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On Wednesday this week, I took part in a discussion about how best to treat depression, on BBC Radio Nottingham’s Morning Show.  News was just in of a fourfold increase in prescription medication for depression, compared with 5 years ago. Frances Finn, presenter of the Morning Show, wanted to challenge Dr Ian Campbell and me about these statistics – are people being prescribed medication by their GP almost automatically, after a quick consultation ?  Wouldn’t a talking therapy (counselling) be better than medication which might become a ‘crutch’ that people learn to depend on and struggle to give up ? And maybe some people are labelling themselves ‘depressed’ and seeking help when if they just ‘got a grip’ and got on with life they could overcome it by themselves.

All interesting points….

Dr Campbell explained the medical origins of depression: it can be inherent in the person, a feature of their psychological/physiological make-up, or it can be caused by a specific event- such as relationship breakdown, redundancy or loss of some kind.

Medication can really help the person to be able to function enough – to keep going at work for example, when it is essential (as they might see it) that they do this. And it can also help them feel ready to tackle the cause of the depression, or underlying issues that have been triggered and have now come to the surface. Selective Serotonic Re-uptake Inhibitors (SSRIs) such as Fluoxetine (commonly known as Prozac) and Citalopram work on restoring the level of serotonin in the brain and maintaining adequate levels of this; serotonin seems to encourage a sense of calm and makes feelings of anxiety and distress less acute and raw. 

Although medication is very effective for many people, the ideal would probably be that those who want counselling as well, or prefer to avoid medication and just have counselling could be offered this ; sadly there are indeed long waiting lists eg 6 months, in some locations, despite the investment made by the previous government in the IAPS scheme (Improved Access to Psychological Therapies) which has seen a dramatic increase in numbers of trained counsellors (usually in Cognitive-Behavioural Therapy). It seems this has been more than matched by the numbers of people presenting with depression. Some reports suggest that 1 in 3 of us has or will have an episode of depression at some point in adult life.

Depression has been described as a Black Dog (eg Winston Churchill). The stigma surrounding it is diminishing due to various celebrities ‘coming out’ – Alastair Campbell, Ruby Wax, Stephen Fry and many others. Most people know that it is characterised by a dark negative mood, outburst of anger or general grumpiness, tearfulness, loss of energy and interest in activities that were previously enjoyed, appetite changes, sleep disturbance and a tendency to want to withdraw and isolate oneself.

In Cognitive- Behavioural therapy the emphasis is on identifying ,monitoring and encouraging activities that bring feelings of pleasure rather than effort and also in challenging Negative Automatic Thoughts.  In other therapies, we also work with underlying ongoing problems, often unfinished emotional business from the past, helping people to come to terms with these, accept the situation or take necessary action, and move on.

Depression certainly can be treated with counselling/psychotherapy, and this process can be supported by medication, which I particularly recommend when someone is in such a distressed state that they are unable to focus and engage.

If counselling waiting lists are too long, there are other local (Nottinghamshire) sources of possible support. Some of these agencies and charities may only ask for a small donation towards the cost of their service:

Nottingham counselling Service – 0115 950 1743

Nottingham Womens Counselling Service – 0115 978 2040

New Dawn  (Christian) – 0115 917 0500

Cruse (bereavement and loss) – 0115 924 4404

Relate (couples and relationship issues) – 0115 856 5205/0115 950 7836 /01623 636553

There also agencies which specialise in alcohol/drug related difficulties including depression/anxiety

For emergencies there is also Samaritans 08457 909090

There are some excellent self-help books available:

I Had a Black Dog – Matthew Johnstone

Living with a Black Dog – Ainsley and Matthew Johnstone

Overcoming Depression – Paul Gilbert

Depression The way out of your prison – Dorothy Rowe

Help online includes websites where you can download free leaflets like northumberland  tyne and wear nhs and various cognitive behavioural programmes.

You don’t have to just ‘get a grip’ – but you do need to reach out for support when you may least feel like doing so!

Some people would prefer to avoid medication of any kind and opt for counselling.

On Friday 1st April, I took part in a debate on Radio Nottingham’s Morning Show about the significance of mothers returning to work after baby is born, leaving fathers to do the nurturing.

My guiding text on this is Sue Gerhardt’s ‘Why Love Matters’ which explains how babies’ brains develop through the bonding with the primary caregiver, usually mother. The key to this is the emotional availability of the parent, expressed through caring touch, holding, eye contact and also verbally. The parent provides soothing for the infant, and he/she starts to internalise a model of how to do this, which becomes a template for life.

I do not feel that only the mother can provide this. Indeed if mother experiences severe post-natal depression, which in rare cases can lead to hospitalisation and thus seperation from baby, it is really important that the other parent, or another consistent person fills this gap.

