I have looked at a few terms that have snuck out of therapy consulting rooms and psychology books into everyday conversations. We can use them easily because they nestle in a culture of increased psychological, and emotional awareness that didn’t exist in the same way when I started work as a psychotherapist. We notice, acknowledge, and advocate more for our emotional and mental needs, and prize our ‘wellness’ or ‘wellbeing’ or ‘welldoing’ more than I have ever known. Some of this depends on others, while the rest depends upon our ‘self-care’. But what this term means partly depends on the meaning of ‘self’ and partly on what ‘care’ is.
I’ll come onto look at the view that our new emphasis on ‘self-care’ reflects our increasing individualism, as a culture, or even that it is a designed outcome of Western neoliberal economies that encourage consumption and production. In other words, the very many products, services and practices of ‘self-care’ fuels a need, and responsibility, to tend to ourselves. At worst, ‘self-care’ can be asserted to avoid someone you’d rather not face, and the idea often includes advice to define our ‘boundaries’ well. My friend was irritated by an ‘out of office’ message from a colleague that told her there would be a delay to a much-needed response, because she was ‘attending to my wellbeing’. She sigh-said, ‘This is self-care gone too far.’
I then go on to look at how self-care relates to another, longer in the tooth one of ‘self-help’, both of which might help us understand what we have come to mean when we think of ‘self’ these days. I touch on the contemporary idea of ‘self-optimisation’ too. After looking at these, I move on to looking at how self-care has been conceived politcally.
While some think the popular notion of self-care runs the risk of unthinkingly trumping others’ needs, another view runs parallel that I look at: that self-care is also necessary. It might be our only option of care at all and can encourage a healthy dose of resilience and self-reliance. The MIND website now has a page for ‘self-care for mental health problems’, linking to another: ‘How to improve your mental wellbeing’. Neither existed when I started offering help for the same, but neither did ‘wellbeing’ or other related terms.
While the advice on both pages makes good sense (such as spending time with friends, and in nature, and attending to good sleep habits), our NHS, MIND, and many other mental health charities, are struggling to cope with demand for their support. Despite successive governments promising more help and support for mental health issues, it remains thin – often vanishingly so – on the ground. And, despite repeated promises for more public spending and structural improvements that would help people’s distress – good public housing, better transport links, schools and funding for the NHS – ‘Shit Life Syndrome’ to use a cynical term, makes self-care, as best as can be done, our only option. It also means that our practice of ‘self-diagnosis’, that has come up in other chapters, is both one of necessity and as of one of concern.
I finish looking at how self-care has mapped onto our NHS, and end on a note of hope springing from one area of healthcare in our communities. I wonder if we have an opportunity to diffuse our sense of self. From the work that I do as a therapist, I now know with confidence that self-care works best when it relies less on supplements and wearables and diets, and more on plugging into positive relationships with others – our friends, families, communities and Mother Nature.
Self-Care commodified
Looking after ourselves physically and mentally is obviously not a new or radical idea, and before any social system of healthcare existed, we tended to ourselves and each other with knowledge passed down and between generations. We absorbed ideas from early physicians and wise folk – such as the Ayurvedic text Charaka Samhita, the ancient Chinese Yellow Emperor’s Classic of Internal Medicine or, in the West, the works of the Ancient Greek physicians Hippocrates and Galen. My Colombian grandmother learnt from hers – including making rose water skin tonic after leaving petals out in the glow of a full moon.
Some point to the Taqw?m as?si??ah (‘maintenance of health’) as the earliest example of a ‘self-care’ manual, written by the 11th-century Iraqi Christian physician Ibn Butlan. This was later translated into Latin and became known in Europe as the Tacuinum Sanitatis (‘Tables of Health’). Much of its advice echoes contemporary ideas of holistic health, and in reverse, many contemporary health practitioners like to emphasise the ancestral wisdom they learn from. Acupuncturists rely on ancient Chinese texts, yoga practitioners learn about the Sutras of Patanjali and David Hoffman, the author of my well-thumbed book of Welsh herbs, derives his wisdom from the 13th century Physicians of Myddfai.
