Our understanding of ‘madness’ and anguish has changed and developed over many generations. When I look at this process something that strikes me is how each framework has its own strengths and limitations, places where it was helpful and others where it was destructive. There’s also a kind of pendulum swing from polarized positions – all mental illness is caused by genetics, all mental illness is caused by trauma, until finally in many of the debates the reality has been found to be somewhere in between. Both nature and nurture shape us. Attempts to find a way to comprehend and respond to bizarre or distressing experiences seem often to originate in an attempt to move away from the destructiveness of the framework that came before. I’m not too hard on the medical model for this reason. It has strengths! One of them is the idea that madness could be understood. That it could be studied, researched, comprehended, and possibly even treated. When madness was understood as a spiritual or moral failing, people suffered. A medical approach was at the time, filled with hope.

Another thing I like about the medical model is the way it is being used to demand better resources for people with a mental illness. There is talk about a medical apartheid, where money available to support people who have diabetes or are recovering from strokes is compared to the money available to support people who have schizophrenia or postnatal depression. It IS outrageous that there is not yet the funding to develop better testing so that people with mental illnesses are not exposed to medications to which they will have an allergic reaction. It is appalling that perceptions such as ‘people with mental illnesses are never going to get better anyway’ slows the development of quality resources. I’m happy that our ideas about sanity have become much more sophisticated than the two categories of crazy and sane.

In my opinion, the medical model also has some major limitations. One of them is the inability to distinguish between illness and injury. We do not have a language to describe psychological injury in the way that we do physical injury. So for those who have been psychologically wounded by trauma, abuse or neglect, they are diagnosed with a mental illness. Our entire mental health system in some ways is predicated on the idea that there is something wrong with the victims.

Our mental health system has become a catchment for hurting people, and it tells them that there is something wrong with them because they are wounded. In my experience, people who have been mistreated react in entirely predictable ways, and develop difficulties in the areas that were damaged – such as navigating relationships, coping with intense emotions, experiencing chronic shame. There is no place in ‘abnormal psychology’ for these reactions, they are the normal reactions of human beings to these kind of circumstances, in greater or lesser degrees. For those most catastrophically wounded, so many areas of life are affected that they often receive multiple diagnoses, the labels pile up giving the impression of a case of the most hopeless overwhelming sickness and deeply discouraging the person who carries them around. We don’t do this when people have been physically wounded. As Dr Middleton, Australian psychiatrist put it:

If an individual were to be dragged out of the wreckage of a train crash and dispatched to the nearest hospital emergency department he could perhaps be diagnosed with ‘compound fractured tibia-fibular disorder’, ‘respiratory distress disorder associated with pneumothorax’, ‘hypofusion, hypotensive disorder’, ‘renal shock disorder’, ‘tachycardia’, ‘endocrine stress disorder’ or ‘post abrasian skin integrity disorder’ etc. Alternatively, such an individual could be seen as (barely) surviving a major physical trauma that impacted on all bodily systems and where particular physical defences automatically became operative from the point of trauma… We can view the survivors of emotionally deprived and severely abusive childhoods as suffering from multitudinous DSM-IV diagnostic entities: post-traumatic stress disorder (PTSD), borderline personality disorder, dissociative disorders, somatization disorder, affective disorder, drug and alcohol related disorders, sexual dysfunction etc., or we can view them as the survivors of a psychological train wreck in which no psychological system was unaffected and in which whatever psychological defences that were available were pressed into service to ensure survival.

Research suggests that while Depression can appear at random without any clear cause, people are certainly more vulnerable to it after experiencing major life stress such as the death of a family member. The trend is easy to chart – the more of these stressors, the more likely it is that someone will develop a major depressive illness. Once again, if we are dealing with situations where most people who experience a sequence of catastrophic life events will develop depression, isn’t the obvious conclusion that depression is a pretty normal and common human response to certain situations?

