Merging Fact with Fiction - with Lionel Shriver

Verbatim notes from Guardian Masterclass with Lionel Shriver (4 April 2016).  Huge thanks to my long-suffering husband for bagging me a place on this, as a very early and thoughtful birthday treat!

Merging Fact with Fiction

Novels often incorporate non-fiction elements / research.  There is an art to this!

How is the use of non-fiction helpful?

• If writing is intended to be realistic (i.e. not fantasy genre) then non fiction details help create “verisimilitude”, pinning the story to a real time and place
• If details are off, then readers’ faith in the author will be destroyed (“the spell is broken”) – factual content needs to be accurate for it to be beneficial
• Authors get lots of reader credit for getting details right
• For example, a good route into creating well-rounded and believable characters is in thinking carefully about their jobs/occupations and doing requisite research (as you would do if choosing a profession in real life!)
• Details like this come back to the writer in spades, by offering up potential conflicts, worries, protagonists… Too many novels take a person’s work-life for granted, characters become too domestic. (But DON’T make your characters writers – writers don’t do anything!)
• Use non-fiction to edify and educate readers – they are grateful for this, especially those that struggle to digest traditional non-fiction. “Sugar coating the facts” of an issue or topic.
• Even more important is self-edification.  Enrich your own life as you write.  Start to care about things.
• With caution, you can use fiction to make a social/political point or champion a cause.  But you may have to disguise this a little – don’t preach!  Nobody likes being lectured to.

Some “Fields of Authority” that Shriver has used in her work:

• Anthropology (in “Female of the Species”)
• Rock n Roll drumming and US immigration system
• Northern Ireland politics/troubles ("Ordinary Decent Criminals")
• Population control/demography
• Inheritance law/disputes
• Professional tennis (“Double Fault”)
• Foreign correspondents
• School shootings/ Attachment Disorder (“We Need To Talk About Kevin”) (Interestingly, when I questioned Shriver about whether she did much research into child psychology for Kevin, she answered that actually she didn’t want to get too hung up about that.  The mother in this book didn’t seek professional advice or get any real answers about what (if anything) was wrong with Kevin, or their relationship, so she felt this gave the book more realism/authenticity).
•  US health care system (“So much for that”)
•   Economics / dystopian economics (“The Mandibles”, forthcoming).

Actually doing the research – some tips:

·         May be useful to “page through” some academic journals – try to find out what the most esteemed journals are in the field and where the main academic divides lie.

·         Remember: make up the people/places/things that you need to author (i.e. have complete control over – they are then in your complete authority)

·         Shriver claims she is not as obsessed with actual settings as other writers, and tends to fall back to places she knows/has lived in (e.g. NYC, London, Boston, Raleigh). But, even within a city such as London, there are LOTS of different worlds to explore.  Walk around a bit!

·         Use what you know.  Any unusual or faintly interesting experience is gold dust to the writer.

·         Look at places with a fresh eye when using it for fiction. Carry a notebook everywhere. Take photos.

·         Internet is normally primary resource – but BEWARE the Wikipedia novel!  It’s lazy and doesn’t work.  Don’t just “dump” information into your work – this is as bad as copying and pasting.

·         Use google maps (especially Street View) to get detailed information on places (and also Trip Advisor reviews, photos, etc)

·         But original experience (i.e. leaving the house!) is very important.  Sensory information can’t be gleaned over the web alone.

·         Make a commitment to the topic.  Buy an expensive book in the subject area.

·         Create little individual libraries for each book you write, as a tribute to your hard work.

·         Don’t procrastinate.  Don’t use research to put off writing the book.

·         Be active in your research, like writing in a notebook.

Other points:

·         When something requires too much explanation, it can distract from the story.

·         You can use a “Glossary of Troublesome Terms” (see “Ordinary Decent Criminals”!) to provide background information.  But do it in a classy, entertaining, unique style.  It should be part of the book.

·         Don’t neglect libraries.  Not everything is on the internet (especially for historical topics)

·         Your job is to tell a story.  Don’t weigh it down. Be judicious.

·         Don’t be a show-off.  Be impressive without trying too hard.

·         Treat the audience as an equal. 

·         Be artful. Don’t duplicate.

·         Try not to use information that will quickly date a book – try to write about something timeless or universal (even if you’re writing about something very topical, it can have a universal message).  For example, “So much for that” is no just about 2007 healthcare in the US, it is also about what it’s like to be terminally ill and facing death.

·         Remember – enthusiasm for your subject is contagious!

·         Deliver your information with style and attitude.  E.g. an extract in “Kevin” delivers some facts about real school shootings with accuracy, but also infused with (the mother’s) emotion.  The facts are delivered in authentic dialogue.  This makes it less “authorial” and more animated.  In dialogue, people trade in information, usually to a purpose.