The Tacuinum Sanitatis encourages (free) measures to both keep us well but also offers advice to ward off disease and illness, guiding the reader to make wise choices in six essential areas: air quality and environment (for the sake of the heart), food and drink (with advice on seasonal eating and remedies), exercise and rest, sleep and wakefulness, states of mind (managing joy, anger, fear and distress) and the ‘secretion and excretion of the four humours’ (the body systems then thought to govern our health).
A thousand years later, at least five of these essential areas have birthed their own thriving industries with brands jostling for prime position. (Our four ‘humours’ have been replaced, after many centuries of use, with our modern knowledge of the human body, which can’t always be said to apply to modern products concerning the other five areas of health). So, for example, and taking each ‘area’ in turn: we have air purifiers, de-humidifiers and crystals, we invest in dietary hacks and supplements, we pay others to teach us exercise regimes (with yoga and Pilates reigning supreme) and buy tech and supplements to help with our sleep.
Our states of mind are now helped by an exponentially growing profession of assistance – bar the obvious ones of psychiatry, psychology, counselling and psychotherapy. We also have variously described wellbeing practitioners, and ‘therapists’, meditation experts and a glut of specialist coaches (for divorces, for infertility, for eating, for finances) and other wise folk sharing their experiences of coping or survival.
My profession of psychotherapy and counselling has ballooned with new specialisms in the past two decades – guesses vary wildly from 250 to 500 – and some are territorial, competing with each other or claiming one-upmanship (for instance, long-term therapies emphasising ‘relational depth’ between a therapist and client don’t tend to like ‘mental health boot camps’ and short-term therapies like CBT).
The massive market in self-care means that clients tell me more and more about their new potentially game-changer products. (I take the point, which makes me uncomfortable, that I also benefit from this market, as it encourages therapy). Some have ‘wearables’ that track heart rates and steps, (forging a new cohort of heart rate variability experts), some buy home blood-testing kits to measure nutrients and minerals, and others go to branded gym or yoga studios. I’ve lost track of which specialist diet works best and I have resisted the encouragement of one person I met to buy a £1000 magnetic mattress topper.
Many commentators critique this commercialisation of our self-care industry, usually citing Gwyneth Paltrow’s company Goop’s supply of jade eggs for the vagina as a, ahem, seminal example. The artist and author Jenny Odell, who I mentioned in my Introduction, writes cynically about the grabs at our attention by digital market forces in her book. She notes how the idea of a ‘self’ that this industry targets tends to conflate it with the idea of a ‘personal brand’ too. …’I don’t know what a personal brand is other than a reliable, unchanging pattern of snap judgments: ‘I like this’ and ‘I don’t like this’, with little room for ambiguity or contradiction.’
Dr Pooja Lakshmin, a US psychiatrist also writes questioningly about the stratospheric rise of the self-care market in her 2023 book Real Self Care (Crystals, Cleanses and Bubble Baths Not Included). She responds to what she sees as plentiful ‘faux self-care’, that are actually ‘quick fix’ commodities that do little good in the long run, although maybe some good in the moment. She worries that such ‘care washing’ ultimately serves to avoid some profound societal and structural issues that are the cause of so much distress.
Y, my NHS nurse client who I wrote about in the post about burnout comes to mind as I write this. She was fed donated cakes and biscuits during her hospital shifts in the pandemic and wore PPE both made and donated by women sewing it in their homes. Much of what I suggested to her in order to look after herself felt futile, and frankly embarrassing, given the obvious ways to alleviate the most of her distress – such as more staff, consistent messaging from the government, more and better equipment, more time off, and emotional support paid or provided for, rather than voluntarily given by people like me.
