- Email: [email protected]
A labour of love
Insight
plans can be quite personal”, he says, “and let’s face it, there’s still a lot of stigma and misunderstanding associated with mental health conditions even among health professionals.” Management of this system for patients with mental health disorders, says Hugo de Waal, a psychiatrist and clinical director for dementia at the South London Heath Innovation Network, will not only be about protecting information, but improving the flow of it to patients. de Waal has been advising Coordinate My Care about the service’s roll out later this year to patients with dementia. The service’s urgent care planning for dementia is being developed in close collaboration with MyBrainBook, a separate initiative from de Waal and colleagues at the South London Health Innovation Network that aims to put people with dementia and their family carers at the centre of their care planning process, including urgent care planning and helping anticipatory care for physical co-morbidities often seen in dementia. Speaking about the anticipated roll out of Coordinate My Care to patients with mental health disorders, with which he is not involved, de Waal says: “Mental health patients have to understand the benefits but also the limitations of the service. Drafting an urgent care plan in psychiatry is more difficult than with, say, end-of-life care where patients decide on palliative interventions and place of dying. These are fairly circumspect preferences, whereas for mental health care they are more complex.” A patient, he says, might have previously been sectioned under Section Two of the Mental Care Act. “They might
say ‘it was a nightmare and I didn’t get the care I wanted or needed. Can we please avoid that at all costs?’ It makes sense at the time—and it’s the stated aim of any decent psychiatric service—but if the decision is made by the usual process and the care plan is over-ruled and the patient is again sectioned, then the patient’s previously expressed preferences are utterly meaningless.” Riley is not perturbed by the complexities of the challenge. “To my knowledge nothing like Coordinate My Care has been done before”, she says. Madrid and Hong Kong, she adds, are the only other places in the world with systems that link planned with emergency health care, though Madrid’s is not as technologically complex, based on a largely email system, and Hong Kong has the technology “but doesn’t have the care planning. Coordinate My Care is about the wrap-around teaching and training process as well as the IT”, says Riley. “The whole programme”, she continues, “is all about anticipatory care rather than reactive care. It means a culture change as it’s not how doctors and nurses have traditionally been trained. We’ve seen with palliative care that we get outcomes that are repeatedly good and I don’t see why that won’t be the same in mental health. Our main aim is to improve patient care and stop people falling through the gaps in services. As we’ve done with palliative care and are doing with dementia, we’ll make sure that the system in mental health will not veer from this central tenant of improving care.”
Dara Mohammadi
Essay A labour of love
www.thelancet.com/psychiatry Vol 2 December 2015
started to develop severe paranoia due to smoking cannabis through my teenage years. I started an art foundation course in Bristol and there was a lot of self-expectation, finally being back where I wanted to be. I had been thinking about being back home for years, and was infatuated with all things about Bristol at that age: drugs, drum and bass, and graffiti! I started spray-painting seriously, and came up with stencils based on Banksy that I sprayed around Bristol. I came up with a tag called Hardie, an abbreviation of my second name. But things began to go off the rails. I started to see prophetic meanings in graffiti including my own tag and felt grandiose and immense elation that made me perceive in a new way and was very spiritual. I thought I could change the world but when I told others they thought it was strange. I lost touch with day-today things that keep you grounded and my thoughts spiralled because I was trying to find a reason or crux to existence. I couldn’t sleep for days on end thinking. The elation turned into existential despair as I couldn’t find a reason and started
George Harding
As a child I was lucky to live next door to a great art teacher called Jane, who was friends with my mum and gave me lessons from a very young age. I loved it, and my passion grew from there. My grandpa, who was a farmer, entered one of my paintings into a competition at his local market show in Cricklade. I won a rosette, and I was so happy that I knew I wanted to be an artist right then. At secondary school, Jane introduced me to the impressionists, Magritte and other surrealists, Lucien Freud, Stanley Spencer, and Francis Bacon who still influence me today. At 14, I got an art and sport scholarship to a boarding school called Millfield. The school had a dyslexia unit, which would be a help to me, as well as a very good art department. It was also the school my dad went to. He’d had a great experience, so there were high hopes for me to do the same. Unfortunately, although Millfield is a great school, I didn’t see that at the time. I hated being away from my home and family. I fell in with a bad crowd, and by the end of my time there, though I had got straight A grades for my subjects, I
