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MH17

When I was 21 years old I started a 6 month placement on an acute mental health ward. I was inspired and enchanted by many of the people I met.

There was a small elderly woman on the ward who had been admitted because she was having a manic episode. Apparently she had spent thousands of pounds within a few days and had been smoking over 100 cigarettes in a day. She ended up collapsing on the ward after a few days because she was having difficulty breathing.

Whilst on the ward, staff encouraged her to ration her cigarettes and monitored her physical health closely. Staff also kept her credit card in the safe and supervised her when using it, because otherwise other patients would take advantage of her generosity.

After a couple of weeks her manic episode appeared to subside and she became fairly depressed. She was put on to medication to help improve and stabilise her mood and then discharged. Whilst in the community she was monitored by the Home Treatment Team and her family. Thankfully they were very supportive and kept staff informed whenever her behaviour changed.

alexisstone55:

Worth a read, especially as it’s ME awareness day on Thursday…

Originally posted on Dead Men Don't Snore:

The other night as I switched on the TV I encountered the following exchange on the sitcom Benidorm:

“My mother’s got MS.”

“Sometimes think I’ve got that.”

“You think you have MS?”

“Yeah, sometimes. I read about it in a magazine. A lot of people think they’ve got it don’t they?”

“Do you mean ME?”

“Oh, I don’t know. Which is the one where you can’t be arsed to do owt?”

“I think you mean ME.”

“ME, MS, it’s all lazy buggers cracking on there’s something wrong with them, in’t it?”

Now I would hazard a guess that many MS sufferers found that joke amusing, safe in the knowledge that most people recognise MS as a genuinely debilitating disease, but many people with ME will not have been laughing. This is not because ME sufferers can’t take a joke, but because they know that many people watching that episode will…

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MH 15

When I was 21 years old I started a 6 month placement on an acute mental health ward. I was inspired and enchanted by many of the people I met.

There was an elderly patient on the ward who used to spend most of the day in bed. He rarely spoke during the day apart from a few whispered replies. However, around 8pm every day he would start to come out of his room and approach staff. Each time he would say over and over ‘I am evil, I am evil, I am evil’. Staff would reassure him that he was a good man and then usher him back to bed. Within about 5 minutes he would be back again, saying the same thing. Sometimes it would last until the early hours of the morning. Staff tried on several occasions to determine why he thought he was evil but he never elaborated on his statement.

The Psychiatrists were continually debating his condition and whether he might have a form of dementia. By the time I left the ward they were transferring him to an older adult ward.

INSIGHT copy

A homeless man came to the Substance Misuse Service for assessment. He reported struggling with alcohol use, depression and suicidal thoughts.

I completed the assessment, which took about an hour. We discussed why he’d come in, his substance misuse amounts and frequency, previous convictions, social issues and housing, family (especially details of any children who may be at risk), mental health, physical health, prescribed medication, etc. It also involved completing a risk assessment (eg risk of self neglect, suicide, harm to others, etc) and an initial care plan.

It was important to use Motivational Interviewing skills to during this assessment to encourage change. I’ll explain this in more detail later.

At the end of the assessment, he was asked to complete a urine drug screen and breathalyser.

His assessment indicated that he was physically dependent on alcohol. This means that if he stopped suddenly then he would be at risk of having a seizure (and in some cases people have died from this). I therefore advised him to keep drinking, especially if he was starting to experience shakes, and that he would have to reduce the alcohol gradually (generally by 10% every couple of days).

I discussed his assessment with the rest of the multi-disciplinary team (nurses, psychiatrists, social workers, occupational therapists and psychologists) at the allocation meeting. The client was assigned to the alcohol drop in service; this meant that he would come in once a week during drop in hours for motivational interviewing. After a couple of weeks I was then assigned as his keyworker and continued to work with him on a one-to-one basis.