Lakshmin also thinks that many activities or products that are promoted can wind up increasing our stress or guilt if and when they don’t help, and while ‘crystals, cleanses and bubble baths’ aren’t bad per se, marketing them as solutions to mental ill health, can be. I see how this messaging often plays out for my female clients struggling, and desperate, to conceive or have a live birth. Their vulnerability makes them more likely to be susceptible to persuasive marketing language. Not only do they have to deal with a medical systems that has, historically, valued a woman’s reproductive efforts higher if they conceive and birth easily (in my case, my ‘incompetent’ cervix meant a ‘failed’ pregnancy), but they also receive the idea that they have to do more to ‘succeed’ in making babies. Ironically, this might also mean doing less, as the ‘fertility industry’ promotes the impossible task of having to banish stress.
When I was desperate to remain pregnant after many losses in my 30s, I ate almonds, carried an amethyst in my pocket, and borrowed a friend’s Ugandan ‘fertility mask’ to hang on my bedroom wall. My clients now download guided visualisations that help create a ‘receptive womb’ or ‘positive mindset’ and invest in fertility clinic ‘add-ons’ that are not backed by good evidence. Some dietary supplements make good scientific sense, but others make outlandish claims for their worth, with no evidence to back them. The sum of many of these marketable parts is often a weighty pressure to purchase, and the creation of a rich seam of guilt if they aren’t.
Self-help
While it seems to me that self-care has become a global commercial industry, its sibling ‘self-help’ industry has been around longer, and between the two of them, we might sift out some idea as to what ‘self’ has come to mean in these contexts – well outside the lofty realm of philosophical circles.
While the notion of self-care generally pivots around tending to ourselves in the moment, self-help has tended to refer to more active and goal-oriented change. It looks at growth for ‘personal development’, and improvement of, for example, our time-management, presentation skills or destructive or unhelpful habits of mind (such as negative thinking or worrying). Much of the messaging seems to boil down to increasing our ‘productivity’ though, with some ideas specifically targetting quantifiable ‘success’, such as earning X million or gaining Y social media followers (regular spam emails tell me I can buy the latter).
The original self-help ‘thought leader’ (to use another recently coined identity-making noun) is often quoted to be the Scottish government reformer Samuel Smiles who wrote the best-selling Self-Help, in 1859. He emphasised the Protestant ethics of perseverance, hard work, and personal responsibility as a route to success, as opposed to relying on help from others or the state.
Less than a century later, the best-selling self-help genre was set to launch with Dale Carnegie’s evergreen 1936 How to Win Friends And Influence People, which has estimated to have now sold over 30 million copies (one of which I have of course). Authors have made millions from their books, courses and academies and ancient texts have been revived in print too: the ancient Chinese military treatise Sun Zsu’s The Art of War is used to advance business strategies, and various editions of the Roman emperor Marcus Aurelius’ Meditations have been pressed into my hands of late.
The academic sociologist Daniel Nehring has an interest in self-help literature, as a part of his wider thinking about ‘therapeutic cultures’ like ours, a term he describes as referring to the ‘transfer of psychotherapeutic knowledge, concepts and terms into places outside of consulting rooms, such as family life, government and the media’. In 2024, he wrote an article for Sociological Research Online: ‘The self in self-help‘ in which he analysed the ideas of ‘self’ and ‘self improvement’ as conceived in bestselling self-help books sold in the UK from 2008 to 2022. He wanted to understand if the 2008 global economic crash had influenced the view that scholars had taken that ‘popular therapeutic narratives promote neoliberal accounts of an autonomous, masterful ‘entrepreneurial self’, able to thrive in the world on its own.’
Nehring’s conclusions extends previous ones and he discerns the emergence of a new strand of ‘therapeutic discourse’ that involves ‘alternative, survivalist and spiritual’ themes, such as ‘self-making’ (such as Dale Carnegie’s still-selling book and James Clear’s Atomic Habits), ‘survivalism’ (such as Ant Middleton’s Military Mindset and John Parkin’s F**k it books) and those illustrating an ‘inward turn’ (such as the memoirs of Fearne Cotton and Ruby Wax).