1063
George Harding
Insight
to make connections that were delusional and it became very frightening for others around me. I was admitted for treatment for cannabis psychosis, and dropped out of the art foundation. Meeting the patients and staff made me feel like I could cope again and that it was all just a rough experience, but the next year I relapsed and was diagnosed with a mental health condition. I have relapsed now seven or eight times in 10 years since my first episode, with many different diagnoses. It has been hard to diagnose me as I was using drugs and was not compliant with the medication at first but also forgot to take tablets everyday. This has changed though through having a monthly depot of paliperidone which is slow release and has the least side-effects. I have been able to function normally with it and am now able to work and have made huge progress since being on it. Art has always been the focus of my life, and even though I have suffered from illness, it has always been something I have been able to rely on. I managed to get into Chelsea for my degree, which was a real achievement. I did this while heavily tranquilised on medication and I was sleeping a lot — probably 12 hours or more a day. I was like a zombie but when I was up I spent a lot of time at the easel painting, which I love and always will. Painting was, and is, my therapy. I couldn’t interact with people at that time as well as I would’ve liked to, and I was very slow, but I got through it and managed to get a 2:1 selling my whole degree show despite having to deal with my illness. This made me think that art is the way that I can overcome my difficulties. I painted as much as possible because I couldn’t do anything else. My art work at the time 1064
reflected the pain and hurt that I was going through and was a very creative period for me. Like Joseph Cornell, I enjoy collecting objects that I pick up in flea markets, antique fairs, or bric-a-brack shops. I often juxtapose these objects in stilllife scenes. I also use symbols that are traditionally universal, communicating a solid concept—I put them against other symbols and signs in collaged environments, and the concept becomes more poetic, with narratives that are often rooted in my experiences, thoughts and feelings. The finished pieces are often paintings, but I also use the objects directly. I sometimes make resin boxes that encapsulate objects, suspend things like marbles, and create playful universes in what seem like pools of water to magnify and suspend what is below. These are about the joy of looking. My portraits try to capture the person’s relationship to me. It is a moment in time. I rarely do commissions, so it’s quite random when I do a portrait, but it’s because I’m interested in the subject. The scene is sometimes collaged and altered from initial photographs, but not always. I try to get an expression that I think reflects the person’s character, and I use material things around them to give the viewer an idea about what they do, what they like, and that celebrates who I think they are. This is somewhat different to my self-portraits, which often explore the inner self. I take photographs in the mist of shower mirrors and other surfaces, which act as a starting point for paintings. The paintings dissolve the figure within, pointing to different states of being that are temporal and ethereal. I am looking at how a surface can reflect, distort, fragment and transform the real. I want people to relate to this in an emotive way, and I want people to see this in themselves. We are all temporal, and people are scared of this. It makes reality seem uncertain. We try to control this uncertainty by rooting ourselves in things that are tangible and material—but the opposite is also true, and I think this needs to be made visible. Like any profession, there are pluses and minuses to life as an artist. I like the way art is self-directed, that the ideas and everything you do comes from yourself. I find this liberating in some ways, but because there are no rules or boundaries it can also seem too big and complex. When creating through experience, you start to make decisions that are intuitive, and in a way you create your own rules. This becomes familiar, but you also don’t want to be too comfortable, because then the art gets stagnant. For people to understand what you are doing, you need to be consistent, which might mean sticking with a certain idea, technique, or ways of making for a long time. This makes your art marketable: it becomes recognisable as your own. I have found consistency hard, as I like and do many different types of art from graffiti, portraits and using resin. My art is also harder to market as my practice is multi-disciplinary but is starting to become more focused purely on painting due www.thelancet.com/psychiatry Vol 2 December 2015
Insight
