Art Therapy

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I decided to have a go at a technique called ‘Aux Trois Crayons’ that uses only 3 colours – black, white and red. The girl is not someone I know, but a photo I thought would be fun to draw.

Recently, I’ve been trying to practise what I preach. I frequently find myself asking patients questions like this:

How do you destress?

What about some ‘you time’?

Or: What could you do that you know usually makes you feel good?

What I love about these questions is that I can never predict the answer – the things that make us feel good, that so absorb us they have the power to take us away from our present situation and help us forget our stresses for a while, are very personal. For one person it will be exercise; going on a run, working out in the gym or swimming 50 lengths. For another it might be music – listening to it or playing – while a third will find it helps to occupy their mind with a crossword or a sudoku.

The answer I would give is ‘Art’ (oh, and gardening, but that’s for another post!)

I never did art at school, but have loved it ever since – even more so since I learnt the importance of enjoying the process more and worrying about the end product less. When I paint or draw I have to concentrate so hard on what I am doing that there is no space left in my head to worry about anything else; any stresses that might be lurking there are pushed out by thoughts about line, tone and colour; time takes on a different quality as minutes turn into hours with unexpected swiftness and I have to set an alarm if I have something important to remember.

Her hair was always going to be the biggest challenge so it was good to be able to make some headway with it.

Most of all, I know that it does me good – and that I don’t do it often enough.

In the whole of 2014 I only managed the time to paint one picture and I am trying to rectify that this year – which is partly why the blog posts are coming less frequently. Making time for things that do us good means deciding what is important, and takes a bit of planning; the things that help often get pushed out by all the other, more urgent – but arguably less important – stresses in our lives.

Finding a regular time for art this year has really made the difference, and has come in the form of a monthly art space at my church. It’s not a class as such, since there’s no teacher, but we have a quiet room to use, regular tea and coffee and a mix of fruit and cake to keep us going; there’s no need for any talent, just enthusiasm for doing something creative and a willingness to spend a Saturday morning with others doing the same.

We’ve only met twice so far, but it’s got me drawing again at other times in the week too and now I’ve finished the picture I’ve been working on, I thought I’d share it here. On the whole I’m quite pleased with it, and it’s been great to try out a completely new technique – I’ve done a few charcoal portraits before, but not tried the 3 pencil technique before, and it’s emboldened me to have a go at a full colour pastel portrait next time. More than anything, it is a sign to me of 12 hours well spent, and it has done me a great deal of good.

Now she has hair on both sides of her face I’m trying to work on the balance of light and dark as the light is all coming from over her left shoulder – the hair over her right eye seems too light to me.

There’s a bit in the Bible that I’m reminded of here – something that I’m sure we could all relate to, whatever our position when it comes to matters of faith, and it is this:

Finally brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable – if anything is excellent or praiseworthy – think about such things. (Phil 4 v 8)

I’d encourage everyone to think about things that do them good, and more than that, to make time to do them. It might not be Art Therapy  – it could be Park-Run Therapy, Family-Weekend-Walk Therapy, Knitting Therapy or Origami Therapy – whatever it is, try to find time to fit it in if you can.

Aux Trois Crayons - the finished picture
The finished picture – her hair looks more balanced now, with more warmth added to the hair on the right side.

Hypochondria – a Word Desperately in Need of a Makeover

Hypochondria is an ancient word. It stems from the Greek meaning for the upper abdomen; hypo- is the prefix for below, and -chondro refers to the ribs, so that the Greeks referred imaginatively to the upper abdomen as ‘the bit below the ribs.’ For the Greeks, the abdomen was felt to be the seat of melancholy, in the same way that we consider the heart to be the home of love. At some point in the history of medicine, this psychological association with the word hypochondria developed pre-eminence over its anatomical origins, and the condition of hypochondriasis was born.

Since that time, however, hypochondria has taken a bashing. The problem starts with the fact that it makes such very good comedy. Whether it is an icon portrayal by a master of the art such as Tony Hancock, or throwaway one-liners like ‘Hypochondria is the only illness I don’t have‘, the image of someone endlessly worried about their health is irresistible material for laughs. This I can handle – comedy is part of how we cope with the human condition, and we should never be so sensitive about illness that we are afraid to laugh at it.

More of an issue, however, is when the condition is misunderstood – and unforgivably so, when this is done willfully. A particularly bad example of this was written in The Observer recently by the columnist Barbara Ellen. It may be that she is simply ignorant of the nature of hypochondriasis, in which case she is guilty of gross journalistic laziness, and should improve her research. However, with a sub-title that reads: ‘Hypochondriacs are themselves a pain – and they take up valuable surgery time,’ I suspect that she knew full well what she was doing and was happy to take cheap potshots in order to sell a story.

