‘We have seen this background hum of menace become louder’

Your previous book, How We Are was published 10 years ago, how does your new book, How We Break follow on from this?

The first book was about the role of habit and the work of change in normal life. In the first half of How We Are, we looked at how underneath the smooth operation of daily living was a largely unconscious and automatic mechanism, a learned repertoire of habits keeping life going without perceptible agency. I drew on 4E (embedded, enacted, embodied, extended) cognition to show that our automatic systems comprise people, places, things and cultural institutions as much as they do our brains and bodies.

In the second half, we look at what happens when the complex system that is us has to adjust and change. That work of change is what we call allostasis, and until the new normal is established, our bodies hearts and minds are forced to move up a gear or two. This is costly in terms of our resources, so we work hard to establish new habits to keep those costs down.

In the book we look at what happens to us when this turbulence of change and adjustment doesn't give us any let-up, and what happens to us when the allostatic load – the costs of change – starts to impact upon us physically, mentally and emotionally. I end How We Break with a clear sense of how we can begin to recover from that. I thought it important to end the book on a note of hope. Each book is free-standing, feel free to start with the newer one.  

The timing of this book is particularly relevant. The pandemic has had a monumental impact, and more recently the increased costs of living continue to place great levels of stress and anxiety on many individuals. As a practising health psychologist, have you noticed significant changes in the prevalence and severity of anxiety and its side effects within society?

I think we all have noticed the change. In the last 10 years, we have become collectively much more aware of how perilous and exhausting the work of trying to establish 'new normals' can be, and that sometimes we just can't. We get stuck in that liminal zone where we are all at sea and struggling to stay afloat.

There is a chapter in the new book called The Ambient Hum of Menace (a title I stole from a New Yorker article). In it I tried to enumerate the different kinds of social, economic and cultural circumstances that we are all more or less exposed to that add to our allostatic load, by rendering us uncertain, precarious, over-scrutinised, audited, devalued or threatened. I got stuck in writing that chapter for a long time, because every time I thought it finished, something else happened to our world.

In the end, I had to switch focus away from specific events to looking at how living in difficult times gets folded in to our bodies. For instance, in the NHS trans-diagnostic fatigue clinic in which I worked, we saw austerity show up in exhausted bodies as conscientious people tried to follow the mantra of the day - do more with less - and got worn out in the process.

It's one of the things that health psychology has really brought to the fore, how embodied our distress is. It's not just anxiety we are feeling, we are also more or less worn out. In the last 10 years, we have seen this background hum of menace become louder and for some overwhelming. I do think all of us feel it one way or the other. 

There is a strong sense of realising and authenticity in the book; not just your inclusion of real case studies but also from personal admissions given about yourself and individuals very close to you. How did your own life experiences shape your career focus and the writing of this book?

I was a visibly queer kid in a working-class Scottish comprehensive in the 1970s. I didn't fit. Those of us who don't fit are given back to ourselves as work. We learn early that we are problematic social objects, and we need to manage the difficult thoughts, feelings and interactions that come with that.

But this early encounter with ourselves can also be the beginning of wisdom. It's usually in crisis or difficulty that we really get to know ourselves, and some are forced earlier than others to work out how to manage the kind of creature we are and the hand we have been dealt.

As an adult, I trained as a psychiatric nurse, then in Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT), and now I work as an academic and clinical health psychologist. These disciplines have allowed me to put meat on the bones of that early self-understanding.

I can combine sociological and psychological research findings, clinical wisdom, and my own biography to make sense of why I am who I am. This is what I try to do with all the cases in the book, bring the science to life by showing how it plays out in individual cases. In doing so, I encourage the reader to do the same. 

You mention the importance for individuals to first understand their own suffering as a starting point for improving their health. How can self-awareness of one's own struggles help improve or protect our wellbeing? Is this a struggle for many people?

Know thyself seems to be an edict at the heart of many spiritual, philosophical and therapy schools of thought. So, for instance, in Buddhist and Vipassana meditation techniques, a key rasion d'etre of the practice is to achieve insight into our true nature (something like pure awareness) and to disidentify with our conditioned, narrative self.

Adherents of these schools would argue that this insight is in itself enough to end our suffering. Of course, this dis-identification with our narrative self as an exit from suffering is also key to ACT, and other Mindfulness-Based Therapy (MBT) approaches, though I would argue they often dilute the radical nature of the original practices they have purloined.

More mundanely, if I go to see a therapist, say for my social anxiety (a lifelong companion of mine), then I will want them to lift up the diagnostic hood and see how that social anxiety shows up for me; I would want my therapy based on an individualised formulation. I think this understanding of our own case is key to the beginning of healing.

Most of my adult life I have worked in healthcare, so I've had a ringside seat at people going through difficult times. And over the last decade of working on this book, I've seen not only research participants and patients struggle with life, but also colleagues, friends, family and myself.

If you dig underneath any diagnostic label, you see no two cases are the same. For instance, when we were developing and trialling a new intervention for fear of falling in older adults, we found that each of the over 400 people we treated had a unique interplay of factors keeping them stuck, and each needed a different approach to help them get going again.

Having a narrative that makes sense of how you got to where you are is often the first step of healing, and a coherent narrative can be healing in itself. We saw the flip side of this in the fatigue clinic: people who can't make sense of their suffering suffer more.

It seems that individuals have different breaking points when dealing with life stressors, psychologists have attributed this to a variety of personality (such as mental toughness) and cognitive (method of appraisal) factors. Could you summarise some of the cognitive processes or vulnerabilities that can facilitate psychological breakdowns?

The flip side of the narrative work I just described is that we can also become 'stuck in our stories'; locked in narratives about ourselves, the world and other people that no longer serve us. We see this happen to my mother in the book… she gets stuck in a story about her blighted life, and it being her fault, and this poisons the last years of her life.

I've got a fair bit of sympathy for ACT and MBT approaches which would argue, essentially, that trying to change these stories, or getting locked into a debate with them, as in old-school Cognitive Therapy, just gets us further caught up in our narrative web. Rather we should try to take a step back from them and hold our stories more lightly.

However, I want to add one large caveat to any account of suffering that foregrounds individual psychological factors such as (lack of) resilience. We must beware of what Mark Fisher called the privatisation of distress. I saw dedicated senior colleagues in the public sector buckle then break under the weight of their ever-increasing workloads.

When they turned to management for help, they were offered resilience training. They were offered an idiocentric solution to what was in a systemic problem, and we need to be careful not to replicate this violence in our formulations of human suffering.

How much of an impact would you say societal expectations about working contribute to this?

In many of the narratives of breaking I've been witness to over the last ten years, work has had a starring role. But I think we also need to see this interactionally: it's often the way work interacts and sometimes exploits our sense of self-worth.

One of the key stories we can get stuck in is that our worth equals our productivity. Given a work climate where whatever we do is never enough, this story can quickly turn toxic.

Could you perhaps end with one nugget that our readers can take away to help them deal with life's struggles and prevent their health from deteriorating through stress and anxiety?

Befriend yourself – you're the only lifelong relationship you will have! Treat yourself with the kindness, respect and understanding that you would your best friend. And think about what you value in the people you love; it is rarely their productivity. Value yourself accordingly.  

Professor Vincent Deary is a writer, researcher and practitioner health psychologist, based at Northumbria University Newcastle. How We Break is out now.

Dr Dara Mojtahedi is a Chartered Psychologist, Reader in Criminological and Forensic Psychology at the University of Bolton, and Associate Editor for Books.