Nehring sees a central feature of self-help today as depicting a ‘thin self’, divorced from wider structural, social and community issues. He defines it as ‘a de-socialised self, faced with overcoming purely personal troubles on the basis of its own intrinsic capacities’, and offers a ‘tentative explanation’, lying in the fact that our therapeutic culture largely emerges from our increasing numbers of commercial channels, including the ‘adshel’ (bus stop advertising) by my house which promoted online therapy. Our very many ‘therapeutic entrepreneurs’ foster a focus on individual consumers who are seeking individual solutions to individual problems (my emphasis).
Therapy as thin self
As a psychotherapist, I could also be challenged for thinking that overly focuses on individuality, and self-improvement. The theories taught to me over two decades ago all had their roots in Western philosophical traditions of autonomous selfhood, which tilt toward the life of the individual mind. In turn, these emphasise personal agency over collective experiences and responsibility for each other.
I learned how Freud and Jung battled out their different views about our mind’s internal conflicts, while Gestalt (pioneered by Fritz Perls) and existential schools (such as one that Irvin Yalom led) tune into understanding our individual ‘lived experiencing’. Carl Rogers, the founding father of person-centred psychotherapy also wrote about the importance of ‘self-actualisation’. All of these ideas of ‘self’ diminish others held by many other cultures that prioritise family, community and our earth above the ‘I’.
In the early days of my practice, when I worked in an area of East London with a very high South Asian population, I tended to think of the ‘self’ as defined by the edges of our body. I talked to more than one young woman, secretly dating, or in love, with a white man who they knew their family would disapprove of and they came to me stuck painfully between two cultures. My ignorance meant that I encouraged them to think along the lines of ‘what do you want?’ without understanding that the ‘you’ I referred to meant one inextricably bound up with their parents, siblings, uncles, aunts and extended family beyond them.
Change is, at long last, taking place, and psychotherapy trainings are beginning to reflect broader cultural values. While family therapy has always considered individual suffering in a wider context or system (and I discussed Minuchin’s work in the post about boundaries), trauma-informed therapies, narrative therapies and feminist therapies also think about our broader contexts. The influential notion of ‘intersectionality’, coined by legal scholar Kimberlé Crenshaw in 1989, also provides wind to these sails. This describes how we need to consider that the usual ways we categorise and oppress each other – such as via gender, race, class, sexuality, and disability – all relate, and intersect with each other to forge unique experiences of suffering.
Intersectionality means that people’s lived experiences can’t be fully understood by looking at one aspect of their identity in isolation – for example, the experiences of Black women must consider both racial and gender discrimination, and how the two relate to each other. I return to the idea of self being part of something bigger after a return to ‘self-help’ in its latest guise.
Self-optimisation
A newer iteration of self-help (or indeed self-care depending on how you cut it) has emerged in recent years, influenced by tech break throughs, and Silicon Valley performance culture – ‘self-optimisation’. A decade ago, we were excited about micro-dosing LSD or psilocybin to deal with stress, mental health issues and underperformance, but now we invest in ‘superfoods’, supplements and regimes that claim to do wonders to our brains and bodies, and ‘wearables ‘ that track our heart rate and blood content, such as rings and watches and patches. Our human body can now be seen as a system to work with, or ‘bio-hack’, so we can become more healthy, productive and long-living. A pioneer of this pursuit is the US entrepreneur Bryan Johnson who has invested millions of dollars into his attempt to extend his (and by extension, others) life as long as possible. ‘Project Blueprint’, as he calls it, hit the headlines when he transfused his plasma with his son’s, but it proved to lack benefit, which was a relief to me.
This increased emphasis on productivity in our contemporary ‘self-help culture’ sits uneasily with me, not least because I talk to people every day about how this corrodes mental health. The author Oliver Burkeman who spent 14 years as a Guardian columnist writing about self-help (and writes a lot on this platform), also challenges this zeitgeist in his 2021 book, Four Thousand Weeks: Time Management for Mortals. He homes in on our relationship with time, because it lies at the heart of our modern urge to squeeze every moment for productivity’s sake.
Burkeman grapples with the ‘paradox of limitation’ that is at root of our contemporary distress: ‘The more you try to manage your time with the goal of achieving a feeling of total control, and freedom from the inevitable constraints of being human, the more stressful, empty and frustrating life gets’. Instead, he suggests, deriving ideas from ancient wisdom, that we need to square up to our existential woes: life is finite, and we are imperfect.
