Back after a Blog Break

Apologies for the long gap between blog posts of late. And for also deleting a previous post – something I’ve not done previously, as far as I remember. An explanation for both is needed!

First, about the break. I’ve started to get a couple of my comment pieces published online. This is fantastic – however, a few caveats. I’m not getting any editing work, and the number of hours that go into an article isn’t commensurate with the pay (who’d have thought?).

I’ve had three articles published in online newspapers/journals, and two of these were on paying sites (well that’s what they’ve promised). Of course two paid gigs do not a writing career make!

If the editing work starts back up (and it’s usual for me to have gaps, especially at the beginning of the financial year) then it would be a nice little combination – the writing satisfying the creative genie, the editing work channelling the left-brain-dominated control freak (and paying much better per hour).

But it is great for my confidence. Truth is it couldn’t have happened earlier.  I just wasn’t ready. I can’t help wanting to use the word ‘maturity’ at this point, which is a bit sad considering that I’m 51 years old.

Blogging alone has helped develop my writing – just doing it – but the willingness to bend my own concerns to the needs of the journals just wasn’t there earlier. Getting my point across in 800 words or less? Where did these people get off? Any subject I was interested in required at least 2500 words.

Now I am slowly developing the art – not unlike haiku, or any kind of poetry – of making my points succinctly. After a while you realise that it actually takes less time to write a short article than a long one, so it’s an advantage.

But it’s bloody exhausting in a way that blogging is not.

Now about the little um blog entry deletion. Self-censorship? Perhaps.

The entry was about the revolution underway in the mental illness treatment community. These changes are both exciting and controversial. (As an aside, there doesn’t seem to be a consensus in the psychiatric community at the moment about what causes mental illness, and this in itself is all at once interesting, promising and disturbing.)

I originally started the article before moving house in May, and then other concerns intervened. When I went back to it a few months later I didn’t really think the issues through before completing and publishing it. Much of the impetus had come from reading the book Anatomy of an Epidemic and the blog Mad in America.

But the issues that these changes bring up are challenging and potentially life changing for many people. As someone with OCD, who is always concerned about the effects her writing may have on others, I’m more aware now of the caution that it is preferable to exercise when covering this area.

I’m probably overly cautious, but that’s my hang up – the internet is scary in its ability to disseminate information, and change the way people behave, very quickly. When it comes to mental health, that makes writing about it a big responsibility.

The other thing that made me pause for thought was that the health system in Australia is so different from the American one. The Australian system is a chaotic hotchpotch of public and private services, and everything in between, while the US system is, in my understanding, almost completely controlled by health insurance companies.  It’s quite possible that there is more mismanagement and a greater reliance on drugs in the US, and therefore much more angst among consumers. In fact in Australia some of the new approaches, such as peer support, are being adopted by mainstream services, which is very exciting.

This doesn’t change the fact that the public system in Australia is desperately under resourced. My impression from the limited reading I’ve done is that psyche hospitals, which should be soothing, welcoming havens for recovery, are for the acutely sick only, and that after being stabilised on drugs you get kicked out quickly, leading to a revolving door syndrome for those without adequate community support (there are good community services available in some areas, but I’m not sure how comprehensive these are, and they are in flux right now).

The other problem is that I don’t find myself in either of the major narratives – the biological idea of illness and the anti-psychiatry push. Not that the anti-psychiatry movement denies the existence of acute mental suffering at all. It's just that for me, labels themselves aren't the problem - it's the kinds of treatments that they too often give rise to which need monitoring and review.

Anyway I am not going to weigh into any debates for the minute. I am very interested in writing about  new treatments, but my OCD is a factor that I need to take into account. Still, it is an exciting time that may well lead to a synthesis of the best of old and new treatments.

And whether my other writing leads to a new 'career' is something that only the future can reveal!

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Going off SSRI Medication – Pros and Cons

The following is my personal experience. Please make decisions regarding SSRIs with your doctor and any other trusted helpers. If you are tapering off antidepressants, please do it slowly.

I took the SSRI antidepressant Luvox (very imperfectly) between October 2012 and November 2013. I wanted to write some thoughts about this experience, and how I've been feeling since going off it.

Drugs are powerful things that change the workings of the brain and involve significant psychological risk. Depending on your condition it may be risky not to take them, and it may be risky to go it alone during the period when you first start taking them or when you are tapering off. This article gives no recommendations or advice. It is simply my experience. But it seems fraught to even write about that experience; drugs, for all their nuisances and imperfections, can save lives in the short and medium term, and sometimes the long haul.

For some people being on drugs, despite the side effects, turns out to be inevitable if they are to have any long-term peace or sanity. I may yet turn out to be one of those people. Then again I may not. For me at the moment, the process is important. I need to add that some of what appears to be recklessness (taking myself off Luvox last December) is partly because I had had previous experience with it and knew it was a drug I could safely wean myself from. Other drugs (and physiologies) may not be so forgiving. Also the dose I was on was very low, so it was never a case of having to wean myself off a high dosage.

Trying Luvox for the second time in 2012–13, I was a lot more self-aware; I don’t remember many of my reactions the first time around about a decade earlier. Adjusting to the drug the second time around was difficult, and ideally I should have been ‘babysat’ for the first few weeks of the new regime. This is something doctors seem unforgivably ignorant about. People going on SSRIs should be told to expect to feel very strange for a couple of weeks and to have a support system in place, even if it’s just someone to check in with by phone on a daily or twice-daily basis.

Doctors would also do their patients a real service if they checked for a history, say, of impulsive behaviour. Someone with such a history might need very close monitoring if going on a new SSRI.

First impressions

I was in the worst throes of OCD when I first started taking the drug, and the relief of those first few weeks is still sweet in my memory. What Luvox seemed to do for me was get rid of my obsession with embarrassing social interactions and mulling over possible interpretations of what I had said, done and thought. Everything was suddenly in perspective again. My brain grew still, and what a wonderful stillness it was.

But only weeks after my system had adjusted to the drug, difficulties emerged. There’s no doubt in my mind that it affected my work adversely. The silence in my brain seemed to result in a reduced ability to ‘take in’ the outside world, to grasp facts, and my memory was also affected. Now, that’s not to say it would do the same for most people; I have multiple food intolerance, low blood sugar and an incredibly sensitive system. As well, I’ve always been a bit slow on the uptake, and obsessively aware of this tendency.

My job as a freelance editor meant it was absolutely vital to be alert. I developed an elaborate system of moderating the dose if I was doing a particularly demanding job. I wouldn’t recommend this; it worked up to a point because my intuition is very finely tuned (I’ve spent years developing it) and because the jobs were short term. But it was a very unhealthy way to be, playing havoc with my moods – risk-taking behaviour for the sake of my work. I began to wonder what my brain would be like without the drug.

Deciding to quit

After about 11 months on Luvox, I noticed something that made my heart sink – it wasn’t helping with the OCD as much as it had been. In my newly quietened brain, the scary thoughts were starting to reassert themselves. One option was to increase the dose, but I was scared of turning into a zombie. Without really consciously deciding, I tapered the drug in November and December and by January was completely off it, and it began to leave my system entirely. As I was doing this I researched other SSRIs and found a new one, Lexapro, that seemed to have far fewer side effects. Early in January I was notified of a three-week full time job that would take place about mid-February. I decided to do the job drug-free, and to try Lexapro afterwards.

Without the drug in my system, my OCD was almost unbearable for a few weeks. This suggests I was taking a significant risk not switching straight to another drug. The only thing that kept me going was the thought that in a few weeks or months I would be trying Lexapro.

Having said that, I had time to work through some of my OCD issues. I did a bit of research and got a much better understanding of what I was up against. I gradually developed a more detached approach – no longer identifying with the OCD thoughts as much. Some of the fears and dreads that had banked up while I was on Luvox were gradually reduced, though never dispelled completely.

I have come to understand the difference between OCD ‘spikes’ when the thoughts come, and the ruminations that follow. I now have some post-it reminders near my computer screen about how to deal with the OCD. One of them says to accept the thought-spikes, and go on calmly without reacting to them; but to avoid the ruminations, which are much more voluntary than the spikes and more of a habit (the compulsive part of OCD).

But if I had had less of a long-range view I could have been in a serious situation. I am fifty now (it sounds so ancient!) and the brain as it gets older can take a very long-range view. So I consider what I did not to be recommended.

Back to the future?