Then we have the issue of treating emotional pain as a medical problem. Part of what it is to be human is to be capable of being hurt. Those humans who do not ever suffer, never feel fear or sorrow or grief, we have other words for them and they not examples to be lived up to. Yet with our medical model, people in pain can only access services if they have an illness label of some kind, as though to hurt is to be sick. In crude terms, mental health becomes synonymous with being happy, and mental illness with being sad or hurt. This scares me. It is not only normal, but mentally and emotionally healthy to react to certain situations with a deep sorrow, with anguish, grief, fear, and wrenching pain. To be shattered, heartbroken, heart sick, soul sick, desolate and distraught. Happiness in the face of profound loss is not a healthy human response. But the language of mental illness makes it hard to say to someone – there is nothing wrong with you! And here, let me help.

Please don’t misunderstand me, I’m certainly not saying that all mental illnesses are a response to emotional trauma. I’m not suggesting that we leave people to tough it out alone. I’m not saying that the medical model doesn’t fit exactly some of what some people experience. But in situations where people are wounded, not sick, where their reactions are normal, although deeply distressing, and where they are made to feel that there is something wrong with them for simply being human, I’m distressed that we don’t have a language nuanced enough to capture these ideas. The medical model feels to me a little like pleading guilty in return for a chance at parole when you are innocent. People must first self identify as being ill before any care or comfort can theoretically be offered. There are only services for the sick.

If you’ve just come to this page, it will make more sense if you start with part 1. 🙂

Too much emphasis on the physical:

Many people in my position with what seem to be physical illnesses are very upset if a doctor suggests that the condition may be psychosomatic. Sometimes they fight very hard to have the illness considered physical and refuse any approach that is geared to reduce stress or anxiety. When physical illnesses are characterised as ‘real’ and mental illnesses are seen as ‘weakness of character’, faking a problem for attention, or other demeaning ideas, we would all fight to have our problem seen as physical. When you add in issues such as trouble getting insurance for mental illnesses, doctors being dismissive of psychosomatic problems, and an emphasis on mindless optimism in the general culture that says everything is a case of ‘mind over matter’ and if you stay positive you’ll be fine, you can understand why the debate gets pretty heated.

Here’s the downside, even assuming that the condition is a physical one, treatments that aim to lower stress, anxiety, fear, depression and emotional pain will be helpful. Good doctors offer these kinds of treatments to people experiencing all kinds of debilitating physical health problems! If you’re going through cancer, arthritis, or heart disease, reducing stress is a great idea! In my experience, many of the treatments you try for your illness are quite inconvenient or even physically painful. I’ve done detox diets, skin scrubs, and all kinds of things it was hoped would help that actually increased my day to day pain level. Add to that a regular battery of tests, and life becomes pretty miserable.

In my case, I’ve got a fairly high tendency to somatize – that is, I often express overwhelming emotional pain as physical pain or illness. That’s very common for people who’ve experienced chronic trauma and who have dissociative conditions. Sometimes being chronically distressed and disrupted lowers your immune function so you catch everything going around. Other people are very prone to tension headaches or stress-induced skin conditions. Engaging as if these problems were physical actually made me worse, partly for the reasons outlined above, partly because I was always really scared that the next test would reveal something life-threatening, and partly because many of the treatments were geared to get me to ignore or drug my pain. If your physical pain is an expression of emotional pain, than ignoring it can make it worse. It just shouts louder as you try to tune it out. Some people in this situation end up dependent on high doses of pain medication, or symptom swapping, where as they learn to ignore one symptom, a new one takes it’s place. I now concentrate on healthy options that don’t hurt. Walks on the beach, going swimming, eating well, painting. Taking care of myself emotionally helps me give me the strength to manage all my conditions, whatever their cause. If we ignore our emotional well-being we don’t look after ourselves and we get tired and worn out when dealing with issues like chronic pain. Even scarier – if our problem really is psychosomatic, we won’t ever deal with heart of the problem and get better. I work hard now on expressing emotional distress through art, talking, journaling instead of waiting for it to get my attention through rashes, headaches, and muscle pain.

