- Email: [email protected]
Everyday compassion
Insight
the UK National Health Service (NHS), inefficient, expensive overuse of medication, and poor utilisation of natural spaces were tabled. Maughan tells us more: “For the NHS to be able to continue providing high-value health care into the future, sustainable paradigms of health-care delivery need to be created that focus on prevention, patient empowerment, education, and community integration.” To remain financially, socially, and ecologically sustainable, we need to start being proactive in changing the ways we work, Maughan continues. “We need to harness every available resource, if we are to cope with rising expectations and decreasing budgets. This means broadening our understanding about the resource we have available to us and making the best use of peer support groups, online therapy and education, third-sector organisations, and community support structures.” Everyone can make a difference, even if it’s only by deciding to take email referrals instead of printed letters, or cutting down on unnecessary review appointments by prescribing depot injections at the longest reasonable interval. As well as being sustainable in terms of the environment, which the project does with aplomb, they are also sustainable in terms of people. Some service users who currently attend Growing Better Lives are seeking training in peer mentorship, mental health nursing, and social work, creating a virtuous cycle of empowerment and support. “When someone who’s been through it themselves starts to tell you about how they felt, it makes you feel like so much more of a human being. Your internal voice said you’re not right, you’re weird, you’re not normal, but when you hear about someone who’s been through it, has come out the other side and is doing a job like this, it gives you such a sense of wellbeing, that you can get over it and move on”, says Ellaway.
The inspiration felt by service users seems to emanate not least from the three of the five codirectors of Growing Better Lives who have had personal experience of mental illness and contact with local services. Jones has come full circle to complete a PhD and is starting to build an evidence base for the project. The team use mostly qualitative methods and are affiliated with the Centre for Social Futures, a research division of the Institute of Mental Health at the University of Nottingham, Nottingham, UK. In addition to strengthening the evidence base for the services they already offer, the team want to branch out. Among their many ideas is the provisionally named GreenFamilies project, which will aim to get entire family units of people with PD spending time in their healing environment, hopefully preventing the all-toocommon scenario of children being removed from a home. Psychoeducation groups for families and friends of people who attend the existing project seem to be a well supported endeavour among the team too. When asked what other services could do to emulate their ethos, Haigh offers a suggestion that he feels might be surprising: “Never see people by themselves. Always see them in groups, or with more than one member of staff, so you never have a dyadic relationship, so it can all be held in a network of relationships. Relationships have to be the absolute focus of the work, rather than symptoms or medication.” Lomas answers in no less striking a way: “You don’t recover by being boxed in, you recover by branching out, by experiencing different things, by challenging yourself”, which just about sums up Greencare in a sentence.
Alex Langford
Essay Everyday compassion
Sheila Terry/Science Photo Library
My 29th year could be seen as a high point: I had three books published, completed a full-time MSc—receiving a distinction on the dissertation—taught at Imperial College London, and completed another book. My 29th year could be seen as a low point: mood swings of paranoia and fury drove me to question my mental stability. Privately, when I wasn’t feeling angry, it was a good bet I was weeping in abject despair. What happened? Looking back, the geography of my childhood was bounded in concentric, gendered circles. An aerial view of home would show my parents’ house, with a large back yard stretching into a field of several acres, which then met up with my grandparents’ house. The houses were the women’s domains, and the yards, which each held a converted barn, 686
now garages, were the men’s. My identity came almost entirely through my mother’s mother’s side, an old New England matriarchy run by my grandmother. Men seemed part of the furniture, probably largely because they were so much less voluble than the women. My brother naturally spent most of his free time learning stuff about cars from our dad, in the garage, where dad had installed under-floor heating (he hadn’t done the same for the house, a point of eternal chagrin to my mother). I read, climbed trees, wrote poetry, and picked blueberries for my grandmother to bake muffins. From this, I choose to study at an all-women’s college, influenced largely by my feeling that high school boys were idiots, so college boys would be, too. College, where I studied for a BA in English, was everything I hoped it would be—the small campus community felt www.lancet.com/psychiatry Vol 2 August 2015