I often see how this quest to ‘do’ and ‘perform’ and ‘improve’ sets people up to fail in my consulting room. I meet clients drowning themselves with ideas to flourish rather than languish – just as my clients desperate to conceive might. Often though, as Burkeman suggests, these commitments tend to backfire. In the ‘doing’, there’s less scope for ‘being’ and tuning into what matters far more to people than ticking off lists.
Burkeman reminds us that the average human lifespan is, as his book title says, ‘four thousand weeks’, and rather than attempting to wrestle with time, as if it is some outside force, it is far more helpful to accept its constraints. We just can’t do everything we want, or think we want. The tasks of life are Sisyphean and there’s no way to ‘optimise’ to make them any easier or to vanish. He concludes that it is far better that we accept our limitations, consciously choose what to do and leave undone, and focus on what really matters to us – and in my experience, this involves nourishing, reciprocal, human connections.
Self-care as a political act
The cultural sway of self-care that I’ve been writing about so far sits very far removed from the idea as it was conceived by the Black Panther Party in 1960s US, and also interpreted by other marginalised groups around the same time. To use the phrase from Dr Lakshmin’s book title, ‘crystals, cleanses and bubble baths’ were not on the minds of Black Americans who were, and still are, fighting for dignity, justice and equality in all areas of their lives. Self-care can be framed as both an indulgence, or a necessity.
The BPP viewed health care as a fundamental right for people, and this became part of their broader agenda for social justice, and for the promotion of self-determination. Their notion of self-care was deeply integrated into this political philosophy and was a major part of their community work, particularly through ‘community survival programs’ that responded to the immediate needs of the oppressed Black community.
Alandra Nelson’s 2013 book, Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination looks closely at the BPP’s important relationship between health activism and racial justice. She charts their many free initiatives, such as breakfast clubs for children, supplementary education about Black history and empowerment, clothes and shoes supplies, medical clinics, and education of the systemic medical neglect Black people suffered. They also launched campaigns to research sickle cell anaemia, testing for hypertension and lead poisoning, and helped people with housing and employment problems.
Nelson concludes that the BPP’s ethos laid foundational ideas for our ongoing health activism, with its emphasis on community-led interventions, culturally sensitive care, and an urgency to address structural inequities in healthcare. Applying these to a context I know well, this form of activism has shown up recently in our maternal health care in the UK.
At very long last, attention has been drawn to the disgraceful fact that maternal mortality for Black women is nearly three times higher than for white women, and significant disparities also exist for women of Asian and mixed ethnicity. A House of Commons Committee report in April 2023 notes the role of activism in bringing this to light, ‘These disparities have existed and been documented for at least 20 years, but only received mainstream attention and Government action since around 2018. Considerable credit for putting the issue on the political and public health agenda goes to campaigners, such as Five X More and Birthrights, who have worked to publicise the issue.’
The author Audre Lorde’s famous exhortation from her 1988 book of essays, Burst of Light, connects to this radical tradition of care: ‘Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare’. She wrote this as a Black lesbian feminist, with cancer, and her words determined that her self-care was a survival strategy against oppression. Like the BPP, she also emphasissed the inextricable link between self-care and human connections, stating ‘without community, there is no liberation’ – an idea expanded on by the philosopher Myisha Cherry’s in her 2020 powerful essay, Solidarity Care: How to Take Care of Each Other in Times of Struggle.
Cherry argues that caring for each other is essential to long-term, effective activism and as a necessary component of social justice. She writes, ‘Being aware of social injustices can cause existential and mental pain; comes with a burden; and may impede a flourishing life. However, I shall argue that this is not a reason to despair or to choose to be willfully ignorant. Rather, it’s a reason to conclude that being conscious is not enough. Rather, during times of oppression, resisters must also prioritize well-being.’