One thing that was important to say was that some of the brain changes that took place while on the SSRI seem to have remained, to some extent. This suggests that short-term use of SSRIs could allow for behavioural changes (for example taking social risks) that, through brain plasticity, could remain do-able after the drug is no longer taken. For example, I am still able to sit through a two-hour Grow meeting, even though I only went to my first Grow meeting when I was already on SSRIs.

The meetings are harder though, and my social fears can produce some nasty spikes. Some of the ability to stay in the meeting is because I am very familiar with the majority of members. But I now have to make concessions to my fears; for example, I have been known to change seats if I felt where I was sitting was too prominent.

It became clear to me as the drug completely left my system that my general shyness was returning; Luvox had remained more effective in dealing with that than it did with the OCD. I find it hard to look other people in the eye and my OCD fears are worse.

The low-level depression I’ve gradually developed in the last 15 years has also returned. It’s certainly not the kind of depression that makes it a struggle to get out of bed, but the kind that means I’m always just on the verge of tears. And if I’m not sad I’m angry and having mini-tantrums where I throw my pillow to the floor and silently curse the great god of Destiny or Fate, the inescapability of Things As They Are. I can’t decide if this depression is the result of my lifestyle or something I’d have anyway – possibly a bit of both.

Here are the things I’m doing to counter all this:

• a few minutes mindfulness meditation as soon as I get up
• abdominal breathing exercises in front of telly every day
• free tai chi class in the park once a week
• dancing to some music with the blinds down in the lounge room most days
• about three times a week, some yoga stretches and muscle-building exercises
• University of the Third Age courses
• writing lots of poetry!

 What’s dropped out is the walking around the oval of my local park – must get into this again.

At this point, I'm not as desperate as I was before about trying out the Lexapro after the Big Job. I am basically monitoring the situation. A friend of mine who recently went off Lexapro said that he believed one of the side effects of antidepressants was 'an inability to love'. I smiled wryly at this, because while that kind of numbness could be incredibly frustrating – I couldn't always cry when I needed to, for example – in social situations it could be wonderfully freeing for me, supersensitive as I am to every tiny perception that passes through me.

So, I'm not sure what I'll do ultimately – the situation is fluid. In the meantime I am enjoying my greater brain power, trying to look after myself, and keeping a watching brief.

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Back from the Brink

For the last four months or so I’ve been going slowly downhill. Not surprisingly my blog has reflected a growing distance from self. Sometimes it is impossible to write about something when you are in the midst of it, because you actually lose sight of what is happening.

Insight is a strange beast. When it comes to my evaluation of my own illness compared with those of other sufferers, it seems everyone else is genuinely suffering but me. I’m not mentally ill at times like this, just a mass of self-loathing surrounding a collapsed ego. There is no me left to say ‘Don’t worry – you’re just having an attack of whatever it is’.

And when I emerge into the light, and find that self again, the eternal self that hid from me, I wish I could provide a magic thread from that knowledge to the collapsed me so that the collapsed me would always know that the real self would emerge sooner or later.

I still don’t know if this latest outbreak is caused by OCD alone or from low-level OCD with, say, GAD and depression thrown in. But who cares? It’s my unique version of room 101 and my psyche cannot seem to let me off the hook.

Now that the antidepressants are kicking in, I look back and realise that I have been playing around with them almost from the very beginning. Still in thrall to the idea that they would harm both my short-term functioning and the long-term ability off my synapses to fire up. All I know now is that without drugs my brain is not a nice place to be any more. It’s a murky, guilt-wracked quagmire of morbid fears and misplaced connections. I wouldn’t wish my worst enemy to live there, let alone me.

With drugs, in contrast, my brain is like one of those characters in a 1950s Alfred Hitchcock movie - you know how in those movies everybody, even the extras, is so controlled as to seem to be obeying some invisible, internalised authority? Clip-clopping along in their hats and trench coats to whatever official or unofficial desk or meeting they're due at next. Even the crims - especially the crims - seem obsessively organised in Hitchcock movies.

I have a lot of vague hope right now – hope in my brain’s ability to renew itself, partly through chemical means but also through natural means – physical exercise, emotional support and perhaps some kind of mental exercise.

I picture a profound healing medium. It is an electric liquid, inkily reflective yet not wet – when you immerse yourself in it, it parts like a curtain. It is thick and dark but also ice-clear, not murky. A substance not of this earth but constituting it. A mysterious medium that renews and reawakens the essential self. Perhaps picturing this in my brain is helping me to move towards whatever healing the world might be able to bring.

If you enjoyed this blog entry, you might also like New and Improved Version? Or Slightly Nutty Does Drugs and Tiny Steps up the Mountain: Exposure and Social Phobia Recovery.

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A Pill Popper's Progress

Please note: the following is my experience only and is not advice about whether or not to take antidepressants. If you are experiencing any serious side effects from pharmaceutical drugs, including suicidal thoughts, contact your doctor or a close family member immediately.

Now that Christmas is over and I have time to breathe I can finally catch up on this neglected blog. It's more than three months since I started taking an antidepressant for the first time in ten years – and probably the first time that I was capable of handling the side effects and waiting for the worst ones to stop. It's high time for a progress report!

I'm taking only 25 mg of Luvox a day, a miserly dose compared with the allowed daily maximum of 300 mg. Being incredibly sensitive to anything I put into my system, I can't imagine what I'd be like on the full dose, apart from comatose – I'd probably make a zombie look like an ADHD sufferer. So even on my tiny 25 mg I'm declaring the experiment a success. This amount is enough to take the edge off my fears and obsessions, to the extent that I can perform certain social feats, and I've totted up a few triumphs that are improving my quality of life. Then there's the relative freedom from obsessional thinking that was becoming more and more debilitating.

On the minus side, there are continuing side effects that won't go away. I consider the trade-off worthwhile but they are significant enough to warn me off a higher dose. As well, despite my progress, the basic structure of my social anxiety is still intact.

The graces

When I started taking Luvox, I was amazed at how quickly I noticed positive change (I know what you're thinking – the placebo effect!) and how quickly life itself seemed to respond to my improved resilience.

Reduction in OCD

The most quick-acting and lasting effect of the Luvox has been a reduction in obsessional thinking – a low-level form of OCD, I'm now convinced. My obsessional fears about people and groups have been par for the course for decades, and in recent years I'd developed a mild body dysmorphia that had me examining various body parts in the mirror in an attempt at reassurance that instead led to horror whenever I discovered some shocking new flaw. But I hadn't realised just how debilitating my OCD had become until my latest periodic fixation reared its head yet again – stains on clothes.

Every now and then, an incident in which a piece of clothing was ruined by an irremovable stain – oil is a common culprit – would spark an obsessional fear that all my clothes, as well as sheets, doona covers and so on, were or would become irrevocably stained. Everything else shrank in the face of that possibility and I would wonder how civilisation was at all possible with this ever-present threat, and how people with children managed to afford to clothe them, when surely the little blighters would be routinely ruining everything they wore (I'm still amazed at the temerity of anyone who wears white, including brides!). I'd had a couple of these attacks when I started to realise they might actually signal the OCD that I'd been wondering if I had.

The strength of this fear in me is a good measure of my obsessional thinking in general, and Luvox has quietened these fears. When a loved piece of clothing stains, I still get upset but it no longer signals the arrival of the four horsemen of the apocalypse. I still obsess about people and social situations, too, but less so.

Reduction in social anxiety

Work has been an area of giant strides. Two days in a row – try to imagine the angst – I had to drive out to different locations to meet clients I'd never met before (well, I didn't have to – but with the drug in my system I was willing to give it a burl). Both of these involved long drives to locations of varying familiarity with all sorts of fears of doom and dark forebodings going on beforehand.

Having the two meetings in the same week created an accidental curve of therapeutic exposure. Upping the ante even further, both happened to be male clients, which I find far more anxiety-provoking than female. The second one was far harder than the first, connected as it was to my main copywriting client.

To top it off, I actually went into the workplace of a long-standing publisher client and worked in-house for three days – three whole days! While this was a triumph, there's no way I could have sustained it – or would even have wanted to. But to be able to actually achieve some work while in the company of others, and to say hello and interact with people I hadn't seen for a couple of years and had communicated with mostly by email was a huge boost to my confidence.