The text of the article is even worse than the headline. Ellen was apparently trying to be on the side of doctors, empathising with why we might sometimes be tempted to prescribe a placebo. An article that alleges to understand my frustrations as a doctor has rarely left me so angry, but with outrageous claims like: ‘the fact remains that there is no known cure for the determined hypochondriac attention-junkie’ and ‘hypochondriacs are shameless liars’ the only way I was able to keep my blood pressure in check while I re-read her rant, was to remind myself that she is a professional journalist who has set out to shock and I shouldn’t take it too seriously.

There is a serious side to this, however, which is that words affect attitudes, and attitudes drive behaviour. True hypochondria is a fearful and much stigmatised illness; the way we talk about it will influence the way doctors, patients and the public in general behave towards those affected, and at the very least I feel the need to try to redress the balance a little.

At this stage I should say what I mean by hypochondria; it is easier to start with what it is not. It is not someone who worries a bit more than most about their health. Neither does it describe those among us who are – and there is no other way to say this – a bit of a wimp when it comes to suffering. Some of us do complain more than others, and our friends, families, and even our doctors, have to put up with this – but that is not hypochondria. Nor is it malingerers who make things up for personal gain – people who pretend to be ill in order to skive off work for a bit. Despite what the Government would like us to believe, I don’t think there are many people like that, but I would be naive to say that they do not exist – although they are not hypochondriacs. Most importantly, hypochondria does not refer to illness that cannot be explained by doctors – medically unexplained symptoms are common, and their causes many and varied, while hypochondria is rare and quite specific.

A true hypochondriac really is worried that they are unwell. The illness is often focused on one fixed belief – a lump in the throat becomes a cancer, abdominal cramps can only be explained by a bowel infestation. The level of anxiety takes on an obsessional, even delusional, quality, with a constant drive to find an answer for the symptoms, and a need for reassurance that can become like an addiction. Just as an alcoholic finds his thirst is slated only for a while with a drink, so reassurance brings an all too temporary reduction in anxiety, and as soon as it wears off anxiety rises to overwhelming levels, with a search for more reassurance being the only offer of respite.

A patient may check their body for changes 30, 60 or 100 times a day; it can dominate conversation with friends and family, exasperating all involved. The internet – always a mixed bag when it comes to health information – becomes a snare, with its 24-hour availability and tendency to promise answers, while usually delivering just more questions. Reassurance-seeking behaviour, inevitably, involves frequent trips to the doctor, A&E, specialist clinics, investigations – the risk from medical tests and treatments becomes a very real danger. This is a debilitating and life-controlling illness – hardly the domain of a lying, time-wasting whinger.

The challenge with hypochondria is to help someone move from focusing on physical symptoms to an understanding of the nature of their anxiety. This is hard enough without having the very word for their illness mired in stigma, ridicule and misunderstanding. I suspect Hypochondria as a diagnostic label is now beyond rehabilitation – which is why the illness is often referred to today as health anxiety – but the word still exists in our popular vocabulary, and we should treat it with respect, because it will continue to represent the experience of real people with real lives.

If It’s Good Enough for Wiggo – Marginal Gains and Health

Sir Bradley Wiggins is a truly extraordinary athlete, but I am sure he would be the first to admit that his achievements in recent years are in large part due to the inspirational leadership of his fellow recently appointed Knight of the Realm, Sir David Brailsford. Sir David, in large part, puts his own success down to the holistic approach he has taken to improving performance – the concept of Marginal Gains. He explained the idea to the BBC during the high point of this summer of success:

“The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together.”

Since the Olympics, people have begun to realise that there is no requirement within the concept of Marginal Gains to have spokes, wheels or a crash helmet, and disciplines unrelated to sport are using it to develop their thinking. Teachers are leading the way in the classroom and business bloggers have also latched on to the concept. Increasingly I have found myself talking about it in the consulting room, and wondering how doctors and their patients could learn from Sir David’s idea.

Health problems often leave people facing huge, seemingly insurmountable challenges. How can I get a good night’s sleep? What can I do about my weight? How do I stop my teenager shouting all the time? The success of medical treatments for simple, single cause health problems can often lead to both doctors and patients searching by default for that elusive single solution when faced with more complex issues – which leads to frustration and demoralisation when the problem remains unmoved by this approach.