Too much emphasis on the emotional:

Swinging too far in the other direction also has problems. In the extreme, people do a complex blame-the-victim idea that puts the source of all illness squarely in the realm of unresolved emotional conflict. Any of us who’ve lost someone kind, caring, loving, and deeply alive to an illness knows how unfair those ideas are. Assessing all our problems as being psychological also leaves us vulnerable to the development of dangerous physical health problems that go undiagnosed. There is currently a lot of work being done by many people to address this misconception that people with mental illnesses don’t need regular assessments of their physical health. Many physical health issues like hormone troubles, thyroid problems and digestive issues can present like a mental illness. Assuming a psychological problem without proper investigations can leave someone struggling with chronic illness that doesn’t respond well to anything they try, when what they need is an accurate diagnosis and physical treatment. Some people discover they have food allergies or intolerances, trouble regulating their sugar levels, or sensitivity to lack of sleep. People who experience palpitations and chest pain as part of an anxiety issue still need to have their heart health checked! It becomes even more important to check physical health when emotional stress may mask the symptoms of a developing problem.

I’ve had personal experience with this too, I went through a year where I suffered random attacks of acute stomach pain. At the time this was presumed to be psychosomatic, caused by emotional distress. So each time it happened, I would wrack my brains trying to work out what was upsetting me. I would journal or talk about everything I could think of that might be causing such severe pain. Each attack lasted a number of hours before subsiding enough that I could sleep it off. One of them became so severe and lasted so long that I went to emergency. I explained that I’d had an incredibly stressful week and very little sleep so the problem was probably stress. They agreed until blood tests revealed a major infection, at which point I was scheduled for surgery. It turned out that I had been experiencing attacks of chronic appendicitis. The pain was not presenting in a typical way, so no one had thought to run a blood test. My manky appendix was removed and I learned a very important lesson about the dangers of making assumptions when it comes to health!

I hope that this may be of some help to you if you’re trying to work out what’s causing your troubles and how to react to them. Assuming that both physical and psychological factors might be at play may be safest route and treating for both can give you the best chance of quality of life. And don’t let anyone tell you that psychosomatic means it isn’t real!

Is a term that is often used to mean it’s not real. In much the same way that someone presenting with unexplained chronic digestive troubles may be told “You’ve just got depression” when tests come back normal, people with physical pain or problems who have normal test results may be informed “There’s nothing wrong with you, it’s psychosomatic”. Quite understandably, people suffering from chronic, painful physical problems find this pretty hard to take. Using the term psychosomatic in this way is terribly unhelpful and inaccurate. For the person rushed to hospital afraid they were having a heart attack, the news that they are experiencing panic attacks is good news or bad news, often depending on how it is delivered. The good news is that hopefully, their ticker is going well, and they don’t require invasive surgery or procedures. The bad news is discovering they are dealing with a debilitating mental health problem, which can be very embarrassing and stressful. When mental health problems are presented as if they are insignificant, we feel humiliated by how difficult they can be to manage. Sometimes in a very busy medical setting, a diagnosis of a mental health problem is given is very offhand and dismissive way – you’re no longer their problem. This can leave the poor person involved actually wishing they had been having a heart attack! Sometimes people are referred for information and support, sometimes they are just sent home to try and deal with the problem by themselves.

Anyone who has a mental illness knows that just because it’s in your head, doesn’t mean it isn’t real. Your head is actually pretty important and a lousy place for an illness to be! Mental illnesses can be extremely disabling and in sadly too many cases, terminal. Having them treated as if they are less important than ‘real’ physical problems can cause so much distress and embarrassment that people don’t go for help, don’t get support, don’t learn how to manage it appropriately, and become very overwhelmed and hopeless.

I have a couple of chronic health problems that are of unclear origin (as well as others with a clear physical origin). As a result, medical and psych doctors have been debating with enthusiasm whether they are physical or psychological problems. This happens with every health problem while the cause is uncertain. It’s my understanding that tuberculosis was linked to having a type A, driven and high achieving personality until the bacteria responsible were identified. This can cause a huge amount of stress for people with these conditions, as they bounce between specialists with different theories and opinions.