·         Make it funny!

·         Inject your own perception/acuity/thoughts/interpretation – what do you conclude?

·         Disguise information as if your reader knows it already.  Flatter them.

·         Try to let some other views/dimensions into the book, even if you disagree.

So you think you might like to work in perinatal psychiatry?

I was asked to speak at an event at the RCPsych today, encouraging more doctors to enter the perinatal psychiatry field.  Obviously I couldn't attend (being on the other side of the Atlantic!) but I sent over some thoughts in writing.  Please share with anyone who might consider this career.  Worldwide, we need many more perinatal psychiatrists (not to mention mental health nurses!).

Why choose perinatal psychiatry?

You've already studied medicine, and taken an oath to Do No Harm.  You are scientific and yet artful.  Pursuing the noblest of professions.  The world will always need doctors.

You are thinking about a career in psychiatry.  Perhaps you'd rather work with thoughts, emotions and behaviours than with blood and guts.  Be warned though - we psychiatric patients can still provide plenty of the latter!  Your tools in psychiatry will be your OWN mind, rather than the scalpel or stethoscope - how you communicate with us, what you choose to hear, how you evaluate the complex human pictures before you.  Are you good at managing chaos?  If you aren't yet, you soon will be.

You've come across the term "perinatal" and are curious to learn more.  What is perinatal psychiatry?  Might it be the path for me?

I'm not going to paint you a picture of roses and unicorns.  You are too clever to fall for that.  Instead, as someone who spent some time in a Mother and Baby Unit, I will give you realism. 

MBUs: inspiring, rewarding, emotional, tense, suffocating places.

Scenes of utter joy one minute (imagine a new mum looking into her baby's eyes and smiling at him for the first time!).

Hilarity (explosive poo crisis in room 2!).

Friendship (between patients thrown together in the most inauspicious circumstances - and, yes, the staff caring for them).

Heart break (the decisions that you - yes, you - may have to make will be life's hardest: removing babies from families; treating mothers against their will; deciding their problems are not psychiatric after all but social - and you have no drug or therapy for that).

But if you are considerate, calm, good at balancing risks, seeing the bigger picture, communicating with both the psychotic and their equally frantic family members, then perhaps an MBU could be the place for you to make a real and positive difference.  

Because if you help fix one severely mentally ill new mother (and I was one) then not only do you send her home but you give her and her whole family their life back.  You give the baby back his mum and the dad back his partner. You give each family a new start.  And rather than remembering the hideous psychosis and the fear and the distress and the panic of their postpartum days they will remember the care they received throughout it all.  They will get on with their lives, not just recovered from that spell of illness, but hopefully stronger and more able to cope with whatever life throws at them next. 

So - consider it.  Do not enter into it lightly.  But consider it.

An open letter to Jamie Oliver

Dear Mr Oliver,

So happy to hear you are looking for a new cause to campaign on.  You must (justifiably!) be very proud of your work on school lunches, nutrition and now the sugar tax.  I have no doubt that your interest in the health and wellbeing of our country's children is heartfelt and genuine.  

But, please.  If you want to campaign on something - please don't start telling mums what type of milk to feed our infants. 

Choose the fight against child poverty and the punishing cuts to our welfare state.  We'll all miss it when it's gone - even IDS realised that. 

Choose the fight against the forced closures of local children's centres and libraries.  Hundreds of facilities are at risk, or have already shut their doors.  Turned over to properly developers, fitness chains and supermarkets.  These places were a lifeline to me when I was a struggling new mum.  Our communities need community centres.

Choose the campaign for better perinatal mental health services.  Help the Maternal Mental Health Alliance close the postcode lottery of vital specialist services like Mother & Baby Units.  Help us put in place trained mental health midwives and health visitors so we can reach more families and save lives.  

Choose Child and Young adult Mental  Health Services - everyone these days is aware of how shockingly underfunded CAMHS is.  Long waiting times, high thresholds and devastated families.

Choose to join the 1001 Critical Days campaign.  An incredible campaign working in Parliament to ensure the best possible services from conception to Age 2.   If even half of what they call for is put in place then a generation of children's lives will be transformed.

Choose any and all of this, and more. But please.  Don't choose milk.  I'm fairly confident most women out there are planning on feeding their babies milk.  Why should you care whether it comes from a boob or a bottle?  The difference it might make to an infant's life chances is so disputed I can only conclude it is negligible.  Unlike the list above.  Those causes - I know from bitter experience - are life changing.

