexile) March 19, 2016

There is this prevalent idea that the rise in mental health and neurodiversity diagnoses is … about coddling kids, about replacing parenting or teaching with pill popping, …
And the more I think about these arguments, the more they anger me.

Media: where arguments enter the memosphere

One of the great classics in this genre is Why French Kids Don't Have ADHD in Psychology Today:

French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress—not in the child's brain but in the child's social context.

This is taken as supporting evidence that instead of being a neurological difference, ADHD is a manifestation of the environment somehow being off, and thus the US medical culture is medicating where they should counsel. Only … it's not actually true. Also in Psychology Today, the psychiatrist Dr Elias Sarkis is interviewed, pointing out that

[The french model] is "at the price of the child experiencing increased anxiety and internalizing problems". For those children who are not able to receive excellent parenting and high structure, ADHD behaviors can be extremely impairing.
In France it is difficult for parents to get an evaluation and treatment for their ADHD child.  It takes 8 months for a child to get an appointment with a specialist, and it can take another 8 months before a child is prescribed medication (Getin, 2011). 

Or, take The Atlantic arguing that ADHD is in fact “normal narcissistic personality traits”.

Facebook: people pick it up and run with it

From a Facebook thread discussing the article from The Atlantic:

Or here, from a Facebook thread discussing ADHD in French kids:


A big theme out there is how Back In The Day, the things now getting diagnosed were just boys being boys; just a fact of life; and the hardy and good ol' people were just sucking it up — just like these spoiled kids should.

And it makes me furious.

So, the diagnosis didn't exist…

…but that does not mean that the diagnosis is wrong.
That does not mean we shouldn't do anything about it.

If anything it means it is a tragedy we haven't picked up on it earlier.

One red thread running through my own journey, through my contacts with mental health professionals, is how the fundamental criterion is Does this cause suffering? The one thing that keeps returning is whether it degrades my quality of life.

If it does, it is worth trying to alleviate.
If it doesn't, there isn't really a problem.

And this is pretty much an invariant. Even if you fit cleanly into diagnostic criteria in the psychiatric diagnostic manuals, it all stands or falls with this fundamental question: is it a problem?
If it is a problem, you should get help — even if you are not easy to diagnose.
If it is not a problem, there's nothing to fix — even if you are a good diagnosis fit.

The fact that it didn't use to be a problem is in no way an argument against help now.
It might be an illustration of how suffering might have been both widespread and repressed in the past, but it is not an argument against doing anything about the problem now.

But… but… overdiagnosis! overprescription!

Sure, these things might be overdiagnosed.
Treatment through medication and medication only might be way too common.

It still doesn't mean diagnosis and treatment are bad ideas.
We need more funding, better health care, so that even more labor intensive treatments are an option.
We need more research, so we can get better at recognizing and distinguishing possible issues.

What we really, really, really, don't need is shaming and repression of the problems that do exist. That leads pretty straight to more suffering.

Besides, “more diagnoses” is far from the same thing as “over-diagnosed”.
Why do we see more ADHD and autism diagnoses? More depression and anxiety diagnoses? How about:

1. Better diagnostic criteria, research advances, so we can tell what's going on better than we used to.
2. (Slowly) decreasing stigma, so more people even try to seek help instead of just sucking it up and suffering on their own.
3. More diagnosed adults of hereditary issues that have been viewed as childhood issues, like ADHD, leading parents to consider it as a possibility for their children, and allowing them to be diagnosed.

By all means, it might have been that people weren't diagnosed depressed, ADHD, autistic, bipolar, anxious, phobic, … when you were a kid.

It is a tragedy that they weren't. And it is not a reason not to diagnose and help today.

I Think You'll Find It's More Complicated Than That

This is another guest post by Dorothy Donald.

The old CBT-vs-psychotherapy argument will, I suspect, never die. Particularly not while people think that when you go to see someone about your depression, you will either get one kind of therapy or the other. That you can either talk about how your thoughts operate day-to-day right now, or the events of your childhood.

Would you rather learn some new mental habits, or understand yourself? Do you want your therapy to be practical, or empathic? Formula-driven or intuitive? Quick and surface-level, or slow slow slow… and life-changing? Do you want it to work, or feel good? Do you want to be fixed, or cared about? Do you want your therapist to be your coach, or your friend?