One of the tricky things about health and sickness, is that to some extent, they are both psychosomatic. Now, let me be super clear here – I’m NOT saying that you get cancer because of feeling bitter, or demeaning rubbish like that. But, our emotional state does have an impact on our health. Feelings of grief, fear and anguish can be measured in changes in our bodies. One of the areas we’ve done the most study on is the effects of fear. Because feeling fear is geared to keep us safe, the effects are often really fast. Hormones kick in quickly, we feel changes such as our heart rate increasing, our blood flow restricts somewhat to stay around our brain and vital organs so our hands may feel cold or tingly, energy is diverted away from non-essential functions like digestion, so we feel our mouth go dry. These responses are all geared for the fight-or-flight response so we defend ourselves or get away as quickly as possible from whatever is frightening us. And they could all be called psychosomatic, because they are caused by how we are feeling.

Psychosomatic simply means that the problem you’re dealing with is being caused or exacerbated by your emotional and psychological state, rather than purely physical issues. In some cases, emotional pain is being expressed as physical pain, or psychological blocks are expressed as physical disability. If this happens in a really severe or disabling way, you may be diagnosed with a Somatoform Disorder. If it happens in milder forms, such as sleeping problems, disturbances in your senses, rashes clearly related to emotional distress etc., you may be diagnosed with a Dissociative Disorder. The line between these kinds of conditions is rather blurry and difficult to distinguish. It may be that the psychosomatic disorders are more severe forms of the kinds of distress seen in dissociative conditions, at least in some cases. It’s such a difficult area to make sense of because we don’t know all the causes of physical sickness yet, and because our emotions always impact on our health. Most of us get some kind of physical symptoms when we’re stressed – headaches, back pain, a sore mouth from teeth grinding, flaring of skin problems like dermatitis. On a mild level, that’s a psychosomatic reaction. Most of us have also experienced how our psychological state affects how we cope with physical problems. Have you ever been in pain from a tummy bug or headache and suddenly received some great news? The pain recedes to the back of your mind and you feel warm and happy and like you can cope.

For a while, some doctors thought that people with mental health problems would need less physical care because their issues were psychological. Lately it’s being shown that people with chronic mental health problems often have chronic physical issues that are not being attended to. Some of these are a direct result of the mental illness; for example some people with an anxiety disorder suffer from chronic dry mouth and as a result need extra dental care. Sometimes they are the result of unfortunate side effects of treatment, such as increased cardiovascular problems due to weight gain associated with certain medications. Also, physical health problems can cause mental health problems like depression to develop as people struggle to cope with the demands of chronic pain and disability. So the divide between mental and physical is not very clear. Our head is attached to our body, and stressors and problems in one do affect the other.

part 2 of this discussion can be found here. 🙂

Why bother? Well, self awareness is one the many skills that help you manage life in general. We had a great chat about this at Bridges today. When you’re dealing with something as complex and difficult as a mental illness, self awareness can be one of the keys that help you cope and recover. Learning who you are, how you function, what you need, what keeps you well and what sets off your symptoms are all part of being able to better predict and manage a mental illness. Knowing more about what’s going on for you can help put you back in the driver’s seat. Instead of feeling helpless, overwhelmed, and like the illness is running the show – which it certainly does in those really bad times, you can gather information and feel more like you’re in the driver’s seat. I hope that you may find something useful in my experiences with self awareness.

I confess I have come from a place where I had very little self awareness. I collected information about the people around me, when their birthday was, what their favourite flowers or food were, if they like company when they’re struggling or if they prefer to be left in peace. I was proud of being able to remember all these details so I could tailor how I responded and try to be as good a friend as possible. In contrast, I felt blind to myself, like when I tried to look inside myself everything was in shadow. My head felt full of fog and mist. My mental illness felt totally unpredictable and unmanageable, good days or bad days seemed to come out of nowhere without warning. Nothing made sense to me. I felt like I was in a tiny boat at sea, storms came or went and I just tried to survive.