In all these scenarios the drug didn't take away the fear but it took away the worst of the physical symptoms. Having fear is strange on an SSRI like Luvox. To an extent your body and mind still perform their usual, rusted-on routine (mind conjuring up social catastrophes while stomach churns and somersaults) but there's a numbness there too, a sense of detachment, as if you know you're bluffing and there's a fair chance you might actually be alright. The first time around on Luvox in 2001, I remember telling a friend it was like having a platform underneath me for the first time, whereas before in social situations I was always falling into the cellar of my unconscious terrors. This time around it sometimes feels as if the drug is holding me, keeping me steady. It's like a good fairy or a guardian angel.

The other triumph is that I'm now attending a mental health group that meets on a weekly basis. We sit in a circle in the front room of a forties Tudor-style house converted to the group's office in a middlebrow suburb about fifteen minutes' drive from my place. I can't say I go every week – sometimes work forbids it – but the exposure has been incredible. The meetings go for two hours, way too long for someone like me, and my usual habit of homing in on 'scary' people is still there, but the Luvox allows me to stay put and work through this (touch wood – as I become more familiar with the group members, it actually becomes harder for me).

Better sleep

I'm also sleeping better. Nothing seems that pressing any more that I can't eventually get to sleep. My dreams are clearer too, vivid and fun to interpret in the morning, although they fade quickly after I wake.

The curses

Here are the side effects of Luvox that have continued into my third month on the drug. I can't speak for others – I suspect some of my symptoms are to do with have a dodgy immune system and a sensitivity to common food chemicals rather than being typical side effects of the drug, but I could be wrong.

Memory

My memory isn't as good on Luvox. For example, I struggle to remember what is on telly that evening after checking the guide online (the litmus test for me of good working memory). The other thing is reading. Depending on the level of detail, I struggle to recall much of what I've read even after a few paragraphs. Non-fiction, with its endless new names of players and organisations, is much worse than fiction. Part of this, I tell myself, is low blood sugar. There's no doubt the drug makes me even more susceptible to blood sugar fluctuations than I was previously.

Being more careful with my diet would definitely help. My weekend treats, mild as they are (rice cakes, tomato and hummus; cashews) result in greater tiredness, even exhaustion. So I need to indulge less, and this is difficult.

However, it not's all bad where memory's concerned. Having a quieter mind in some ways increases my ability to focus (although I can be a bit slow on the uptake), so I suspect in some ways I might be retaining some information better, especially the kind that occurs in conversation.

Digestion

There is evidence that SSRIs can disrupt the workings of the digestive system. I don't know whether this is related, but I have a permanently bloated stomach. (I've heard people complain of putting on weight while on anti-depressants, although I haven't put on a pound, probably because I'm on such a strict anti-allergy diet.) On the other hand my body image issues are reduced on Luvox, so the slightly distended tummy isn't such a terrible thing now I've got used to it.

Numbness

Unlike many on SSRIs, I mostly enjoy the relative emotional numbness I feel on Luvox. It's preferable to the combination of disassociation and depression I used to feel. I still feel just as concerned about the fate of the world, and the suffering of humans and animals, but the concern doesn't make me feel as unhappy and unsettled as it did in the past.

However, the reduced sexual response that is a common effect of SSRIs is also my experience, and this is where numbness (not just sexual but emotional) can become a burden.

Future possibilities

While Luvox alone is helping me, combining it with therapy would enable me to get the maximum benefits.

As I've said, Luvox blunts rather than removes my social anxiety. For me there are two aspects: the performance itself and then the replay at home afterwards. Common to this is an 'oh no!' reaction as I relive one or two incidents where I feel I've made a terrible fool of myself. I torment myself by going over the incidents again and again, and cursing myself for whatever I said or did. (I'm aware that the 'oh no!' is something my brain has built into it, and then finds a memory to attach itself to, but awareness doesn't seem to make much difference to the angst.)

The Luvox doesn't actually stop this process, but it blunts the pain and shortens the length of the remorseful period. Therapy could be a useful adjunct: someone to hold my hand as I expose myself to the horrific social possibilities my mind conjures. In theory I could do much of this exposure work alone, but in practice I need a skilled and knowledgeable psychologist who can parent me through the worst. 'So what if you acted strangely in front of aunty X and cousin Y the other night. What if you're right, and they do think you're weird – so what?' the skilled psychologist might say.

Or as I face my mental health group and try not to blush and look self-conscious, I could be doing something more useful: not simply allowing myself to think disallowed thoughts but actually making myself think them. My imaginary psychologist might encourage me to picture myself in bed with half the meeting as they sit opposite me – so that I'd gradually become more accustomed to, and less fearful of, such 'scary' thoughts.

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Coming your way - the empowered patient

I was reading a forum recently on the topic of 'staring OCD', a very distressing condition. The discussion was headed by a doctor who was either a psychiatrist or psychologist. Some of the sufferers suggested that their condition seemed to be caused by a combination of social anxiety and OCD. The doctor responded that this wasn't the case; instead the staring OCD was causing the social anxiety.

How could he know that this was true for each individual sufferer? To my mind it's arrogant to make a sweeping dismissal of patients' lived experience of comorbidity in this way. Staring OCD has been all but ignored; many therapists seem not to have heard of it. For some patients it could well start off as an obsession with staring and progress to social phobia, but it's not exactly farfetched to suggest that the two are often connected from the beginning; the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) acknowledges that social phobia and OCD in general often occur together.

This is an example of doctors being in love with particular categories that patients then have to squeeze themselves into, even if it's an uncomfortable fit.

It also suggests how important it is for patients to empower themselves and learn to trust their instincts (as opposed to 'listening' to their illness).

An empowered patient might refuse to take this doctor's opinion as gospel truth if it doesn't chime with her lived experience. At the same time she might recognise the doctor's overall expertise and use his knowledge in other areas as a resource.

What does empowerment mean if you have a mental illness?

About two months ago, for the first time in a decade, I started taking Luvox, an SSRI that is often used to treat OCD. Around this time I became fully aware of one of my 'conditions' for the first time, and the many ways it has affected me over the years and continues to do so – pure obsessional OCD, or 'pure O' as it's sometimes called (sounding more like a soap powder than a mental illness).

Being on the drug has made me think a lot about what it means to be mentally ill, to have a condition that affects the way you relate to others, and to be 'medicated'. It's renewed some of my regrets about my earlier failures to make the most of drugs to improve my mental health, and to take responsibility for my life rather than handing over too much power to therapists. Here, then, are some of my thoughts about these issues. Please be aware that the recommendations I make are reflections of my own experiences.

Psychiatric drugs that have an acceptable degree of clinically proven efficacy and safety are neither good nor bad – assuming, of course, that the patient needs the drug and can benefit from it. Along with therapy they are tools, with two people wielding them and responsible for their safe use – the therapist and the patient.

Both need to understand that a drug is not a cure but a starting point. Assuming the drug is compatible with the patient's biochemistry, along with therapy it may enable her to reach a level of functioning that makes further change possible. Positive changes in the brain made by the combination of drugs and therapy may lead the way to further brain changes as the patient gets used to ever riskier and more challenging activities.

Whether positive change takes place depends on the commitment and hard work of the patient, and the effectiveness of the therapy, but there are also a host of other factors: the severity of the illness, the patient's support structure, whether she has security in housing and finance, and whether she has other addictions or health issues.

All this suggests an approach that considers the dynamic between patient, drug, doctor and the patient's larger social context. Within this dynamic there is one factor beyond all others that to my mind determines success.

The patient's degree of maturity is a key element in the treatment. She must be ready for the effects of the therapy, including the initial side effects of drugs, and the ups and downs to expect. She must be able to 'hold herself' and to withstand the whirlwind of change without dropping the therapy in a panic if her beliefs are challenged or as soon as something goes wrong.

Maturity enables the patient to be as fully aware as possible of the nature of her illness, and the way it operates in her life, and to separate the illness from her own self-image.

Maturity implies empowerment and self-advocacy. In some instances it may mean a patient who talks back, who appears to be non-compliant, who doesn't always take the therapist's word as gospel.

In some respects the patient may be more knowledgeable than the doctor about the day-to-day, lived aspects of her illness. This should not be surprising; given that less than half a century ago some doctors were still sticking ice picks into people's eye sockets and detaching the prefrontal cortex from the thalamus, it's fair to say we're at an early stage when it comes to understanding the nature and causes of mental illnesses. For example, we now know that the diagnosis of schizophrenia actually refers to a cluster of illnesses rather than just one.