to cost constraints and limited time. I don’t intellectualise it to much. I want to feel it, which means making a lot of artwork, but it can seem random. This has been a problem for galleries. I think this is normal for all artists, but the anxiety and self-consciousness of being a public artist can be crippling at times, and isn’t good for my health or anyone’s for that matter. I find the isolation difficult too. I like being around people: this is why I have a day job in a café, as you need to be grounded as much as possible. As an artist you’ve got to find a gallery that suits your ethos. A gallery relationship is like any relationship you develop with an individual: there can be synergies, tensions, compromises and accommodations. Every gallery’s ethos is different, and you’ve got to build a relationship that is meaningful and fulfilling for both. In many ways a gallery is like an artist in themselves: it has to find an identity, style and market. I am lucky to have found in The Bethlem Gallery a place that understands me. We have a good relationship. as much as I do what I want to do, there are also ideas and developments that the gallery will suggest. It is like having a good friend in many ways, and hopefully it’s mutually beneficial. My experiences of mental health have changed my art for the better. I have more experiences to draw from and have experienced things that most people may not touch on in a lifetime. Even though I have found it hard at times, I do think my illness is a blessing as it gives me new insight into what it is to be alive and human. It also lets me experience a broader spectrum of perception. I find the different ways the mind can perceive the world fascinating. It gives me a glimpse of what reality truly is. I feel I have resolved the past as much as I can, and have moved on from what has
happened. This has been due to moving back to Bristol, with family and friends close by, and a great support network that includes the Bethlem Gallery. I have also stopped using drugs and have been having hypnotherapy and doing meditation, which has helped resolve destructive patterns of thinking and behaviour. I also try to exercise regularly, keep in a good routine and eat well. You need to fight the illness at its core and not just rely on the medication which keeps me from relapsing but also has negative side effects but these are less so when you keep on top of your general wellbeing. As an individual you’ve got to be very switched on, resilient, professional, and good with people to put yourself and your ideas across, which I’ve found hard due to my illness. I used to worry about this a lot, and was very critical of myself. But I was pretty unwell then, and when you don’t stand out, you’re lost. I think people who have mental health problems find it harder than most to fit in. There is a lot of networking, self-promotion and selling involved in the art world, which is not about the art, and if you are not naturally good at it, self assured and confident you will suffer. I’ve found surviving as an artist a challenge with everything that it entails. It’s not just about making work, and to be accepted is the hardest thing you can imagine. You are trying to sell something that you’ve put your heart into, for what seems like a lot of money, but when you’ve accounted for the all the costs of time, materials, and gallery commission fees, you get very little. You need to eat. If I wanted to make money and have an easier life, I would not make art at all. It is a labour of love, and I would say this is true of most artists.
George Harding http://www.georgejharding.co.uk
Books Breaking the silence There have been many outstanding books on depression; considering the number of sufferers (myself included—I have had extensive periods of anxiety, low mood, thoughts of self harm, and severe clinical depression), it is a very important topic. However, in The Other Side of Silence, Linda Gask, Emeritus Professor of Primary Care Psychiatry at the University of Manchester, UK, gives the reader something new: a psychiatrist simultaneously describing their own experiences of depression and their work with patients. Gask states that she was trained to consider biological, social, and psychological determinants of mental illness, and had always leaned towards the latter two, but did prescribe medication. This is reflected in her writing both about herself and her patients. The book is organised into themes, such as vulnerability, fear, taking tablets, trust, and loneliness. Within each theme, www.thelancet.com/psychiatry Vol 2 December 2015
Gask describes her own struggles while training to be a psychiatrist and working with people who have very complex and painful emotional problems. She describes incredibly difficult situations, such as finding herself in a room with someone who is struggling with alcohol dependence, selfharm, or severe anxiety and depression, while also fighting to get through each day despite help and support from medical specialists, therapists, and medication. I felt extremely moved by the empathy and compassion in her descriptions of her patients—of how she wanted so much more for all of them. Especially vivid, and affecting, are the passages in which Gask writes about her desire to end her life and struggles to continue living on many occasions. Gask describes early on in the book her struggles with her family, the painful experience of her father passing away, wanting to help her brother who has obsessive compulsive disorder, and particularly, her
The Other Side of Silence: A Psychiatrist’s Memoir of Depression Linda Gask, Vie, 2015 272 pp. £9·99 ISBN 978-1849537544