Sincerely yours,

Kathryn 

My Baby, Psychosis and Me

Like many others involved in the campaign to raise awareness of, and improve services for, postpartum psychosis and other perinatal mental illnesses - I tuned in to BBC One's "My Baby, Psychosis and Me" earlier this week.  The documentary was aired as part of the BBC's #InTheMind season, and achieved both impressive viewing figures (for being on so late) and astonishing viewer reactions.  I gathered just a selection of the Twitter response to the programme in this Storify:

https://storify.com/katgrant30/my-baby-psychosis-and-me 

A few days later, I wish to record some of my own thoughts on it all.  Before I begin I declare the following interests (baggage?):

1) I am a huge fan of Dr Alain Gregoire (the consultant in charge of the Winchester MBU, where the documentary was filmed) and his whole team.

2) Like the two women featured, Hannah and Jenny, I survived PP through being hospitalised for a significant length of time and medicated using powerful antipsychotic drugs.  I am hugely grateful to Psychiatry and the allied professions.

Ok, with that out of the way, let's begin our analysis...

We are introduced to Hannah and Jenny with no pleasantries.  They are both acutely unwell and in desperate need of a Mother and Baby Unit bed.  There were rumblings from some quarters of the audience about not knowing enough of the women's backgrounds, their history, their psychology.  But I think the filmmaker's approach in this case was to mirror reality: in a psychiatric emergency there is no opportunity for lengthy introductions or even so much as a how-do-you-do.  I liked the way the women came into the film: at the start they were their illness.  The psychosis in each case had largely consumed them, and it was the job of Dr Gregoire to find them again.

At times the film was almost unbearably sad.  It was during those times I, personally, retreated to the relative safety of Twitter and took a "social media management" approach to viewing the show.  My husband (who was in London, while I was visiting my family in Scotland) texted me to say how he thought I was "more of a Hannah psychosis than a Jenny psychosis".  I think he may be right.  I found Jenny's illness fascinating (the links to her bipolar, the ebb and flow of her mania, her paranoia)... But it was in Hannah that I really recognised myself: the sheer desperation, the terror, the restlessness, the crippling anxiety and self-doubt.  Watching Hannah in this state made me want to reach into my television and hold her tight and whisper intently into her ear: you will be ok.  You will get out of here.  You are a brilliant mum.  Hold on.  Hold on.  Hold on.

One thing the cameras didn't quite manage to convey (and perhaps this was deliberate) were the actual hallucinations.  Seeing things that are not there, hearing voices, experiencing the world completely differently from those around you, that is the nub of psychosis and the truly petrifying element of the disease.  I can only imagine that in those moments the cameraman was perhaps shepherded away.   In my own case, when I was "floridly psychotic" (how I love that term!), the other patients and any visitors to the ward would be ushered away to the safety of the communal nursery where the heavy door would clunk shut and a member of staff be on guard until it was safe for them all to come back out.

The cameras didn't capture these moments, but I'm sure they were experienced by Jenny and Hannah nonetheless.  And allowing a film crew to capture even just the recovery from this absolute Hell is a testament to their strength and courage.  We viewers were privileged to see ward round discussions (an absolute insight to the staff's continual balancing act of risk and recovery), the side effects and treatment effects of various medications, and even Hannah's experience of Electro-Convulsive Therapy (ECT).

I had seen ECT before but only in movies (remember Requiem For A Dream?).  Seeing it performed on Hannah "in real life" was gut wrenching and shocking.  But it worked.  And I kept thinking only how brave and determined she was: willing to try anything in order to just get better and be there for her daughter.  She wanted to die so much - and yet she desperately wanted her daughter to grow up with a mummy.  It was true incredible to watch.  And it seemed to work!

There have been a few comments online about how medicalised the programme was, with its focus on medication and ECT.  Yes, there was a lot of psychiatry on show.  But, again, I think this is realistic: postpartum psychosis is a psychiatric emergency.  There is a huge amount for psychology and other types of complementing therapy to do - but only after the PP is under control.  I personally would have loved a second part of the documentary, which went on to show the role of clinical psychologists, psychotherapists, family therapists, peer supporters, art therapists, occupational therapists and so on. But there was only an hour and given this was a documentary about the experience of PP it seems right that the focus was on psychiatry.  And what a psychiatrist!  I think even the most skeptical anti-psychiatry voices were won over by Dr Gregoire.

He explains his considered thoughts on mental illness and the brain so eloquently.  If even just a tenth of Dr Gregoire's compassion and understanding could be captured and inserted into every single health care professional we would go a long way to treating mental illness properly.  To achieving that "parity of esteem" our current government loves to speak about.

And I wish everyone could listen to Jenny's husband Henry as he speaks of his wife - how funny, how kind, how caring she is.  All of which is at first hidden by her illness.  I think Dr Gregoire and his staff "get it".