The second wave of feminism similarly focused on empowering women – and Black women – to join forces with each other, in mutual self-care, to better advocate for improved mental and physical healthcare. One good example – that men really hated – was Carol Downer’s lead on women’s self-examination, along with the campaigning she and others did for abortion rights and reproductive choices. The 1973 book Our Bodies, Ourselves by the Boston Women’s Health Book Collective can also be seen in the same light (and one battered copy introduced me to my cervix for the first time).
These issues persist, half a century on. The Women’s Therapy Centre was originally founded by feminist psychoanalysts Susie Orbach and Luise Eichenbaum in 1976 as a response to a desperate need to support women facing unwanted pregnancies, abuse, and other forms of misogyny. It is as busy as ever.
The reality of mental ill health
While our increased psychological awareness may do us a dissservice at times – for example when we define ourselves too narrowly, or categorically, or inaccurately – I hope to also emphasise that there is also an undeniable swell of suffering in the UK, and a dire lack of public resources to deal with this well. It makes sense that self-care – in its various iterations – may be the only option for many.
According to November 2024 data from the Department of Health and Social Care levels of anxiety of over 16-year-olds in England has increased from 21.7% in April 2012, to 23.3% in April 2023. Patients with recorded cases of schizophrenia, bipolar affective disorder and other psychoses have increased from 0.84% in April 2013 to 0.96% in April 2024. Deaths from suicide and ‘injury of undetermined intent’ increased from 10.3 per 100,000 (2001- 2003) to 10.7 (2021 –2023). In a population of 57 million or so, these small looking shifts translate into significant numbers of lives.
Our 18-24 year olds are widely reported to have the poorest mental health of any age group in the UK. Two decades ago, the opposite was true. (I felt some tiny relief in learning that hospital admissions for intentional self-harm in people aged 10 years to 24 years decreased a small amount from 347 per 100,000 in April 2012 to 319 per 100,000 in April 2023).
Our young are growing up in a world with an uncertain future, a competitive job market, a cost-of-living crisis, the legacies of a pandemic (including ongoing illness and grief), prohibitively expensive housing in many cities and a digital life that can bring harmful influences. You probably know of particularly long waiting lists for talking therapies, eating disorder services, child and adolescent mental health services and of lengthy waits for crisis care response times.
There are also significant staff shortages across mental health services, high vacancy rates for psychiatric nurses and psychiatrists, and burnout and retention issues among the staff that hang on in there. Anecdotally of course, every psychotherapist or psychologist I know who worked for the NHS has left to work in private practice in recent years, feeling that they have run out of the goodwill that kept them there.
The ‘postcode lottery’ amongst care also means that I can speak to clients in one London borough getting quicker, and more, support than others in the neighbouring borough. The help that is on offer to families and individuals has also been getting slimmer and slimmer, to dangerously thin. When I began in private practice, the parents of unwell teens that I talked to would be encouraged by the weekly psychotherapy offered to their child, and regular family meetings that kept them in the loop. These days their teen may get a handful of counselling sessions (often not weekly) and their parents next to nothing, bar guidance as to how to support their teen.
In June 2024, the charity Rethink published the results of a survey of 656 people who had attempted to access mental health services in England within the last two years. The woeful findings add to longstanding (ie pre-pandemic) concerns that under-resourced mental health services are unable to provide timely, or consistently effective care. A staggering 80% of respondents experienced a deterioration in their mental health as they waited for support. Of these people, 25 % attempted suicide, 42 % sought urgent and emergency care, and 22% had contact with the police due to their distress.
Furthermore, 66 % of people reported that they did not receive mental health support for enough time, and 35 % who were lucky, reported it to be too brief (or cut short) to be effective. The survey also suggests that people may be falling between the gaps too: 41 % reported that they were denied support because their condition was considered not severe enough, while 35 % reported the opposite – that they were denied it because their condition was considered too severe. Despite our ongoing cost-of-living crisis, 35% of respondents were pushed to seek help privately, which certainly chimes with my experience in recent years.
