How robots are helping children with autism


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How robots are helping children with autism

Anthony Arceri is seven and has autism. His clothes are covered in sensors, and he is standing in front of Zeno, a smiling, 2ft-tall robot. “What is your favourite food?” Zeno asks Anthony. “Chocolate milk and french fries.” “I love chocolate milk,” Zeno replies. The robot raises its arm, and Anthony copies. Zeno rubs his stomach, and so does Anthony.

It looks like fun – and for Anthony, it is. But researchers believe the interaction between Anthony and the robot also holds the key to early diagnosis and treatment of autism. Zeno is the result of a collaboration between Dr Dan Popa at the University of Texas at Arlington, Hanson RoboKind, Dallas Autism Treatment Centre, Texas Instruments and National Instruments – and is the brainchild of Hanson Robot owner and former Disney imagineer David Hanson.

Diagnosis of child autism has traditionally taken place through social interaction and speech exercises. This means that, until a child can speak, diagnosis is either a lengthy process, or can’t happen. But Zeno can interact with children through nonverbal communication such as body movements and facial expressions, speeding up diagnosis and perhaps even enabling it to be carried out before a child can talk.

Zeno isn’t just used for diagnosis. Children with autism can sometimes find social interaction threatening – making them withdraw, even from family members. Robots such as Zeno have features that look slightly human, but are obviously not human. This makes communication, with all its complex and frightening subtleties and nuances, less complicated and more comfortable for the child.

Anthony’s mother, Pamela Rainville, found out about Zeno from the Dallas Autism Treatment Centre, and thought the project might benefit Anthony. “It’s always good for him to be put in different situations, things outside his normal routine. Anytime he can be around other people, it’s a good learning and growing experience for him.”

So far, Anthony has had two therapy sessions with Zeno. Rainville believes he got more out of the second meeting than the first, and she expects he will get even more out of subsequent interactions with the robot. “This second time, Anthony fist-bumped Zeno, which was great. It shows he was a little more relaxed.”

Popa believes that Zeno is a good motivator for children as he is engaging and non-threatening: the children listen to the robot. “The idea is for the robot to instruct kids, give them some useful social skills and at the same time observe their reactions and calculate their reaction times. That calculation could form some kind of an autism scale.”

He says there are three ways in which therapists can use Zeno. “The first mode is called a scripted mode of interaction, where you pre-programme a certain sequence of motions. For the second mode, we have added a control system so we can have an operator or therapist control the robot by tele-operations. In this mode, it mirrors the motions of the instructor.”

In the third mode, the child can take control of the robot. “This can be unsafe as the child can do things – such as slap himself – that the robot will copy and possibly break. So we tend to use this third mode as entertainment only.”

Zeno now has a brother, Milo, as well as an international family. Zeno came first, and is used in research and classroom settings. Milo was created specifically to work directly with children. According to Richard Margolin, director of engineering at Hanson RoboKind and part of the team who developed both robots, some children with autism who had never spoken directly to an adult teacher spoke to Milo.

Milo looks very similar to Zeno. His expressive face is an important feature, because a characteristic of autism is the inability to read and connect with the emotions of others. Children are asked to identify the emotion shown by Milo from multiple choices on an iPad. Milo’s eyes are cameras, recording feedback. The child wears a chest monitor that records changes in heart rate and therefore emotion. A typical lesson would involve Milo and a child interacting one-to-one; the child responding to the robot with an iPad, and a therapist or teacher present to help if needed and record difficulties and progress.

One of Zeno and Milo’s international relatives is Kaspar, designed in the UK by the University of Hertfordshire’s Adaptive Systems Research Group. The size of a small child, unlike Zeno and Milo, Kaspar has a neutral expression so that children can interpret him how they wish. Research is under way to see how Kaspar’s use could support children with other developmental conditions, such as Down’s syndrome or attention deficit hyperactivity disorder, known as ADHD.

Another distant cousin is Nao, who was created in 2006 by Aldebaran Robotics and is being developed as a “house robot”. Along the way, Nao has been used as an educational tool, and the University of Birmingham’s Autism Centre for Education and Research worked with Aldebaran Robotics on a version of Nao to help children with autism. But like Kaspar, Nao has an expressionless face.

What seems to be unique about Zeno and Milo is the way that their expressiveness defies long-held robotic conventions. Designed to be the first advanced social robots in the world, they could eventually have an impact far beyond the diagnosis and treatment of autism. RoboKind envisages a broader role for its robots in educating young children. In the words of his creators, Zeno represents the future of robotics and could be “a wonderful addition to every household”.

Doctors’ new prescription: ‘Don’t just exercise, do it outside’


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Doctors’ new prescription: ‘Don’t just exercise, do it outside’

It’s become commonplace for San Francisco physician Daphne Miller to write prescriptions that look like this:

Drug: Exercise in Glen Canyon Park
Dose: 45 minutes of walking or running
Directions: Monday, Wednesday, Friday and Saturday at 7am
Refills: Unlimited

She estimates she has now written hundreds of prescriptions for outdoor activity. “For some reason, it is much easier to keep up a movement or exercise regimen when it’s outdoors,” Miller says.

Perhaps it’s because of the varying scenery, the fact that monthly dues and expensive Spandex outfits aren’t required, or even because of what she calls “the camaraderie of the trail”.

Miller’s not alone. Faced with mounting obesity rates and a stubbornly sedentary population, physicians – especially pediatricians – are refining their exhortations that patients need to get more exercise.

Nationwide, they are dispensing thousands of prescriptions with specific instructions – not just going to a gym, but exercising in nature, at a park, along a trail. They’re literally telling their patients to take a hike.

“This is a lot more than getting people physically active. This is about getting them outdoors,” says Zarnaaz Bashir, director of health initiatives for the National Recreation and Park Association, a group that melds parks, recreation, the environment and now, health.

When terms like “park prescriptions” began popping up in 2008 or so, many experts viewed it as a niche idea.

“It was a quirky, fun play on words. I don’t think a lot of people thought there was going to be much substance,” says Kristin Wheeler, program director at the nonprofit parks advocacy group, Institute at the Golden Gate, in San Francisco. “Now, it’s been validated.”

The number of programs has risen steadily. Officials have identified at least 50 specific programs in the US, Wheeler says, but smaller ones may be under their radar, and new programs are popping up all the time.

The trend is spreading to other countries as well – including Australia, where a conference was recently held to discuss the health and medical benefits the country’s natural parks can offer.

In the UK, doctors are prescribing visits to Green Gyms, outdoor sessions run by a conservation group. The idea is to not only improve health and stamina through exercise and activities, such as planting trees, but also to benefit local green spaces.