I was lucky to have just spent a day at the Winchester MBU where I witnessed first-hand how therapeutic the whole environment is.  Without compromising safety (always a huge priority in any acute mental illness ward) the staff are all trained and guided to be therapeutic at all times.  Every interaction is an opportunity for them, from taking a patient for a walk to the shops to helping them with baby's sleep routine at night.  The patients are encouraged to cook meals together (with the help of their very popular young Occupational Therapist), to take part in gardening projects, to do lots of messy play and crafting activities (with and without the babies).  None of this was captured in the documentary - it wasn't the focus - but I do wish to reassure any viewers who might be left with the impression that all the patients were treated with were pharmaceuticals.

I will leave it at that.  I'm off to watch it again on iplayer (still available here: http://www.bbc.co.uk/iplayer/group/p03hybyj ).  I want to watch it alone, with my smartphone switched off, and just let it all sink in properly.  

Service user or service provider?

Over the last year or two I have forged a busy (if hardly lucrative) career in having been a former mental patient.  It's called being a "service user voice" or "patient representative".  I have attended workshops, spoken at conferences, commented on service specifications and care pathways, and reviewed services.  The health care professionals and managers involved are always keen to engage with us, but I'm not sure how meaningful it all is in practice.  I still read the same jargon and buzz phrases, week in week out:

Collaborative care.

Integrated pathways.

Patient-centred.

Whole-system.

Multi-disciplinary.

Ad infinitum.

As a result, I'm reaching the natural end of my contribution to perinatal mental health services - as a patient or service user. But I still want to make a difference. I genuinely want to transform the way perinatal mental health services are delivered.  I want to understand how this is done now, and how we can make it better.  And I want to help individual women and families along the way. 

In my personal life, we are coming to terms with our inability to have another child.  And I am thinking seriously about what to do with myself (besides the novel writing and MHFA training!) once The Boy starts school in September 2017.

Perhaps I am madder than I think, because I am now seriously considering a new career, at the advanced age of 35.

I am looking into the possibility of retraining as a mental health nurse, and starting a career in the NHS.  I have two degrees already (if you want my full CV: MA(Hons) Economics & Politics 2002, and MSc Economics 2005), so apparently I could even join an accelerated postgraduate entry programme (the PGDip in nursing with registration, mental health branch).

But in order to be accepted, I need to show almost 600 hours of "accredited prior learning and experience".  See, for example: http://www.kcl.ac.uk/study/postgraduate/taught-courses/nursing-with-registration-graduate-entry-pg-dip.aspx

I have built up some relevant experience through all the patient rep work mentioned above, as well as the peer supporting I have done and Mental Health First Aid training.  But I need much, much more.

Can you or your organisation help?

I'm looking for flexible (due to childcare constraints) work experience placements in or around London, in mental health care settings (primary, secondary or tertiary; statutory services or third sector; traditional or alternative). 

In return you would get the services of a very enthusiastic and committed work experience student who has plenty of "lived experience".  I also have a full DBS, MHFA training and some specialist Perinatal MH training too.  I'm looking to do as much work experience as I can in the next two months, before our family goes away on secondment.  However my university application is not due to be submitted until June 2017.

If you would like to discuss please do leave a comment here, or message me on Twitter (@KatGrant30). Thanks!

In praise of "Woman's Hour"

My father-in-law is a fan.

Prime ministers are held in its thrall.

It provides companionship to thousands.

And as for me? It has schooled me on everything from sex and relationships, to child refugees, to work-life balancing, to the lives of tribal women around the world, to forgotten female scientists, to best lemon drizzle cake recipes.

The forty-five minute 10am slot on BBC Radio 4 is a fixture in my podcast library.  Having recently taken up (slow!) jogging, I am an avid listener.  Even while puffing away around the local park I am at once calmed and intrigued by Jenni Murray, Jane Garvey and their guests. 

It's hard to pin-point the attraction of the programme.  I like to think I'm a modern sort of woman, who's had a busy career and identifies as a feminist.  But I also love to bake, worry constantly about my parenting skills or the state of my marriage, and love to hear interviews with women leading interesting and unusual lives.

I would be beating down the door of BBC Broadcasting House, if ever they cancelled it.  But that does not look likely.  In fact, the Powers That Be have recently commissioned the superlative Lauren Laverne to host a "Late Night Woman's Hour" - like Jenni Murray with added sex chat and swearing.

Recent discussions have included "taboo subjects" like the menopause, and whether the idea of women "Having It All" is a myth dreamed up by advertising executives.  

It is quietly, politely, subversive.

Politicians understand its reach and importance (especially within the key pensioner cohort).   It does not present any party political bias (many assume it is "small c" conservative, but I see little evidence of this).  It simply holds its interviewees to proper account. Be they researchers presenting a new thesis on the cause of cervical cancer, a cabinet minister answering questions on departmental spending priorities, or a novelist explaining their inspiration for their new controversial book. 