However, the doctor will be more objective and have insights that the patient needs; the patient must find a balance between trusting her own instincts and taking full advantage of the doctor's expertise and objectivity. And doctors need to retain a degree of open-mindedness about the lived experience of patients and to look at qualitative as well as quantitative evidence, while not indulging or kowtowing to their patients.

Benefits of empowerment

It took me years to become empowered because I had to struggle with lack of information from therapists and my own dysfunctional thought processes to get a clearer view of the world. You need to know yourself and the operations of your illness very well before you can be an empowered, assertive patient and not simply non-compliant.

Ironically, the very psychiatrists who disempowered me by refusing to give me a clear diagnosis – something I didn't think to ask for myself – helped me in other ways by encouraging me to shed many of the deluded ideas I had about life, to grow up and to take some responsibility for myself.

It's my belief that if therapists want ultimate success they should try to foster empowerment in their patients. I'd go so far as to say that encouraging the necessary maturity for patients to actually grapple fully with their illness should be one of the major goals of therapy. While a certain degree of empowerment and self-knowledge can only come from experience, therapists can do a great deal to hasten the process.

No therapist should feel threatened by the idea of an empowered patient. Without life skills, self-knowledge and maturity, the patient can't get the full benefit of the therapy. An empowered patient is one who is motivated to change and recover to the extent possible. An empowered patient and their therapist can become a team with a common goal while still having separate roles and responsibilities.

Below are my ideas for the way therapists might do this. Of course some therapists already do some of the things I call for, such as encouraging their patients to join a self-help group.

A better way

These are the steps I believe therapists should take when they're establishing a relationship with a new patient.

• After gaining an overview of the problem, explain herself, her qualifications and methods of treatment, and let the patient 'interview' her.
  
  The patient needs to find out whether she wants to work with the therapist, while the therapist needs to ascertain whether she feels she can help the patient or whether the patient should be referred to someone else. Many therapists simply assume that they are the person for the job.

• Once enough information has been gained, tell the patient exactly what she believes is wrong with her and the implications of this. The therapist should be open-ended about these implications.
• Point the patient towards resources rather than suggesting that she is the only resource.
• Encourage the patient to arm herself with knowledge and join self-help groups.
• Encourage questioning and feedback, while being willing to call the patient out when she exhibits thoughts and fears that may be related to the disorder.
• Set up a treatment plan with goals (to be agreed by the patient) and ways to achieve those goals.

• Encourage the patient to pursue a healthy lifestyle and to get the basics of life right – housing, work or financial support, strong relationships. If there are barriers to any of these, they should be treated as goals and included in the treatment plan.

• Work out if the illness has created distorted thinking and ideas about life, society, and important life goals, and personality factors such as dependency and narcissism. If these kinds of things aren't identified they could stymie the treatment. Personality problems don't need to be fully blown personality disorders to sabotage progress.
• Share these findings with the patient and incorporate them into the treatment plan. 

• If the patient has concerns about medication (common for OCD sufferers, for example) rather than taking offence or trying to fob the patient off she should talk about risks versus benefits, ways to minimise side effects, and assume the patient has a 'What's in it for me?' approach.

Empowering young people

I was pleased to hear that some aspects of this approach are being used in the treatment of schizophrenia in young people. In a recent discussion on Radio National about the latest treatments, the practitioner spoke about the importance of early intervention, and the need to tell young patients that it was important to focus on two things that are basic to happiness: work and love.

I couldn't agree more. Young people with mental illness need to be encouraged to grow up faster than their peers. Work and love are, after all, the goals of most people's lives (which is not to say that a recovery plan should always aim for, say, a full-time nine-to-five job and a long-term relationship – recovery for some people could mean volunteering and establishing new friendships).

Following a thorough diagnosis (including personality factors) and treatment plan, this is what I wish I'd been told when I first presented to a psychiatrist at the age of 21 with an unspecified nervous problem. I would like to see all young people receive a similar introduction when they first enter therapy.

•  How you manage this condition will affect the quality of your life.  The most important thing you can do now is grow up and learn to look after yourself, and work on your treatment plan. While a certain degree of rebellion and acting out is normal for your age group, it may just hold you back and threaten your recovery.
• Get the basics right.  A secure roof over your head, good diet and exercise, strong and healthy relationships are essential to your recovery.
•  Alcohol and caffeine are not your friends.  If you have any serious addictions, go into treatment for them.
•  Use your time wisely to develop as a person.  Focus on strong friendships, and work towards being partner-ready without being obsessed about finding a partner. A strong relationship can greatly assist your success, so work on yourself.
• Don't try to do all this perfectly.  There will be plenty of times when life gets temporarily busy, and there will be setbacks as well as strides forward.
• Be sensible about sex. Sexual experimentation can be good and healthy but only if it is fully consensual and you feel happy and comfortable about it. But sex as an escape, or sex that is exploitative and not enjoyable for you, is simply a waste of your time.
• Learn to separate your thoughts and intuitions from your feelings.  Trust yourself, but don't necessarily trust all your feelings all the time – they will chop and change. Learn about your intuition and separate it from your emotions. Learn to follow your gut but remember your emotions aren't always telling you the truth.
• Don't give away responsibility for yourself.  Respect professionals and their advice but view them as resources.You are not there for their benefit; if they're not helping you, you are under no obligation to keep seeing them. On the other hand, try to tolerate a state of openness and unknowing; it may take time to form an opinion on whether a treatment is working. Leaving simply because a therapist challenges your boundaries, prejudices or distortions would be self-defeating.
• Understand that there is nothing wrong with the essential you.  Your disorder is stopping your true self and personality from expressing itself. Your goal should be to come home to, and learn to love, the body and mind you have, and to live your own life, not someone else's.
• Work towards a sustainable career.  Where work's concerned, it's a fine balance between taking your illness into account and stretching the boundaries. Accepting and managing the illness is vital to your success. Choose your vocation carefully – whether you have to give up on a particular dream or pursue it will depend on individual circumstances but management of your illness must come first if you want long-term success and health. At the same time, sometimes only experience can tell you if a career path is right or not; cultivate flexibility and be willing to change to a related career or different way of working if a job or vocation is too stressful.

I was a very rigid thinker, and had strange ideas about the world, when I was 21 and first spoke to a psychiatrist about my nervous condition. Would I have been able to take advice like this on board at the time? Probably not if it was verbal, but if something similar had been given to me as a leaflet, and presented as advice from other sufferers, it might have helped.

Most of all, if I'd been told that I had a serious condition, a chronic illness if you like, that I would have it all my life, that no magic Freudian catharsis was going to get rid of it and that it was up to me to accept this and learn to manage it, I might have cultivated more sticking power, patience and resilience. I hope people going into therapy for the first time can get the full benefit of the many resources now available to them, and understand that they are their own greatest resource!

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Body Dysmorphic Disorder and the Sins of the Camera

I have a mild verson of body dysmorphic disorder. I impose impossibly high standards on my attractiveness and then feel dismayed and inadequate when I can’t meet those standards. It’s a mean way to live, to judge myself so harshly.

I’ve never been diagnosed with BDD, and its arrival in my life was subtle – it never really felt like a new disorder, more like another outlet for my existing obsessiveness.

Most of the time I’m okay with my appearance these days, but every now and then something happens that throws me completely off kilter.

Given that BDD is related to OCD, I imagine one treatment would be exposure therapy based on getting used to the sufferer's own appearance. In the case of ageing, this exposure would need to be constant: our faces regularly show small alterations as we age, alterations that would be imperceptible to the average person but can spell doom to the BDD afflicted.

This is disconcerting, but I’ve learned to cope. I can now adjust my expectations each time there’s some slight change in my actual appearance. I’ve learned to accept and live with many changes  in recent years and I’m confident I can keep doing this.

Photos of me present an additional problem: I have the sort of bone structure that doesn’t flatten well into the two-dimensional image. This means that the face that I’m familiar with simply doesn’t translate to a photo. I look different in the mirror from how I look in a pic.

Just as I’ve gotten used to my changing appearance in real life, I’ve resigned myself to the fact that photos of me will not look like the image I see when I look in the mirror. I don’t like this state of affairs, but I can live with it.

This shouldn’t matter. Photos are an important means of recording our lives for ourselves, friends and family as well as posterity. Even if we personally let down by them (as I do), avoiding the camera isn’t the answer.

But flash photography represents another degree of foreignness altogether.

The other night I was planning to spend the evening at a friend’s place, and I asked him if he’d mind taking some photos of me for my business website. The photo that’s currently on the site is two and a half years old. I’ve kept it on the site that long not just because it shows a younger version of me but because it’s a good photo – and I’m not the most photogenic person in the world.