Self-care between the private & public realms
I have noted how ‘commercial’ self-care has blossomed and thrives, while the public resources for mental health treatment and support suffer from an opposing trend. Self-care has always played some role in the medical management of our physical health, and its current iteration in the NHS could be seen as supportive of the fact that most of us want to feel as much in control of our bodies, minds and treatment by medical professionals as we can. We hope that this is supported by a system that offers and promotes resources for when we can’t care for ourselves though – which you probably know isn’t always the case.
After the NHS was launched in 1948, self-care was largely viewed as a patient’s role to manage their medication, and monitor their basic health markers, particularly in relation to chronic conditions such as diabetes. The idea of ‘patient autonomy’, and of educating patients about their health, and conditions was far more limited, and ‘doctor knew best’, even when he didn’t (it was likely a ‘he’ for decades).
Nursing care has its own notion of ‘self-care’ with Dorothea Orem’s ‘Self-Care Deficit Theory’ (or ‘Self-Care Theory’) of huge, and lasting, influence. First developed in the US in the 1950s, Orem’s ideas rest on the premise that patients want to care for themselves, but often can’t or only in a limited way, which creates a ‘self-care deficit’. Our ability to look after ourselves is partly learned from our family and culture, but it is also heavily influenced by factors like age, privilege, wealth and education. So, for example, as a white, privileged, educated woman working in the mental health field, my ability to look after myself outweighs some of my neighbours who don’t speak good English, have no disposable income, and no access to reliable internet.
Orem sees the goal of nursing as one to help patients become as independent as possible in meeting their self-care needs, with a nurse stepping in when a gap emerges between what we need to do, and what we can do. She identified three types of needs: universal (our basic human needs), developmental (our age-related needs), and health-deviation (our illness-related needs) and three nursing practices to fill the gaps: wholly compensatory (complete care), partly compensatory (shared care), or supportive-educative (guidance and teaching).
These days the NHS tries to avoid complete care where possible, after a growing recognition of patient expertise and our right to be more involved in our treatment options. There has also been a broader push for a focus on preventative care, with the 1992 ‘Health of the Nation Strategy’ explicitly setting targets to reduce preventable diseases, like heart disease, strokes, and cancers. This relies on our self-care and, if all goes well, treads the line between respecting our autonomy, and stepping in when necessary. So, my friend who tracks her infant daughter’s diabetes, also knows she has expert help at hand if something goes awry.
These ideas were reflected in the 2019 NHS Long Term Plan, commissioned by Theresa May’s government, which aimed to reduce lifestyle-related diseases, improve vaccination rates, and address obesity and mental health issues (including those of their own employees). We already have digital health tools such as symptom tracking and apps for insomnia and anxiety, and there are ambitious plans for an expanded digitised (and AI) NHS future ahead. The Plan has been scuppered by the pandemic, change in government and economic outlook, and as I write, its status remains unclear.
While researching this post, I stumbled across the annual NHS backed ‘Self Care Week’ (themed ‘Mind & Body’) promoted by the Self Care Forum which, I discovered to my surprise, has been running below the radar since 2011. The aim, stated on their website, ‘is to further the reach of self-care and embed it into everyday life. We also hope to create a self care movement, an evolutionary shift towards people being more informed and empowered to look after their own health and their family’s health and to understand when to self care and when medical intervention is necessary’.
This seems to strike the balance between welcomed autonomy and appropriate intervention, or, another way of looking at it, a balance between individual responsibility and collective responsibility – although the latter needs to go far beyond the NHS. A young man I recently met with a perpetual leak in his council-owned flat may manage his stress better with an app for anxiety and to exercise more, but a far more effective treatment would be for the roof to be fixed.
One remarkable NHS response to the complexities of mental health problems, along these lines, is the ‘Deep End’ GP movement, with its first network forming in Scotland in 2009, using a metaphor from a swimming pool. It focuses on addressing healthcare inequalities in very deprived areas, where needs are high, yet access to healthcare resources are low (the so-called ‘inverse care law’ coined in 1971 by the doctor and campaigner Julian Tudor Hart).