This morning the Woman's Hour team tackled the issue of breastfeeding: why is it so hard for some mothers, and so easy for others?  What advice and support can help?  How long should babies be breast fed for, and in what situations might bottle feeding be a better option?  Among my "mum friends" (both in real life, and on social media) this is a hugely divisive issue.   For example, I strongly believe that the "Breast Is Best" message pushed onto me by the NCT and others throughout pregnancy was a contributory factor in my postpartum psychosis.  I sacrificed everything - my sleep, my well being, my peace of mind and finally my sanity - on the breastfeeding sacrificial altar.

It felt good to write in to Woman's Hour with a short synopsis of my experience.  I had hoped they might read it out on air, and that my words could help other mums listening in.  I know my story would be in safe hands with the Woman's Hour team.  They always take care to present all sides of any debate.  They give practical, sign-posting, advice and information.  This morning was no different.

So, if you have never tuned in or downloaded their podcast, please give them a go.  I promise at the least you will be mildly diverted. And at best it could be a real eye-opener.

Secondary infertility

Or - the post I hoped I'd never have to write.

The infertility charity RESOLVE defines it thus:

"Secondary infertility is defined as the inability to become pregnant, or to carry a pregnancy to term, following the birth of one or more biological children. The birth of the first child does not involve any assisted reproductive technologies or fertility medications."

It doesn't seem to be talked of as much as primary infertility, or the decision to remain child free.  You have a biological, naturally-conceived child, so how can you say you're infertile?

Well, yes, on the face of it I don't exactly look infertile, running around after my three year old clutching baby wipes and snacks.  But infertility has been in my life ever since we started to try for another child two and a half years ago.  And now this merry dance is over: my ovaries simply don't have any eggs left in them.  Elvis has left the building.

We are left to grieve.  To wonder Why? To blame ourselves and each other.  To be angry at the doctors for giving us so many promises and false hope.  To laugh at our younger, contraceptively-minded, selves.  To hold our son tight and tell him sorry, so sorry, oh how sorry we are that we can't give him a brother or sister.

Since I last wrote about our longing for "Number Two" we did indeed decide to give the fertility clinics a shot.  We naively thought our odds were good, given how awesome our kid is and how compatible our gametes clearly are.  A few false starts later and we finally got down to the IVF business a few weeks ago.  From our first follicle monitoring scan I knew we were in trouble.  The numbers did not bode well: two, possibly three, developing follicles in the right ovary and none visible in the left.  Ok, perhaps they are just slow to develop?  No, by the time the consultant decided to do the collection we were still talking about a maximum of three follicles.

As I learnt to my bitter disappointment today, follicles don't always mean eggs.  They couldn't find a single one, and they aspirated every last inch of my two ovaries.

I don't want to put anyone off having IVF treatment.  The clinic could have handled things better, but I am glad we gave it one last shot, and at least I can lay it all to rest and accept that another biological child is not in our future.

We are going to take our time to regroup, to recover.  And then we will pick ourselves up and count our blessings and look to the future.  Who knows? That future may even involve a child already born, who could be looking for an adoptive family in years to come.

Balance sheet brain

My friend and mental health colleague has written this insightful and heart-breakingly honest blog about her bipolar disorder: 

http://madnessmotherhood.blogspot.co.uk/2016/01/what-goes-up-must-come-down.html

It is a fantastic read, and has inspired me to write down a few of my own thoughts on bipolar, and how it has shaped me.  I was only diagnosed with bipolar in 2013 (following an episode of postpartum psychosis), but I believe it has been with me throughout my adult life.  To be perfectly honest, for most of the time, I give it very little thought.  Why should I be defined by a diagnosis?  I'm a person (a very flawed and imperfect one!) and not a collection of symptoms listed in the DSM.

But, from time to time, I have to accept that bipolar becomes me.  Think of it like a child's see-saw: for much of the time the see-saw gently bounces up and down, the forces acting upon it are balanced and benign.  Gentle ups followed by gentle downs.  And quite a lot of time spent barely bouncing at all.  Bipolar becomes me when the control of the bounce has gone: the see-saw swings wildly from ground to sky and those once-happy tots are in grave danger of bouncing straight out of their seats.

Another useful analogy is the accountant's balance sheet.  Assets and liabilities.  

"Fixed assets" are those elements of my brain which are basically permanent: my genetic inheritance, the nurturing childhood I enjoyed, the relationship with my son and husband, the positive elements of my basic personality.

Conversely, "long term liabilities" are a constant balancing force on the other side of the equation: my innate selfishness, my notorious short fuse, the long-lasting after effects of psychosis and mental breakdown.

Heavy stuff.

