Sometimes it’s OK not to feel OK: and the pain may be real, but so is the hope

Like many people, my thoughts have been with all those affected by last Mondays arena attack. And there were many people. Those who lost friends; families who lost children, wives and husbands, and the many victims who were injured, some critically. I thought about the first responders and all the emergency services, who did a magnificent job right from the start as well rehearsed plans were put into action. I thought about the many ordinary people, men and women who unasked, offered their help on the evening and in the following days. Like me, I suspect that many of these people will need to find ways to deal with the senselessness and horror of what they saw or had to deal with, and I suspect that won’t always be easy.

Shortly after 22.30 last Monday, a lone, cowardly, callous killer, denoted a bomb, killing 22 people and injuring many others as they were leaving a concert at the Manchester Arena. It was a devastating attack that seemed deliberately aimed at an event where most of the audience were children and young people. Why the killer chose to attack so many innocent people is not known. The ongoing police investigation appears to suggest an active terrorist network was involved, and many arrests have been made.

In the days that followed, there were many more people who wanted, or perhaps needed to show and share their hurt, anger and their pain. Yet there were also those who wanted to stand tall, stand together in defiance, and solidarity. Vigils have been held across many parts of Greater Manchester and in othe parts of the UK. Very quickly, St Anne's Square, a short distance from the Manchester Arena, became the focal point for people to come and pay their respects, to leave flowers and messages, pray, to just be there in an acknowledgement of grief, and to share the humanity of others suffering.

Resilience was a word I heard mentioned a great deal last week. I was pleased that emotional and psychological support was offered, and not just to those families and communities directly affected by the attack, but also to the many professionals who were involved in providing care in the immediate hours following the attack. They may be professionals who demonstrated their knowledge and skills so expertly when called upon to do so, but they are also humans as well. Like the rest of us, they are parents, brother, sisters, and partners.  It would be impossible to think that in the safety and quietness of their own homes many people didn’t reflect on what they had seen, heard, or even what they knew might be yet to come for so many other people. 

I was so pleased to see the words ‘it’s OK not to feel OK’ used to good effect in offering mental health care and support. Likewise there was great advice over how we could reassure and discuss the attack with our children, to help allay their fears and anxieties. And reassuringly there was much evidence of how people across all of Manchester and beyond wanted to show how diverse communities can come together in adversity and build upon strong community relationships to create a better future for all.  Last week was one of devastation and pain for so many people. Many people across the Manchester communities and beyond will have been deeply affected by what happened. However, whilst the pain is real, so is the hope. #WeStandTogetherManchester  

The Postman Rang Twice on Talcott Parsons Door

Many readers of this blog might not remember the famous film noir – The Postman Always Rings Twice. Released in 1946, it was based upon the 1934 novel of the same name written by James Cain. The film has a classic plot line - boy (Frank) meets girl (Cora), girl is already married, so they kill her husband. Although they go to court, neither are convicted of the murder due to some double crossing deal making and lack of evidence. Shortly after Cora is accidently killed in a car crash, and Frank who was driving the car, is wrongly convicted of her murder and given the death sentence. It’s a great film and if you haven’t seen it, look out the original not the 1981 remake version.

The ‘postman’ in the film’s title is a metaphor (although not a very good one). It gets explained at the end of the film by Frank who posits that when we are expecting to receive a letter or a parcel, it is of no concern if at first you don’t hear the postman ring the doorbell as the postman will always ring twice. The second ring will invariably be heard. In the story, Frank and Cora escaped punishment for the murder of her husband but with Cora dead from the RTA and Frank facing the death penalty, the postman has indeed rung a second time for them both.  

Now I guess, dear reader you might be wondering where this is going. Let me try and explain. Last Sunday I shared the struggles I was having with depression, a struggle that had slowly crept up on me. I usually let the world know I have posted my blog, and last week I didn’t, instead I just quietly posted it on-line. I was overwhelmed by the number of people, friends, and colleagues and even from those I don’t know, who took the time to send messages of support and kind wishes. I was buoyed up. I enjoyed a day of family fun with a house full of children and grandchildren celebrating my birthday.

Although I knew that acknowledging my mental health struggles was just the first step, and it felt like an important step, actually I hadn’t heard the postman ring for the first time. Last Monday was my birthday and arriving at work, I realised that the family celebrations the day before hadn’t changed anything. For the first couple of hours I sat in my office feeling absolutely desolate and effectively doing nothing. In the silence, my twitter notification pinged and it was my friend June asking how I was doing. Out poured a long rambling response from me that probably sounded very incoherent.