Insight
like home; I formed a close sisterhood of friends; we were encouraged to study A Room of One’s Own and A Vindication of the Rights of Woman, among many other topics. The word “feminism” never came to my attention, yet my whole life was set in a feminist frame. Less than two months into my first year at college, my father dropped dead of a heart attack. And less than two months after that, the boy who had courted me in high school died of an aneurysm. I went straight back to college: it felt like the only thing I could do. Something inside me decided that even dying was a show of weakness. My college, already supportive, wrapped its arms around me, and I was reminded that I could go on to be anyone, to do anything. All around me, from my widowed mother to my female professors, to my bright young friends, women demonstrated that strength, independence, and confidence were characteristics of success. I wouldn’t change my upbringing for anything. The encouragement I enjoyed acted as rocket-fuel to moving to London, writing books, and getting married. But empowerment had, if you will, an Achilles high heel. By 29, I was divorced, living in one rented room, and having a series of emotional breakdowns. For the first time, I thought I might suffer from mental illness: depression, paranoia. Critical voices overwhelmed my mind, damning not me (oh no, I was quite protected from that) but others—my supposed friends, my supposed boyfriend— people who were supposed to help make me strong! Independent! Confident! I’d been taught that the world was for me, not against me, yet the everyday rigours of adult life seemed like a personal attack. I was furious: furious at my job, my partner, and often towards the world in general. Then, all in the space of a week, my partner’s appendix burst and nearly killed him, we had a devastating nearbreak-up, and I was diagnosed with skin cancer. I found myself at home, on the floor, barely able to breathe. My partner was just out of intensive care but still in hospital, and we were not on speaking terms. My family were being fantastically supportive but also defensive on my behalf. And some quiet, unbidden voice within me said, let tenderness in. I faced a choice—the choice I hadn’t realised I’d faced after my father died. Become tough, strong, and fly solo? It had made me successful on paper, but privately angry, judgemental, and self-protective. Something had always been wrong, and that something had always been the notme, whether it was my home, my marriage, or my work. I needed to take responsibility for my emotions, but I was at the end of my twenties by the time I realised it. I had no idea about vulnerability. I hadn’t learnt vulnerability. Vulnerability felt like failure, and I’d been raised for success. I didn’t know how to need, so instead, I condemned myself for feeling needy. It was also becoming evident that I wasn’t the only young woman struggling, www.lancet.com/psychiatry Vol 2 August 2015
that my difficulties were in no way unique. Other female friends had suffered and fallen off the radar, leaving jobs, relationships, and often their health, behind. Some drifted into religion, one discovered the mental health charity Mind, and not a few, it seemed, chose to damn the entire opposite sex for their discontent. How could I love and honour my empowered-femalesisterhood-liberation-history, whilst maintaining a balanced point of view that worked for me? My upbringing was strong in enthusiasm, but not in balance. And while one must consider that the fault is not in your education, Horatia, but in yourself, in my own still-developing hindsight, I would say my crisis was thanks to both nature and nurture. There have been setbacks. A history of successdriven encouragement means that the terrain of selfimprovement has threatened to turn into a quicksand of selfish improvement. I have to reign in my impulse to solve problems. I have to learn how to listen, without trying to “fix things”. I have to allow for uncertainty. Since I’ve learnt that it’s ok to be scared, things haven’t been so scary. Reading author Chimamanda Ngozi Adichie’s speech, “We Should All Be Feminists,” I was struck by how, growing up in a very un-feminist culture in Nigeria, she points out vulnerability as a major part of the difficulty—but in this case, the crisis of vulnerability is male. She writes: We do a great disservice to boys in how we raise them. We stifle the humanity of boys. We define masculinity in a very narrow way…We teach boys to be afraid of fear, of weakness, of vulnerability. We teach them to mask their true selves, because they have to be, in Nigerian-speak, a hard man…But by far the worst thing we do to males—by making them feel they have to be hard—is that we leave them with very fragile egos. The harder a man feels compelled to be, the weaker his ego is.