The aim of Motivational Interviewing was to develop a discrepancy between the person’s current situation and where they want to be. By heightening their ambivalence you can encourage change.

One technique I used is the decisional matrix. This involved asking the client to identify the advantages of staying the same, the disadvantages of staying the same, the disadvantages of changing and the advantages of changing. It was helpful for the client to see that there were many more positives to changing, compared to staying the same.

Another technique was to ask the client to rate their current physical/mental health on a numerical scale and then ask them what it would take to increase that rating by 1 or 2 points. This encouraged the client to think of ways of changing. By coming up with the suggestions himself, he was more likely to accept them compared to being told by someone else. For example, he is more likely to accept his own suggestion ‘I guess I would feel better if I quit smoking’ compared to me saying ‘you should quit smoking’.

It was also important to use the elicit-provide-elicit technique when providing information in to avoid resistance. This is where you ask the person what they know about a topic, then ask permission to give them a bit more information about it, then afterwards elicit it again by asking them how they understand what you’ve just told them.

Throughout the session I used summaries to emphasised the reasons he had given me for wanting to change and encourage ‘change talk’. I also used reflections to manage any resistance. For example, when he stated ‘my family keep nagging me about my drinking’, I reframed it by reflecting ‘so you’re family care about you a lot and are concerned about you’. Or when he stated ‘I’ve tried treatment before and it hasn’t worked’, I reframed it as ‘you’re persistent because it means a lot to you’. You can also used amplified reflections, for example if a client stated ‘I don’t want to give up methadone’, you could amplify it by reflecting ‘so you want to stay on methadone for the rest of your life’, in order to get them to acknowledge ‘well, no I guess not’.

Through Motivational Interviewing I was able to support the client to gradually reduce his alcohol use, to the point where we were able to put him on the waiting list for a detox. I explained that the Detox was the easy part and the hard part would be remaining abstinent when he comes back out again, back to the same situations, places and people. It was therefore important to have some Relapse Management sessions (based on Cognitive Behavioural Therapy) before the Detox.

The Relapse Management sessions involved using Socratic dialogue; informational questioning, active listening (using reflections), summaries and analytical questioning. In analytical questioning you ask questions that will help the client come up with the answers themselves eg ‘on the one hand you say that you think alcohol will help but on the other hand you say that you feel depressed afterwards; how do you make sense of that?’ will lead the client to realise ‘I guess it actually doesn’t help’.

We also focused on identifying and adjusting his automatic thoughts, underlying assumptions and core beliefs (see previous blogs on CBT for an explanation of this). I explained to him that his thoughts and evaluative judgements mediate between stimuli and his emotions or behavioural response. It is not the event that makes him feel depressed but his evaluation of the event; for example, thinking that not being able to get him a job makes him a failure.

He was repeatedly asked to rate on continuum scales (see previous blog) and keep a positive data log as homework. We looked at goal setting and problems solving as well as how to manage high risk situation (eg if in situations with alcohol present), crisis plans (for what to do and who to contact if at risk of drinking) and lapse chains (to determine factors contributing to any lapses he has). I also explained to him the difference between lapses (one or two instances of previous behaviour) versus relapses (going completely back to the previous behaviour) and explained that lapses don’t have to lead to relapse.

Along with the one-to-one therapy sessions, I was responsible for completing continual risk assessments, focusing on the suicidal thoughts and any protective factors. I assessed if they were constant or fleeting and whether he had any intent or plans.

I was also responsible for helping him find housing by writing a letter to the council, helping him find employment by referring him to our employment specialist and liaising social services regarding his daughter. We always inform social services if a child is involved. I explained to him that, although many people worry about social services finding out, they will actually see the engagement in treatment as a good sign because you are getting help. They will always work with families to try and help them and only take children away as a last resort.

I also encouraged him to join in with the service’s groups, including the gardening group, so that he could meet other people in recovery and start engaging in pleasurable activities again (people with depression often cut these activities out of their life over time).