Funnily enough, most of the therapists I’ve worked with  [*] have drawn on a veritable pick’n’mix of approaches. (It’s almost as if the dichotomous view of therapy is bullshit or something.)

Neil is a CBT counsellor. We ‘do’ CBT. CBT is what I wanted.

And there we were, on Friday, talking about my mother (we are not going there today) and shame (no no no). He invited me to take a moment to be with my emotions and describe how they felt in my body (it felt as if my throat had developed a will of its own and was closing itself up in a bid to choke me to death, in case you’re wondering). In short, it was not flow-chart thoughts-by-numbers control-your-mental-bad-habits training that ignores underlying causes in favour of thinking happy thoughts. This was about making peace with the past events that had been motivating me to do damaging things to myself for years. It was difficult. I cried buckets. I was exhausted afterwards. I have a new perspective on something that happened a long time ago. And, yes, I feel better.

Which I guess is a long way of saying: If you want to avoid talking about your mother, seeking out a CBT practitioner instead of a psychoanalyst is a lousy strategy.

---

[*] I can’t remember how many there have been over the years. Maybe eight or ten? This is a topic for another post. Maybe next week.

Me And My Brain: A Play In Three Acts

This is another guest post by Dorothy Donald.

Act One

Scene - A woman’s bedroom

BRAIN: Hey, Dorothy.

DOROTHY: …

BRAIN: Dorothy. Doooooooorothyyyyyyyy. DOROTHY!

DOROTHY: Wh’?

BRAIN: I’ve made a list of all the things you’ve done wrong recently and I would like to go over it with you in detail.

DOROTHY: What?

BRAIN: I’ve made a list. Of all the things you’ve done wrong recently. And I would like to go over it with you. In detail.

DOROTHY: It’s 4am!

BRAIN: You didn’t look busy.

DOROTHY: I was sleeping!

BRAIN: Yeah. So here’s my list. One…

Act Two

Scene - An office

DOROTHY: Hey, Brain?

BRAIN: …

DOROTHY: Brain?

BRAIN: …

DOROTHY:  BRAIN!

BRAIN: Um. Yeah. So, your query is, like, in a queue or something.

DOROTHY: What? I need you!

BRAIN: Would you like to hear the same few bars of ‘Ashes to Ashes’ over and over?

DOROTHY: No. I want you to help me. I want you to help me to not screw up. What is this? Are you angry with me because I didn’t like your 4am shit-list?

BRAIN: I am not available at this time. Please try again later.

Act Three

Scene - A woman’s bedroom

BRAIN: You didn’t do much today, did you?

Bug report — context and analytic framework

Severity: Critical

Description: My mood suddenly crashes.

Steps to reproduce: I have absolutely no clue.
Well, that's not entirely true. Through the decades I have been looking for workarounds to this problem some patterns have emerged. It's much more likely to show up if I'm hungry. If I'm tired, or haven't slept well. If I run into frustrations. If I'm picked on, or people poke my insecurities too hard.

So those are (uncomfortable) steps to reproduce I guess?

Actual results: I break down crying, or shout at people, or tense up hard trying not to break stuff around me, or hit inanimate objects until my hand aches, or run away from wherever it is I am right now, or possibly I just go really really quiet and stop interacting with anyone or anything.

Expected results: Not crying over relatively insignificant stimuli. Having a causal path leading up to my emotional reactions. Scale my emotional reactions.

Report log:
2000: Original filing of this behavior as abnormal and requiring support attention. Susanne V
2002: Tagged bipolar mixed state, therapy and lamotrigin stabilized the system, and bug was closed. Spånga youth psychiatric team.
2011: Bug reopened. Problem has existed for many years already, time to do something about it already. Me.
2012: Accepted for work. Edinburgh psychiatry, Scotland.
2012: Dropped due to platform change. Edinburgh psychiatry.
2013: Accepted for work. Liljeholmen psychiatry, Sweden.
2013: Re-tagged mild depression with anxiety. Added SSRI. Liljeholmen psychiatry.
2013: Added Bupropion to fix the additional problems induced by the fix. Liljeholmen psychiatry.
2013: Query about ADHD from me. Response: Irrelevant — you finished school, didn't you? Liljeholmen psychiatry.
2014: Removed Liljeholmen psychiatry from the ticket. Do not assign again. Me.
2014: Accepted for work. Huddinge hospital, Sweden.
2014: Re-tagged bipolar not otherwise specified. Removed SSRI. Huddinge hospital.
2015: Added lamotrigin. Added bupropion. Ran CBT group therapy for bipolar disorder maintenance. Increased lamotrigin. Added SSRI. Removed SSRI. Increased bupropion. Huddinge hospital.
2015: Re-opened ADHD as a possible direction. Me.
2015: Ticket sent to ADHD experts for evaluation. Huddinge hospital.