A result of the green-prescriptions movement has been the unlikely teaming up of otherwise unrelated groups. The Appalachian Mountain Club, for example, forged a partnership in 2013 with MassGeneral Hospital for Children to prescribe regular outdoor physical activity for children.

“With so many proven benefits to getting active outdoors, AMC can help families take the first step in trying out new activities, finding places to explore, and making these outings fun for kids,” club CEO John Judge says.

An early proponent was Robert Zarr, a physician with Unity Health Care in Washington DC who quizzes patients about their interests, checks a searchable database for information on parks in or near their zip code, and then writes a script for specific activities. He told one obese teen to skip one of the two buses she takes to school and walk through a park instead. She ended up losing weight and feeling happier.

“We’ve really got this down,” he told attendees at a conference last year in Philadelphia. “I see this as no different from prescribing medicine for asthma or an ear infection.”

Across the continent in San Francisco, Miller says she has learned that formalizing her recommendation to get out in nature by writing it as a prescription is highly effective. “Well over 80% of patients try it, and many stick to it,” she says.

Mounting evidence shows benefits of being out and active in green spaces: less tension and stress, lower blood pressure, improved immune system responses, and milder ADHD symptoms in children. Japanese researchers have found that adherents to Shinrin-yoku – “forest bathing” – have lower levels of the stress hormone cortisol than study subjects who walk the same distance in a lab.

Beyond that, simply spending more time outdoors – versus in front of the TV screen or computer monitor – equates to an overall increase in physical activity.

Proponents say the nature prescriptions shift the focus of medicine from illness to wellness, leading to the potential for widespread changes in medical care.

Diana Allen, chief of the US National Park Service’s “Healthy Parks, Healthy People” initiative, is seeing mergers of medical schools and parks programs. “That’s wild,” she said. “I think there are going to be some new fields of practice.”

She acknowledges possible opposition from traditional practitioners and drug companies – “this goes against the money machine.” And patients who simply want to pop pills for whatever ails them also may balk.

Other than the doubtless eye-rolling of some physicians who may view the programs as gimmicky, participants in the Philadelphia conference had more practical concerns. Were the parks they would send children to safe? Would weather be an issue? Would lack of transportation be a barrier?

While early adopters of the philosophy simply leapt in without much of plan – it made intuitive sense, after all – organizers now aim to standardize programs so other communities can basically plug and play.

In Philadelphia, more than two dozen partners, including The Children’s Hospital of Philadelphia, are developing Nature Rx, a comprehensive plan aimed at ensuring that when kids show up at a park to “fill” their prescriptions, the staff is ready to welcome them with specific activities.

Gail Farmer, director of education for the 340-acre Schuylkill Center for Environmental Education and one of the organizers, says park audits will start this spring and physicians will begin writing prescriptions come summer.

Adopting standards also will help researchers who are moving to the data-gathering stage. Is it really working? Do people follow the prescriptions? And does their health improve as a result?

Wheeler has just finished an economic benefits analysis for the parks of San Francisco, which put the figure at $1bn a year.

“A piece of it is what we’ve known for a long time. People prefer liveable, walkable communities,” she says. “The big new piece is health benefits.” Those, they pegged at $50m in avoided health care costs.

Self-harm is not just attention-seeking: it’s time to talk openly about the issue


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Self-harm is not just attention-seeking: it’s time to talk openly about the issue

Three years ago, with her parents and sisters out for dinner, then-13-year-old Lucy found herself alone in her family’s Lincolnshire home. Dressed in her pink Tinker Bell pyjamas, she began to make herself a cup of tea. Then she spotted an object on the kitchen counter that immediately diverted her attention. “Shall I do it?” Lucy asked herself. “Will it stop the pain?”

For Lucy, now 17, that evening marked the start of a two-and-a-half year struggle with self-harm. Two weeks before, she had been brutally attacked and raped (which she now describes as “the incident”). At the time, anxious they wouldn’t believe her, Lucy never fully revealed to anyone what had happened. In her mind, she tried to repress the rape. She began shutting herself in her bedroom. She told her parents she was feeling unwell. Physical pain, she decided, was the only way to purge her pent-up emotional pain.

“When you keep all your problems in, it feels like you’re screaming inside,” Lucy says. “But when you cut or burn yourself, the pain is more physical. You feel like you’re releasing that scream. After a few months, self-harming became part of my daily routine.”

Eventually, both at school or at home, Lucy was self-harming four times a day. She wore black jeans, black tops and even black gloves to conceal her scars. “I pushed everyone everyone away” Lucy says. “I stopped caring about school. My grades suffered. Self-harm became a real obsession. It took over my life.”

Today, having made a huge effort to stop, Lucy has not self-harmed for more than six months. But self-harm is still on the rise among the UK’s young population. Data published last year by a collaborate study from England Health Behaviour in School Aged Children (HBSC) revealed that up to one in five 15-year-olds across the country self-harm. During the past decade, according to the same study, there has been a three-fold increase in the total number of UK teenagers self-harming.

What drives young people to self-harm? Therapist Jenna Mutlick, who has a personal experience of it, says it is usually some form of “self-punishment”. People believe they have done something wrong – even when they haven’t – and then feel they deserve the pain. “I know a few people who self-harm because they are bullied and eventually come to believe that they then deserve to be bullied,” she says. “When you self-harm, it is so hard to escape from the [mental] space that you are in.”

“It’s a very heterogeneous group of people who self-harm, and there are a variety of reasons why people might start,” says Professor Glyn Lewis, head of psychiatry at University College London. “Clearly, there are people who self-harm because they want to take their own lives, but there are also people who want to self-harm because they are in difficult situations or want to relieve stress.

“As a long-term strategy, of course, self-harm is not very effective,” he adds, “but people do report that they get some form of relief from upsetting thoughts or emotions. Some forms of self-harm are obviously very dangerous, but there’s a continuum. Some people may only scratch themselves very superficially, for example, which won’t do any long-lasting damage.”

The causes of self-harm are likely to be complex, even if the person harming does not see the issues in that way. Kieran, from Glasgow, began self-harming after five years of “constant” physical and verbal bullying at school. His parents split up when he was seven, though he says it was the bullying – which still torments him today – that incited his self-harming. “The bullying made me feel really unbalanced,” says Kieran, now 23. “I started to self-harm when I was aged 11, and it kind of just snowballed from there. I stopped eating. I isolated myself from a lot of my friends and family. I kept it a secret for almost a decade.”

