K is for Keeping Your Head

I am standing at the bus stop trying not to cry. Again. These last few days have felt like wading underwater, with a weight tied around my ankles that is preventing me breaking the surface. My throat is sore from the insistent lump at the back of it, and tears keep streaming unbidden from my gritty eyes. It feels like a long time since I last slept soundly; I can’t imagine when the next time will be. It feels like a long time since I laughed with pure and unadulterated joy; I can’t imagine when the next time will be. I can’t draw my mind away from sad and morbid thoughts, and I can’t seem to stop listening to sad and morbid music. I don’t even like this music, much less all this misery. This is not me. I don’t even recognise this person I have become. Where have I gone? And how will I ever find my way back?

If you can keep your head when all about you

Are losing theirs and blaming it on you…

– Rudyard Kipling, If

In 1995 Rudyard Kipling’s ‘If’ was voted the nation’s favourite poem, receiving over twice as many votes as the runner up. The poem tells us everything we need to know about those traditional British ‘virtues’ of stoicism and self-control, and it’s continued popularity speaks volumes about our national character, and the value we place on keeping our chins up, and our upper lips stiff. I come from a part of Britain (Yorkshire) which is not so much known for that Etonian ideal of Britishness evoked in Kipling’s poetry, as for economy of absolutely everything, including emotion. There is restraint, there is understatement, and then there is a Yorkshire analysis of personal catastrophe. Cancer, in these ‘ere parts is a ‘bad job’ (unfortunate situation) – or, to those inclined to melodrama, a ‘reet bad job’ (very unfortunate situation) – because you are ‘badly’ (suffering anything from an isolated sniffle to the bubonic plague). It is important not to ‘take on’ (show anything resembling emotion), or start ‘blubberin’ (show anything resembling emotion), because that will render you ‘neither use nor ornament’ (useless). Instead, you must ‘frame yersen lass’ (pull yourself together woman), and get yourself ‘on’t mend’ (recover), because in the end ‘it’ll all be reet’ (things will remain just as grim as they were before this happened).

Which is all very well – I am a graduate of this Yorkshire School and an advocate of its teachings. Northern grit has seen many a generation through many a crisis, and a county doesn’t come 12^th in the Olympic medal table without being built on some serious psychological steel. The issue, however, with continually maintaining a stiff upper lip and an elevated chin, is that they are of sod all use if the rest of you has shattered into tiny pieces under the strain of holding yourself together.

Emotional Balance

Yorkshire people, being famously tight, would perhaps talk a lot more about their emotions if they considered the health of their emotional bank balance. To my mind, every time life deals us a blow it is the emotional equivalent of having to fork out for a new kitchen. It depletes your resources and you have to have a period of investment, to build them up again and regain your emotional health. But if you keep taking the blows – or the blow is big enough – then you’re going to go emotionally overdrawn. And if you remain consistently emotionally overdrawn for long enough, then it stands to reason that eventually you will face bankruptcy; that you will have no reserves left to pay the next bill. We all have a different emotional balance, and it takes different events to take us into emotional deficit – for some it is a single, massive blow, for others it might be the consistent overspend that comes from a prolonged period of stress. Either way, as I feel sure Martin Lewis would confirm, ignoring your debts is the one thing guaranteed to ensure that they don’t go away.

Black Friday

A common question I have been asked is if I knew before my diagnosis that I was unwell. The not very reassuring answer to that is no, I didn’t. But for a faint and intermittent throbbing pain under my arm, and the fact that breast cancer was the thing that scared me most in the world, I wouldn’t have found the time to phone the GP, let alone undergone the full battery of tests. I felt fine. But I was, like most people, frazzled, starting each week with maybe just enough energy to get through it, attempting to achieve more than was possibly or practically achievable, groaning under the sheer volume of administration that has become necessary to exist, popping painkillers and antacids for headaches and indigestion, and grinding to a halt at Christmas with the inevitable cold that accompanies a sudden adrenalin drop. I was, in hindsight, a woman under pressure – pressure to forge a successful career, keep a nice home, meet a future husband, have a future family, eat well, exercise more, look good, socialise, keep up hobbies, take up more hobbies, answer more e-mails…to do everything, succeed at everything, be everything I was ‘supposed’ to. Strangely, I never felt under any pressure whatsoever to kick back and binge on a box set, spend all afternoon reading in the bath, or lie quietly on my bed contemplating the mysteries of the universe. They were just the things I did when I felt too rotten or worn out to ‘achieve’ anything else. My stress level, just like my schedule, was finely balanced, maintained precariously at the limits. I was living exactly within my emotional means. And then Black Friday dawned, and I got hammered over the head with a cancer diagnosis. This was my Financial Crisis – my markets were in meltdown, I was in freefall, and suddenly all of those onerous ‘first world’ pressures I was under were replaced by a single, desperate imperative – to stay alive, and to be well.