Because it was evening, my friend took the photos using flash. The result? Pictures that were so at odds with my actual appearance that they gave me a distinct downer. I looked like a ghost, incredibly gaunt and with dark shadows under my eyes.

I don’t think I’m being overly critical here. I think the camera is! Now I've reached my late forties the camera's two-dimensional images are harsher than they've ever been, and flash photography increases the disparity between the real me and the photographic one.

So the question is: now that I know flash photos show a ghostly avatar that bears little resemblance to the real me, what should my response be? Should I gradually expose myself to these images for longer and longer periods of time so that they eventually lose their ability to discombobulate? Or should I avoid flash photography like a vampire avoids the light?

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The perils of internet dating

After a long absence, Slightly Nutty recently returned to the exciting, unpredictable world of internet dating. What a ride it’s proving – and I haven’t even met the Gentleman in question.

I admit to being on a rather ‘questionable’ dating site, down a notch in the respectability stakes from RSVP, which I hate to give free publicity to but have to admit is probably the best known dating site in Australia.

But I prefer the dodgy site I’m on, for a host of reasons. And they don’t include posting naughty pics of myself in compromising positions with my face artfully blanked out.

I’ve only met one person through this dodgy site so far and he, like me, was a refugee from RSVP. And the Gentleman I’m hoping to meet up with in the next week or so also looks like he could easily be on RSVP – he’s fully clothed in all of the three pics he sent me.

So why do I bother? Why not just get back on the RSVP treadmill?

The main thing is the expectations are lower. RSVP meetings are fraught with danger for the slightly nutty. I’ve been on and off RSVP for ages (you can hide and display your profile at will) and, now that I’m in my forties, I’m finding that dates basically expect me to own. Yes, property. They don’t like genteel poverty and fear you are going to sponge off them. My one and only female date asked me if my job was full or part time, and whether I owned or rented. It felt like a job interview.

It’s not just that, but the general expectations that accompany an RSVP date, mine included. They evoke a host of long-buried needs, hopes and unrealistic expectations. In contrast, when I meet someone from the dodgy site I’m not scrutinising them as closely and asking the questions: ‘Could this be my next life partner? If so, does it matter that they like playing obscure board games/have appalling taste in restaurants/break wind in intimate moments?’ The thing I’m mainly interested in is the chemistry. Is there something there? Are there things to talk about? Do I want to spend time with them?

But there are still difficulties, the main one being the need to have a recent photo on hand for prospective suitors.

Because the site I’m using is a bit dodgy, I didn’t want to have pictures of myself on my profile for all the world to see. Even if I did, the last decent picture of me is two years old and shows someone who looks younger and prettier than I normally do. When this current Gentleman responded to my profile, sending me recent non-rude pictures of himself, I realised I would have to update my own pics and send some to him. (On the website you can post your photos on a ‘private gallery’ and tick a box when sending a letter to allow the recipient to view the pics.)

So I asked an obliging friend to help out. We went to the urban forest near where he lives and took lots of shots, in heaps of different poses, in the hope of choosing the best ones. Predictably I was disappointed with the ones he sent me to choose from. I’ve never been that photogenic, but I’ve become less so as I’ve gotten older. It didn’t help that I had bad PMT that day either. And it also didn’t help that the photos were on large files that gave uncomfortably detailed close ups! (Tip: if you're not happy with photos of yourself, blame the photographer!)

But no excuses. I would upload the best three to my ‘private gallery’. I did, asking the Gentleman to contact me if he still wanted to meet up for coffee. (The photo-taking friend and I had rationalised that it was preferable to supply ordinary photos rather than pics so flattering that the prospective would be dreadfully disappointed when he first clapped eyes on me.)

I uploaded the pics on Wednesday. I went away on an overnight trip on Thursday and was hopeful that on my return on Friday afternoon a response would be waiting for me.

No response. Saturday morning arrived. Again nothing. Saturday afternoon also proved unfruitful.

I reeled, I quavered and I quaked. This would be the first time I had been rejected on the basis of a photograph!

I spoke to another friend whose roles include being a kind of mental health buddy. We discussed the concept of exposure, a popular therapeutic tool in the treatment of anxiety and OCD. Exposure therapy involves putting up with discomfort in relation to a phobia, fear or obsession, and gradually increasing one’s exposure to that discomfort.

As someone with a minor case of body dysmorphic disorder (which in my stronger moments I admit is actually an impossible demand that I be beautiful) one of my worst fears is being rejected on the basis of my appearance. The silence on the Gentleman’s part suggested this might have actually occurred.

But in fact, my mental health friend and I agreed, there was no way I could know this for sure. Perhaps the Gentleman didn’t like my ‘look’ rather than my ‘looks’. Alternatively he might simply be away, or incredibly busy, etc etc. Staying in this state of uncertainty, of unknowingness, rather than forcing some unalloyed truth from the world is the essence of exposure therapy.

I told my mental health friend I had wanted to send the photos to him to get his opinion. But we both agreed that that would constitute seeking reassurance, a no-no in exposure therapy.

Anyway, on Saturday evening the longed-for answer finally arrived. Yes, the Gentleman would still like to do coffee. He explained his slowness by saying that he wasn’t addicted to the dating site and didn’t check his messages that often. This had the ring of truth to me, as there had been a lapse of several days between telling him I was going to post the pics and actually doing it.

We still haven’t spoken, but it looks like we’re going to catch up on Saturday morning. Wish me luck!

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Changing my mind: slightly all-over-the-shop thoughts about brain plasticity, excessive worry, and mindfulness

For many years I have pictured my condition/illness/neurosis (whatever you want to call it) as a small child constantly tugging at my sleeve and demanding care, attention and protection. Of course, I’m not Robinson Crusoe in seeing myself this way – inner child therapy suggests that we all have a needy child inside us that we need to listen to, love and support.

What I’m trying to do more actively these days is actually learn to manage this child, look after it, but also keep it in line. And to do this I’m finding myself viewing my brain as a pliable thing that I can manipulate.

I know this sounds a bit negative and mechanistic so let me explain. Ever since I read The Brain That Changes Itself by Norman Doidge, a book that reveals some of the latest research into just how plastic and changeable our brains actually are, I’ve been pondering how disempowered I’ve always felt about handling my chronic anxiety and panic.

These feelings of disempowerment have only increased over the last four years or so, since I gave up therapy and decided once and for all that my body couldn’t handle antidepressants. During this time I have done a few empowering things – I learned how to control my breathing and still practise abdominal breathing when stressed; I did a short group therapy course for social anxiety sufferers; and I bought a mindfulness book and CD, and still do a mindfulness session with the CD about four times a week.

I also try to practise mindfulness (staying in the present; being aware of my surroundings and sensory experiences; noting but not judging thoughts) but I’m not strict about letting the thoughts go – more on that later.

These are all good things, but with my wayward brain they’re simply not enough!

The Brain That Changes itself was an incredibly affirming book. I’m the sort of person who needs constant affirmation, and exterior, visible proof that something is working. I think that’s one reason I’m finding it hard to make further necessary changes like starting meditation – there’s no-one there to say ‘I can see that’s making a difference’, no machine I can hook up to that will show my altered brainwaves after a meditation session.

But Doidge’s book, even if it can’t make my brainwaves visible to me, has been making me see my brain as something fluid, something that I can change, something that’s constantly affected by what I think, do, and tell myself.

So I don’t want to manipulate it in a way that denies my reality (‘I am now a multimillionaire with a swish New York apartment and a cottage in the south of France’). I just need to give it a bit of discipline. When I think of manipulating my brain, I’m actually thinking of a process more like, say, massaging sore muscles into shape or, conversely, exercising slack muscles.

Some examples. I can fall prey to obsessive thoughts sometimes, and while I don’t class myself as having OCD (I have enough problems!) I found the section on OCD in Doidge’s book very helpful. (It’s also useful for anyone who worries excessively.)

When you have an obsessive thought that won’t go away, you do two things: you refuse to focus on the content of the thought, and tell yourself the actual content is not the problem, but the obsessive thinking is; and then you do something pleasurable to distract yourself.

It’s so simple, and yet, if you do it over and over, determinedly, you’re actually changing your brain, creating positive new circuits and connections. What a fantastic idea!

Of course, it’s hard work, and takes perseverance. And it doesn’t mean you actually eliminate the old mental habits. Instead, you create new, competing circuits.