Like Lucy, Kieran says that self-harming became a secret obsession. The bullying made him feel “physically and mentally numb”. Self-harm, by contrast, made Kieran feel more alive, and he would regularly self-harm in his bedroom at night. “It brought me out of my slumber,” he says. “It made me feel normal, and I became addicted to doing it for that reason.” He says that the self-harm was like an “adrenaline shot” that brings everything back into focus.”

Kieran admits that he still has a “daily battle” with self-harm. He is significantly better than he was a few years ago, though, when he would harm himself up to 400 times in one evening. “It’s a high level of emotional distress that causes people to resort to self-harming,” he says. “People sometimes feel like they can’t cope with their emotion. It’s how they cope with life’s daily stresses.”

Chris Leaman, from the UK mental health charity YoungMinds, says it is still very much a taboo subject in British society. “Every year, we work with Childline, YouthNet and selfharmUK to try and combat these sort of stigmas for Self-Harm Awareness Day,” he says. “There is a definite problem around young men not feeling like they can talk about their issues, which can make self-harm quite a common issue among them.”

“Some people do talk about self-harm quite openly, but that’s relatively unusual,” says Professor Glyn Lewis. “A lot of people conceal self-harming behaviour from their friends and family. There are not necessarily signs to look out for; it’s more a case of often asking people how they are feeling, and keeping communication open with them. As a rule, families and friends concerned about someone self-harming always should talk to the person themselves and encourage them to seek professional help.”

Statistically, teenage girls are still more than twice as likely to self-harm than young males, and this has helped create another gender-based stigma: that self-harming girls are simply seeking attention. Fiona Brooks, professor of adolescent and child health at the University of Hertfordshire, who led the investigations for last year’s HBSC report, identifies this as a prevalent problem. “Nowadays, young people are in a much more uncertain world than before,” she says. “Instead of self-harming just being dismissed as attention seeking, it’s something that needs to be taken seriously. Equally, if young girls are self-harming for attention, that’s a different matter that needs to be taken just as seriously.”

Lucy thinks back on that evening she started self-harming, and wishes that she could tell herself to stop – and talk to someone. Talking, like with most former self-harmers, has been a significant part of Lucy’s recovery, but she also credits her own determination as a decisive factor. “If you don’t want to stop, you won’t,” she says. “In the end, a lot of it comes down to how you see yourself. I used to feel people were always judging me, but now I feel I don’t care what they think. Why should I let them control my happiness?”

Domestic violence could be stopped earlier, says study


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Domestic violence could be stopped earlier, says study

Victims of domestic violence are abused for almost three years before they get the help they need, and some are subjected to more than 50 incidents during that time, according to a study of the largest database of domestic violence victims in the UK.

The figures from the domestic abuse charity SafeLives reveal that almost a quarter of “high-risk” victims have been to an A&E with injuries sustained during violent abuse, and some went as many as 15 times before the problem was addressed.

Analysis of the SafeLives database, which has records of more than 35,000 cases of adults experiencing domestic abuse since 2009, found that 85% of victims had been in contact with an average of five professionals in the year before they got “effective” help from an independent domestic violence adviser (IDVA) or another specialist practitioner.

“Time and time again no one spots domestic abuse, even when victims and their children come into contact with many different public agencies. It’s not acceptable that victims should have to try to get help repeatedly. This leaves victims living in fear and danger and risks lifelong harm to their children,” said Diana Barran, the chief executive of SafeLives, which was previously called Co-ordinated Action Against Domestic Abuse (Caada).

Barran said the study was “more shocking evidence” that domestic violence could often be stopped earlier. “Every conversation with a professional represents a missed opportunity to get victims and their children the help they need,” she said.

SafeLives estimates that there are at least 100,000 victims at high risk of murder or serious injury in England and Wales, 94% of them women.

The study found that victims and often their children lived with abuse for an average of 2.7 years. Three-quarters reported abuse to the police, and 23% went to A&E because of violence sustained in abusive relationships.

Frances Wedgwood, a GP in Lambeth who provides training on domestic violence to health workers through the national Iris project, said a challenge for doctors was that many women did not come to them to disclose domestic violence.

“Domestic violence is still a very hidden problem and in my experience women do not disclose if they are not asked,” she said. “We need to get better at asking people directly if they need help.”

The study sheds light on the long-lasting impact of living in a family coping with domestic violence. According to the survey, in about a quarter of cases on the domestic violence database the victim has a child under the age of three. The study estimates that 130,000 children in the UK are living with domestic abuse, and that children are directly harmed in 62% of cases.

Among teenagers who suffered domestic abuse in their own relationships, almost half had grown up in households where violence was commonplace, the study found.

Vera Baird, former solicitor general and the current police and crime commissioner for Northumberland, said professionals needed help and training to have the confidence to deal with domestic violence.

“Domestic abuse is not a one-off violent attack. It is deliberate long-term use of coercion to control every part of the partner’s life. Violence, sexual abuse, financial control, constant criticism, isolating from family and friends are all familiar tools,” she said.

“People in that situation do not find it easy to speak and need those who could help to be alert. The alternative is what these figures suggest: victims and their families locked unnecessarily into cruelty and ill-treatment for years.”

Case study

Rebecca, 34, lived with domestic abuse for eight years before she sought help

One time I was having a nap in the afternoon, the baby had been teething so I’d been awake all night, and I woke up he was standing over me with a mop handle carved into a point, like a spear. He was pushing it into my throat, accusing me of cheating. Then he picked me up and threw me against the wall. I ran downstairs but he followed me, kicking and punching me and split my lip.

I locked myself in the bathroom and called 999. When the doorbell rang I heard chatting, calm talking. There was one young male officer, and my ex-partner was telling him that I was postnatal, that I’d gone mental and he was just defending himself. I started shouting at the officer: ‘Why aren’t you helping me?’ I swore and the officer said people could hear me, and it was a public disturbance so I swore again. He put handcuffs on me. He wouldn’t let me put my shoes on, so I wouldn’t move, and he lifted me up by the handcuffs and put me in the back of the car.

I was in a cell for hours asking for a solicitor. The duty sergeant finally came and when he opened the hatch he could see I’d been attacked. He got the officer to come and apologise to me and asked me if I wanted to file a complaint, or if I wanted to press charges against my partner. But I said no. I was exhausted and my baby was at home with my partner, who’d been drinking since the morning. It got worse after that. He was sort of smug, saying he could do what he wanted. I know there’s more training for police now, but that put me off calling the police for years.

By 2003/4 the abuse was worse. We had two girls by that time. I was hospitalised with concussion after he’d kicked me in the head wearing steel-toe-capped boots. The police and the paramedics came and I was patched up and sent home. They asked me if I wanted to press charges but I didn’t want to go through all that, I thought it would make it worse. I didn’t know where the support would come from, where I could get help.