But the more interesting aspect of the balance sheet analogy is the current assets and liabilities: those things coming in and out of my life, impacting my emotions and feelings and behaviours in an immediate (and usually temporary) way.  In a person who doesn't have bipolar disorder, these ebbs and flows tend not to have too many untoward effects.  But for a person with bipolar, they can have profound consequences.  

On the "asset" side:

- financial overconfidence

- workplace arrogance

- lowered inhibitions

- impulsiveness 

- thrill seeking.

All things which feel wonderful at the time (hence landing on the asset side) but which can quickly become "hypomania" and perhaps even mania or psychosis.  I have a long list of people to whom I really ought to make amends: old friends, ex boyfriends, work colleagues, former managers, family.  (I don't include the credit card companies which must have made a small fortune from the constant high-interest debt I serviced for over ten years).

On the liabilities side:

- Low self worth and self esteem 

- Anxiety

- Sadness

- Paranoia.

These are all the R easons why bipolar disorder is a "disorder" and not some Limitless-style magical way of being.  Feeling sad, low, unworthy, are all normal human emotions.  But in bipolar disorder it seems that the thought processes going along with it are an extreme: catastrophic, overwhelming, fearful. 

The cumulative effects of all these current "assets and liabilities" then become the long-term and fixed aspects of me.

I won't ever not have bipolar disorder.  I will always have this balance sheet brain. 

But I can certainly learn how to manage it, how to account for it, and (apologies for stretching this tenuous analogy to the very limit) be my own book-keeper.

Happy "Time To Talk" day!

It shouldn't have to be this hard...

... But it is.

Today I (along with my wonderful friend and fellow campaigner Eve Canavan) gave another television interview, about perinatal mental health services.  The topic is of great interest currently, with the EastEnders storyline and all the associated coverage.  The team from BBC Breakfast, putting together a segment for Tuesday 19 January edition, were interested to know how women like Stacey may be treated, and what barriers to treatment they might face.  We spoke to the journalist at length about what had happened to us, and what we would like to see happen in the future.

Eve's story is particularly shocking.  You can read it here: https://smalltimemum1.wordpress.com/2015/11/22/i-need-a-bed-of-strawberry-creams-in-a-place-of-recovery-dreams/ .

As I spoke, it all came tumbling out.  I'm afraid I may have been rambling and not a little emotional.  But, you see, it's hard to remain dispassionate when we are talking about people's lives.  Babies growing up with poorly parents and (completely treatable) illnesses worsening and lingering.

Politicians love to talk about Parity of Esteem for mental health (in relation to physical).  There was great fanfare this week (on Monday 11 January) when David Cameron announced a near £1 billion funding boost for mental health services.  But already, we know this isn't enough to reverse the years of underfunding.  Speaking starkly: you have to literally be at death's door to access real care for your mental illness.

Have you tried to take your life?

Have you made any detailed suicide plans, such as stockpiling medication?

Are you a danger to others?

No?

Well, I'm sorry, but please get back in the line.

You don't meet our thresholds.

You aren't in immediate danger.

You can cope at home with your family.

There are people a lot sicker than you, you know.

This is a familiar story for anyone suffering with a severe mental illness.  For children and young people the thresholds are even higher.  Mums are (generally) quite fortunate: perinatal mental illness is becoming more recognised.  But even in this field, huge gaps remain.  The Maternal Mental Health Alliance "map" of service provision illustrates the problem: 

Getting help is just too hard, for too long, for too many.

It shouldn't have to be this hard.

But it is.

In a previous life, I used to be a health economist.  I once worked on a project for the Department of Health, looking at the cost of long term conditions such as diabetes, heart disease, and mental illness. It was clear from that research that mental illness was a huge burden to both the NHS and society (as well of course completely debilitating for the families concerned).  The research I looked at showed that just small investments in tackling mental illness - at the earliest opportunity - could lead to massive gains and cost savings further down the line.

It is a no-brainer.

In other branches of medicine, it is completely accepted that the earlier you identify and start treating a condition, the better.  

Lump in your breast?  Referral for mammograms and if there is any doubt, proceed with appropriate treatment.

Nasty chest infection?  Course of antibiotics, to prevent it developing into full-blown pneumonia.

Had a minor stroke?  Start a course of preventative medication to avert future crises.

Broken leg?  Immediate fix, and physiotherapy to get you back on your feet.

In none of these cases would a doctor employ "watchful waiting".  But in presentations of mental illness, this is precisely what they do.

Depressed?  Well you're not actively suicidal so there isn't really anything we can do.  Here's some advice to exercise more and get some fresh air.

I have been busy in the world of mental health campaigning for almost three years now, and this seems to me to be the biggest recurring problem: access, recognition, identification and treatment.  Just how bad does a new mum (for example) have to feel, before being given access to specialist help and support?  I have heard too many stories of closed doors and families living on the edge, trying their best to keep their loved ones safe.