Instinctively I feel that mother and baby are the ideal unit, especially given the researched benefits of breast feeding. However, if necessary, the other parent can offer the conditions vital for healthy emotional development. The key point is that the parent(s) are content in themselves because this seems to be communicated (absorbed) by the baby.

At the beginning of the pre-Christmas week, I thought it might be helpful to reflect on the difficulties some families experience at Christmas time, and suggest some coping strategies. The Morning Show, on BBC Radio Nottingham, with Frances Finn, was the forum for this.

In Western cultures, Christmas is often promoted as a special time for families, when everyone must enjoy time together and have fun. This peaks on Christmas Day itself, which can become a steaming pressure- cooker of expectations: the perfect turkey, complete with all the trimmings served at the right time, in a festive environment, with each individual’s preferences accounted for….. This is often against an alcohol fuelled, noisy background, with over-tired children (and exhausted adults) trying to get their own needs met!  Small wonder that this is also a peak time for episodes of domestic violence, when tensions can boil over into verbal conflict and finally erupt into physical expressions of anger and distress.

The Christmas expectations are only a part of the problem; sometimes the family members assembled together may be present from a sense of duty – perhaps with little in common with each other other than this relationship. Or perhaps there is unfinished business – emotional conflict which is unresolved from the past, with the initially suppressed sense of unfairness and frustration re-ignited by the disinhibiting effect of alcohol…..and alcohol can also upset careful attempts to ‘say the right thing’ and walk on eggshells around known sensitivities of particular individuals….or cause people to misinterpret well-meant remarks and make apologies clumsy at best and futile at worst. 

Another factor in all this is the concept of Self-fulfilling Prophecy. This describes the tendency to anticipate an outcome with such intensity that we actually influence it by our behaviour – even without conscious awareness of doing so. If, for example, we really dread this Christmas being a repeat of a bad experience last year, we may start to ‘awfulise’ and ‘catastrophise’ – and these negative thoughts are expressed non-verbally in our body language and picked up by the people around us, creating a ‘bad (uncomfortable)  atmosphere’ …..which degenerates into awkward silences and abrupt remarks ….and then possibly hurtful comments….and replies…and finally full-on rows, plate throwing and physical assaults.

Violence is usually the final resort of the person whose anger exceeds their capacity to fully verbalise it, and is sometimes a pattern copied from the behaviour of a parent. Typically the person who becomes violent feels threatened by something or someone (past or present), and the circumstances of Christmas, especially the element of alcohol (ironically ‘Chrismas cheer’), enflame this and it is deflected onto an available victim – someone less powerful; or it may be that this victim is a reminder in some way of the original threat, or holds a different kind of power over the abuser – perhaps the power to abandon him or her. 

COPING STRATEGIES

1. Awareness: recogising the potency of Self-fulfilling Prophecy and the effect of carrying a sense of ‘it’s going to be awful, a DISASTER!’ Aim to keep an open mind and treat the situation as a fresh start.

2. Set BOUNDARIES:

– Limit the time you spend with family members, in an enclosed space. Try to mix things up, spend some time outdoors if possible, make full use of space.

– Prepare ‘safe subjects’ for general discussion; avoid the 3 Taboos of Sex, Religion and Politics

– Focus on ‘now’ and not ‘the past’ . Leave Unfinished Business outside and don’t try to get to the bottom of issues/make amends/ repair broken bridges  -about things that have gone wrong in the past.

3. Avoid or limit alcohol; as a rough guide, the more strongly you think ‘I need a drink’ the less advisable it is to have one…..

4.Ground and soothe yourself: take Time Out. You absolutely can absent yourself for a few minutes to do some soothing rhythmic breathing. (Inhale fully for 3 seconds, inflating your abdomen with air (fresh air if possible) – the hold for 3 seconds – and breathe out with a long exhale, 3 seconds).  Repeat to yourself a calming phrase such as ‘It’s ok, it’s just one day, all over soon…’

5. And finally, remember, Christmas Day is just one day of 24 hours (and some of those you will be asleep) made up of 60 minutes in each hour. You can get through this ….and you may even enjoy it.!!    

Early September found me once again in the BBC Radio Nottingham studio, on the Morning Show with Fran. Our subject was the effect of the changing seasons on people who experience the August Bank Holiday as marking the end of the summer, a return to work and the beginning of the long, dark haul towards Christmas…..

Many people enjoy autumn, with its misty mornings, crisp sunshine and beautiful foliage. However, many more feel their hearts sink as they contemplate the prospect of chilly mornings and shorter daylight hours, with little or no time off from work until the Christmas break. The roads get busier as the autumn term starts; summer holidays become a fading memory, and there may seem to be little to look forward to.