Another time I went to the hospital walk-in. I had a black eye and it wasn’t getting better. A doctor asked me what had happened and I said I’d been punched in the face. He repeated what I said: ‘You were punched in the face.’ I didn’t know what he wanted me to say. I was ashamed, I didn’t want to say my husband did this to me. If he had asked, I’d have told him. But he didn’t.

Social services got in touch because of the paramedics’ reports; he got put on an anger management course. But Christmas Day night he’d been drinking. He grabbed me by the throat and I stumbled and fell; he kept kicking me over and over again. My teeth went through my lip, my nose was bleeding, I couldn’t see. He picked me up and carried me to the bathroom saying: ‘Look what you made me do. Why did you do that?’ I crawled to the living room and phoned the police before he ripped it out of the wall.

I did press charges that time. He was sentenced to four months for ABH. He served two. We were separated, but we got back together. Why? I had such low self-esteem and he was always there, always pestering me, grinding me down. He’d be so nice, helping with the children and I was exhausted, I needed the help. I thought it might be OK.

It was OK for a while. The kids had been on the at-risk register because a couple of incidents had been reported, but they came off that and social services were visiting less. His behaviour just went back to the way it had been before, and that’s when I decided to leave.

I remember the exact moment when I saw the sticker for the Women’s Aid helpline: it was on the back of the toilet door in Asda. It took me a couple of months to call but when I did they offered me refuge. I didn’t even know that existed. They organised transport when he was out. It was quite surreal, but it was such a relief.

Women’s Aid were so helpful, they gave us so much support including counselling. My eldest daughter was seven when we left, her sister was three and their brother was nine months. That was the main reason I left, I was terrified for my kids.

I do think professionals should offer support. If they can’t support victims themselves, they just need to know who can. I think if I’d had that information I would have left earlier.

I was 16 when we got together; he was 23. By the time I was 17 we had a daughter. I thought it was a good relationship, he helped with the parenting and around the house, but about a year later, in 1999, slowly controlling behaviour crept in. He wouldn’t like certain friends, or me going out without him, wearing certain clothes or makeup. It was quite subtle at first, but then when we argued there was pushing, then hair-pulling – each time it was a little worse than before.

Soon it was normal to have slapping, kicking, punching, throwing things. At first I didn’t tell anyone; my self-esteem was very low. I just tried to pretend it wasn’t happening, I didn’t know anything about domestic abuse.

Exporting trauma: can the talking cure do more harm than good?


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Exporting trauma: can the talking cure do more harm than good?

A few years ago Andrew Solomon had to get into a wedding bed with a ram. An entire village, taking a day off from farming, danced around the unlikely couple to a pounding drumbeat, draping them both in cloth until Solomon began to think he was going to faint. At this point the ram was slaughtered along with two cockerels, and Solomon’s naked body was drenched in the animals’ blood, before being washed clean by the village women spitting water onto him.

Solomon had been taking part in a traditional Senegalese ceremony to exorcise depression as research for his book The Noonday Demon. “I discovered that depression exists universally, but the ways that it’s understood, treated, conceptualised or even experienced can vary a great deal from culture to culture,” he says now. He describes being the subject of the ceremony as “one of the most fascinating experiences of my life”.

When in Rwanda, interviewing women raising children born of rape for another book, Solomon mentioned his experience in Senegal to a Rwandan man who ran an organisation helping these women. The Rwandan told Solomon they had similar ceremonies in his country and that the disconnect between the western and traditional approaches to treating mental health had caused problems in the immediate aftermath of the genocide. “Westerners were optimistically hoping they could heal what had gone wrong,” says Solomon. “But people who hadn’t been through the genocide couldn’t understand how bad it was and their attempts to reframe everything were somewhere between offensive and ludicrous. The Rwandan felt that the aid workers were intrusive and re-traumatising people by dragging them back through their stories.”

As the Rwandan, paraphrased by Solomon, puts it: “Their practice did not involve being outside in the sun where you begin to feel better. There was no music or drumming to get your blood flowing again. There was no sense that everyone had taken the day off so that the entire community could come together to try to lift you up and bring you back to joy. Instead they would take people one at a time into these dingy little rooms and have them sit around for an hour or so and talk about bad things that had happened to them. We had to ask them to leave.”

The best way to improve mental health after a crisis is something NGOs working in Ebola-hit countries are currently considering. International Medical Corps (IMC) recently released a report assessing the psychological needs of communities affected by the disease. IMC’s mental health adviser Inka Weissbecker is aware that they must avoid previous mistakes by international NGOs. “Whenever there is a humanitarian crisis agencies flood in,” she says. “Though with good intentions, counsellors turn up from the UK [for example] and often create more problems … It’s a very foreign concept in many countries to sit down with a stranger and talk about your most intimate problems.”

During the recovery from Haiti’s earthquake five years ago mental health researcher Guerda Nicolas was even stronger in her message to American counsellors who wanted to ease the trauma of survivors. “Please stay away – unless you’ve really, really done the homework,” she said. “Psychological issues don’t transcend around the globe.”

The fact is that different cultures have different views of the mind, says Ethan Watters, the author of Crazy Like Us: The Globalization of the American Psyche. “In the west a soldier coming home might be troubled by their battlefield trauma. They think of the PTSD [post-traumatic stress disorder] as a sickness in their mind and they take time away from responsibilities to heal. That makes sense to us and it’s neither wrong nor right but conforms to our beliefs about PTSD. For a Sri Lankan, to take time away from their social group makes no sense because it is through their place in that group that they find their deepest sense of themselves.”

While researching his book Watters spoke to anthropologists who had in-depth knowledge of Sri Lanka’s culture and history. They said that western approaches after the tsunami had done real damage in the country where there were certain ways to talk about violence due to the long-running civil war. He says: “Into that very delicate balance came western trauma counsellors with this idea that the real way to heal was truth-telling, where you talked about the violence and emotionally relived it. That’s a western idea, it makes sense here, but it does not make sense in these villages. It had potential to spark cycles of revenge violence.”

International NGOs describe dealing with the mental health of a community after a disaster as the “psychosocial” response – meaning caring for individual and collective psychological wellbeing. The UN advertises dozens of jobs under this keyword and the American Red Cross says that since the 2004 Boxing Day tsunami there has been “increasing recognition of the need for psychosocial responses”. It also says – perhaps implicitly acknowledging that mistakes have been made in the past – “we are still in the process of identifying and documenting good practices”.

