I recently read a book called How to Come Alive Again by Beth McColl, which has led to me thinking a lot about a subject which doesn’t get discussed often enough: the work involved in managing chronic mental illness. One of the book’s strengths is its acknowledgement that readers will have varying levels of functionality and these may fluctuate a lot, even over short periods of time, yet everyone has to work hard to try and maintain or improve their mental health. Some days, this means challenging ourselves and flying through a list of tasks. Other days, it means forcing ourselves to do basic tasks like drinking some water or getting out of bed. It’s all work.
A lot of people take this work for granted. If you haven’t spent years struggling with your mental health, it may be difficult to believe that simple activities are hard work for some of us. You may not understand how taking a shower can sometimes seem like a gargantuan challenge. You might wonder why people who have mental illnesses can’t just “pull themselves together” and carry on like a “normal” person (a viewpoint I have, unfortunately, encountered many times). But doing these things can be hard work. Mental health problems can drain us of energy, motivation, self-belief and a thousand other things which would enable us to cope better. Things which many people don’t need to consider when tackling mundane tasks.
Working on yourself
Managing one’s mental health also involves extra work, such as addressing complex issues and engaging in activities which have a positive neurological and/or psychological effect. Last week, some counsellors of my acquaintance were talking about their work and mentioned that many clients expect counsellors to fix their lives for them. Instead of embarking on counselling to work on their issues, they seek a quick fix. As one of the counsellors said, “I can’t fix their lives for them. I’m not magic.”
I was fascinated by this conversation, because I have received counselling at different points in my life and had never approached it as a quick fix. In fact, the NHS counselling I have received in the past is often criticised for being too brief to be effective in the long term: six sessions, the first of which is an introduction rather than a proper session. I went through two or three rounds of this with different counsellors and it was a sticking-plaster solution which helped me feel slightly better for a few weeks, only to deteriorate when I encountered more challenges. I had been given neither the support nor the skills to negotiate life as someone who has mental health problems. This started to change when I was given a year of drama therapy, which enabled me to work through a lot of personal issues.
I have also received longer-term counselling (around nine or ten months) from a local charity in more recent years and I was grateful to be given the opportunity to learn coping skills, including how to be more supportive of myself. The counselling itself was hard work, but putting what I have learnt into practice is an ongoing slog. I need to learn to be more accountable to myself now I don’t have anyone to check I’ve done my “homework” each week. Learning not to judge and criticise myself is also a constant challenge—I worry I’m not pushing myself enough and accuse myself of being lazy, even when I know I’m doing my best.
Tailoring your work to fit you
The work I do to manage my mental health is very personal—not so much private, but adapted to my own needs and preferences—and probably looks different to what many other people do. It has been a long process of trial and error which is still ongoing. I have also changed my approach at different points in my life, depending on what is most effective at any specific time.
The biggest difference in my approach over the past eight years is the prominence of exercise in managing my mental health. I started walking on a treadmill, because I was too scared to walk outside alone. My intention was to get a little fitter, because I had been very inactive for a couple of years and my lack of fitness was beginning to scare me. I had no idea it would lead to the decision to replace medication with exercise and if I had started getting fit with that intention, I probably would have been disappointed because it took around four years to reach the point where I could consider reducing my antidepressants.
Medication is another thing people consider a “quick fix” yet, like counsellors, antidepressants are not magic. They rarely work instantly—it can take several weeks to see an improvement, which is normal—and it may take some experimentation to find a variety and dosage which works for you. However, even when I found antidepressants which helped me, I didn’t experience the complete turnaround in mood expected by some people: they simply took the edge off my depression, which meant I could do more basic self-care tasks and work on improving my mental health.
All of these things seem so ordered when I write about them: counselling, medication, exercise and other coping strategies all organised into discrete boxes, all tracking a linear progression from “worse” to “better”. The reality is very different. My symptoms fluctuate a lot and the treatments I have used have been both effective and ineffective at different times.
I emphasise this point because reading about other people’s mental health can create false impressions, especially since many of us can’t write about our experiences during the worst times so write with the benefit of hindsight. These paltry lines of writing represent over fifteen years of struggle following my diagnosis of anxiety and depression; especially during the eight years before I was diagnosed with BPD (borderline personality disorder) and could finally make sense of the symptoms which didn’t fit with anxiety and depression. I don’t think I could ever fully convey my experience and while I can make sense of chunks in retrospect, other aspects I will never understand.
It might be tempting to take some things out of context and to make assumptions about the decisions I have made about managing my mental health. For example, many people assume I disagree with anyone using medication because I have stopped using it myself, whereas I actually credit antidepressants with keeping me alive. Without medication, I would not have been able to access therapy and counselling. I would not have started exercising. I would not have been able to do a large proportion of the work I need to do on a regular basis in order to maintain and (hopefully) improve my mental health.
So, what does this work involve?
My current mental health management plan prioritises exercise: strength-based gym classes and dog walking constitute its core, but I add running and yoga when I feel able. Exercise has a strong impact on my hormones and neurochemicals, which is why I have found it effective as a direct replacement for antidepressants (though not without its drawbacks). I also find it very powerful psychologically, as feeling strong and fit helps me feel more prepared for life’s challenges and I gain a sense of achievement from every workout. Focusing on strength and fitness means I approach exercise with a healthy attitude—it’s not merely a way to control my weight through burning calories and I know that over-exercising would risk injury without providing extra benefits for my mental health. My exercise plan also gives my life structure, but without forcing me into a strict routine which I would be unable to follow when my symptoms fluctuate.