After a successful Detox, he went to rehab. When I left the service he had been sober for 3 months, had improved mood, no suicidal thoughts, had found housing and was completing training (to improve the likelihood of employment). I was glad that I was able to see the case through, as often I have to leave the placement half way through working with someone. It was rewarding to see how far he’d come.

alexisstone55:

Worth a read

Originally posted on Living Well With Depression:

Today I’ve been reflecting on how surviving a mental health crisis-event is “simply” about making more good decisions than bad ones.

Yesterday, I was struggling. I don’t mean the usual lack of energy, feelings of intense worthlessness, and so forth; yesterday was about feeling completely overwhelmed, puncturing the skin in grief, watching the pain well up, and trying desperately to gather frayed threads of will to live. Yesterday wasn’t about detached contemplating the misery of life; it was snot, mess, shame, and trying to contain tsunamis of emotion.

Things were not good.

How did I make it through the day without committing an irredeemable act? Looking back, I see that I made more positive choices than negative ones. OK, there was a considerable amount of self-harm, and I spoke a little too openly to a relative on the phone – something which might come back to bite me later; those…

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cbt

I recently had a course of IAPT for depression/perfectionism. I thought I’d share the handout I was given with you incase any of you find it helpful.

Understanding depression

Symptoms of depression:
– Depressed mood: feeling hopeless/miserable/irritable/numb/empty.
– Losing interest and enjoyment in previously enjoyed activities.
– Self-criticism and guilt.
– Pessimism.
– Hopelessness.
– Loss of energy.
– Reduced activity.
– Withdrawal from social activities.
– Difficulty concentrating.
– Memory difficulties.
– Changes in sleep patterns.
– Changes in appetite and weight.
– Loss of interest in sex.
– Thoughts of death (If you are having thoughts about suicide, get professional help as soon as possible)

Myths about depression:
‘Nothing bad has happened to me, there’s no reason I should feel depressed. It must be my fault’.
Reality: It can be hard to understand why you feel depressed but a psychologist can help. Depression is not your fault.

‘Depression is biological – there’s nothing you can do about it. Only pills can make a difference’.
Reality: Depression does appear to have biological factors and medication helps many people. However, therapy can also be very beneficial by helping you make changes in the way you think and behave.

‘Other people can cope with worse things happening to them without getting depressed. I must be weak’
Reality: A lot of people may appear to be coping, when really they’re struggling too. Also, it is important to remember that feeling you cannot cope is a symptom of depression.

‘I should be able to just snap out of it’
Reality: If it were this simple, no one would ever be depressed. Vast amounts of money is poured into mental health resources because it is recognised that people can’t just snap out of it. Talking in a constructive way has been shown to help a lot of people.

‘Why should I take medication? It won’t help change the things that make me depressed’.
Reality: Medication can help improve your mood and help you cope with your problems in a different way.

Links between thoughts, emotions and behaviour

Your thoughts and evaluative judgements mediate between experiences and emotions/behaviour.

Situation: Lose job
Certain life experiences can make people more likely to develop depression. However, not all people with these problems get depressed- it depends on their evaluative judgements of the event.
Thoughts: ‘I’ve failed. I’ve let my family down. I won’t get another job now’
Even if something bad happens, there are a number of different ways of thinking about it. John could have thought ‘well, that was unfair but I’m sure I’ll find another job- maybe even something I like more’. People with depression tend to see things in a way which is harsh, self-critical, unfair and unrealistic. With thoughts like ‘I’m a failure’ it is understandable that John should feel low.
Physical changes: Can’t sleep. Poor concentration. Loss of appetite. Fatigue.
Depression has many physical symptoms, which can in turn have a big impact on people’s behaviour.
Emotions: Sad. Disappointed. Depressed.
Once people start to think in a negative way, their feelings naturally follow. Once the negative emotions start, they make it more likely that people’s thinking will become negative, leading to a vicious circle.
Behaviour: Withdraws from friends and family. Stops doing hobbies. Stays in bed.
Often people with depression are withdrawn, stop caring for themselves, have problems with everyday tasks and have less involvement in rewarding activities.