As awareness has grown that the western talking cure is not always the answer, global organisations have tried to find better ways to help. In 2007 WHO issued guidelines to advise humanitarians on their work to improve mental health and psychosocial wellbeing in emergencies. Coordination between the organisations working in the post-disaster zone as a key recommendation. Weissbecker says that this is crucial. “We reach out to organisations who might not know about the guidelines to coordinate,” she says. “It’s part of every agency’s job to watch out for other organisations doing this kind of work.”

The guidelines also stress learning local cultural practices. IMC now always start with an initial assessment that looks at the understanding and treatment of mental health that exists in that country before putting any programmes in place. “We usually don’t provide direct mental health services to the affected population because we feel that most of the time that’s not culturally appropriate and not sustainable,” says Weissbecker. In many communities, she has been impressed with indigenous coping strategies. “In Ethiopia people say depression is related to loss,” she says. “So the community takes up a collection and they all give them something. This is very positive.” IMC meets with traditional healers and builds up relationships with them.

Many argue that for some mental illnesses western expertise can be genuinely helpful. In Ethiopia Weissbecker’s team discovered a man with schizophrenia who had been tied up in a goat shed for seven years. “Once this family was connected to our services he started taking medication was unchained and participating in family life,” she says. “The father held up the chains to the community and said, ‘look I used these chains on my son and now he’s part of the family again’. People will throw stones because they are understandably frightened [of people with severe conditions].”

The Rwandan that Solomon met questioned whether talking therapy helped survivors of the Rwandan genocide. “His point of view was that a lot of what made sense in the west didn’t make any sense to him,” says Solomon. But Survivors Fund, a British NGO that works in Rwanda, has found that western-style group therapy sessions have really helped women who were raped. “It’s 20 years since then but many of the women our groups have never told their story before,” says Dr Jemma Hogwood who runs counselling programmes for the charity. “A lot of women say it’s a big relief to talk,” she says.

Hogwood has been working in Rwanda for four years but hasn’t heard of traditional ceremonies like the one described by Solomon. The group therapy sessions incorporate local practices such as praying before and after, as this is something the women wanted to do. Weissbecker adds that one-on-one therapy with expats can help people who have experienced extreme violence, rape or torture. “Some of them want to talk to foreigners because they don’t trust people in their communities,” she says. “So then it’s also important for them to have that one-on-one option.”

Some feel that aid should be focussed on food, medicines, shelter, and stay away from mental health. International relations academic Vanessa Pupavac has researched the effect of the war in former Yugoslavia, and has argued that “trauma is displacing hunger in western coverage of wars and disasters … Trauma counselling, or what is known as psychosocial intervention, has become an integral part of the humanitarian response in wars.” The problem with this, she believes, is that blanket-defining a whole population as traumatised becomes “a reinforcing factor that inhibits people from recovery”. Her recent work with Croatian veterans found that the PTSD label stops them from moving on with their lives and contributing to society.

“There are more Croatian veterans on post-traumatic stress disorder pensions now than there were ten years ago,” she tells me. “The international-PTSD-framing of people’s experiences has not only inhibited recovery but has also created social, economic and political problems for postwar Croatia.” She believes NGOs should stop psychosocial programmes altogether because they disrupt communities’ own coping strategies.

But this point of view is rejected by Weissbecker and her colleagues, who don’t accept “the romantic idea that without intervention everything will be fine”. The response to mental illness in many countries is often harmful, she says: “Psychotic patients are chained. Children with developmental disorders are at risk of abuse. Mothers with depression have a higher risk of malnourished children. People with anxiety are often given benzodiazepines which can be very addictive.” The solution, Weissbecker says, is to bring together global and local expertise.

The best experts to bridge the gap between international and local experience are those who might not have a health or psychology background, but have deep knowledge about cultural differences: anthropologists. Since the Ebola outbreak there is a growing recognition of this discipline’s role in emergencies. The American Anthropological Association has asked its members to become more involved in the west African countries hit by the disease. It argues that if anthropologists had been more involved from the start of the outbreak more people wouldn’t have caught the disease due to misunderstandings over traditional burials and conspiracy theories about westerners spreading the illness.

Médecins Sans Frontières (MSF) has employed anthropologists to inform their work for years but one of them, Beverley Stringer, says there’s been a “surge” in interest in what they can offer humanitarian work. “I was at a seminar at the Royal Anthropology Institute recently where they said ‘finally the humanitarian world is interested in our perspective’,” she says. “They’re quite excited about that.”

But Stringer warns that getting anthropologists to work for NGOs should not just be a case of parachuting in an expert; aid workers and volunteers on the ground need to recognise that their own experience gives them insight. “If mums aren’t coming to get their kids vaccinated you don’t need to be an anthropologist to work out why,” she says. “My work is to encourage curiosity and to equip teams with the skills to be able to understand.”

Whether it’s through working more with locals and anthropologists – or ideally both – there is recognition that cultural insight is essential for preventing aid workers from causing damage when they are trying to do good.

“I think enlisting the anthropologists in this process – people who truly know about how to go into other countries and be culturally sensitive – is very important,” says Watters.

“One anthropologist asked me to imagine the scenario reversed. Imagine that after 9/11 or Katrina these healers come from Mozambique to knock on the doors of family members of the deceased to say ‘we need to help you through this ritual to sever your relationship with the dead’. That would make no sense to us. But we seem to have no problem doing the reverse.”

What they don’t tell you about dementia


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What they don’t tell you about dementia

My mum doesn’t know who I am. Sadly, I don’t mean that in an angsty way – she literally has no idea who I am. Sometimes I’m her sister. Sometimes I’m her dead mother. Once I was Shirley Bassey, which made for an interesting evening. My mum was diagnosed with dementia with Lewy bodies three years ago, when she was 64 and I was 30. She’d just retired, and we were looking forward to spending more time together.

I’d spent my 20s doing my own thing, having selfishly assumed that we’d have lots of time to get to know each other properly when I got bored of clubbing. I was wrong. Instead of visiting coffee shops, we ended up visiting the memory clinic. After months of appointments we were finally sent home with a diagnosis, an information leaflet and a six-month review booked in to see how we were getting on. I imagine it’s a bit like going home with a newborn baby, but with less support and no balloons. Having previously struggled to even take care of a houseplant, I was fairly apprehensive at the prospect of becoming a carer.

As mum’s dementia progressed I came to realise that despite all the meetings, visits and consultations you have to go through to even get to the diagnosis, nobody actually tells you about the reality of this horrendous disease. They don’t tell you how to deal with your previously gentle mother swearing at you, or that she’ll hit you around the head as you desperately coax her into the bath. Neither do they tell you what sort of nappies to buy when she becomes incontinent, let alone how you’re supposed to persuade her to wear one or stop her taking it off and stashing it in a pillow case. I thought I might be changing nappies at some point in my 30s, but I didn’t imagine it would be like this.