It shouldn't have to be this hard.

£290 million

This morning, David Cameron announced a huge injection of cash into mental health services. (http://bbc.in/1RvwrDg)

Included in a package of almost £1 billion is a sizeable £290 million (spent over the next four years) to provide specialist care to mums before and after having their babies.

This money is welcome, it is significant, and it could make a real difference to the 1 in 5 mums who suffer mental ill health during the perinatal period.  However.  Government hasn't got a great track record when it comes to protecting mental health services and in fact seem to have done their best to belittle and diminish what patchy care there is.  

But let's let bygones be bygones.  Here's a real chance to get it right. If they were to ask me, where would I tell them to spend it?

1. Perinatal mental health midwives in every maternity service.

This is the first decision I would make: to recruit, train and commission enough specialist posts to cover the entirety of the UK's maternity system.  These midwives would have time to care for the most at-risk, distressed and struggling pregnant women and new mums.  They would provide special antenatal and postnatal classes to women in their care, as well as being a continuous point of contact in each mum's care pathway.  They would also be a first point of call for psychiatric emergencies in the pre and postnatal period. 

2. Mandatory perinatal mental illness module included in all midwifery, health visiting and general practice training schemes.

All healthcare professionals likely to be in contact with pregnant and postnatal women will have undergone a minimum training in perinatal mental health.  The aims of the training are to increase awareness of different mental illnesses, how to signpost to the correct sources of support, and how to provide immediate support and reassurance. 

3. Mother and Baby Units in every region of the UK.

At last, here is a chance to close the gaps and end the postcode lottery of perinatal mental health services.  Let's stop closing down MBUs (unit numbers have fallen from 22 to just 16 in recent years, with more under threat).  Let's protect and nurture those units we have. And let's open much needed new MBU beds in regions such as the South West, Wales and Northern Ireland.

4. Enhanced therapeutic programme for all perinatal services (inpatient and community).

This is the ultimate "Nice To Have" in perinatal mental health care.  Psychiatrists are a wonderful breed who can do remarkable things with illnesses of the brain.  But they aren't miracle workers.  Recovery from severe mental illness, or living well with an enduring mental illness, takes guts.  It takes tenacity, ingenuity, creativity.  Everything and anything should be considered, depending of course on the individual. I would like to see a non-neglible portion of funds set aside for grant-making programmes for local sources of support:  walking groups and buggy fitness for mums and dads, group mindfulness therapy, art and drama therapy, parent-infant therapy, and (especially) high quality peer support.

Meanwhile, in another Dimension...

*** This essay was inspired by a similar piece written by Bipolar Blogger last year, and available to read here: https://purplepersuasion.wordpress.com/2014/03/19/a-mental-health-fairy-tale/ ***

Imagine a world where the government in power is committed to the long term future of the NHS.  The energetic MP Luciana Berger enjoys a cabinet-level post with a brief to drastically improve mental healthcare, and ensure that every family gets the health and social care services they need.  The Government has acknowledged the LSE report (http://everyonesbusiness.org.uk/wp-content/uploads/2014/12/Embargoed-20th-Oct-Summary-of-Economic-Report-costs-of-Perinatal-Mental-Health-problems.pdf) which found that undertreated mental illness amongst new parents costs the UK economy over £8 billion every year.  And furthermore, the Government has fully signed up to the 1001 Critical Days campaign, calling for the best start in life for every child, to grow up in households free from the debilitating trauma of untreated mental illness.

Into this world, a baby is born.  Jacob was much anticipated and planned for, the son of a young couple, John and Susan, with no history of mental illness.  His birth was traumatic, and shortly afterward Susan was behaving erratically.  Her family became worried.  They consulted the pack given to every new parent upon leaving the maternity ward: in it, was a plain-speaking leaflet on perinatal mental illness, and a list of local resources.  They called the local number and a specially trained midwife answered the phone.

The midwife Maya asked John a few questions, before arranging a home visit.  By the time she came over, later that afternoon, Susan was delirious.  Maya explained that Susan may be suffering from a condition called postpartum psychosis, and needed to be seen by a perinatal psychiatrist straight away.  She advised John to pack an overnight kit for both Susan and baby Jacob, as most often a spell in hospital was necessary.  She reassured him: don't worry, this is very treatable, with the right help Susan will be recovered very soon.

In this Dimension, Mother and Baby Units are the standard way of treating severe perinatal mental illness in the UK.  The Government had invested enough money to ensure that there was an MBU in every region of the UK - including Wales, Northern Ireland, the South West and Highlands and Islands.  This couple were fortunate: their local MBU was just a ten minute drive away.  It had an international reputation for the quality of its care.