This time of year brings fears for some people of the onset of Seasonal Affective Disorder (SAD), a form of depression experienced by approximately 2% of the population, with a further 10% who present with just some of the symptoms (eg lethargy, increased appetite and anxiety) and may feel they have the ‘Winter Blues’. One theory is that reduced sunlight impacts the processing of serotonin in the brain (serotonin is a neurotransmitter associated with wellbeing and efficient transmission of messages through the brain); it is also thought that light stimulates the hypothalamus in the brain, which is responsible for mood, sleep and appetite and is sensitive to melatonin levels (melatonin is a hormone produced by the pineal gland when it gets dark to help us sleep) – and people suffering with SAD may produce too much melatonin in the winter months. They consequently almost want to hibernate, feeling constantly tired, tearful, moody, stressed and forgetful, having difficulty concentrating, poor quality sleep, appetite changes and loss of pleasure in favourite activities.

People who are already feeling depressed, stressed or anxious may also notice an increase in symptoms at this time of year.

However, some people who would not normally consider themselves to be affected by the changing of the seasons, also experience particular feelings of dread as they contemplate returning to work after the (long) holidays.

There may be a number of reasons for this:

1. Performance Anxiety: often associated with people who have ‘full-on’ jobs or are high-flying/ambitious, but not exclusively so. Tendencies include a mad rush to get everything sorted before going on holiday – last minute phone calls from the airport to work to check on minutiae. Finally can’t contact the office any more…and RELAX ! (and then they may fall ill with flu-like symptoms – almost as if the ‘flu’ had been biding its time, waiting for the person to slow down/stop!). Intermittent worries whilst on holiday may include thoughts like ‘hope things are going to plan/ x has done what he should /they remember to do x  etc’ . When it is time to return to work the person with performance anxiety may feel sick, tummy churning, sleep poorly etc. Typical thoughts include: ‘I bet it has all gone wrong and they are blaming me/ what didn’t I remember to tell them?/ what if xxx happened?/ what will they be thinking of me?/ they will have discovered that x is so good at replacing me that they won’t need me any more…’ Lots of self-blame and self-criticism (insecurity)

2. Unresolved stressful work-place issues: typically, relationship difficulties with manager or close colleagues (= affecting self-worth/sense of unfairness); boredom or hate the job (= very stressful); too much to do/too little time to do the job properly (= sense of personal inadequacy, frustration, unfairness); communication problems at work (=frustration); redundancy worries (= helplessness). On holiday the person may be thinking/saying ‘I wish this could go on forever/ I could live here/ don’t want this holiday to end’ and may start to become sleep-disturbed, moody and become especially irritable on the morning of the flight home, for example. The juxtaposition or contrast with the holiday experience in which all the work issues were put on hold to the back of memory, can produce a sense of being overwhelmed ‘can’t go back/face this again’ and can sometimes result in the person putting off the return due to ‘sickness’ in which there are real physiological symptoms (as well as psychological unfinished business).

Working with the Dread

1. SAD and associated Winter Blues – light-boxes and/or anti-depressants to counter the chemical effects on the brain of melatonin surfeit and serotonin inefficiency; Cognitive-Behavioural therapy to explain the links between thoughts/behaviours/feelings and physiology in depression and structure a programme of activities and negative thought -challenging;self-help by seeking maximum natural daylight, exercise, balanced diet especially vitamins C and D, avoiding stress and seeking support from others!

2. Perfomance Anxiety – possibly incorporating self-help techniques auch as negative thought-challenging, but in addition developing a self-soothing capacity eg a gentler, warmer, wiser ‘other’ self, an imge which acknowledges the hidden key fears (rejection, exclusion, shaming) and gently and firmly challenges them, putting them in perspective as magnified, generalised and the product of fear, terror, even, and belonging in a past time, not relevant now, offering a more positive, realistic picture of what awaits at work. One to one therapy ( a Compassion-focused approach, or Humanistic/Person-centred approach) can help with this.

3. Unresolved Stressful work-place issues – most of these hinge on the person’s sense of powerlessness. The fear of change has created procrastination and avoidance of taking control of the situation. Books such as ‘Who Moved My Cheese?’ (Spencer Johnson 1998) shed more light on the strategies we can use to sabotage ourselves and keep ourselves stuck. Surrendering our power to others and tolerating the intolerable arise typically from impaired self-valuing, often itself the product of past deficits in key relationships, eg parenting/abusive partnerships. Developing the courage to change what we can – which is potentially lots – also requires the capacity to self-soothe and self-encourage. Again therapy can provide the environment we need to develop this capacity.

On BBC Radio Nottingham’s Morning Show with Frances Finn last week, our hot topic was Redundancy,  after the recent announcement by Notts County Council, that 3000 jobs are to go.