Whilst Adichie goes on to contrast the role of Nigerian women against this hardness, I feel the hardness of which she speaks, the fragility of the ego, applies also to feministraised, Western-educated women. And the conclusion is the same: how do we learn not to fear fear, not to fear weakness, not to fear vulnerability? How do we embrace these characteristics, and instead experience their value? Compassion for ourselves, and for those in our lives, is vital. Fulfilment will not come from framing the argument as simply “us-versus-them”. It would be a sad irony if ambitious young women built a narrowly-defined matriarchy to rival the patriarchy from which their mothers and grandmothers struggled so hard to break free. It’s time to expand the aims of feminism into an inclusive new humanism. We are people with hopes, fears and ambitions, and whatever our gender identity, we can bring about positive change only through communication, support and forgiveness. A sense of perspective is also vital. While any crisis is valid, and valuable, we must balance feelings of hurt, 687
Insight
anger, or oppression against a larger backdrop, to gain perspective. On whose behalf are you angry? Where is your anger coming from? How best to take your emotions in hand and seek help—medically, psychologically, physically, or spiritually? How to make responsible efforts on behalf of situations you feel are unjust? Weekly psychodynamic therapy and twice-daily Buddhist practice have helped me out of the most difficult time of my life. These two methods are teaching me to articulate and manage my vulnerabilities in a healthier way, whilst helping me realise that all of these points are an on-going process, rather than something to “fix”. And, in a seeming paradox, I’m sure it is thanks to all of the support and encouragement, all of that early
reinforcement of the young me as strong and confident, that kept me from giving up—on myself, or on my relationship. I must let tenderness in—and I must share it out, too. Our mothers and grandmothers’ generations worked hard to make women’s voices heard. More work is necessary. But now, in the context of Western cultures, we must rediscover a capacity to listen. The men in our lives—be they husbands, brothers, or friends—feel just as curious, just as uncertain, just as hopeful for encouragement and love, as we do. As well as practising compassion for ourselves, we must practise it for one another, consistently, in our everyday lives.
Kelley Swain
Theatre Dark arts
Justin Dowling
International Beckett Season was at The Barbican Centre, London, until June 21, 2015
Plunged into intimate darkness (even exit signs extinguished), Lisa Dwan’s masterful performance of Beckett’s one-woman triptych Not I/Footfalls/Rockaby is a breathtaking feat—and not one for the faint-hearted. The three short experimental monologues were written between 1972 and 1980, but had not been performed together until the first run of this production in early 2014. In Not I, the strange and abstracted image of “Mouth” confronts us, illuminated by a single spotlight. Dwan, suspended and shrouded eight feet above the stage, perfects a formidable feat of memory. The audience, at undefinable distance in the darkness, share her sensory deprivation as, babbling an unbroken stream of jumbled sentences at hypnotically high speed, a rasping voice struggles to express themes of abandonment, a loveless life, and unknown trauma.
After 3 minutes of anticipation in breathless silent darkness, a ghostly spectre materialises. May meditatively paces with metronomic rhythm, back and forth across a strip of bare landing outside her dying mother’s room, her footfalls precisely punctuating the conversation with her mother’s disembodied voice (also performed by Dwan). And, finally, in Rockaby, Dwan greets us as the elderly and lonely W, dressed in evening gown as a rocking chair mechanically moves her deathly pallor in and out of the light, with the chilling repetition of a slowing heartbeat. Although written 5 years apart, the ghoulish rhythms of Footfalls and Rockaby make them natural partners, while the frighteningly ferocious pace of Not I contrasts sharply, uniting with its stage companions only thematically. The unrelenting speech of Not I is delivered with a tempo almost exceeding that of the intended stream of consciousness—a feat mastered by Dwan with tutoring from Billie Whitelaw, who Beckett personally coached for the role. Like true Beckett characters, Mouth, May, and W exist purely on the stage, with a mere semblance of plot or back story, and Dwan’s ability to impart the agonies of loneliness through three such transient conduits is testament to her mastery and the power of Beckett’s words some 30–40 years on. With long-time friend of Beckett’s, Walter Asmus, at the helm, it’s perhaps no surprise that the production offers no dramatic reimagining, but the legacy of Whitelaw’s instruction and Asmus’ strict subscription to Beckett’s original direction produce a precise and captivating performance that will please even the most devout of worshippers at Sam’s shrine.
