Hello? Is anybody there?

I had an interesting conversation yesterday with someone from the mental health trust about some of my stranger mental episodes, the ones where I feel completely separated from myself and my own life. Sometimes it's as though I'm observing the world through a pane of glass. I often feel completely disconnected, have no feelings at all, neither good nor bad, and I can even start to feel as though I'm unreal and my life is unreal. It can be quite distressing at times and it definitely creates a certain amount of distance between me and the people I care about. Anyway, I've now been given a name for these experiences - they come under the broad heading of "dissociation."

Dissociation is a form of psychological defence that has been called "the escape when there is no escape." I'm simplifying here but it's seen as the brain's attempt to protect the person from unpleasant experiences -  events that are so traumatic they can't be processed and instead are 'pushed away,' denied and compartmentalised. Used as a buffer against trauma, this protects the person from an unpleasant reality they'd rather not face. Unfortunately, over time, the process can start to take on something of a life of its own and the person can continue to dissociate even during non-traumatic experiences, thus interfering with their ability to be fully present within their own life.

There are many forms of dissociation, ranging from day-to-day experiences that most of us are familiar with, such as making a familiar car journey then not remembering how we got to where we were going, or getting lost in a good book; to full blown identity splits in dissociative identity disorder (the more recent name for what used to be called multiple personality disorder). Clinically- significant dissociation is believed to be an over-zealous defence against stress, but whereas in most people the dissociation is transient and reversible, in some people it has longer-lasting effects.

Dissociation can sometimes be a symptom of an underlying mental health issue such as bipolar disorder, but it can also exist as a standalone issue. Specifically, I experience what's known as depersonalisation and derealisation, as well as a good bit of identity confusion. Go me! Intriguingly, it's linked to migraines - something I get a lot of - and epilepsy too, so it appears there may be a neurological connection.

From my point of view, I'm thankful it's recognised as an actual 'thing' and is not simply a case of my wayward brain acting up. I can see how it's a learned response to stress - in an attempt to protect me from psychic difficulty, my brain holds things at arms length to the extent I feel separated and remote from my own life and even start to question what's real. I'm comforted by the knowledge that it's an exaggerated version of what most people experience. Personally I don't see it in terms of illness; I see it more as an adaptation that was once useful but has now become unhelpful.

I'm intrigued about the extent to which dissociation might be related to having a good imagination because it's common for children to dip in and out of "real life" and retreat to what's inside their heads. And not just children, we all indulge in a little daydreaming here and there. Maybe some of us are a little more reluctant than others to return to the real world? It obviously serves a purpose otherwise it wouldn't stick around but I'm finding it troubling and distracting so I'm hoping I can tackle it (along with a host of other stuff) in therapy.

Institutional Anxiety

As some of you will know, my PhD involves applying psychoanalytic insights to the way NHS psychiatry works. Previous research tells us that in the UK, the NHS "contains" social anxiety that we might become ill, elderly or frail. Similarly, in mental health, we know that psychiatry and the mental health system operate as something of a 'psychic shield' against anxiety that we too might become mad. We also know that faced with the emotional burden of caring for patients, healthcare staff employ a variety of psychological defence mechanisms, including denial and projection, to offset what's been termed 'institutional anxiety.'

Personally, I reject a too-narrow focus on the biological when it comes to mental health and would point to the wealth of research evidence that highlights the role of abuse, trauma and social adversity in its development. This has now been largely accepted within mental health practice but all too often, it gets lost in the talk of dysfunctional brains. My argument is that this happens not only because of well-documented professional pride and big pharma profits, but because in many areas, there aren’t acceptable alternatives - they exist, but they aren’t where you tend to be referred by your GP. More importantly (for me as a researcher) I also believe that medicalised narratives serve another purpose. 

At the level of the subconscious, I believe that medicalised ways of thinking about mental ill health function as a way of containing another form of social anxiety. This comes from the fact that if we were to fully accept the contribution of abuse and trauma to mental health problems, we would be forced to accept that these unpleasant realities are more prevalent within our culture than we'd like to think. And who really wants to believe that so many lives are blighted in such ways? 

Previous academic work suggests that even those who encounter such stories every day; psychiatrists and mental health nurses, can feel uncomfortable dealing with disclosures of past abuse - in the face of such topics, they report feeling de-skilled and tend to want to refer such cases to psychotherapists; often involving a considerable wait. Previous research also shows that mental health staff can feel helpless in the face of huge social problems, knowing they have only medical responses at their disposal. They know they can't go back in time and magically erase people's pasts, nor can they intervene directly in peoples' social circumstances. As such, these feelings of hopelessness are sometimes directed towards the patient; someone who has already been abused, neglected and not heard. Redeploying the problem as residing within the person may feel emotionally 'safer' for health care staff but it comes at the cost of attacking the wrong target - the patient. Sometimes it’s expressed as frustration - believing that people “aren't trying hard enough to get well,” or aren't getting better in the right kind of way. This adds to the patient’s existing depressive burden and often, low self worth. Ironically, we know that engaging in these defensive processes is unhelpful to staff too - it inhibits the creation of working relationships that would help to offset the anxiety and encourages burn-out. 

I’d argue that similar processes occur at a societal level too. The abused, the mad and the traumatised tend to occupy a binary position - either pitied as ‘victims’ (particularly if they are children) but in adolescence or adulthood,the anger that might be rightly directed towards the perpetrators of abuse, the victims end up being on the receiving end of projected frustration, anger and upset about what's happened to them. In mental health, we hear a lot of comments along the lines of "surely he/she could take more personal responsibility for their own wellbeing?" And "This person is taking the piss ' playing the system."   

Our unwillingness to accept the uncomfortable realities of some people’s lives is partly, I think, due to our understandable reluctance to ‘blame’ families and wider social circumstances. It's a big deal to accuse families of failing to provide the conditions in which people thrive. It's a big deal to say we live in an abusagenic culture where we fail to adequately value human life. It’s not always about deliberate neglect and abuse, as awful as those things are. Sometimes, the adversities families face are things like poverty, isolation, bereavement and bullying. These things have become so normalised that they are reinforced at the level of government policy to 
only muted unease. 

Sometimes the patient is equally reluctant to frame their experiences in this way. The counsellor's consulting room is full of people who had 'happy childhoods.' Given such a murky picture, it’s hardly surprising that we tend to frame experiences in terms of brain disorders; it's a highly convenient euphemism. I don't deny that the brain is involved, there's no question that it is. I just happen to favour explanations that locate brains inside the heads of actual human beings; people existing in dysfunctional circumstances and their brains responding accordingly, by fundamentally altering stress responses. (The HPA Axis, if you're keen to find out more). Given the evidence, I find brain-based explanations much harder to believe than ones which say the family and society are often sources of conflict, adversity and harm, as well as providing us with a great many good things. For the purposes of my research though, we know that these things are way beyond the remit of the NHS.

If we are to find any answers to mental ill health, we should be looking way beyond the role of the individual - as instrumental as individuals are in managing their own recovery - and to the way we organise our wider society. I think if we were to accept the role of abuse and adversity in causing mental ill health, we would justifiably become angry, start to kick up a fuss and demand that changes are made, perhaps forgetting that these changes start with the personal. My belief is there'd be some loss in abandoning euphemistic medicalised explanations, but potentially enormous social gain.

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