Survival Instinct

Even in the immediate disorientation of diagnosis, I remember that my body took over and my survival instinct kicked in almost instantly. I wanted all the treatment, I wanted it yesterday, and I wanted to do everything I could to help myself. So within a matter of days, as the dust was settling and the emergency bailout was being devised, I asked to be referred to the psychologist.

Swallowing my pride and asking for that kind of help did not come naturally or easily to me. I am not the kind of person who asks for help. I am the kind of person who laughs in the face of Ikea assembly instructions that insist upon 2 people, even if it means I will spend Sunday afternoon buried under my bookcase with a mild hernia in my bid to just get it done and prove them wrong in the process. But even I can recognise my own limits, and my limits are that there are some things that I am neither qualified nor capable of handling by myself, cancer being right at the top of that list. I could see that to stand up to whatever ordeal lay ahead would require at least as much strength of mind and spirit as it would of my body, and that was the one thing that was definitely my responsibility. It was also abundantly clear to me that, however uncomfortable it might make me or anyone else feel, I would simply be the world’s most enormous fool if I didn’t take ALL the help that was available to me. And if there’s one thing I find even less appealing than admitting I need help, it’s the prospect of being the world’s most enormous fool.

Misery such as mine has no pride. I care not who knows that I am wretched – Jane Austen, Sense and Sensibility

In the waiting room

Seeing a psychologist or therapist for the first time is a nerve-wracking experience, primarily because, however many leaflets you have read, or testimonials you have heard, you don’t really know what to expect. What are they going to ask me? What if I don’t know the answers? What if they think I’m weird? What if I think they’re weird? What if they ask me to do stuff that’s weird? What, specifically, for the purposes of this session, do I consider to be ‘weird’? Will there be incense and chanting? If there is incense or any suggestion whatsoever of chanting I am going to have to leave immediately. Seriously though, what are they going to ask me? And what if it’s just the tip of a colossal iceberg which is going to melt and completely engulf me? However hopeless I feel currently I can’t see how drowning in the glacial meltwater of my own deep-seated anxieties is going to be an improvement. This was a bad idea. Is it too late to leave? It’s too late to leave. Why can’t you just STOP THINKING and settle down and read a magazine in the waiting room like everyone else?

In the Blue Chair

In America, which is the spiritual home of therapy, I am led to believe that psychological treatment is conducted on a couch, but this being Britain and the NHS, mine was conducted in a blue chair. Like almost anything in life, the anticipation of the blue chair is nothing like the reality. I love being in the blue chair. This room, this time, this professional’s uninterrupted attention and expertise is exclusively mine, to use as I wish, and that in itself is soothing. Which isn’t to say that it is an altogether comfortable experience. Truthfully answering the simple question “how are you?” can take some building up to when the real answer is black with terror/white with rage/blue with sorrow/green with envy/red with embarrassment/grey with despair/nothing with numbness, or somewhere between any and all of the above. But good therapists are skilled excavators of emotion. They know exactly what they are looking for, the right questions to ask to coax the truth out of you, and the suggestions that will help you see things from a different perspective.

Sometimes the simple act of verbalising the worry that has been gnawing away at you is enough; like pent up steam you release it and it evaporates into thin air. Other issues are weightier, more difficult to admit to, or even to know how to describe. With those the benefit comes not only from being able to put them into words, to pinpoint exactly what ails you, but also from the reassurance that it is OK or ‘normal’ – that you are not somehow weak, or broken, or indeed alone in feeling the way you feel. And then, by examining those anxieties, you get to know them better, to understand their causes and constituent parts, and to see how you might be able to leave them behind you, or carry them forwards repackaged as a lighter burden.

Give sorrow words; the grief that does not speak

Whispers the o’er-fraught heart and bids it break

– William Shakespeare, Macbeth

I staggered my psychologist sessions throughout my original treatment. Occasionally I was laid particularly low; more often I was feeling more defiantly positive, but however I was feeling I was never at a loss for something to discuss. Cancer affects every part of your life, and forces you to confront a whole range of turbulent emotions. First there are all the ‘usual’ feelings associated with grief – shock, denial, anger, guilt, sadness – which is not to underestimate the power of those to knock you off your feet, and batter you down for a long time. On top of these are the emotions that stem from your particular type of cancer and treatment. Invasive, body-altering surgery can naturally bring with it low confidence and self-esteem. Medications can be accompanied by insomnia, mood swings, and lifestyle changing side effects. Chemotherapy depresses the immune system, and it doesn’t take a leap of the imagination to understand how it depresses mood and sense of well-being. And the practical implication of cancer treatment is that you are no longer in control of your own life – you are in limbo, and the ongoing cycle of tests, results and treatment is an uncertain and highly stressful way to live.

Beyond all these text-book reactions are the emotions that are more personal to you – ‘normal’ feelings and anxieties that are amplified by your own situation and experience. For me they were driven primarily out of my youth and my family history. I have felt a strong sense of frustration and isolation at having my ‘real life’ hijacked by cancer, and being forced to reside a reality so remote from that of my peers. And for us, like so many other families, cancer was associated with dark days and devastating loss; a painful past we have each had to re-confront, and a deeply embedded narrative we have needed to revise in our own minds to deal with a very different present.