Jennifer Thorley 688
www.lancet.com/psychiatry Vol 2 August 2015
the UK National Health Service (NHS), inefficient, expensive overuse of medication, and poor utilisation of natural spaces were tabled. Maughan tells us more: “For the NHS to be able to continue providing high-value health care into the future, sustainable paradigms of health-care delivery need to be created that focus on prevention, patient empowerment, education, and community integration.” To remain financially, socially, and ecologically sustainable, we need to start being proactive in changing the ways we work, Maughan continues. “We need to harness every available resource, if we are to cope with rising expectations and decreasing budgets. This means broadening our understanding about the resource we have available to us and making the best use of peer support groups, online therapy and education, third-sector organisations, and community support structures.” Everyone can make a difference, even if it’s only by deciding to take email referrals instead of printed letters, or cutting down on unnecessary review appointments by prescribing depot injections at the longest reasonable interval. As well as being sustainable in terms of the environment, which the project does with aplomb, they are also sustainable in terms of people. Some service users who currently attend Growing Better Lives are seeking training in peer mentorship, mental health nursing, and social work, creating a virtuous cycle of empowerment and support. “When someone who’s been through it themselves starts to tell you about how they felt, it makes you feel like so much more of a human being. Your internal voice said you’re not right, you’re weird, you’re not normal, but when you hear about someone who’s been through it, has come out the other side and is doing a job like this, it gives you such a sense of wellbeing, that you can get over it and move on”, says Ellaway.
The inspiration felt by service users seems to emanate not least from the three of the five codirectors of Growing Better Lives who have had personal experience of mental illness and contact with local services. Jones has come full circle to complete a PhD and is starting to build an evidence base for the project. The team use mostly qualitative methods and are affiliated with the Centre for Social Futures, a research division of the Institute of Mental Health at the University of Nottingham, Nottingham, UK. In addition to strengthening the evidence base for the services they already offer, the team want to branch out. Among their many ideas is the provisionally named GreenFamilies project, which will aim to get entire family units of people with PD spending time in their healing environment, hopefully preventing the all-toocommon scenario of children being removed from a home. Psychoeducation groups for families and friends of people who attend the existing project seem to be a well supported endeavour among the team too. When asked what other services could do to emulate their ethos, Haigh offers a suggestion that he feels might be surprising: “Never see people by themselves. Always see them in groups, or with more than one member of staff, so you never have a dyadic relationship, so it can all be held in a network of relationships. Relationships have to be the absolute focus of the work, rather than symptoms or medication.” Lomas answers in no less striking a way: “You don’t recover by being boxed in, you recover by branching out, by experiencing different things, by challenging yourself”, which just about sums up Greencare in a sentence.
Alex Langford
Essay Everyday compassion
Sheila Terry/Science Photo Library
My 29th year could be seen as a high point: I had three books published, completed a full-time MSc—receiving a distinction on the dissertation—taught at Imperial College London, and completed another book. My 29th year could be seen as a low point: mood swings of paranoia and fury drove me to question my mental stability. Privately, when I wasn’t feeling angry, it was a good bet I was weeping in abject despair. What happened? Looking back, the geography of my childhood was bounded in concentric, gendered circles. An aerial view of home would show my parents’ house, with a large back yard stretching into a field of several acres, which then met up with my grandparents’ house. The houses were the women’s domains, and the yards, which each held a converted barn, 686
now garages, were the men’s. My identity came almost entirely through my mother’s mother’s side, an old New England matriarchy run by my grandmother. Men seemed part of the furniture, probably largely because they were so much less voluble than the women. My brother naturally spent most of his free time learning stuff about cars from our dad, in the garage, where dad had installed under-floor heating (he hadn’t done the same for the house, a point of eternal chagrin to my mother). I read, climbed trees, wrote poetry, and picked blueberries for my grandmother to bake muffins. From this, I choose to study at an all-women’s college, influenced largely by my feeling that high school boys were idiots, so college boys would be, too. College, where I studied for a BA in English, was everything I hoped it would be—the small campus community felt www.lancet.com/psychiatry Vol 2 August 2015