All of these are connected and influence each other, often leading to vicious circles. It can be difficult to manage but it can also mean that making positive changes in one area, can lead to changes in others.

Steps to start tackling your depression.

Get going again.

When people feel depressed they often start doing less, including stopping activities they previously enjoyed. This can then make them feel worse.
Step 1: See what you’re actually doing by keeping a diary or using an activity monitoring sheet. Rate each activity in terms of achievement and enjoyment.
Step 2: Make a list for yourself including involvement with family and friends, Self-care, Personally rewarding activities and Small duties (eg paying bills).
Step 3: Pick your goals: Pick 2 of the activities (preferably from different areas) that you listed that are the most practical for you to start doing now.
Step 4: Make SMART goals: They should be Specific, Measurable, Achieveable, Realistic and Time specific.
Eg instead of ‘I want to eat more healthily’ you could say ‘I want to eat 2 pieces of fruit every day for 2 weeks’
Step 5: Carry out your goals: Keep a record of how you’re doing and reward yourself. This can be hard because when people are depressed, they tend to focus on the things they haven’t done and ignore or downplay their achievmenets. Deliberatiely remind yourself of what you’ve done.
Step 6: Review your progress: Are these activities having a positive impact? Do you want to increase your goals slightly?
Are you struggling with them? Do they need to be more specific or manageable?

As your energy starts to come back you will be able to do more and more. The most important thing is to start moving, no matter how slowly. When you feel ready start adding another smart goal.

Negative thinking and depression.

Our evaluative judgements of an lead to low mood, rather than the event itself. For example, if someone walks past you without saying hello, the evaluative judgement ‘they must be angry with me’ would leave you feeling bad, whereas the evaluative judgement ‘they must be really busy’ wouldn’t. Either judgement could be true but people with depression tend to focus on the most negative one.
The first step is to start becoming aware of these thoughts. Try to note down the situation, negative thought and emotions (rate each one in terms of intensity).
Find alternatives: For each negative thought, try to note down a more adaptive one. Then rate your emotions again. It is important to do this repeatedly if you want to see change. It is not enough to do it once or twice if you want to start breaking the habit of negative thinking. Here are some questions that might help you come up with some more fair and realistic thoughts:
– What evidence do I have for this thought?
– Is there any alternative way of looking at this?
– How would someone else think about this situation?
– Am I thinking in all-or-nothing terms?
– Am I forgetting relevant facts?
– How will things be in X months time?
Preparing for trigger situations: There will be situations in your life which make it more likely for negative thinking to occur. Look back over your thought records and try to make a list of the top 3 situations. In future when you find yourself in these situations try to be aware of any negative thoughts and think of alternatives.

Recognising the positive

People with depression often ignore positive events and focus on negative things that happen.

Step 1: Keep track of good things that happen. Make a record of everything, no matter how small. Even if it’s just that you got out of bed today.
Step 2: Reward yourself for things you do manage. Eg go for a walk in the sunshine or spend 30 minutes watching your favourite program.
Step 3: Get a more positive view of yourself:
Make a list of as many positive characteristics you can think of.
If you’re struggling then ask friends and family to make a list for you.
Or think about what bad characteristics you don’t have eg I’m not rude.
Try to carry the list with you and look at it when you’re feeling low.

Also remember

Physical activity can help. Frequency is more important than duration. Pick activities you enjoy.
Sleep is important for mood. Try to have a set bedtime and rising time.

Perfectionism

Identifying Over-evaluation of achieving
Most people evaluate their self-worth based on a variety of things, such as their relationships, hobbies, leisure activities, achievements at work, and other abilities. Their self worth pie chart could include 11% social life, 15% money, 21% family, 6% body shape, 8% job, 6% travel, 11% sport and fitness, 11% future goals, 6% partner and 5% community.