This part of the book was quite tantalising, because the book as a whole doesn’t include a lot of practical suggestions for dealing with anxiety and so on.

But it does suggest how important self-talk is in general, something I’ve been working on in a separate but related area, my social anxiety. Every time I go into a scary social situation, I now tell myself I’m safe. I tell myself I’m doing well. I talk sense to myself. I guess this is a very basic form of cognitive behavioural therapy, which seeks to identify and challenge irrational thoughts.

The book also offers a concrete way of thinking about those more esoteric habits that are hard to introduce, such as meditation, progressive relaxation or mindfulness in daily life. These practices are not simply good in the abstract; over time they’ll produce new neural connections and new mental habits.

When I think about it, meditation (even if it’s not specifically mindfulness meditation) and progressive relaxation (where you progressively tense and relax all the major muscles in the body) are related to mindfulness, if not forms of it, because they’re both about being in and experiencing the present moment.

But mindfulness actually seems to clash a bit with the good self-talk and the anti-worry treatment described in Doidge’s book.

Mindfulness is quite interesting in relation to the general kind of brain manipulation I’m discussing. If I adopt it along with my anti-worry strategy I’m at once attempting to take control (by introducing a new practice that will alter my mind for the better, and striving to stay in the moment) and let go (by not trying to control or judge feelings, behaviours, thoughts but simply observing them; by letting life be the way it is).

This is consistent with Doidge’s suggestion of not buying into the content of the thought. But it contradicts the idea that I should challenge my thoughts, either in relation to persistent obsessions and worries, or specific anxieties like social anxiety. According to mindfulness practice, I should simply note thoughts, not buy into them as fact, and let them go.

Perhaps this apparent contradiction doesn’t matter – perhaps the main thing is to have a grab bag of tools one can use? Oh dear, I can feel a worry coming on …

If anyone has any suggestions about reconciling mindfulness with CBT and the treatment of obsessive thoughts that I’ve briefly sketched, I’d be glad to hear them!

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What I see when I look in the mirror: ageing, body image, feminism and psychoanalysis

I often assume I suffer from mild body dysmorphia, which means that I supposedly have a distorted view of how I look. It’s much worsened by the fact that I have rosacea: the degree of horror varying with how pink the cheeks are at any one time.

But I’m not even sure about whether it is dysmorphia. For a start, my face is simply never the same each time I look in the mirror; with the rosacea affected by my food intolerances, I sometimes have ‘egg eyes’ (pinched and defeated looking); ‘tuna eyes’ (red and shrunken) or ‘oil eyes’ (same as previous). Usually there is some degree of swelling on my cheeks. The menstrual cycle complicates this further and I literally appear to age five years just before my period.

I suspect what actually afflicts me is hypervigilance coupled with an unhealthy narcissistic streak!

As a coping strategy, I go for long periods where I don’t do mirror close-ups. Everything except eyebrow plucking is done from a distance and even then I just focus on the relevant area, not the whole face.

It hasn’t always been like this. There was a time, before the ageing and rosacea started their ghastly double act, when I could gaze into the car rear view mirror and see my plumped-up, pale, glabrous skin and believe, momentarily, that I was beautiful.

So what happens when I allow myself, after a long interval, to edge closer to the mirror, to witness all the flaws – most of them identifiable as age spots, milia, broken blood vessels, enlarged pores, but some of them inexplicable, indeterminate markings, as if someone had smeared a tiny piece of non-removable charcoal on my forehead?

I got a close-up look the other day after perhaps a year of being too scared to. I was in the four-lane highway of Dandenong Road, in the Saturday morning traffic, waiting for a red light to change, and the face had gone. I mean the face as a whole, the face as an idea, as a unified concept. The new face was defined by its irregularities: the uneven vertical wrinkles on each side of the nose bridge, the deepening labial folds, the tiny crimson paths under the left eye socket and on either side of the nose. The expression in the eyes one of distaste. Not scared exactly, not quite horrified but somewhere close.

I almost stopped the car to check again. It’s unbearable, the desire to check. You check once and are shocked and then when you move your eyes from the mirror your imagination makes a monster of what you have witnessed, so you check again to reassure yourself. And in between the first and second checks you compose the expression on your face, you adjust your hair, you point your chin upwards, you civilise and arrange yourself.

You’re okay, your mind finally decides, overriding that first visceral reaction. Barely.

P.S. I’ve just done some basic internet research on dysmorphia and I probably do have a mild version!

Stuck in the mirror
Like many women before me, the ageing process has made me question my identification with what I see in the mirror. In the way I’ve written this blog entry so far, I have refused to identify with ‘the face’, distancing myself from it. It is no longer me. (In certain mirrors, with a bit of make-up on, it becomes ‘me’ again – for the moment.)

Could the discipline of psychoanalysis shed some light? Sigmund Freud explored the unconscious through psychoanalysis, and Jacques Lacan basically developed and elaborated on Freud’s theories. But other theorists of early child development such as DW Winnicott have extended and challenged their work.

I studied a little Freud and Lacan at university. I’m no expert on either of these controversial thinkers, but my obsession with the mirror made me think about a stage in infantile development that Lacan posited. It supposedly occurs between the ages of six and eighteen months and is called the ‘mirror stage’.

I wondered if I was going through another kind of mirror stage, a kind of de-identification with self.

Psychoanalysis, so often discredited these days, can be incredibly useful in explaining aspects of human behaviour that social theorists might struggle with. For example, like me, many Western women have long been crippled by a form of narcissism that sees them invest way too much in their body image. The fallout from this is obvious in eating disorders, as well as excessive time, energy and money spent on appearance.

Perhaps body dysmorphic disorder is some extreme manifestation of this?

Naomi Wolf wrote her feminist classic The Beauty Myth almost two decades ago. In it she posits a trenchant and disturbing thesis – that current standards of beauty came about as a backlash against second wave feminism. According to Wolf, when the popular media such as women’s magazines could no longer control women’s actions after feminism sent them scurrying out of the home, they introduced the body as a site of feminine guilt and preoccupation. The perfect woman, a 20-something, underweight blonde with translucently clear skin, is the uber-woman that none of us can ever measure up to (Twiggy was, of course, an early major prototype).

This is a compelling argument, one that is still useful in the twenty-first century to explain why women are willing to risk disfiguration and ill health to explore ever more invasive anti-ageing procedures, so ‘raising’ the standards that apply to all women.

But I think we need psychoanalysis and related theories to explain why so many of us are so invested in the beauty myth and our own appearance in relation to it; and why the ageing process threatens our self-image so gravely.

Feminine narcissism – not just a metaphor but a psychiatric condition, albeit mild in most – is one reason why feminism was spectacularly unsuccessful in luring the mass of women into checked shirts and overalls, and convincing them to bare their faces (another, of course, is that in an unequal world women feel compelled to compete via appearance).

Thus, women are not lying when they say of the face lift, the botox injections, the face peels, ‘I did it for me’. Advertisers encourage this: ‘Because you’re worth it’.

A word of warning: narcissism is often used as a term to denigrate women, to imply that we are foolish and frivolous to be obsessed with our bodies and appearance. This is the double standard of patriarchy: set up an impossible ideal, then complain when women spend all their time and energy trying to live up to it.

A recent article in The Age’s Good Weekend would have horrified many readers. It featured four women of various ages who spent what most would agree was excessive amounts on their beauty routine – the average was $16 762 a year, but two of the four spent more than $19 000 annually. These sums were for beauty and hair products and treatments only, not clothes, shoes or jewellery.

Before looking at how these women justified their spending, let’s take a very condensed journey through some of the theories that consider how we look at ourselves.

Lacan’s mirror stage
What happens at the mirror stage? Basically it takes place when the child sees its reflection in the mirror, and recognises itself as itself, for the first time.

At this point the very young child is a bundle of drives and experiences, with little control over its needs and bodily functions. It doesn’t experience itself as a unified being and it does not see itself as separate from the world.

When the child recognises itself in the mirror for the first time, it’s thrilled – the self that looks back at the child appears to be far more unified than the child feels itself to be.

The mirror stage supposedly helps the child develop an ego. But there are two sides to this. The child rejoices in this image of the unified self it sees in the mirror. But the child also becomes aggressive and angry towards the image in the mirror because unlike the image, it is still stuck with the reality of its uncoordinated, helpless body.

