Stoicism isn’t only an antidote to anger and emotional distress. It’s a recipe for genuine joy – the kind of joy and wonder that comes from endless discovery and the satisfaction that ensues ‘just because’.
Stoics don’t need a reason to be joyful. It’s enough that we’re alive and able to be joyful.
Today we consider the very first principle of Stoicism as defined by Epictetus in his handbook, The Enchiridion. What can we control and what can’t we control?
This means understanding the difference between problems and facts.
Stoics choose not to waste energy or emotional effort on facts that they cannot change – it’s pointless. Instead they work on things they can change, control or influence. That means they work on (and worry about) surprisingly little.
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Stoic philosophy isn’t the dry, humourless approach to life that many think it is. ‘Stoic joy’ comes from the ability to manage and control our emotions, the ability to choose our feelings without being blown this way or that by the winds of fortune.
Much of modern mental health practice comes from the wisdom of the ancient Stoics. Some of our most successful modern therapies are derived almost exactly from the Stoics whose philosophy leads inevitably toward happiness, contentment, self control and yes, joy.
This video series introduces the basic elements of Stoicism to a modern audience. It’s the antidote to the instant gratification, consumer culture that is the root of so much misery today.
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If anxiety is a call to action that is there to help us solve a problem (how to be safe) depression is the opposite. Depression is a form of physiological de-arousal. This is about giving up. Very broadly speaking depressed people are no longer interested in finding a solution. They have decided that there is nothing to be done and so they give up. Of course there are degrees of this ‘giving up’ and it’s not really as ‘cut and dry’ as all that but none the less depression does have an element of giving up about it. That’s not to suggest that it’s a voluntary ‘submission’ to depression but it is fair to say that depressed people are generally less determined to sort out their problems than anxious people are.
This may seem strange but it actually links very well to the stress and vulnerability model we mentioned in an earlier episode. As people’s stress levels increase they become anxious and try to solve their problems. However if they are unable to solve their problems and the stress increases they give up trying to sort things out and so their anxiety (a call to action) subsides. At this point they move up the scale of mental disorder into depression.
Biological (physical) signs of depression include sleep disturbance (too much or too little), appetite disturbance, apathy and lethargy, tearfulness, slowing down of physical movement and passivity (the opposite of assertiveness).
The service user who never seems to cause any problems or demand anything from the staff might not be content – they are just as likely to be depressed. Be aware of the risk of suicide. According to the Beck Suicide Scale (BSS) the best indicators of impending suicide apart from past behaviour are ‘helplessness’ and ‘hopelessness’. Both of these things are features of depression.
Clinical depression is different from sadness. We all have bad days and the occasional low mood is just part and parcel of normal mood variation. Clinical depression includes the biological symptoms mentioned earlier and is thought to result from a reduction in the levels of various brain chemicals such as serotonin. However, as we noted in a previous episode on physiology there is a ‘chicken and egg’ situation here. Low serotonin levels can cause depression but inactivity (a major symptom of depression) also reduces serotonin levels still further. It’s not always terribly important to worry whether the depression came first or the inactivity was the cause. As is often the case dealing with current problems may well be far more important than trying to understand the history of the disorder. Sometimes ‘here and now’ is all we need to work on – at least in the beginning.
For example ensure that people’s current behaviour doesn’t undermine recovery. Many people turn to alcohol when they’re down but that simply makes things worse. Alcohol depletes serotonin levels which not only deepens depression it also prevents anti-depressant medication from working properly.
However as the depression begins to lift that sort of historical information can be extremely useful – but only if we know how to use it and what to do with it. That’s where diagnosis falls down – it’s only really interested in current symptoms. Formulation is more comprehensive and takes account of the many factors that led people into depression as well as the aspects of their thoughts and behaviours that kept them there. If diagnosis helps us to know what the problem is, formulation helps us to ensure people overcome it and then have at least a fighting chance of avoiding relapse in the future.
All that fancy stuff aside (we’ll get to it later) the basic trick with depression is positive action. Get people active again and give them a reason to continue to take an interest. This is more than mere distraction – it involves purpose. Clearly purpose can be difficult to achieve with some people but it’s worth working at none the less. Purpose and security also make it much less likely that people will present with challenging behaviours too. They have no reason to so long as their needs are being met.
There is, of course, much more to depression than we’ve covered in this little introduction. In particular we need to consider the specific thoughts and behaviours that both create and maintain the disorder. We’ll get to those as the series progresses. For now it’s enough to describe in broad terms what depression is. How it is assessed and what we do about it will come later.
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“Don’t blame people with mental disorders for behaving like people with mental disorders”
Too often mental health workers expect far more from their service-users than they are currently able to give. Then they blame them for having the very problems that brought them into mental health services in the first place. This is a fundamental misunderstanding of mental illness, of the process of recovery and of the role of mental health workers themselves.
It’s true that people are just people and there really is no ‘us and them’. But when people are struggling it’s not fair to expect them to perform at their best. Instead we should practice ‘therapeutic optimism’… Accept the person’s current difficulties but continue to expect them to overcome those difficulties with a succession of little steps.
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This video tutorial outlines the stress and vulnerability model as a tool for mental health recovery. It’s intended for anyone with an interest in mental health and recovery as well as workers at all levels in mental health and social care.