Perfectionists tend to judge their self-worth based almost entirely on achieving their unrelenting standards. They overvalue achieving and achievement. They may have other interests, but over time these seem to take a lesser place in their lives. This system of self-evaluation may have developed through particular life experiences and/or positive reinforcement from people around them. People who try hard and are successful are often rewarded by others so achieving can become equated with being hard-working, conscientious and intelligent- in short, being of worth.

Perfectionists come to believe that they are only of worth if they are pursuing or achieving the high standards they set for themselves. Activities involving achievement take up a very large part of their pie chart, and become overly important in their lives. They begin to judge their self-worth largely on their ability to achieve. Their self worth pie chart could include 9% sport and fitness, 9% studies, 7% friends, 11% family and 64% achieving at work.

They often focus on one area of their life giving them all of their self-worth. This is very risky as any problems in this area will then lead to the person judging themselves negatively and think they are of no value. They are therefore putting a huge amount of pressure on themselves to make sure that it works out. That’s why it’s not surprising that perfectionists tend to be very focused on achieving the high standards they set themselves. It is also not surprising that they often feel stressed, irritable, depressed, anxious and guilty, and think negatively about themselves. When a goal is achieved they may feel relieved but they don’t tend to feel happy for very long. In fact, perfectionists tend to dismiss their success (‘I was just lucky’) or conclude that the standard set was too low (‘anyone could have done that’) and re-set the standard higher for next time.

Work and education take up most of my pie chart. Try drawing your own one and see if it’s balanced or unbalanced.

To expand your self-evaluation across different life areas. For each of these areas, think ‘Who do you want to be in these areas? What do you want to do in these areas?’

My social life
My work/education
My finances
My emotional health
My relationship with my partner
My relationship with my children
My relationships with my close friends
My relationship with my parents/siblings
My contribution to the community
My spiritual life
My valued pastimes and hobbies
My fitness and physical and nutritional health
Etc

Then identify goals for some of these areas by looking at
The changes I want to make:
The most important reasons I want to make these changes are:
The steps I plan to take are:
I will know the plan is working if:
Things that might interfere with my plan and how I will overcome them are:

MH21

A young man was admitted to the ward in a catatonic state. He appeared to be unable to move, eat, talk or respond in any way. He was immediately put onto medication and a nutritional supplement. Staff regularly tried to engage him in conversation and support him with basic tasks, but there was little progress until they took him to the Creative Group.

The group involved drawing and painting while listening to music. Within a few minutes of being there the catatonic man began to respond to the music. His hand was tapping along to the beat and his head began to move too. With each session he responded more and more to the music, until he was moving most of his body and making eye contact with others.

At the same time his engagement outside of the group began to improve and he began to eat with support from staff. He occasionally had lapses, where he would return to his catatonic state, but on the whole he seemed to be doing well. He even got up to say goodbye to me when I finished my placement on the ward.

MH 8

When I was 21 years old I started a 6 month placement on an acute mental health ward. I was inspired and enchanted by many of the people I met.

There was a woman on the ward who was several months pregnant and experiencing Puerperal Psychosis. This mostly presented in the form of paranoid delusions; she believed that people were trying to kill her.

Her medication had to be carefully monitored because of her pregnancy and she was kept under close observation to make sure that she was safe.

After about a month it emerged that the expectant mother had been forced into marriage by her aunts and that her relationship with her partner might be abusive. Staff therefore had a difficult time trying to determine which of her reports were the result of her paranoid delusions and which were actually true.

The safety of the expectant mother and her baby were discussed at great length in safeguarding meetings, involving staff from all disciplines. It was decided that she would be sent to a mother and baby unit when the baby was born, so that staff could monitor her condition, her ability to care for the baby and her relationship with her partner.