1065
plans can be quite personal”, he says, “and let’s face it, there’s still a lot of stigma and misunderstanding associated with mental health conditions even among health professionals.” Management of this system for patients with mental health disorders, says Hugo de Waal, a psychiatrist and clinical director for dementia at the South London Heath Innovation Network, will not only be about protecting information, but improving the flow of it to patients. de Waal has been advising Coordinate My Care about the service’s roll out later this year to patients with dementia. The service’s urgent care planning for dementia is being developed in close collaboration with MyBrainBook, a separate initiative from de Waal and colleagues at the South London Health Innovation Network that aims to put people with dementia and their family carers at the centre of their care planning process, including urgent care planning and helping anticipatory care for physical co-morbidities often seen in dementia. Speaking about the anticipated roll out of Coordinate My Care to patients with mental health disorders, with which he is not involved, de Waal says: “Mental health patients have to understand the benefits but also the limitations of the service. Drafting an urgent care plan in psychiatry is more difficult than with, say, end-of-life care where patients decide on palliative interventions and place of dying. These are fairly circumspect preferences, whereas for mental health care they are more complex.” A patient, he says, might have previously been sectioned under Section Two of the Mental Care Act. “They might
say ‘it was a nightmare and I didn’t get the care I wanted or needed. Can we please avoid that at all costs?’ It makes sense at the time—and it’s the stated aim of any decent psychiatric service—but if the decision is made by the usual process and the care plan is over-ruled and the patient is again sectioned, then the patient’s previously expressed preferences are utterly meaningless.” Riley is not perturbed by the complexities of the challenge. “To my knowledge nothing like Coordinate My Care has been done before”, she says. Madrid and Hong Kong, she adds, are the only other places in the world with systems that link planned with emergency health care, though Madrid’s is not as technologically complex, based on a largely email system, and Hong Kong has the technology “but doesn’t have the care planning. Coordinate My Care is about the wrap-around teaching and training process as well as the IT”, says Riley. “The whole programme”, she continues, “is all about anticipatory care rather than reactive care. It means a culture change as it’s not how doctors and nurses have traditionally been trained. We’ve seen with palliative care that we get outcomes that are repeatedly good and I don’t see why that won’t be the same in mental health. Our main aim is to improve patient care and stop people falling through the gaps in services. As we’ve done with palliative care and are doing with dementia, we’ll make sure that the system in mental health will not veer from this central tenant of improving care.”
Dara Mohammadi
Essay A labour of love
www.thelancet.com/psychiatry Vol 2 December 2015
started to develop severe paranoia due to smoking cannabis through my teenage years. I started an art foundation course in Bristol and there was a lot of self-expectation, finally being back where I wanted to be. I had been thinking about being back home for years, and was infatuated with all things about Bristol at that age: drugs, drum and bass, and graffiti! I started spray-painting seriously, and came up with stencils based on Banksy that I sprayed around Bristol. I came up with a tag called Hardie, an abbreviation of my second name. But things began to go off the rails. I started to see prophetic meanings in graffiti including my own tag and felt grandiose and immense elation that made me perceive in a new way and was very spiritual. I thought I could change the world but when I told others they thought it was strange. I lost touch with day-today things that keep you grounded and my thoughts spiralled because I was trying to find a reason or crux to existence. I couldn’t sleep for days on end thinking. The elation turned into existential despair as I couldn’t find a reason and started
George Harding
As a child I was lucky to live next door to a great art teacher called Jane, who was friends with my mum and gave me lessons from a very young age. I loved it, and my passion grew from there. My grandpa, who was a farmer, entered one of my paintings into a competition at his local market show in Cricklade. I won a rosette, and I was so happy that I knew I wanted to be an artist right then. At secondary school, Jane introduced me to the impressionists, Magritte and other surrealists, Lucien Freud, Stanley Spencer, and Francis Bacon who still influence me today. At 14, I got an art and sport scholarship to a boarding school called Millfield. The school had a dyslexia unit, which would be a help to me, as well as a very good art department. It was also the school my dad went to. He’d had a great experience, so there were high hopes for me to do the same. Unfortunately, although Millfield is a great school, I didn’t see that at the time. I hated being away from my home and family. I fell in with a bad crowd, and by the end of my time there, though I had got straight A grades for my subjects, I