Insight
like home; I formed a close sisterhood of friends; we were encouraged to study A Room of One’s Own and A Vindication of the Rights of Woman, among many other topics. The word “feminism” never came to my attention, yet my whole life was set in a feminist frame. Less than two months into my first year at college, my father dropped dead of a heart attack. And less than two months after that, the boy who had courted me in high school died of an aneurysm. I went straight back to college: it felt like the only thing I could do. Something inside me decided that even dying was a show of weakness. My college, already supportive, wrapped its arms around me, and I was reminded that I could go on to be anyone, to do anything. All around me, from my widowed mother to my female professors, to my bright young friends, women demonstrated that strength, independence, and confidence were characteristics of success. I wouldn’t change my upbringing for anything. The encouragement I enjoyed acted as rocket-fuel to moving to London, writing books, and getting married. But empowerment had, if you will, an Achilles high heel. By 29, I was divorced, living in one rented room, and having a series of emotional breakdowns. For the first time, I thought I might suffer from mental illness: depression, paranoia. Critical voices overwhelmed my mind, damning not me (oh no, I was quite protected from that) but others—my supposed friends, my supposed boyfriend— people who were supposed to help make me strong! Independent! Confident! I’d been taught that the world was for me, not against me, yet the everyday rigours of adult life seemed like a personal attack. I was furious: furious at my job, my partner, and often towards the world in general. Then, all in the space of a week, my partner’s appendix burst and nearly killed him, we had a devastating nearbreak-up, and I was diagnosed with skin cancer. I found myself at home, on the floor, barely able to breathe. My partner was just out of intensive care but still in hospital, and we were not on speaking terms. My family were being fantastically supportive but also defensive on my behalf. And some quiet, unbidden voice within me said, let tenderness in. I faced a choice—the choice I hadn’t realised I’d faced after my father died. Become tough, strong, and fly solo? It had made me successful on paper, but privately angry, judgemental, and self-protective. Something had always been wrong, and that something had always been the notme, whether it was my home, my marriage, or my work. I needed to take responsibility for my emotions, but I was at the end of my twenties by the time I realised it. I had no idea about vulnerability. I hadn’t learnt vulnerability. Vulnerability felt like failure, and I’d been raised for success. I didn’t know how to need, so instead, I condemned myself for feeling needy. It was also becoming evident that I wasn’t the only young woman struggling, www.lancet.com/psychiatry Vol 2 August 2015
that my difficulties were in no way unique. Other female friends had suffered and fallen off the radar, leaving jobs, relationships, and often their health, behind. Some drifted into religion, one discovered the mental health charity Mind, and not a few, it seemed, chose to damn the entire opposite sex for their discontent. How could I love and honour my empowered-femalesisterhood-liberation-history, whilst maintaining a balanced point of view that worked for me? My upbringing was strong in enthusiasm, but not in balance. And while one must consider that the fault is not in your education, Horatia, but in yourself, in my own still-developing hindsight, I would say my crisis was thanks to both nature and nurture. There have been setbacks. A history of successdriven encouragement means that the terrain of selfimprovement has threatened to turn into a quicksand of selfish improvement. I have to reign in my impulse to solve problems. I have to learn how to listen, without trying to “fix things”. I have to allow for uncertainty. Since I’ve learnt that it’s ok to be scared, things haven’t been so scary. Reading author Chimamanda Ngozi Adichie’s speech, “We Should All Be Feminists,” I was struck by how, growing up in a very un-feminist culture in Nigeria, she points out vulnerability as a major part of the difficulty—but in this case, the crisis of vulnerability is male. She writes: We do a great disservice to boys in how we raise them. We stifle the humanity of boys. We define masculinity in a very narrow way…We teach boys to be afraid of fear, of weakness, of vulnerability. We teach them to mask their true selves, because they have to be, in Nigerian-speak, a hard man…But by far the worst thing we do to males—by making them feel they have to be hard—is that we leave them with very fragile egos. The harder a man feels compelled to be, the weaker his ego is.