Sleep difficulties are a good example. Losing sleep night after night can be so debilitating that the prospect of a single, simple solution is understandably very attractive – which must explain why the idea of a sleeping tablet is so seductive for both patients and doctors. The patient’s motivation to reach for a quick fix that might guarantee a full night’s sleep is perhaps more noble than the doctor’s temptation to resort to a tablet in order to bring a rapid conclusion to the consultation, but both are equally understandable when other solutions seem to offer less hope of a cure. The siren call of a sleeping tablet, however, is often less effective even in the short-term than we might expect, and brings with it the very real dangers of tolerance and dependence.

I might suggest that an insomniac tries a warm bath before going to bed, or keeps the room well ventilated at night, to which I will often receive the ‘done that, been there’ response, or the raised eyebrows of someone who really can’t see how that would help, and thinks I am trying to fob them off. The problem is that we often evaluate health solutions in a linear fashion – an approach that goes: ‘If this doesn’t work, try that’ as we work through one solution after another until we hit the jackpot. There are merits to this when it comes to some aspects of medicine – like using medication or arranging investigations where to try several things at once could be hazardous, but there are many health issues that could benefit from a more holistic way of thinking, both by doctors and patients.

There is nothing new to the concept of holistic health care, but this is often in the context of teaching doctors how to think holistically about their patients, as is enshrined in the GP curriculum for trainee GPs. What we may have neglected to do, however, is to find ways of helping patients how to think holistically about themselves. I wonder if there is an opportunity within health to use the concept of Marginal Gains, and its current high profile in the public consciousness due to the success of the British Cycling team, in order to encourage a different approach to solving health problems.

If having a hot bath before bed only gives a 1% extra chance of sleeping well, what would that mean if it was combined with a 1% improvement by having the right pillow? A similar gain might be achieved by a cup of hot chocolate, a well-ventilated bedroom, a ‘stimulation curfew’ after a certain time in the evening or going caffeine free. How many more marginal gains could we think of? Relaxation tapes, getting enough exercise, and eating earlier in the evening could all make their contribution. If they added together they could really start to make a difference – and even one good night’s sleep could reduce the dread of going to bed by a further 1%, bringing its own marginal gain in a virtuous cycle of improvement. Where we apply marginal gains we need to expect only marginal improvements – which will mean we will be less inclined to lose heart and give up when we don’t see instant results.

We could apply the same principles to many other health problems – where are the marginal gains for improving your relationship with your teenage children for instance? What small changes could start to add together in your life-long battle with your weight? What minor adjustments could you start to make to reduce the risk of burnout at work? It’s not glamorous, sexy medicine, but all too often the glamour in medicine turns out to be a mirage that lacks substance, or even does harm. In the gritty reality of the lives of real people maybe the hard, but achievable, graft of looking for marginal gains is a more honest and worthwhile approach to making a difference in health problems. And best of all, not only do you not need to become an Olympic athlete like Sir Bradley to apply start to think this way – you don’t even have to grow sideburns!

I’m sure I have more thinking to do on this one – more working it out in practice with my patients…expect more blogs to follow!

On Pacing Spoons and Resolving to do Less

Falling between the claims last week that we would all be subject to Frazzled Friday, and the hazards of negotiating the alleged (and dubiously unscientific) Blue Monday later in January, falls New Year – and the opportunity to make New Year’s resolutions as we face the year to come.

No doubt gym memberships will rise, tobacco sales will suffer a temporary blip, and our eating and drinking levels will return to their pre-Christmas norm. For some of us this will be a powerful opportunity to make significant changes to our lifestyles, while for most I suspect our resolve will be packed away with the Christmas decorations and a promise to try harder next year.

With the busy-ness and stress of our modern lives the bias for New Year resolutions towards trying harder or taking on new things may not be doing us any favours. I wonder if we could change our mindset to resolve to try less hard, and even stop doing something. We could look beyond the usual suspects of cigarettes, alcohol and chocolate and stop doing things which in themselves are not bad – but which conspire with a host of other activities to overwhelm us, leading to stress on family life, a loss of perspective of what really matters, and ultimately ill-health through burnout.

We could resolve to stop worrying so much about making our house into a set for ideal home – by dropping our house-keeping standards just a little or deciding that the bathroom really is ok and maybe we don’t need the hassle of all that DIY this year. We could learn to delegate more effectively at work, and rationalise what we do in the workplace, shedding things that stress us but don’t really matter. We could allow our children to do less – maybe they would really prefer to swim once rather than five times each week, and have been trying to find a way to tell us that they aren’t really hoping to go to Rio in 2016 after all. For the self-employed perhaps we need to find a way to cut our finances so that we really can have that holiday we’ve been promising ourself, but never quite felt able to justify. I’m well aware that I need to be talking to myself here as much as anyone – maybe I need to blog less, Tweet less…oh dear!