We begin with an overview of the 3 main symptom groups of mental disorder before outlining the model itself and the progressive role of anxiety, depression and psychosis.
Next we consider categories of vulnerability and stressors before defining recovery and providing a brief overview of how it might be achieved.
Finally a collection of slides are included for download. Screenshot the images and save them in a word document to make handouts for reference.
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I often get to take student mental health nurses around in my day to day practice. It’s part of their training to spend time ‘in the field’ so to speak and learn their craft. We don’t just drag them around and let them watch what we do though. We try to help them understand what seems at first to be a very complicated world of diagnoses and disorders, mindsets and medications.
This short video is intended to reassure new students and others that mental disorders don’t need to be complicated. It’s true that we can (and often do) make the world of mental health as complex and convoluted as we like. But there are still some basic principles that can help guide us all through the maze.
This is how I explain the basics of diagnosis and disorder to those students unfortunate enough to cross my path. We should always begin with simple principles and then build upon those foundations. That way, when things start to get complicated there’s something straightforward to rely upon as we go.
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Different people learn and process information in different ways. One way to think about these differences is to imagine that you were training a group of people who spoke different languages and so needed some sort of translation to make sense of the information and skills you present.
Of course we’re not really talking about formal language. We do occasionally need to rely upon translators in training (I often work with interpreters skilled in British Sign Language for example). But even when working with people who have no hearing or other sensory impairments and whose native language is English there is a real issue with ‘translation’ of a different sort.
It is possible to become so wrapped up in issues of learning style that inexperienced trainers become effectively paralysed when trying to determine the best ways to put their message across to a group of people, all of whom have their own preferred learning style and cognitive processing methods. The deeper we look into learning styles the more complicated it becomes and the variables become increasingly subtle. Fortunately though we don’t need to be experts in the fine detail of learning theory to design and deliver a good course. We do, however need to understand the broad principles. I like to boil learning theories down to three broad areas. These are:
Convincer strategy;
Sensory modality;
‘Top down’ or ‘bottom up’.
Convincer strategy
Different people are convinced by different types of evidence:
For this reason we need to ensure that there is a mix of exercises and case studies as well as trainer presentation, group discussion and lots of Socratic questions designed to help people work out their own answers. It’s also useful to have a selection of stories and anecdotes (including those involving respected figures).
One of the more common mistakes new trainers make is to fill their training days with their own preferred type of exercise or activity without realising that there will be a mix of training styles in the room before them. For example my own preferred learning style is to think things through ‘in my head’. I don’t need direct experience so much as cognitive understanding but if I confined my training only to theory and ‘lecture’ I’d fail most of my trainees.
Similairly a day full of case studies with no room for discussion or more abstract theory would be inappropriate for people like me.
Sensory modality
We have five senses and they matter. It is only through our senses that we make sense of the world around us. The five sense of
Are the interface between us and the rest of the world. They are our personal computer keyboard, if you will.
The problems begin when we realise that different people have different ‘preferred’ senses. Some people (most people in my experience) are very adept at processing visual information. That’s one reason why I use a lot of visual imagery in training. Flipcharts allow us to respond to questions with pictures or basic charts that can save huge amounts of time clarifying points of contention.
The visual sense is so important that Piaget, the renowned educational psychologist came up with the training dictum…
“I hear I forget,
I see I remember,
I do, I understand.”
Visual memory is an excellent standby and it’s always useful to bring in visual imagery. Even when relating stories and anecdotes paint pictures with words. It’s important.
But visual learning isn’t the only type of learning that matters.
Some people need words whilst others need more ‘experiential’ ways to process information. Of course it may be difficult (depending upon the topic) to involve taste and smell but role play can be a half decent substitute for the experiential aspects of touch. This mirrors the point we made earlier about case studies and experience.
There is just one rider I’d place on this.
Most trainees enjoy role play once they begin but almost all people expect that they will not. So use role play sparingly. It’s odd.
The experience of role play is generally positive but the memory of it (and certainly the anticipation) is often much more negative.
Very often though we can involve the elements of role play by setting up small group case studies without ever needing to get over the resistance that most trainees have to the technique.
The only time when I would definitely use role play would be when I’m training people on particular therapeutic or inter-personal techniques. Otherwise I use other methods rather than risk alienating the participants.
‘Top down’ or ‘bottom up’
The final aspect of learning theory I want to introduce here is ‘top down’ or ‘bottom up’.
I used the analogy of a jigsaw puzzle in earlier instalments and I want to return to that analogy now.
If the training course is a jigsaw then ‘top down’ learners prefer to see the picture on the box before they start to put the jigsaw pieces into place.
Bottom up learners are rarer in my own field of health and social care but are better represented in some other fields. It’s very well worth taking time to get a feel for the predominant style in your profession.
In my training sessions I always make a point of providing an overview very early on. A common way to do this is with an introductory exercise that serves not only as a warm up but also introduces the main themes of the training (as discussed earlier).
I often use an ‘introductory quiz’ to do this because the subsequent debrief allows me to provide that broad ‘picture on the box’ straight away before spending the rest of the training day ‘filling in the gaps’ with the remaining jigsaw pieces.
However you choose to do this make sure that your initial activities take account of ‘top down’ and ‘bottom up’ learning styles.
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