They don’t tell you about the hours of bureaucracy and meetings with social services that you have to trudge through, when what you desperately need is some advice and support. They don’t tell you that it takes six months for them to assess whether you’re entitled to even get on the waiting list for advice and support. They don’t tell you what to do when she thinks that the small boy you pass on your walk is her grandson, and tries to talk to him. Nobody tells you how to placate the angry parents who think they’ve encountered the world’s frailest child-snatcher. I had no idea what to say to the helpful passerby who insisted on intervening because he’d mistaken her having a meltdown in the street for a geriatric kidnapping.

They don’t tell you how to deal with the crushing realisation that she’s never going to phone you again, let alone see you get married or be a grandmother to your kids. Nobody tells you how to channel the anger you feel that your fellow thirtysomethings’ lives now involve marriage, mortgages and children, and yours revolves around a terminally ill, confused old lady who doesn’t even know who you are. They’ve chosen their responsibilities; you’d give anything not to have yours.

They don’t tell you that once she nears the final stage you’ll spend hours desperately trying to feed her a spoonful of hospital jelly even though she’s pretty much given up on eating, because you can’t just watch her starve to death. It doesn’t matter how distraught you are that she’s wasting away before your eyes, or how much it upsets you to agree to the doctor’s request for a DNR order; this disease is relentless in its cruelty.

Dementia has robbed my mum and me of the time we were supposed to have, and I’m still not sure how to feel about it when there’s nothing tangible to mourn. “Waking grief” – that’s what someone called it. When the person you knew is gone, but not gone. But it’s not. It’s a waking, sleeping, relentless cloud of despair that never quite goes away, even when you think you’re OK. But then nobody tells you how to grieve either, do they? Especially when there’s no funeral to go to, just an endless stream of pointless review meetings.

My battle with depression and the two things it taught me


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My battle with depression and the two things it taught me

It’s often said that depression isn’t about feeling sad. It’s part of it, of course, but to compare the life-sapping melancholy of depression to normal sadness is like comparing a paper cut to an amputation. Sadness is a healthy part of every life. Depression progressively eats away your whole being from the inside. It’s with you when you wake up in the morning, telling you there’s nothing or anyone to get up for. It’s with you when the phone rings and you’re too frightened to answer it.

It’s with you when you look into the eyes of those you love, and your eyes prick with tears as you try, and fail, to remember how to love them. It’s with you as you search within for those now eroded things that once made you who you were: your interests, your creativity, your inquisitiveness, your humour, your warmth. And it’s with you as you wake terrified from each nightmare and pace the house, thinking frantically of how you can escape your poisoned life; escape the embrace of the demon that is eating away your mind like a slow drip of acid.

And always, the biggest stigma comes from yourself. You blame yourself for the illness that you can only dimly see.

So why was I depressed? The simple answer is that I don’t know. There was no single factor or trigger that plunged me into it. I’ve turned over many possibilities in my mind. But the best I can conclude is that depression can happen to anyone. I thought I was strong enough to resist it, but I was wrong. That attitude probably explains why I suffered such a serious episode – I resisted seeking help until it was nearly too late.

Let me take you back to 1996. I’d just begun my final year at university and had recently visited my doctor to complain of feeling low. He immediately put me on an antidepressant, and I got down to the business of getting my degree. The pills took a few weeks to work, but the effects were remarkable. Too remarkable. About six weeks in I was leaping from my bed each morning with a vigour and enthusiasm I had never experienced, at least not since early childhood. I started churning out first-class essays and my mind began to make connections with an ease that it had never done before.

The only problem was that the drug did much more. It broke down any fragile sense I had of social appropriateness. I’d frequently say ridiculous and painful things to people I had no right to say them to. So, after a few months, I decided to stop the pills. I ended them abruptly, not realising how foolish that was – and spent a week or two experiencing brain zaps and vertigo. But it was worth it. I still felt good, my mind was still productive, and I regained my sense of social niceties and appropriate behaviour.

I had hoped that was my last brush with mental health problems, but it was not to be.

On reflection, I realise I have spent over a decade dipping in and out of minor bouts of depression – each one slightly worse than the last.

Last spring I was in the grip of depression again. I couldn’t work effectively. I couldn’t earn the income I needed. I began retreating to the safety of my bed – using sleep to escape myself and my exhausted and joyless existence.

So I returned to the doctor and told her about it. It was warm, and I was wearing a cardigan. “I think we should test your thyroid,” she said. “But an antidepressant might help in the meantime.” And here I realised, for all my distaste for the stigmatisation of mental illness, that I stigmatised it in myself. I found myself hoping my thyroid was bust. Tell someone your thyroid’s not working, and they’ll understand and happily wait for you to recover. Tell them you’re depressed, and they might think you’re weak, or lazy, or making it up. I really wanted it to be my thyroid. But, of course, when the blood test came back, it wasn’t. I was depressed.

So I took the antidepressant. And it worked. To begin with. A month into the course, the poisonous cloud began to lift and I even felt my creativity and urge to write begin to return for the first time in years. Not great literature, but fun to write and enjoyed by my friends on social media. And tellingly, my wife said: “You’re becoming more like the person I first met.”

It was a turning point. The drug had given me objectivity about my illness, made me view it for what it was. This was when I realised I had been going through cycles of depression for years. It was a process of gradual erosion, almost impossible to spot while you were experiencing it. But the effects of the drug didn’t last. By September I was both deeply depressed and increasingly angry, behaving erratically and feeling endlessly paranoid.

My wife threatened to frog march me back to the doctor, so I made an appointment and was given another drug. The effects have been miraculous. Nearly two months in and I can feel the old me re-emerging. My engagement and interest is flooding back. I’m back at work and I’m producing copy my clients really love. Only eight weeks ago, the very idea that I would be sitting at home tapping out a blog post of this length on my phone would have made me grunt derisively. But that is what has happened, and I am truly grateful to all those who love and care for me for pushing me along to this stage.

And now, I need to get back to work. Depression may start for no definable reason, but it leaves a growing trail of problems in its wake. The more ill I got, the less work I could do, the more savings I spent and the larger the piles of unpaid bills became. But now I can start to tackle these things.

If you still attach stigma to people with mental illness, please remember two things. One, it could easily happen to you. And two, no one stigmatises their illness more than the people who suffer from it. Reach out to them.

You needn’t be wrong to be called delusional


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You needn’t be wrong to be called delusional

It’s not clear who forcibly sedated her in 1972. It’s not certain that she was admitted to a psychiatric ward in the following year. What’s definite though is that many people thought she was mad as she ranted about conspiracies in the White House during eccentric phone calls to the press. Questions about Martha Beall Mitchell’s sanity were encouraged by the Nixon administration, who consistently briefed against her and probably had her medicated against her will. But ultimately her claims were proven correct when the Watergate scandal broke.