Finally, running through all of this, is the constant refrain of fear – What has it done to me? Will the treatment work? Can I get better? What if it comes back? Cancer, like any serious disease, forces us to face up to our own mortality – a daunting question to grapple with at the best of times, and a lonely one in a society that still seeks to look absolutely anywhere else rather than to stare that one certain fact of life square in the face.

That is a lot of emotion for one person to ‘process’. What does it feel like? Sometimes it has felt like being alone in a boxing ring going round after round, taking blow after blow, until you don’t know how you will raise yourself off the ropes. Sometimes it has felt like being stranded on a boat in a lashing storm, with wave after wave threatening to engulf you and the safety and security of dry land tantalisingly close, yet impossibly distant. I have endless different analogies, but the root emotions are always the same – be it a boat or a boxing match, a mountain or a marathon it is always relentless, exhausting, threatening, uncontrollable and isolating. It is never a walk in the park.

A matter of life or death

It is not surprising then, that there is a strong link between cancer and depression. Almost two thirds of breast cancer patients experience some kind of mood disorder¹, and mental health is increasingly considered to be essential to positive long term outcomes. A recent 10 year study showed that breast cancer patients who subsequently were diagnosed with depression had a 45% higher risk of death, even when all other factors such as age, and other illnesses were taken into account². The patients who were depressed were more likely to die. Sobering proof, just when it is needed, that dealing with your feelings isn’t self-indulgent – it’s key to survival.

But survival is also a question of how you live. As an increasing number of people are successfully treated for cancer there is an emerging focus on the long term consequences of treatment for both physical and mental health. The 2013 Macmillan paper “Cured – but at what cost?”³ highlighted that one in four people living with cancer face long term poor health or disability after treatment, and half of those are living with mental health problems. And as the number of people facing cancer grows, so too does the circle of people affected. There are now estimated to be 1.4 million carers of people with cancer in the UK – a figure that has leapt by 500,000 in the last 5 years. The patient may be at the epicentre, but family and friends are also victims of the quake, and they too feel its aftershocks.

Survival of the fittest

As Charles Darwin never actually said, it is not the strongest of the species that survives, nor the most intelligent. It is the one that is most adaptable to change. Cancer is a new and alien situation that requires us to adapt – to face the realities of today, and look forwards to the possibilities of tomorrow, rather than dwelling in the dreams or despair of yesterday. The time I spent with my psychologist helped me to do that. It gave me private space to reflect and accept my situation. It helped me to understand what makes me tick, versus what might make me explode. It didn’t immunise me from feeling mad, bad or sad – I still lose my cool as spectacularly as the next person – but it did equip me with the mechanisms to recognise and manage my emotions, so that I am able to meet the waves with greater calm and confidence, and avoid drowning in their wake. It was, in short, an indispensable part of my treatment. We so often associate medicine with physical healing – the surgeons who wield the scalpel, the doctors who prescribe the drugs, the nurses who tend to our needs – but there is an army of mental health professionals on the front line who are just as instrumental to our wellness, and they deserve our credit too.

Finding Meaning

My psychologist once asked me how I was finding meaning in my experience. I didn’t know how to answer. Was it a trick question? After a(nother) long silence I ventured that I was reading a lot of poetry. Kipling and his contemporaries have played an important role in inspiring me to strength in the face of adversity – good, old-fashioned fortitude is a quality to which I aspire, but I believe you can become tougher in spirit and stronger of mind by acknowledging, rather than denying, the fragilities of your heart. I have found the most meaning, therefore, in the pop poetry of David Bowie and Queen. ‘Under Pressure’ is at the top of my ‘most played’, and it speaks to me as only music can – it is a salve to my stressed-out soul; a simple, distant melody of hope that builds in power until it soars triumphantly over the relentless thrumming of the bass. We are all under pressure. The connected world we have created for ourselves exerts a closer, more claustrophobic pressure than we have ever known, with little time or space to retreat, reflect or to heal. The rumours of a revolution have not been exaggerated – we are witness to the most drastic social transformation in 250 years, and the explosion in the number of people learning to live with or through disease is just one dimension of that change. Cancer was the blow that sent me reeling, but it could easily have been anything else – a different illness, a bereavement or a broken relationship. We all deal with trauma in our own way, but to imagine that we don’t sometimes need a bit of assistance to pick ourselves up and regain our balance is, to coin another Northern term, just plain daft (silly and foolish). We none of us would reject the offer of a cast and crutches for a broken leg, so why do we cling to a notion that fractured hearts and minds should heal without help? Keeping your head and disowning your emotions was a sentiment for a different century, but ‘Under Pressure’ is a message for our times. Our challenge is not just to change our way of caring about ourselves, but to change our way of thinking about ourselves – to accept that our mental and physical health are inextricably connected, and we can only enjoy well-being if we treat our minds, as well as our bodies, with the tender loving care that they need and deserve. That, I have concluded, is not just how you survive, but how you can still seek to thrive during the most testing of times.