1063
George Harding
Insight
to make connections that were delusional and it became very frightening for others around me. I was admitted for treatment for cannabis psychosis, and dropped out of the art foundation. Meeting the patients and staff made me feel like I could cope again and that it was all just a rough experience, but the next year I relapsed and was diagnosed with a mental health condition. I have relapsed now seven or eight times in 10 years since my first episode, with many different diagnoses. It has been hard to diagnose me as I was using drugs and was not compliant with the medication at first but also forgot to take tablets everyday. This has changed though through having a monthly depot of paliperidone which is slow release and has the least side-effects. I have been able to function normally with it and am now able to work and have made huge progress since being on it. Art has always been the focus of my life, and even though I have suffered from illness, it has always been something I have been able to rely on. I managed to get into Chelsea for my degree, which was a real achievement. I did this while heavily tranquilised on medication and I was sleeping a lot — probably 12 hours or more a day. I was like a zombie but when I was up I spent a lot of time at the easel painting, which I love and always will. Painting was, and is, my therapy. I couldn’t interact with people at that time as well as I would’ve liked to, and I was very slow, but I got through it and managed to get a 2:1 selling my whole degree show despite having to deal with my illness. This made me think that art is the way that I can overcome my difficulties. I painted as much as possible because I couldn’t do anything else. My art work at the time 1064
reflected the pain and hurt that I was going through and was a very creative period for me. Like Joseph Cornell, I enjoy collecting objects that I pick up in flea markets, antique fairs, or bric-a-brack shops. I often juxtapose these objects in stilllife scenes. I also use symbols that are traditionally universal, communicating a solid concept—I put them against other symbols and signs in collaged environments, and the concept becomes more poetic, with narratives that are often rooted in my experiences, thoughts and feelings. The finished pieces are often paintings, but I also use the objects directly. I sometimes make resin boxes that encapsulate objects, suspend things like marbles, and create playful universes in what seem like pools of water to magnify and suspend what is below. These are about the joy of looking. My portraits try to capture the person’s relationship to me. It is a moment in time. I rarely do commissions, so it’s quite random when I do a portrait, but it’s because I’m interested in the subject. The scene is sometimes collaged and altered from initial photographs, but not always. I try to get an expression that I think reflects the person’s character, and I use material things around them to give the viewer an idea about what they do, what they like, and that celebrates who I think they are. This is somewhat different to my self-portraits, which often explore the inner self. I take photographs in the mist of shower mirrors and other surfaces, which act as a starting point for paintings. The paintings dissolve the figure within, pointing to different states of being that are temporal and ethereal. I am looking at how a surface can reflect, distort, fragment and transform the real. I want people to relate to this in an emotive way, and I want people to see this in themselves. We are all temporal, and people are scared of this. It makes reality seem uncertain. We try to control this uncertainty by rooting ourselves in things that are tangible and material—but the opposite is also true, and I think this needs to be made visible. Like any profession, there are pluses and minuses to life as an artist. I like the way art is self-directed, that the ideas and everything you do comes from yourself. I find this liberating in some ways, but because there are no rules or boundaries it can also seem too big and complex. When creating through experience, you start to make decisions that are intuitive, and in a way you create your own rules. This becomes familiar, but you also don’t want to be too comfortable, because then the art gets stagnant. For people to understand what you are doing, you need to be consistent, which might mean sticking with a certain idea, technique, or ways of making for a long time. This makes your art marketable: it becomes recognisable as your own. I have found consistency hard, as I like and do many different types of art from graffiti, portraits and using resin. My art is also harder to market as my practice is multi-disciplinary but is starting to become more focused purely on painting due www.thelancet.com/psychiatry Vol 2 December 2015
Insight