Mitchell was the wife of the US attorney general and saw the planning and cover-up of the Watergate burglaries first-hand. In retrospect, her seemingly paranoid claims made sense and, in her honour, Harvard psychologist Brendan Maher named the Martha Mitchell effect after her to describe the situation where someone is incorrectly diagnosed as delusional but turns out to be right.

But, contrary to popular belief, the relationship between madness and truth is a complex one. They are made out to be strangers but often they are more like distant cousins.

This relationship has recently been acknowledged with the publication of the new version of the psychiatrists’ diagnostic manual (the DSM-5) where one of the most interesting but less noticed changes has been the redefinition of the delusion, a symptom that has long been considered the “basic characteristic of madness”.

Delusions, in the medical sense, are not simply a case of being mistaken, as the everyday use of the term suggests. They are profound and intensely held beliefs that seem barely swayed by evidence to the contrary – even to the point of believing in the bizarre. My heart has been replaced by steam. My thoughts are being stolen by satellites. The government communicates with me through birdsong.

But many delusions are not outlandishly eccentric, they are simply implausible. Consider the scenario where people believe that their neighbours are conspiring against them or that they are the subject of a film star’s secret affections. Occasionally, these beliefs turn out to be true, but this is not a reliable guide to whether someone is delusional or not. This was memorably illustrated by the psychiatrist Andrew Sims, who warned in his psychopathology textbook Symptoms in the Mind that spouses of people with delusions of infidelity may occasionally be driven to infidelity. This romantic betrayal does not suddenly cure their partner of their mental illness.

The general idea is that delusions represent a problem with how you believe – that is, a problem with forming and changing beliefs – not a problem with what you believe. In other words, simply believing something strange or unusual should not be considered a problem but having “stuck” beliefs that are completely impervious to reality suggests something is mentally awry.

On the ground, mental health professionals are often required to decide if someone’s thinking indicates a disturbance in their understanding of the world, and this is where the new DSM-5 definition of a delusion may usher in a quiet revolution in psychiatry. No longer are psychiatrists asked to decide whether the patient has “a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary”. A wordy and unhelpful definition that has so many logical holes you could drive a herd of unicorns through it.

Instead, the new definition of delusions describes them as fixed beliefs that are unswayed by clear or reasonable contradictory evidence, which are held with great conviction and are likely to share the common themes of psychosis: paranoia, grandiosity, bodily changes and so on. The belief being false is no longer central and this step forward makes it less likely that uncomfortable claims can be dismissed as signs of madness.

And this is where the larger issue lies. As happened with Martha Mitchell, claims against authorities are often dismissed by suggesting that the person has mental health problems.

History is littered with such examples but sadly there are enough contemporary cases to illustrate the point. In a controversy currently rocking Germany, evidence of money-laundering at a big bank has become a huge scandal, not least because it was dismissed as delusional seven years ago when the accuser was diagnosed with mental illness.

Closer to home, when the NHS whistleblower Kay Sheldon reported failings in the Care Quality Commission, the first response was to suggest she had a mental health problem and to commission a psychiatric assessment.

I have no idea whether these people had mental health difficulties but it should have had little bearing on how seriously their concerns were taken. The fact that their claims could be dismissed by allusions to poor mental health is part of the unfortunate stigma that still surrounds the issue. But the stigma goes both ways, and assuming people do not have mental health difficulties because they are correct is the flip side of this.

In the years after Martha Mitchell had been dismissed as delusional, it emerged, contrary to her claims, that she was under the care of her own psychiatrists, drinking heavily and, at times, suicidal. Nixon, for his part, said Watergate would never have happened if it wasn’t for Martha. Both believed that mental illness would undermine her credibility. History, however, came down on the side of truth.

When intensive care is just too intense


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When intensive care is just too intense

I still remember the first patient I saw in intensive care. A naked man, covered by a white sheet, was plugged into banks of machines through cables that radiated from his body. His face was covered by a breathing mask, his blood connected to bags of fluids. Muted and voluntarily immobile, so as not to break the fragile web that kept him alive, his eyes tracked me as I entered the cubicle. Intensive care can be a disconcerting place.

As a treatment, it is remarkably successful. Perhaps the greatest tribute to the people who work in critical care is this simple fact: most people leave intensive care alive – despite being dangerously close to death when they arrive. Through a combination of dedication, decision-making and technology, critical care staff ensure that most people pull through. This is the result of years of careful research that has focused clinical practice on restoring the body’s functioning as quickly and efficiently as possible.

But recently there has been a dawning realisation that the impact of intensive care extends beyond the survival of the body. Dorothy Wade is based at University College Hospital in London and is one of the country’s few intensive care psychologists. She led a recent study which found that more than half of patients assessed at follow-up had marked psychological difficulties. “We learned that patients were suffering from serious depression or having frightening flashbacks and nightmares to their time in intensive care,” says Wade. “This badly affected their quality of life and also held back their physical recovery from their illness.”

In another study, recently submitted for publication, Wade interviewed patients about the hallucinations and delusions they experienced while in intensive care. One patient reported seeing puffins jumping out of the curtains firing blood from guns, another began to believe that the nurses were being paid to kill patients and zombify them. The descriptions seem faintly amusing at a distance, but both were terrifying at the time and led to distressing intrusive memories long after the patients had realised their experiences were illusory.

Many patients don’t mention these experiences while in hospital, either through fear of sounding mad, or through an inability to speak – often because of medical breathing aids, or because of fears generated by the delusions themselves. After all, who would you talk to in a zombie factory?

These experiences can be caused by the effect of serious illness on the brain, but painkilling and sedating drugs play a part and are now used only where there is no alternative. Stress also adds to the mix but is often caused inadvertently by the way intensive care wards are organised. “If you think about the sort of things used for torture,” says Hugh Montgomery, a professor of intensive care medicine at UCL, “you will experience most of them in intensive care. As a patient, you are often naked and exposed, you hear alarming noises at random times, your sleep-wake cycle is disrupted by being woken up for medical procedures through the night, you will be given drugs that could disorient you, and you will be regularly exposed to discomfort and feelings of threat.”

This has led to a recent push to reorient treatment toward reducing patient stress, and long-term psychological problems, without sacrificing life-saving efficiency. Take this simple example: a study led by consultant critical care nurse John Welch at UCL found that the pitch or tone of alarms on intensive care equipment has no relation to how urgent the situation is. Many frightening-sounding alarms are just reminders – this bag needs refilling in the next hour; don’t forget to change the filter – and are often left until more important tasks are finished. But, to the uninitiated, it might sound as if death is imminent and no one is responding.