However, she came back with warm and wise words for me to consider. Speak with my GP, find some time and space to recalibrate, sleep, rest, and gently exercise, go up to Scotland. Just lose work. All of which was sound advice and all of which seemed pretty impossible to do. I was trapped in a classic case of Parsonion role conflict – professional role versus sick role. As people started to arrive, I went back into professional role, and the day turned into a series of meetings, present giving and good wishes being exchanged. I got through the day, but it was hard - and the emotional drain took the edge of my evenings birthday celebration with W.

The following day had a similar start to it and by the time I had got to lunchtime I knew the road to recovery was going to be difficult if I didn’t change anything. The postman had rung twice. It was time to step off the Merry-go-round. And so I reported sick on Wednesday and agreed with my GP some time off work, and started a course of anti-depressants. Of course the classical Parsonion sick role has evolved these days. Elements of the concept around entitlements and obligations remain, but the rise in the numbers of people living with long term conditions (currently 15 million people and rising in England) has challenged our understanding of the sick role. 

In mental health care, the concept of recovery, also flips the relationship from the doctor being the expert to the patient being the expert and co-creator of what interventions might be the most helpful to ensure a return to a place of well-being.  This is an approach that has given me a pathway to follow. And please don’t worry dear reader, whilst I love writing my blog, and have written one every Sunday since 2nd August 2009, I do not intend for it to become a ‘diary of the depressed professor’ – so I shall continue to try and write a new blog each Sunday, and all I ask of you the reader is please bear with me as I try and regain my inner equilibrium and blog persona. It will return.

A growing awareness of mental health issues

I think of my Father as being a wise man. Of course this may well only be true in the Cartesian sense of ‘I think, therefore I am’. He is however practiced in the use of Socratic Questioning something he’s helpfully challenged me with all my life. Socrates believed that questioning was the only real form of effective teaching. He believed that it could help students to explore what it is they know and not know and that the space created (new knowledge) was the place of greatest learning. I and my long-time collaborator and wonderful friend Sue, developed a slight twist on these ideas in our own thinking and writing. We believe that the space between knowledge and knowing (that is) not knowing, is where the greatest learning can occur.

Socratic questioning allows all the information available in a current situation to be gathered, and connected to prior knowledge in a thoughtful way so as to create new understandings. As I have told my students many times, I can teach you the signs and symptoms of a heart attack, and I can provide you with the knowledge of how to treat that condition. What I can’t teach you is how the individual might be experiencing that heart attack – that is the ‘not knowing’ and an opportunity to create new knowledge. As my friend Jane and lover of all things French might say – ‘je doute, donc je pense, donc je suis’– ‘I doubt, therefore I think, therefore I am’ – and in the example above, I am a person-centred nurse.

Interestingly in mental health care, Socratic questioning underpins some therapies – mainly in therapies such a Cognitive Behavioural Therapy (CBT). It is enables a reframing of negative thought cycles. Our thinking about a certain situation will affect the way we feel, both physically and emotionally and how we act in response. Unlike other talking therapies, CBT deals with the ‘here and now’ and doesn't  start by exploring the past. The evidence shows that CBT is very effective in treating anxiety and depression.  

Last week was Mental Health Awareness Week, an annual event that has been celebrated since 1990. Every year a different theme is used to explore mental health care and how people might experience mental health problems. This year the focus wasn’t so much on surviving mental health problems as in finding ways in which we can thrive and enjoy good mental health. On social media, my #earlyrisersclub friend (and Head of Public Health Commissioning at NHS England) Kenny, shone like a beacon in raising awareness and promoting approaches we can consider in order to achieve and maintain good mental health.

It would seem that in the UK very few of us report living with high levels of good mental health. Indeed it is estimated that 1 in 6 people will have experienced a common mental health problem last week. And if you are female; a young adult; living on a low income; living alone (or in a large household), the risks of experiencing mental health problems are significantly higher than for other folk. Poor mental health is an international issue. Mental health problems are one of the major causes of disability worldwide, with the predominant mental health problems being depression, anxiety, schizophrenia and bipolar disorders. The awareness raising information showed that there is much we can do to keep ourselves mentally healthy, increase our wellbeing and when our resilience is too challenged, there are many interventions available to help recovery. These range from medication through to talking therapies such a CBT. Hopefully, you will also now know some of this information. 

As a Professor of mental health care for the last 11 years, and a mental health nurse lecturer and practitioner before that for some 30 years, I was also aware of these facts, but I was quiet during Mental Health Awareness Week, and I am sorry that I was. I know from experience, that my voice can make a difference. And yet even with all my knowledge and experience it has taken a while to know something wasn’t quite right in my world. Over the past 6 months my usual energy has melted away, I’ve lost interest in many of things I’ve enjoyed doing, my mood has often felt low, I've become easily irritated, had no appetite and sleep was an elusive memory. It was becoming increasingly difficult to concentrate and my self-esteem was at an all-time low. But I've kept on smiling.