to cost constraints and limited time. I don’t intellectualise it to much. I want to feel it, which means making a lot of artwork, but it can seem random. This has been a problem for galleries. I think this is normal for all artists, but the anxiety and self-consciousness of being a public artist can be crippling at times, and isn’t good for my health or anyone’s for that matter. I find the isolation difficult too. I like being around people: this is why I have a day job in a café, as you need to be grounded as much as possible. As an artist you’ve got to find a gallery that suits your ethos. A gallery relationship is like any relationship you develop with an individual: there can be synergies, tensions, compromises and accommodations. Every gallery’s ethos is different, and you’ve got to build a relationship that is meaningful and fulfilling for both. In many ways a gallery is like an artist in themselves: it has to find an identity, style and market. I am lucky to have found in The Bethlem Gallery a place that understands me. We have a good relationship. as much as I do what I want to do, there are also ideas and developments that the gallery will suggest. It is like having a good friend in many ways, and hopefully it’s mutually beneficial. My experiences of mental health have changed my art for the better. I have more experiences to draw from and have experienced things that most people may not touch on in a lifetime. Even though I have found it hard at times, I do think my illness is a blessing as it gives me new insight into what it is to be alive and human. It also lets me experience a broader spectrum of perception. I find the different ways the mind can perceive the world fascinating. It gives me a glimpse of what reality truly is. I feel I have resolved the past as much as I can, and have moved on from what has
happened. This has been due to moving back to Bristol, with family and friends close by, and a great support network that includes the Bethlem Gallery. I have also stopped using drugs and have been having hypnotherapy and doing meditation, which has helped resolve destructive patterns of thinking and behaviour. I also try to exercise regularly, keep in a good routine and eat well. You need to fight the illness at its core and not just rely on the medication which keeps me from relapsing but also has negative side effects but these are less so when you keep on top of your general wellbeing. As an individual you’ve got to be very switched on, resilient, professional, and good with people to put yourself and your ideas across, which I’ve found hard due to my illness. I used to worry about this a lot, and was very critical of myself. But I was pretty unwell then, and when you don’t stand out, you’re lost. I think people who have mental health problems find it harder than most to fit in. There is a lot of networking, self-promotion and selling involved in the art world, which is not about the art, and if you are not naturally good at it, self assured and confident you will suffer. I’ve found surviving as an artist a challenge with everything that it entails. It’s not just about making work, and to be accepted is the hardest thing you can imagine. You are trying to sell something that you’ve put your heart into, for what seems like a lot of money, but when you’ve accounted for the all the costs of time, materials, and gallery commission fees, you get very little. You need to eat. If I wanted to make money and have an easier life, I would not make art at all. It is a labour of love, and I would say this is true of most artists.
George Harding http://www.georgejharding.co.uk
Books Breaking the silence There have been many outstanding books on depression; considering the number of sufferers (myself included—I have had extensive periods of anxiety, low mood, thoughts of self harm, and severe clinical depression), it is a very important topic. However, in The Other Side of Silence, Linda Gask, Emeritus Professor of Primary Care Psychiatry at the University of Manchester, UK, gives the reader something new: a psychiatrist simultaneously describing their own experiences of depression and their work with patients. Gask states that she was trained to consider biological, social, and psychological determinants of mental illness, and had always leaned towards the latter two, but did prescribe medication. This is reflected in her writing both about herself and her patients. The book is organised into themes, such as vulnerability, fear, taking tablets, trust, and loneliness. Within each theme, www.thelancet.com/psychiatry Vol 2 December 2015
Gask describes her own struggles while training to be a psychiatrist and working with people who have very complex and painful emotional problems. She describes incredibly difficult situations, such as finding herself in a room with someone who is struggling with alcohol dependence, selfharm, or severe anxiety and depression, while also fighting to get through each day despite help and support from medical specialists, therapists, and medication. I felt extremely moved by the empathy and compassion in her descriptions of her patients—of how she wanted so much more for all of them. Especially vivid, and affecting, are the passages in which Gask writes about her desire to end her life and struggles to continue living on many occasions. Gask describes early on in the book her struggles with her family, the painful experience of her father passing away, wanting to help her brother who has obsessive compulsive disorder, and particularly, her
The Other Side of Silence: A Psychiatrist’s Memoir of Depression Linda Gask, Vie, 2015 272 pp. £9·99 ISBN 978-1849537544
1065