Regular exercising makes it easier to practice self-care, as it means I have to shower often. Basic hygiene may seem simple and non-negotiable if you have never had depression, but showering less often is one of the key signs I’m relapsing. Ditto with changing bedsheets and wearing clean clothes. This might manifest in subtle ways—leaving it a few days between showers but making the effort when you need to go out or be around people—and may never progress beyond this point, but it can get worse. Sometimes it can feel pointless to make the effort to shower, because your illness prevents you from leaving the house. I have been in this position and yes, I might have felt better if I had showered more often, but I was in a lot of emotional pain and had no energy. Nowadays, self-care tasks piggyback on my exercise routine: I shower more, so I change my sheets more and wear clean clothes more often. It also helps me sleep better, which further improves my mental health.
A lot of the work I do to get/stay well comes under the umbrella of “stress/anxiety management”, which is my way of describing a variety of techniques I use to varying degrees. Goal-setting and planning are key strategies for me, because they help me to focus and stay vaguely motivated. I use breathing exercises when I feel particularly anxious, including 7-11 breathing (inhale as you count to 7, exhale for 11) and box breathing (in for a count of 4, hold for 4, exhale for 4, pause for 4 and repeat as needed). Venting my current stresses on paper also helps me feel better, especially if I can identify action points which could reduce or solve the problem, and I sometimes use a few CBT (cognitive behavioural therapy) techniques I have learnt over the years.
None of this work is easy, especially when my symptoms worsen, but there are some areas with which I struggle a lot. Nutrition is difficult because I’m prone to emotional eating and often grab food which is convenient rather than healthy. My diet is generally healthier than at any other point in my life, but I sometimes slip into unhealthy habits—a situation which is not helped by my gallstones symptoms. Perhaps I will be able to prioritise nutrition in future and do stuff like meal prep and batch cooking every week, rather than intermittently, but it’s not something I’m rocking at present and that’s okay—I try to do what I can and I may fall short of my goals, but I’m doing my best.
Considering the macros along with the micros
Most of the work I have detailed is done at the “micro” level: small tasks performed on a daily or weekly basis. This type of work is what fills most of my days. When things are going well, it helps me feel in control and gives me the ability to enjoy my life. Doing the “micro” work also puts me in a better position to handle the “macro” work.
The “macro” work is the big picture: what I want out of life, my long-term goals and mental health management from a higher perspective. Again, this work is very personal. My priorities are my writing career, inspiring other people with mental health issues to chase their dreams, owning my own home (which seems impossible) and having fun along the way. Your priorities may look very different. My current priorities are different to the ones I have had in the past and will have in the future—they are subject to change, but they emerged from my values and I use them to guide me.
Keeping sight of the “macro” work can be extremely difficult when you have mental health problems. When you are struggling to get through each day, you can’t think about long-term goals. Yet, there’s a paradox: keeping my long-term goals in sight reminds me why it’s worth struggling through the days, why it’s important to keep working on self-care and the other “micro” work which helps me feel better. It gives my everyday life a sense of purpose.
I have learnt to revisit my “macro” work on a regular basis (at least once a month) for this reason. It makes my life meaningful and it makes the small steps I take each day meaningful. Do I get frustrated when I seem no closer to achieving my long-term goals and pushing through my daily wellness work feels like a massive challenge? Of course! I’m human. I wish I didn’t have to deal with mental illness every single day of my life, but it’s the material I’ve been given and I have to mould it as best I can. Considering the “macro” work also reminds me to check for progress, no matter how small, which I might overlook. For example, submitting a short story or making an extra debt repayment. My progress may be slow and excruciating, but it’s still progress.
You control your own work
Nobody can tell you what to prioritise in order to manage your mental health—trial and error is the only way to find out what works for you. It’s annoying when we would all prefer a quick fix, but it’s the nature of mental illness. Just in case you need me to point out the obvious, this also means you can’t dictate what other people should be doing to improve their mental health. You don’t know their struggles. It might be easy to judge from afar and when we find something which works for us it’s tempting to evangelise, but we don’t know what will help other people. You don’t get to decide what treatments and coping strategies someone else tries—they do.
You get to decide what you try and how to determine whether it’s effective. For instance, you may find something which helps you, but is too difficult to implement or access on a regular basis. You need to consider the costs and benefits of different types of work. Some of my current strategies would not have worked for me at other points in my life. For example, I tried to exercise at many different times, but struggled to create a routine—I could only establish some structure when I was well enough to attend gym classes. I still get anxious when I go to gym classes, but the benefits are worth this cost and if that changes, I would have to reconsider my situation. Likewise, the CBT techniques I find helpful nowadays were introduced to me in my NHS counselling sessions and didn’t help at the time. It’s important to keep trying new—and old—things to find out what works for you and your lifestyle right now.
I am not magic. I have to put a lot of work into managing my mental health and trying to get well. Sometimes I make progress, but other times I seem to regress and wonder why I bother making the effort. However, I’m learning that when I keep trying to do the work of wellness, moments of magic come into my life. Half an hour of feeling enthusiastic and joyous, rather than anxious, when I’m chatting with a friend. A moment of gratitude when a butterfly crosses my path. Three solid hours of working on a project which could turn into something. These fleeting moments might seem insignificant, but there have been times when I experienced nothing good or positive for weeks on end. Nowadays, if I remember to look, most days contain a little magic.