Maya patiently explained what would happen next.  They would all drive over to the MBU, for assessment by the psychiatrist.  They would likely be admitted, as a bed was available.  John was very nervous, but he felt reassured by the midwife's kind words, and the written information she gave him to digest later.

They rang the bell of the MBU: from the outside, it looked like a slightly-larger-than-average family home.  It had colourful paintwork and a well-stocked garden.  Other than the double-locked entranceway, there was little indication that this was an acute psychiatric facility. They were greeted by a staff nurse, who showed them into a comfortable sitting room.  Susan, by this stage increasingly agitated, was encouraged to sit in a nursing chair and she used the pillows to prop herself up and continue breastfeeding while the doctor came in.

"I'm Dr Brown.  But please call me Matthew."

Matthew shaked their hands and sat next to the mum.  

"From what I have seen so far, it looks like you may be suffering from postpartum psychosis.  But Susan, please don't worry: you will get better here.  And you and Jacob can stay here as long as you like until you are better."

"Here comes nurse Sarah, to give you the tour and help you settle in".

The young nurse Sarah took Susan by the hand, and showed her around the Unit.  

"You've already seen the sitting room, where we tend to hang out in the evenings.  Quite often the mums like a nice "adult" space away from all the baby stuff.  Here we can stick the telly on, or listen to music.  We've got a great DVD stash. 

"And just down here is the nursery.  We've got everything you might want for Jacob: toys, books, playmats, bouncers.  Don't worry if you've forgotten anything - we've had a lot of donations from former residents over the years, we can always find clothes to fit or toys you are looking for.  Here are the nursing chairs, and you see our resident Yolanda over there? She's using one of our hospital-grade breast pumps.  Our breastfeeding counsellor comes in every day, and she can show you how to use it if you like?

"We've also got the baby sleep zone: you'll see some of the babies sleep in there, so their mums can get a full nights rest.  It's all monitored and of course if Jacob is in there you can pop in and check on him whenever you like."

Sarah opened various brightly painted doors: to the baby changing station, the milk storage room, and the resident's kitchenette (with tea and coffee maker, toaster and microwave).  There was a beautiful dining area with French doors out to the garden.  On the large oak table was a big bowl of fruit, and pots of jam one of the mums had made in the OT cooking class.  Some of the residents were sat outside on the patio chairs, drinking tea.  Their babies were rolling around on picnic blankets.

"We have ten bedrooms here, and you'll soon get to know everyone.  The mums out there are Kate and Daphne - they are both due to go home soon, but not that long ago they were both very poorly themselves.  I've checked and they are both very happy to chat about their experiences, and what helped in their recoveries.  We find peer support here to be invaluable, and we also encourage everyone to attend group therapy sessions and to log in to the online Twitter support group every week.

Here is your room.  I'm sorry it's on the small side, but we used the space to make sure all the rooms had en suite bathrooms.  We really value our residents privacy, and ability to relax, here.  We do have to make regular observations, but we will explain the procedures carefully so that you understand what and why we are doing certain things.  I know a psychiatric hospital is a scary place to be, but I promise we will try to allow you to feel at ease."

Sarah continued the tour, by showing Susan and John the nurses station and notice board.

"This is the real hub of the MBU, right here.  I know it looks confusing, but here on this big board is everything you might want to know: who is on duty, their names and job descriptions, who is your named nurse, when the doctor is next available.  You'll also see all our different timetables: we have one for relaxation and mindfulness activities, one for the group exercise programme run over in the OT gym especially for new mums, and one for the mum and baby activities.  Right now, we have Rhyme Time, baby massage, postnatal yoga, and Monkey Music.  We encourage the Dads to join in with these too, so some of the classes take place at the weekend.   Talking about dads, we believe in the whole-family approach here.  Two of our bedrooms are actually self-contained family units, which might be suitable for the three of you once you are feeling a little better.  You're a family now, and we treat you as a family!

"So, back to the timetables.  We try to encourage our residents to pick just one or two activities, to fit around their regular psychology and psychiatry appointments.  As you start to feel better, you might want to do more - and perhaps explore all the other activities put on by the OT department and patient-led groups.

"I can see this is all a bit overwhelming!  Don't worry, you don't have to sign up to anything just yet.  And all the information is also in your welcome folder, just there by your bed.

"The first step is to start getting you better.  John told the doctor that you haven't really slept since Jacob was born? Ok, so this is the priority for tonight.  Will it be ok with you to take Jacob to the nursery, so you can have a lovely bath and an early night?"

Susan nodded.  As John took Jacob down to the nursery, she felt a wave of relief.  She sank down onto the comfy bed as nurse Sarah drew the bath and added a liberal handful of lavender bath salts.  She felt safe, for the first time since Jacob was born.  She knew she was in the right place.