Whilst Adichie goes on to contrast the role of Nigerian women against this hardness, I feel the hardness of which she speaks, the fragility of the ego, applies also to feministraised, Western-educated women. And the conclusion is the same: how do we learn not to fear fear, not to fear weakness, not to fear vulnerability? How do we embrace these characteristics, and instead experience their value? Compassion for ourselves, and for those in our lives, is vital. Fulfilment will not come from framing the argument as simply “us-versus-them”. It would be a sad irony if ambitious young women built a narrowly-defined matriarchy to rival the patriarchy from which their mothers and grandmothers struggled so hard to break free. It’s time to expand the aims of feminism into an inclusive new humanism. We are people with hopes, fears and ambitions, and whatever our gender identity, we can bring about positive change only through communication, support and forgiveness. A sense of perspective is also vital. While any crisis is valid, and valuable, we must balance feelings of hurt, 687
Insight
anger, or oppression against a larger backdrop, to gain perspective. On whose behalf are you angry? Where is your anger coming from? How best to take your emotions in hand and seek help—medically, psychologically, physically, or spiritually? How to make responsible efforts on behalf of situations you feel are unjust? Weekly psychodynamic therapy and twice-daily Buddhist practice have helped me out of the most difficult time of my life. These two methods are teaching me to articulate and manage my vulnerabilities in a healthier way, whilst helping me realise that all of these points are an on-going process, rather than something to “fix”. And, in a seeming paradox, I’m sure it is thanks to all of the support and encouragement, all of that early
reinforcement of the young me as strong and confident, that kept me from giving up—on myself, or on my relationship. I must let tenderness in—and I must share it out, too. Our mothers and grandmothers’ generations worked hard to make women’s voices heard. More work is necessary. But now, in the context of Western cultures, we must rediscover a capacity to listen. The men in our lives—be they husbands, brothers, or friends—feel just as curious, just as uncertain, just as hopeful for encouragement and love, as we do. As well as practising compassion for ourselves, we must practise it for one another, consistently, in our everyday lives.
Kelley Swain
Theatre Dark arts
Justin Dowling
International Beckett Season was at The Barbican Centre, London, until June 21, 2015
Plunged into intimate darkness (even exit signs extinguished), Lisa Dwan’s masterful performance of Beckett’s one-woman triptych Not I/Footfalls/Rockaby is a breathtaking feat—and not one for the faint-hearted. The three short experimental monologues were written between 1972 and 1980, but had not been performed together until the first run of this production in early 2014. In Not I, the strange and abstracted image of “Mouth” confronts us, illuminated by a single spotlight. Dwan, suspended and shrouded eight feet above the stage, perfects a formidable feat of memory. The audience, at undefinable distance in the darkness, share her sensory deprivation as, babbling an unbroken stream of jumbled sentences at hypnotically high speed, a rasping voice struggles to express themes of abandonment, a loveless life, and unknown trauma.
After 3 minutes of anticipation in breathless silent darkness, a ghostly spectre materialises. May meditatively paces with metronomic rhythm, back and forth across a strip of bare landing outside her dying mother’s room, her footfalls precisely punctuating the conversation with her mother’s disembodied voice (also performed by Dwan). And, finally, in Rockaby, Dwan greets us as the elderly and lonely W, dressed in evening gown as a rocking chair mechanically moves her deathly pallor in and out of the light, with the chilling repetition of a slowing heartbeat. Although written 5 years apart, the ghoulish rhythms of Footfalls and Rockaby make them natural partners, while the frighteningly ferocious pace of Not I contrasts sharply, uniting with its stage companions only thematically. The unrelenting speech of Not I is delivered with a tempo almost exceeding that of the intended stream of consciousness—a feat mastered by Dwan with tutoring from Billie Whitelaw, who Beckett personally coached for the role. Like true Beckett characters, Mouth, May, and W exist purely on the stage, with a mere semblance of plot or back story, and Dwan’s ability to impart the agonies of loneliness through three such transient conduits is testament to her mastery and the power of Beckett’s words some 30–40 years on. With long-time friend of Beckett’s, Walter Asmus, at the helm, it’s perhaps no surprise that the production offers no dramatic reimagining, but the legacy of Whitelaw’s instruction and Asmus’ strict subscription to Beckett’s original direction produce a precise and captivating performance that will please even the most devout of worshippers at Sam’s shrine.
Jennifer Thorley 688
www.lancet.com/psychiatry Vol 2 August 2015