Some stress is simply an unavoidable part of necessary medical procedures. Breathing tubes inserted through the mouth or surgically implanted through the neck are notoriously uncomfortable. And, despite the survival rates, people die in intensive care. A daunting experience if you’re a patient in the same ward.

Helping patients with their intense emotional reactions, whether they arise from hallucination, misunderstanding or medical intervention, normally happens on an ad hoc basis and for many clinicians it is a relatively new situation that hasn’t been incorporated into standard training. In many intensive care units, the approach was to sedate patients for the whole of their admission. As this practice declined, for the first time, clinicians were faced with distressed, possibly hallucinating, awake patients.

Wade is currently working with clinicians to take a more systematic approach to detecting and reducing psychological distress. “There have always been experienced or just naturally empathetic nurses and doctors in intensive care,” she says. “We’re trying to build on that natural care and compassion by teaching nurses and doctors more about the causes and nature of psychological distress… and training them with simple psychological techniques that could help to reduce immediate and long-term distress.”

For his part, Montgomery is less convinced about early intervention. He feels intensive care needs to be reorganised to reduce stress but psychological problems are best dealt with in follow-up clinics.

The best time for treatment is the subject of an ongoing debate, but for the first time studies have been funded that will answer these questions. Intensive care is being rethought and may become, at least psychologically, less intense.

Don’t worry, be happy: overcoming worry may be key to mental health


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Don’t worry, be happy: overcoming worry may be key to mental health

Are you weary of “new year, new you” positive thinking exercises? Tired of trying to feel Tiggerish in the cold, dark, midwinter mornings? Why not try this quick experiment to redress the balance. All you have to do is imagine that something great has happened in your life: maybe you’ve run into an old friend; perhaps you’ve been promoted at work; or you’re about to head off on holiday. Now ask yourself what could go wrong. In what awful ways could it all fall apart? What disastrous chain of events might unfold? Don’t think solutions, think problems. Open the worry floodgates and allow yourself to be swept away.

As you’re likely to discover when you attempt this depressing little exercise, with a sufficiently negative outlook even the happiest moments in life can become a source of anxiety and stress. When we worry, we become preoccupied with an aspect of our lives, desperately trying to anticipate what might go wrong and what might happen if it does. Although we might believe worry is constructive, actually all it usually does is lower our mood. And when we start worrying it can be difficult to stop.

So worry can be an immensely powerful psychological mechanism, but might it also be a defining factor in the development of mental illness? Can studying it deepen our understanding of what mental illness is, how it comes about, and how it differs from psychological health?

As you’ll know if you read about the hoo-ha following publication of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the number of officially recognised psychiatric disorders has mushroomed in recent years, and now stands at around three hundred. That giant total has attracted a lot of criticism – and with some justification – but in fact many of these conditions are pretty similar. It is better to think instead of three main groupings of disorders: internalising (most commonly, depression and anxiety); externalising (addiction, for instance, or anti-social behaviour problems); and psychosis (with its characteristic symptoms often bracketed under the label of schizophrenia). However, even these three broad groupings share many of their causes, which has led some researchers to speculate that underlying and unifying all mental illness may be a single cause: the so-called “p factor of psychopathology”.

At the social level, we know that poverty, isolation, and negative life events all elevate the risk of mental health problems. But when it comes to the psychological p factor, there is increasing evidence that it may be excessive worry. When worry gets out of hand, it now appears, a very wide range of mental health problems can follow in its wake.

This kind of “transdiagnostic” approach represents a major shift in the way we think about worry. Traditionally, problematic worrying has been demarcated as a specific condition: generalised anxiety disorder. And in that box it has remained. (The exception to this rule is depression, for which persistent worry about the past is a recognised symptom. But it’s not called worry: it’s called “rumination”. “Worry” is defined as anxious thinking about the future.)

Yet real life seems to show a lamentable lack of respect for systems of psychiatric classification. Rather than being a separate disorder, excessive worry has been shown to play a significant role in the development and persistence of paranoid thinking, post-traumatic stress disorder, alcohol and drug dependence and insomnia. It has also been linked to the incidence of eating disorders.

The idea that many psychological problems have excessive worry in common seems plausible. As most of us know from bitter experience, worry brings the most unlikely – and unpleasant – ideas to mind, keeps them there no matter how hard we try to shake them off, and convinces us that the events we dread really may happen.

If persistent worry is potentially so damaging to our mental health, what can be done to combat it? Interestingly, we tend to worry less as we grow older. People aged 65-85, for example, report fewer worries than those aged 16-29. But besides simply waiting for the years to pass, the evidence is strongest for an adapted form of cognitive behavioural therapy. This relatively brief, one-to-one treatment is based on a detailed model showing how problematic worry is caused, maintained and overcome. Patients are helped to notice when they’re worrying, to interrupt this habitual thinking style, and then try alternative ways of reacting to life’s problems.

So far this kind of CBT has mostly been used with people suffering from generalised anxiety disorder. A recent meta-analysis of 15 studies, for example, showed that CBT was far more effective than other therapies (or than a non-treatment control) at helping people recover from generalised anxiety disorder and stay well.

But it is now beginning to be piloted for other conditions – the Oxford Cognitive Approaches to Psychosis Group, for example, is testing its efficacy in severe paranoia.

How does CBT tackle worry? For one thing, it helps people to re-evaluate their beliefs about its benefits. Like many of us, individuals who are prone to excessive worry tend to assume that it helps them. They may believe, for instance, that worrying helps them to anticipate and solve problems; that it provides the motivation necessary to tackle those problems; or that it prepares them for the worst if a solution can’t be found. They may even feel that by worrying about an event they can prevent it occurring – despite realising that it’s pure superstition. Learning to challenge these kinds of beliefs can be a huge step forward.

CBT also teaches us to confine our worrying to a regular set period of 15 minutes or so each day. When worrying thoughts arise at other times, the trick is to save them for later and let them go. “Expressive writing” can be effective too: you describe your worries in as much detail as you can, focusing on what it feels like, and resisting the temptation to analyse what’s causing your thoughts. And don’t underestimate the power of distraction: work out when you’re most likely to worry and plan a pleasurable, absorbing activity you can do instead.

Many of CBT’s techniques for tackling worry are not rocket science: with the right guidance we can all put them into practice. By doing so we’re not merely sparing ourselves hours of futile fretting. If excessive worry is truly the p factor it seems to be, we’ll also be addressing one of the key determinants of our mental health.


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