As this happened to me in 2001, after 25 years in senior management with C & A, I have both personal and professional experience of the many different individual responses to this situation.  For me, it was a relief after months of anxiety about ‘what if…?’  and after adjusting to the shock of it actually happening, I began to see it as a chance to do something more meaningful, and re-train.

Whilst this is one typical reaction, some of the people around me had different predominant emotions:

• Anger – how dare they do this to me/us after all I the years I/we have given this organisation……  
• Fear – What is going to happen to me? I’ll never get a job as good as this (at my age/with my skill-set/ working round my other commitments)  
• Bargaining – maybe if business picks up they will change their mind and then it will all be ok again
• Denial – well the end date is 6 months away, that’s ages yet…..
• Sadness – it feels like the end of an era, I am going to miss everyone/thing so much, it will be awful

These emotions, are of course, typically associated with loss and the grieving process. And there are many similarities; we suffer most in bereavement, for example, when we have a high emotional investment in the person who has died, (eg a child, or partner).  Some people value themselves by the job they do, and the professional or social status they perceive they have from it – eg a manager, a teacher, nurse etc.  This means that a partcularly significant part of the person’s identify is lost if redundancy strikes  (or other job loss, eg contract termination due to disciplinary action). Confidence and self-esteem can be thus be severely damaged.

Bereavement is also harder to bear at certain times in our lives, eg when we are vulnerable due to loneliness/isolation or past distress, especially loss.  Likewise, redundancy is tougher to face when an individual is singled out as ‘not needed’, which can feel like rejection, and may trigger recall of other such experiences; whereas when hundreds of others in the same company/organisation are made redundant at the same time, there is a sense of inclusion, a shared problem.

Generally, our reaction to the experience of redundancy mirrors our stance on change and our attitude to control. We are all on a continuum of internal versus external locus of control:  some people at one extreme end of this continuum are extremely prone to take responsibility for everything and anything and try to control their environment, whilst others at the opposite end take the view that ‘what will be, will be’ and abdicate all responsibility. Most of us are in the middle zone, with a controlling attitude to some aspects of our lives and a more relaxed attitude to others. It is a very human tendency to prefer order to chaos, and certainty to unpredictability.  Clearly, those need to control is not extreme are likely to feel  less threatened by change, and vice versa. And of course, those who have a ‘whatever’ attitude to control may well put the experience down to bad luck and just wait for things to improve somehow – not helpful either!

I find the book Who Moved My Cheese by Spencer Johnson (1998) really useful as an illustration of helpful versus self-sabotaging attitudes to change and uncertainty, in my work with clients and students.

The ‘cheese’ in this witty little parable represents something important to you in your life – your career, marriage, professional standing, etc. The point is that nothing stays the same forever – it is essential to keep working at it – as the French philosopher and writer, Voltaire said: ‘il faut cultiver notre jardin’  (we must keep working on our ‘gardens’ / lives)  because CHANGE IS UNAVOIDABLE AND NATURAL – so anticipating it, having a Plan B (eg with regard to job prospects) is really healthy, just as not taking the special people in our lives for granted – and looking for ways to keep the relationship strong – is essential.

When things change, as they must, being willing to let go and move on makes things easier for us. It may help to think about what really matters; for example, if you listed the 5 things that matter most in your life, and had to decide what to jettison first from your hot air balloon that needed to lose weight or crash – how quickly would you throw out work? On a typical scale of health, partner, family, friends etc…… work, important as it may be, could well turn out to be not that high up the list; it pays the bills, it makes life easier, but at healthy aim is to work to live, rather than to live to work? 

Focus the mind by imagining your headstone: ‘he/she was a …… who was ….. and will be …..’

Those missing words are unlikely to descibe your career, possessions and financial status, but rather the relationships of warmth that you had and the feelings of those you have left behind.

The sooner you face forwards, letting go of the past, the sooner you will be able to embrace the future and move on. Sometimes, the sense of failure can be so strong that it anchors us to the past and seems to transfix us; it can be helpful to envisage it as a THING/PROBLEM, place it on the ground and take a couple of big steps back from it, then slowly walk right round it, in a big circle, preferably with someone whose of objective opinion you know and trust. You will see that from each part of the circle you get a different perspective on this ‘failure thing/problem’.

As always, going with the flow rather than fighting the tide, makes the ‘swimming’ easier….so in the words of Spencer Johnson ‘MOVE WITH THE CHEESE’ and enjoy the ride, the challenge and opportunity! and get ready for new changes in the future….

When faced with redundancy, there are many practical steps that need to be taken, eg with regard to finances, job applications etc. It is not part of my role to advise on those; however, with acceptance and understanding of why you may feel the way you do, and a positive mind set to change, I believe the experience can be much easier.