Feminist academic Elizabeth Grosz describes it thus:

The child invests the [mirror] image of itself … with all the hostility directed towards its own lack of satisfaction … The … internalized image becomes an … object of aggression (for example in narcissistic self-deprecation). [my italics].

Therefore, a huge split takes place within us in this important stage of becoming ‘ourselves’ – of developing an ego. Just as we are becoming ourselves, we are also alienated from ourselves.

All about my ‘other’
Before we get on to the bit about narcissism, we need to know that the mirror stage has another important function. It sets up the distinction between the self and the world, the self and the other. This is because for the first time the child sees itself as a kind of double being – reflected back at itself in the mirror – so it’s then able to recognise other people, and other objects, as being separate from it. The child is no longer merged with the world.

The mother is an important part of the mirror stage because she is the child’s main ‘other’, reflecting the child back to itself.

The mirror stage is associated with narcissism because it takes place in the state that Lacan calls the Imaginary – a closed system where mother and child continually reflect each other. In growing up, the child moves from the realm of the Imaginary into that of the Symbolic. What brings about this move is the oedipus complex. (Freud refers to the end point – the resolution – of the oedipus complex as the development of the superego.)

For Lacan, this process is represented by the presence of a male who brings the larger world into the closed system of mother and child. He believed it takes place when we start talking, when we enter language. Similarly, the superego described by Freud represents authority figures that we internalise.

Before I go any further, I have to say that the mirror stage has long been howled down as a developmental phase. Why, other theorists have asked, does it make a material object – a mirror – more important than the role of the primary carer, usually the mother? And how do blind kids develop an ego? Lacan himself later said that it wasn’t a stage at all but a state of being.

I and others have found it compelling, though, because it dramatises so beautifully that split from the self that also separates us from the world. And it uses the mirror, that non-place in which women so often get caught, as a site of self-becoming.

An important aspect of the mirror stage is what Lacan called ‘the desire of the other’. This means that at this point the child comes to see itself as an object of the mother’s desire – it is seeing itself through the eyes of an other, the mother.

For Lacan, then, narcissism might become pathological if we get stuck in the mirror stage, stuck in the Imaginary. And we can see, too, how, if we did get stuck in the mirror stage, we’d continue to feel aggressive towards that mirror image.

But here the concept gets confusing – when we start to age there’s no idealised self to falsely reflect back a unity we don’t feel. Instead, at this point in our lives, shouldn’t we feel more unified on the inside, so that the outer image, which is falling apart, isn’t so important? Shouldn’t the mirror stage be reversed? Perhaps that’s what actually happens when mentally healthy people age – perhaps they begin to detach from the image in the mirror. If so, this would surely be a healthy development.

But what happens if we never get to feel unified and whole on the inside, and the outer image starts to fall apart as we age? Perhaps as we try to detach from the outer image we're also feeling panicky and scattered inside. Or perhaps we simply can't detach – that’s when all hell breaks loose and we seek the two-hundred-dollar face cream, the knife, the injections.

These are speculations only (sorry about the pun). In his discussion of the mirror stage Lacan wasn’t overly concerned with narcissism as a pathology. Indeed, he seems to think that narcissism is the normal state, and goes on to portray conventional heterosexual relationships as narcissistic.

The mother as mirror
Everyone breathed a sigh of relief (not really but it sounds good) when the famous paediatrician and psychiatrist DW Winnicott replaced the mirror with the face of the mother.

It's significant that, just like Lacan and Freud, Winnicott believed that the newborn didn't see itself as a separate being and couldn't distinguish itself from the world. The newborn gets hungry, cries, and the world -- which appears to be part of itself -- feeds it.

According to Winnicott, as the mother tends the child and gives it her attention, the mother’s face literally reflects the child back to itself – in ideal circumstances, ultimately giving the child to itself.

This is very important. If the mother is not in a state where she can reflect the child back at itself, she will not be the mirror the child needs to become itself.

If she does not mirror the child, the child develops a ‘false self’ to protect the ‘true self’. Instead of having its ‘true self’ mirrored in the face of the mother, it searches her face in order to anticipate her moods, and responds accordingly.

The child is in danger of never being able to move into the transitional phase (the phase where kids have an object, like a blanket, they can’t be separated from). In this vital phase the child is slowly coming to terms with the fact that its mother (and others in general) is a separate being with her own interests and autonomy.

It’s not hard to relate this theory to a woman’s relationship with the mirror. Perhaps when we look at ourselves uncritically in the mirror and can accept our ageing process, we act the part of the approving mother who responds to our true self.

If we haven’t had that positive mirroring, perhaps when we see our ageing face we worry only about the reactions of others, and fear they will reject us.

But I think it's worse than that. If we don't get mirrored properly we can't move onto and through the transitional phase. So basically if our parenting's been poor (and there might be a thousand reasons for this, many of them social or economic) then we may still believe on one level that we are merged with the world. We may therefore wait indefinitely to be properly parented by a world we expect to bend to our needs, and we may grapple with the idea that those around us have interests and indeed existence totally apart from us.

Back to the superego
I wonder, though, whether the disapproval some of us experience when we look in the mirror is even more complicated. Is something else going on at the same time, something to do with the wider world beyond the bond of child and mother?

What makes us care about what the rest of the world thinks of us? What makes us subscribe to the beauty myth as an exterior standard by which we measure ourselves? This is where Freud’s idea of the superego and Lacan’s related idea of the Symbolic could prove useful.

I think we really need these ideas when we think of how some women might view their faces and appearance in general. If I think I look bad it’s perhaps partly my superego telling me I no longer measure up to an external standard that the world has imposed on me – the ideal of feminine beauty. I have internalised a disapproving larger world that is telling me I don’t measure up.

Thus, in the Good Weekend article I mentioned earlier, 28-year-old Canna Campbell justifies the $17 754 she spends a year on beauty with the words ‘People say that you don’t get a second chance to make a first impression’. Head of a company that offers financial advice, she’s talking about how prospective clients will view her – seeing herself through the eyes of a larger world. Similarly, 50-year-old Wendy Snyder declares: ‘I want [people] to see a groomed, efficient person’ and 39-year-old Vina Chipperfield believes that ‘People judge us every day on the basis of our appearance’.

Beyond the mirror?
These remarks are very much just possibilities based on my limited knowledge. Not all women are narcissistic and overly invested in their appearance. Not all women have conventional upbringings with father and mother playing traditional roles. Parents vary enormously in their ability to love and nurture children. It would be fascinating to see qualitative studies on how aspects of upbringing affect female narcissism, body image and attitudes to ageing.

But again, let’s not forget Lacan’s idea of the larger Symbolic, the wider world, that we enter through language (but that also includes visual symbols). However loving, parents can’t protect their girls from the saturation of media images that portray society’s ideal of feminine perfection.

But perhaps even perceiving all this gives me choices. If I look bad in my own eyes I now have a choice: I can stay in the world of Winnicott’s false self, or instead play the part of the loving mother/mirror, reflecting a positive image back to myself: ‘I love your true self, and I’ll give you the structure you need to bring it into the world’.

Perhaps I can also realise that in judging my own appearance, my over-active superego is playing the part of a potentially disapproving world. And while I can’t necessarily dismantle the impossible standard of beauty I’ve internalised – how can any one person hope to do that? – I can detach from my image a little bit: if I don’t necessarily like what I see in the mirror – viewed through the eyes of the wider world – that doesn’t mean I don’t like me – the me I feel from the inside.

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Plastic potential

I’ve recently finished reading a book that has made me think about my brain in an entirely new way.

The Brain that Changes Itself by Norman Doidge is an expose of the cutting edge of a new area of science – neuroplasticity.

Doidge is a research psychiatrist and psychoanalyst who is fascinated by the idea of neuroplasticity, a paradigm that is revolutionising neuroscience, the study of the brain and nervous system.

This new paradigm has huge implications for mental illness, brain injuries, the ageing brain, learning disorders and brain events such as strokes.

The old paradigm for understanding the brain was called localisation, and sadly it prevailed for decades despite evidence proving the contrary.

Basically scientists believed that various mental and physical functions were controlled from particular parts of the brain and that the brain itself was ‘hard wired’ in its abilities. If a part of the brain was damaged, it was curtains for whatever functions that part had previously undertaken.

Scientists also thought that children had ‘plastic’ brains only during the crucial developmental years, and that the ability of an adult brain to change was very limited – apart from the fact that it declined! We were told that when you lost brain cells, that was it – they were never coming back.

Doidge calls this way of thinking ‘neurological nihilism’.