‘Deep End’ thinking prioritises working collaboratively with local community resources to help address issues that have profound effects on our mental and physical health – such as loneliness, financial and housing insecurity, and health literacy – and literacy – gaps. It draws on the wisdom of the people ‘in the know’ of both local issues and its barriers to create solutions for better health outcomes. ‘Deep End GPs’ actively share their knowledge with each other (my GP friend is on a WhatsApp group of hundreds of colleagues) to promote a community-driven sense of responsibility toward health and well-being.
In Johann Hari’s popular 2018 book Lost Connections, he argued that the real causes of depression and anxiety, both of which he suffers with, are to do less with ‘chemical imbalances’ of the brain or ‘biomedical’ ideas, and more to do with our many ‘lost connections’. His chapters address nine of them, including nature, a secure future, meaningful work and values, and those with each other. He highlights the pioneering work of the Bromley by Bow Centre, in East London, which is aligned with the Deep End GP ethos.
The Centre offers medical services, but also others that treat their patients holistically, as members with a role in their community. They have pioneered ‘social prescribing’ – where people are seen to benefit from courses or activities such as swimming, gardening, volunteering and other community-led initiatives. It also seeks to address some of the root causes of health issues, like a leaking roof or mould, unemployment, and social isolation. ‘Patients’ are not seen individually, so while their needs are high on the agenda, so is the desire to address systemic changes that benefit underserved groups more generally.
Like the ‘Deep End’ GPs, my work also tells me how the ‘self’ in ‘self care’ can thrive best is if it is one that sustains positive relationships with other humans, and our natural world. On the occasion that a client thanks me for my help in their feeling better, I will never know how much I really did help them. However, I do know that I may well have helped them to turn toward other relationships in perhaps new, or renewed, and nourishing ways, which is the real healing agent for positive change.
This happened with E. When I first started working with her, I struggled to push my tired, private, responses aside, while she moaned about everyone, everything and anything. (Therapists do judge, but if all goes ethically well, we take care to think about this means with our colleagues and supervisors). E found my room too cold or too hot, or my sofa pillow too scratchy, or my water too tepid. Her boss was a ‘psycho bitch’, her sister ‘personality disordered’ and her flatmate ‘a pathetic zombie’.
In the early weeks of our talking together, I struggled to get E to see beyond her nose. But I also knew enough about narcissistic traits to tell me that her unlikeable aspects were busily working to defend against unbearable feelings of unworthiness. Over many months of weekly meetings, E did eventually allow me to be with her more vulnerable parts, and I discovered how, as a very young girl, she had learned to be worthy in her parents’ eyes only by being ‘beautiful’ and ‘clever’. These two qualities were prized above all else, meaning all the many other aspects of her personality were ignored or sometimes denigrated.
As an only child, E shouldered both her of parents’ projected desires, and when I heard stories of her being ignored or overlooked, they were heartbreaking to hear. She wasn’t allowed to cut her hair short (not pretty), follow her passion for art (not intellectually robust enough) or see her friends out of school (her mother would get lonely or bored without her company). The only times she remembered her father stopping to notice her would be if she had a good school test result to please him with, or if she wore something he liked.
I found out about E’s childhood because a part of her became willing, and courageous enough, to confront her painful past. We talked about how her sense of self was built on shaky foundations, and that she had buried them deep under a need to feel worthy by being superior to others around her. In readily judging others, she kept topping up her tiny well of esteem, but this also kept herself isolated from nourishing connections with others, and intimacy.
E softened toward me, and those around her, over time. She described her flatmate, her sister, her boss, and others in broader and kinder terms. As she empathised with others more, she deepened her relationships, and made new ones. She began to party less (being ‘popular’ kept her buoyant), and take more interest in the wider world. I also noticed how she wore far less make-up and relaxed into her chair as she spoke with me about her expanding world.
Without any prompting by me, E also began to volunteer in a local foodbank, where she made friends with people who she would have avoided when we first met and thought further afield about the community she lived in. These new bonds boosted her confidence, and she began to believe that she was worthy for being her true self. This made her feel the best she ever had before.