A few years ago I received the diagnosis of a dissociative condition, and I changed gears. I was desperate to fix the problem and get myself back on track. I firmly resolved to be one of those inspiring patients who faces things squarely, works really hard, and gets everything sorted. I decided that I would be completely cured of my condition within a year.

So, for the first time in my life, I basically made myself my own research subject. Once I started to get past my denial of my mental illness, I studied myself. I looked for patterns. I lay awake at night for hours asking myself questions that I was, frankly, terrified of getting answers to. I wrestled with myself, deeply frustrated and strongly driven to be able to sort everything out immediately. I derailed very quickly. When I faced either driving myself into a suicidal breakdown, or backing off my aggressive approach to self awareness, I realised that what I was doing was actually destroying my ability to function. So, very confused, I backed off a bit and had to re-think my approach.

In my case, I’ve discovered that self-awareness has to be underpinned by two different things. The first is the ability to cope with what you learn. In the case of a dissociative disorder, the dissociation is often playing a protective role. It is buffering you from feelings, memories, information, and awareness that you might find pretty difficult to cope with. So, I was digging around for answers, but also terrified of what those answers might be. This isn’t a great way to learn about yourself. I had a whole bunch of fears about what it meant to have a mental illness: would it be permanent? Was I going to get worse? Could I be dangerous? I desperately wanted information but I was also really scared.

As I read more and educated myself more about my conditions and mental health in general, some of those fears started to calm down. I discovered that mental illness labels are basically a shorthand way for one doctor to communicate with another about the kind of struggles a person is having. No one ever quite perfectly fits a diagnosis, and that’s normal. I spent some time with other people with mental illnesses and found that they were still people. We could find something to talk about, some common ground, some interest or concern we shared. I discovered that statistically, people with mental illnesses are actually less likely than the general community to be violent. My intense fears began to calm down. I learned that there’s a lot of grey area in this field, that sometimes it takes a lot of time to work some things out, that others may never be known. I started to realise that this was going to be a process. I began to engage that process in a more gentle and curious manner, instead of frantic.

The other component to developing my own self awareness has been working on accepting myself. Self-acceptance is another key to recovery, and it’s never been my strong point! I was not treating myself well in the process of trying to learn more about myself. I was harsh, angry, hostile, and contemptuous. I demanded answers to questions, I was furious at the very dissociation that was actually buffering me from overwhelming distress and hopelessness. I was angry at my own weaknesses, driving myself hard to cope better. I would constantly ask myself “what’s the matter with you?”. My self talk was nasty “You’re so pathetic, you’re weak, stupid, ugly, disgusting, no one likes you and they’re right not to”. My self esteem withered and my relationship with myself was like being sandblasted.

I had to develop more compassion for myself. I had to work on building a better, more gentle and caring relationship with myself. Learning about who I am and how I function has been more like tending a garden, or coaxing a hurt animal to care than undergoing a military inquiry. Less about asking the questions and more about just listening to myself. The more I’ve been able to be okay with the answers, and to be gentle with my own limitations, the more I have learned. While I railed and screamed, my mind remained shut tight, closed down. Now, I’ve been slowly able to gather and build up information. I’ve unpicked the dynamics that have fuelled my illness and learned what the keys were to those good days.

Self awareness makes a huge difference to my ability to function. I’ve learned some of my triggers, developed my own grounding kit, learned my early warning signs and what to do about them. This doesn’t mean that I can always prevent the bad days. There’s a lot in life I can’t control, and overwhelming circumstances can bump my stress level past the point I can cope with. But these days I can at least see that coming most of the time. So I set in place strategies – I ask for help, I increase my grounding techniques, I don’t spend time alone if it’s going to be dangerous. It gives me more control to predict and manage my illness and my life. This doesn’t mean it’s something I’m finished with! Still very much a work in progress, and probably always will be. We change, develop, acquire wounds and hurts, and grow over a lifetime. So self awareness is always going to be a process, listening to ourselves and learning our needs, desires, fears, and dreams as they change with us over time.