In fact, the brain is an instrument we are only just beginning to understand. If one part is damaged, another part can often take over all or some of its functions. Different parts of the brain do hold ‘maps’ of different functions. But the map areas will be taken over by other functions if they aren’t used. Doidge has a maxim he uses throughout the book to explain how it works: ‘Neurons that fire together, wire together’.

And our brains are truly plastic in that they are constantly being remodelled by everything we do. For example, brain maps for particular activities (playing a musical instrument for instance) become more and more complex as our skills develop.

The examples Doidge gives of the potential of the brain to renew itself are incredible. They promise new treatments for autism, serious balance disorders, learning disorders in children, even vision impairment and chronic pain.

Depression treatment based on plasticity
One of the fascinating areas for plasticity is the study of severe depression. Apparently, in some types of depression the prefrontal cortex isn’t working properly. A therapy called ‘repetitive transcranial magnetic stimulation’ (rTMS) uses an electric current to generate a changing magnetic field that penetrates the neurons. This can make the neurons fire and, when done repeatedly, they keep firing.

There is a 70 per cent success rate in the use of this therapy for patients with treatment-resistant depression, and its side effects are fewer than those of depression medication.

A new OCD treatment
A new treatment for OCD that takes account of plasticity is significantly different from traditional treatments in that it isn’t focused on the content of the obsessive thought, but on the process that produces it.

When we make a mistake, a particular part of our brain lets us know. This leads to the ‘nagging feeling’ that we respond to by correcting the mistake. When the mistake is corrected, ideally the uncomfortable feeling goes away.

But in OCD sufferers, the part of the brain that tells us not to worry any more – the caudate nucleus – is, to use Doidge’s term, ‘sticky’. He likens it to an ‘automatic gearshift’ that doesn’t work properly.

Traditional treatments for OCD, in particular exposure therapy and cognitive behavioural therapy (CBT), require the patient to focus on the content of the repetitive thoughts in a bid to reduce their power.

But this new treatment enables patients to use their imaginations and thoughts to shift the gear manually.

An extra benefit is that the treatment can also be used for people who are worriers and obsessive thinkers rather than OCD sufferers. And it’s surprisingly simple.

Basically there are two steps:

First the patient relabels the OCD attack. Here she focuses on the fact that her gearshift is stuck rather than the content of the compulsion. She keeps reminding herself that the OCD is the problem, not the fact that, for example, she’ll be attacked by germs if she doesn’t wash her hands again. She also reminds herself that her mental gearshift is stuck.

The next step is to carry out a pleasurable activity, for up to 30 minutes, right at the moment the attack starts.

According to Doidge, when patients work on this therapy, they are literally altering their caudate, and strengthening their ‘manual transmission’. Of course, this therapy takes time – the anxiety about not carrying out the compulsion will still be there, at least at first.

Combatting the ageing brain
Scientists working in the area of neuroplasticity have devised ways to tackle the causes of cognitive decline and not just the symptoms.

The nucleus basalis is the part of the brain that sets off the critical learning period in children. It is always on during the critical period – hence the incredible ability of the young to learn.

But adults use their nucleus basalis only when they are really engaged with something and giving it their full attention. That’s what helps us to learn well.

Trouble with memory is due to an atrophying of the nucleus basalis. Anything that requires focused attention improves its functioning.

Learning new skills is a great way of improving the nucleus basilis because it thrives on novelty and being engaged. It’s important to choose an activity that you’re really drawn to so that you will be deeply engaged. A particularly useful thing to do is to learn a new language.

Other traditional practices that improve brain plasticity in a more general sense include learning a musical instrument, meditation, the Feldenkrais method, tai chi and exercise. (Doidge is particularly enthusiastic about tai chi.)

Neuroplastician Michael Merzenich, along with a team of scientists, has devised exercises to improve adult memory based on the principles outlined above. His company, Posit Science, has developed exercises for adults that help people to process sound better – the first step to strengthening memory – because they stimulate the nucleus basalis.

Better rehabilitation for strokes
Neuroplasticians have proved that people who have suffered devastating strokes can regain many functions, even if the parts of the brain involved in movement are irrevocably damaged.

Edward Taub has pioneered Constraint Induced Movement Therapy, based on neuroplasticity. It’s far more intensive than conventional rehabilitation, features constant repetitions of very basic movements that are designed to be incrementally more challenging, and forces patients to use the damaged parts of the body, rather than letting the undamaged parts take over – the principle of ‘use it or lose it’.

Doidge also tells the story of a stroke victim in his late sixties who after conventional rehabilitation was unable to move. His medical student son took him back to the basics, literally teaching him to crawl again, then walk, and so on. A year later he was functioning and seven years later he was mountain climbing.

Implications for positive thinking
There were so many questions that this book raised for me – many more than it answered. As one of the first attempts to popularise this emerging science in book form, it’s as much a signpost to future possibilities as a description of current treatments.

The following text appears on some editions of the front cover of the book: ‘The power of positive thinking finally gains scientific credibility’. This is very misleading: the book isn’t in the main about positive thinking. But if the book’s findings have implications for positive thinking – and they seem to – this raises many questions in itself.

Positive thinking holds dangers for an obsessive like me. I tried it for years and it would get my brain into a bit of a state. I think this is because it’s a basic denial of the current reality.

For example, I might say to myself ‘I now have a wonderful new job that recognises my skills, with fantastic pay and flexible hours.’ But the fact is I don’t. So my brain is confused and strained because I’m asking it to believe something that isn’t true. At least one new age practitioner has also denounced positive thinking.

Although Doidge’s book doesn’t delve into positive thinking, it gives convincing examples of studies showing that imagining you’re practising a skill can have similar benefits for improving that skill as actually practising it. So it seems some versions of visualising at least may be useful.

Implications for mindfulness
Perhaps the thing that bothers me most about this kind of finding is its implications for mindfulness.

This is a practice increasingly used to combat, among other things, anxiety and depression and it’s derived from ancient Buddhist teachings.

The theory is that, at least initially, you don’t actually try to change your thoughts and feelings. You simply observe them in a detached, non-judgemental, attentive way.

Mindfulness seems to focus on developing the observer part of the brain to help the sufferer understand that the thoughts and feelings are not real, but just the natural fluctuations of the mind. In this sense it's supposed to improve attentiveness because it gently forces the brain to focus on the present moment -- surely a similar aim to that of the exercises, discussed above, that improve adult memory?

It’s also very concerned with minimising the kind of self-analysis that tends to make things worse.

I practise mindfulness in a very lazy way and I feel it’s helped me move a little bit more into reality. It hasn’t cured me by any means, and sometimes it falls by the wayside because my brain just becomes too busy to attend to itself.

But Doidge’s theory seems to suggest that we have to work at making our brains stronger, that we need to focus our thoughts and always use them actively in order to change. This in some ways seems to contradict the theory behind mindfulness.

Again, I hope that in a future book he deals with this issue in relation to two questions: Is mindfulness useful and if so, what is it about the plastic brain that makes it so?

Are there other, more effective treatments for anxiety that relate to plasticity?

Perhaps there are ways that the brain’s plasticity can be deployed to give people a more positive outlook without the brain actually having to lie to itself!

General questions
The material on the ageing brain really interested me and made me think about my own brain, which is subject to allergy-induced brain fog, the effects of insomnia and the clouds of anxiety. Could I improve my poor memory just by, say, learning a language?

The last time I tried to learn French I was shown to be a very mediocre student whereas in earlier years I’d been quite quick so I got discouraged. But Doidge says two interesting things.

He states that it takes six months for a new skill to really lodge in the brain (I didn’t give the French six months). But he also suggests that learning a language will improve the brain anyway – the implication is that the learning process rather than any proficiency gained is the important thing, but this isn’t explored very thoroughly. (If this were the case it would greatly improve my motivation.)

And what about my seemingly futile keyboard thumpings, which I gave up because without tuition I wasn’t improving? Were they worthwhile for their own sake, in helping me be a better editor, for instance?

The website publicising the book doesn’t allow for direct questions to Doidge – it appears there were so many queries that he was no longer able to answer them. The book is now available in over 70 countries and has set off a wellspring of interest from people with conditions that could benefit from plasticity-based treatments.

A documentary of the same name has been made. Doidge is still researching neuroplasticity, so let’s hope a sequel is in the offing.

Doidge will be in Australia next month, to speak at the Sydney Writers Festival on 18 May.

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