So last week when the tears that had so often fallen silently during the darkness of night started to fall in the sunshine of the day, I realised I had to stop my ‘watchful waiting’ and do something about the black cloak of depression that was wrapped so tightly around me. For me the first step was to acknowledge that there was something wrong. I have some good friends and I have told them, I’m telling you dear reader, and I will talk to my GP next week. And with W, my lovely wife, best friend, and tear catcher alongside, I am sure it will be easier now to find my pathway back to thriving rather than simply surviving. 

Health Warning; baby boomers are still tripping on alcohol rather than drugs

Sometime ago I had agreed to open up a session at the North West Major Trauma Symposium. This was being run by the University and the organiser had persuaded me that I should attend as I could showcase the University’s work around translational medicine, collaboration and partnership opportunities. The conference focus was on major physical trauma caused by disease and accident. Whilst such trauma can result in mental health issues (anxiety and long term depression being the most prevalent) it wasn’t the kind of trauma I was familiar with.

It also seemed to be aimed at medical folk, and 'skill thrill' surgeons in particular. The thought of spending a long morning in this company did not fill me with joy. How wrong could I have been! It was brilliant. Humour, science, innovation, humanity, challenge and commitment were the narrative elements that shaped the presentations and discussions. Surprisingly, I knew 3 of the speakers from my previous roles in the NHS and within Universities.

Two former colleagues were also mentioned by speakers. One was Professor Ged Byrne, a surgeon and Director of Quality at Health Education England. His name came up in a session about trauma services in Ethiopia. Ged has long been involved in developing clinical learning placements for UK health professionals in resource scarce countries, particularly those in Africa. I was privileged to spend a very interesting and humbling 10 days with him in Uganda, and it was an experience I will never forget.

The other name mentioned was Professor Dame Sue Bailey, who as well as being a child and adolescent consultant psychiatrist, is also the current Chair of the Academy of Medical Royal Colleges. 35 years ago we worked together in establishing the only NHS Forensic Child and Adolescent service in the UK. It was a service aimed at making a difference to the lives of troubled and troubling children, and I have very fond memories of those pioneering times. However at last Thursdays conference it was older people that provided the greatest focus.

Professor Leela Biant, Academic Head of the Department of Trauma and Orthopaedic Surgery at University of Manchester, and a practicing consultant orthopaedic surgeon presented a paper that looked at trauma services in 2020. Surprisingly, trauma is a growing and serious public health problem. In the UK over 17,000 deaths a year are the direct result of trauma injuries; there are 720,000 admissions to hospital and over 6 million visits to A&E departments annually. Equally surprisingly was the fact that it’s not 19 year old boys driving cars at high speed and then crashing them that accounted for these figures, but older people tripping over a rug or something similar (a low energy, low height fall) and sustaining major trauma injuries as a result.

It is the case that today trauma still remains the largest cause death for people aged under 25, and worldwide, young men aged up to 25 are 3 times more likely to die as a consequence of a road traffic accident than young women. However, it is those over 60 and particular 75 years of age that have the highest incidence of trauma. Its projected there will be 101,000 hip fractures a year by 2020. It is the most common trauma injury associated with this group. It is also likely that most will be female, with nearly 50% of the falls occurring to people living in community based residential settings like nursing homes. Older people are nearly twice as likely to die from their trauma as younger people with equivalent injuries, and some 20% will die within 4 months after the trauma occurred.

Now you may be wondering why I am sharing this information with you. Well in my mind there are a couple of connections that can be made – one was to the story published last week that in the UK, nearly half the population are giving up drinking alcohol. The good news was this group were in the main those aged under 45 so reducing long term harmful alcohol related health problems. The bad news is that alcohol related hospital admissions have risen by 64% over the last decade. There were some 1.1 million alcohol related admissions last year, predominately for liver and heart disease and cancers. Trauma related admissions are not included in these figures. It’s the Baby Boomers (those aged between 53-71 in 2017) who are largely responsible for these challenging statistics. Just because they are in their 60s it appears they are not slowing down when it comes to alcohol consumption. Its easy to picture the scenario - too many glasses of red wine, a loose mat, a low fall = major trauma head injury or other severe fracture = and possible death. 

The second reason is that the health promotion has to be more effectively communicated to folk of my age if the health care of this growing group in our population is to be contained and better health well being outcomes achieved. Interestingly, they are a generation that take health issues seriously, they will seek advice and help for a wider range of mental and physical health problems, and will invest in self-improvement – but excessive alcohol consumption remains stubbornly unchanged for many in this group. As someone who is an educator of health care professionals, and responsible for health care service provision, this fact worries me a lot. Something needs to be done if we are going to avoid the growing tsunami of trauma related problems. Suggestions please, on a post card to the usual place…