I find thinking about bug reports instructive when trying to work with my own mental health.
The observed bug is not that difficult to describe: I have less control over my emotions than I should have. I cry over things, I break over things, and it is causing me problems in my daily life.

Far harder is debugging and fixing the problem. Far far harder.
This is no surprise to anyone who has ever worked on software maintenance.
It is harder than in software however — debugging the brain works on hardware nobody understands, software nobody understands, crude debugging tools (whaddayamean inspect current state? good luck with that one!), and crude ways to introduce fixes (let's flood the brain with this signal substance — and see what happens!). The thing you're trying to diagnose changes as you try to diagnose it, and many possible explanations overlap quite a lot in expression, but far less in treatment recommendations.

So for me at least, building a context is a hugely important part of a diagnostic process. Sure, medication, especially if it does Good Things. But if I can understand what the hell is going on in my brain, and re-label my mood swings into something that triggers a bit less personal guilt, that'd probably help me stabilize.



So far, the context I have had is of an affective disorder. It's emotional dysregulation, so let's label it as a disorder of emotional regulation. This means depression, or bipolar, or something similar. I've never fit very well into this box: both mixed state and not otherwise specified are diagnosis-speak for huh, that's weird...
Whacking me with affective medication has worked sometimes, for a bit, or at least changed the flavor of my problems. Sure, I don't suddenly crash out — that ever-present apathy and growing frustration with no longer having any research drive isn't a problem? right?

And if it is bipolar, it means that the way I handle my disorder is by medicating to stabilize, and then doing behavioral adaptations: when I notice my mood going in one direction, pull out concrete actions that pull it in another direction. when I notice my thoughts getting stuck on one thing or one interpretation, seek out alternative interpretations and prepare ways to dislodge myself from when I get stuck on something.
But since I don't fit the box well, these remedies have been somewhat underwhelming so far.

On the other hand, if my problems at their roots are neuropsychiatric: ADHD or autism, then there is a completely different interpretation to my reactions. Maybe I start crying not because I have an anxiety attack (some things fit, not all), not because I am in a depressed episode (a few things fit, most don't), not because I am in a dysphoric hypomania (seldom really seems to fit), but because I have sensory overload? or because I have built up massive guilt complexes from always feeling like I am performing under my full potential? or because I am Just Not Wired for handling frustration?

These last few months I have started reading up on ADHD, and I have started watching my behavior with somewhat different goggles. What are my sensory inputs right around when I crash out? was there a reason I might be exhausted when I take a nose-dive? was there some kind of frustration around? maybe even changes of plans that I wasn't expecting?




One of the big things I am seeking when I am seeking out an ADHD evaluation right now is a new set of possible treatment options.
Another one is to gain tools to push back against my self-loathing. If sensory overload is a thing for me, and inability to handle frustration gracefully, and decreased ability to handle changes in plans, then there are concrete things there I could manage. And maybe tracking my sensory load is not only easier, but going to be more effective than trying to Increase My Sensory Impressions when I am feeling sad and overwhelmed?
And maybe, recognizing that many people with ADHD have their emotional gain turned to 11 means I can stop freaking out when I suddenly get a wash of emotion. Sure, my emotions are stronger than everybody else's — but maybe I can stop at the point of feeling a strong emotion, instead of spiraling down into a panic rat race of despair over having the emotional reaction in the first place.
Maybe, just maybe, I can watch my emotions show up, let them take some place, and then let them go. That seems like an amazing thing other people apparently do.
And if I get more emotional control through tracking my sensory load, and by disengaging from uncontrolled stimuli when I'm starting to feel the tension build, rather than after I go to pieces, that'd go a faaaar way to help me work more satisfactorily.

This change of perspective changes absolutely everything.
The symptoms are the same, but the potential fixes are different.
The symptoms are the same, but if it's sensory overload, not lack of emotional control, then I'm not lazy, I'm just incautious.