The expectant mother eventually gave birth to a baby boy. I was on duty at the time and supported her through part of the labour; this was difficult because at times her psychosis was so bad that she didn’t even realise she was pregnant. It was hard to convince her to stay in bed.

After the birth she was transferred from the acute mental health ward to the mother and baby unit. I worked a few shifts at the new unit about a month later and was pleased to see her progress. Although there were still some concerns about the nature of her relationship with her partner, she was no longer experiencing delusions and was being supported by staff to care for the baby.

MH 5

When I was 21 years old I started a 6 month placement on an acute mental health ward. I was inspired and enchanted by many of the people I met.

We had a very charismatic patient on the ward, who always dressed in white clothes and wore a white band around his head. He believed that he was the messiah of all the religions and went out of his way to preach to people and spread his story.

He also believed that his ex-girlfriend’s dad had implanted a device in his head, which he desperately wanted removed. He explained that he got nose bleeds a lot and that this was a side effect of the device.

One day he met two other people on the ward, who also believed that they were the Messiah. It was interesting to listen to them talk together and express surprise towards each other. After the conversation I approached him to find out if talking to the others had made him question his delusion. He simply stated ‘those other people are crazy….they all think they’re me’.

One of my favourite memories of him is when he got out his guitar and played songs in the corridor to cheer up all of the patients. Several of them joined in singing and I could tell that it was the highlight of their day.

ME management

I have had ME/CFS since 2005. During that time I have tried various ways of managing it, including seeing specialists. I thought I would share some of their recommendations, incase it’s helpful to anyone else.

Initially I was put on a mixture of supplements designed to boost my immune system. It involved taking 90 tablets a day at specific times. The mixture was designed by Dr Petrovic (I dislike the ‘curative’ claim on his website but the link is there if you want more information).

When my Mum had ME/CFS and my Brother was ill, they both found the mixture helpful. It’s hard to know if the improvement was due to the tablets or just the natural course of their conditions.

When I tried it, it just made me feel sick. My Gran had the same experience when she tried it during her recovery from cancer. We later found out that Dr Petrovic had changed the mixture since my Mum and Brother had used it, which may be why it had a different effect on us.

After that I went to see an ME/CFS specialist/neurologist called Professor Leslie Findley, who is based in Essex/London. I think he may be retired now but I’m not sure. He put me on to NADH, which helps with the energy cycle, and weekly B12 injections, because apparently people with ME/CFS don’t use B12 very efficently. He also gave me citalopram (which is a SSRI antidepressant), which is apparently helpful for ME/CFS at low doses. It’s hard to know how helpful these were because my ME/CFS fluctuated a lot anyway.

He referred me to a physotherapist, who focused on the muscles in my neck and back. They were very tense and contributing to my headaches and migraines. I found the physiotherapy very helpful but it would only last for a couple of weeks and then my muscles would be very tight again.

He also referred me to a dietician and occupational therapist, who recommended that I eat small starchy foods every 3 hours, try to break up activities into smaller tasks, pace myself, have a regular daily routine especially bed time and avoid caffiene and alcohol. The lifestyle recommendations were helpful but hard to stick too. I’m such a perfectionist and workaholic that it’s hard to pace myself.

He also recommended CBT, but I had already had a course of it for the depression.

Someone recommended the Lightning process, but I’ve never tried it so I have no idea if it’s any good.

At University I met with student support services and had a disability assessment. They provided me with a disability allowance, posturite chair, dictaphone to record lectures, extra time in exams and allowed me to do my exams on a laptop.

Recently my parents got a wheelchair for me, which I use on days out to avoid walking too far and wearing myself out. I would definitely recommend this as it means you can still go out and be involved in family trips. The Red Cross are usually fairly helpful if you want to borrow a wheelchair.

Anyway, I think that’s all that I can remember. Good luck with your recovery and feel free to comment if you have any recommendations.

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