I often find myself talking to patients about the importance of pacing. Whether it is recovery from an operation, a debilitating viral infection, depression or living with a chronic illness the principles are the same. Each day you should do something, but still have some energy in reserve by the day’s end. It is sometimes called the rule of 75% – aim to use up about 75% of the pot of energy that you started the day with. That way, if something unexpected happens you still have something left to give – and if it doesn’t then you go to bed with a positive energy balance, so are more likely to wake up the next morning with a bigger starting pot of energy to work with.

A patient of mine has developed an ingenious method for doing this in practice, which she has given permission for me to share here – the idea of pacing spoons. She has to live with a chronic illness which is significantly hampered if she gets her pacing wrong. She has two tubs in her kitchen, containing twelve spoons between them. Each morning the spoons start their day in one tub, and throughout the day she transfers a spoon (or sometimes two) into the other tub whenever she feels she has used up a unit of energy. She makes a deal with herself that there should always be at least one spoon left in the starting tub by the end of the day – and I’m sure that some days she is better at achieving this than others.

The genius of her method is that she has a visual cue for how much she has already done in a day, and so can decide what to take on later in the day and what to defer for another day. Her family can also take a quick look at the spoons when they want to know how things are going. Her children have learnt that a day when the spoons are running low might be a good time to volunteer to cook the dinner, while an evening with plenty of spoons in reserve would be the best time to ask for help with that really tricky homework project. I’m yet to ask her how the family eat dessert when all the spoons are otherwise engaged, but so far this is the only flaw I can find in her system.

If any one else has developed techniques to help with pacing, or you would like to share something that you have resolved to stop doing, it would be great to hear from you.

Wishing everyone a happy, and not too busy 2013!

Antidepressants and the Long Shadow of Stigma

This blog is also to be published as a guest blog on the Mental Health blog The Mental Elf on Monday 6th August – this is an excellent, evidenced-based blog with reliable information on a range of mental health issues and is well worth a browse.

Are GPs prescribing antidepressants too readily?” This is the title of the Today programme article on Radio 4 which went out on Thursday morning. Clare Gerada, Chair of the Royal College of General Practitioners, was invited onto the programme to defend the case of GPs. She made several important points in the interview, but one in particular stood out for me: That there is an underlying betrayal of stigma in the very way this question is being asked.

Dr Gerada rightly pointed out that the assumption inherent in the way the article was presented, and in John Humphries’ questioning, was that increased use of antidepressants must be a problem. Of course, it might be something to be concerned about, but we need to ask why antidepressants are so often presented in such a negative light. Had there been an increase in the prescribing of statins, for instance, GPs would be congratulated for tackling the challenge of heart disease so effectively; were there to be a rise in the number of women having surgery following breast cancer screening, the country would be applauding the increased use of resources in the fight against disease. For antidepressants, however, we are left to deal with headlines like “Prozac nation” and “Happy Pills“.

I am not concerned that GPs might be blamed for this – as a profession we are used to being knocked by the press and can deal with it – but I do worry about anyone suffering from depression who is either taking antidepressants, or thinking about taking them. It is only natural to translate what is happening nationally down to the individual level: If it is bad for the country to be taking so many antidepressants then is it bad for me?

Mark Easton’s report raises some important questions, and we should not be afraid to ask them. There has certainly been a considerable increase in the number of prescriptions for these medications in the last decade.  Maybe they are being prescribed too often, but this is just one of many possible explanations, and it is likely that the truth is a complex mixture of many factors.

For starters, the research looks at the number of prescriptions, not the number of tablets. 10 years ago our practice frequently gave prescriptions for 3 months at a time whereas now we have tightened up on this considerably to reduce waste, and give no more than 2 months worth – well that is a 33% increase in prescriptions at a stroke. Perhaps the data reveals to us underlying social concerns – if increased prescribing means a higher incidence of depression what does this mean for where our society is heading? Or are we just getting better at diagnosing depression? GPs are criticised often enough for failing to diagnose sufficiently quickly, maybe we are just getting this one right?

The most positive interpretation of these findings is to consider that maybe, at last, people are willing to go and see their doctor when they become unwell with this debilitating illness. Perhaps we are actually breaking down some of the stigma, getting the message through that depression can be treated, and deconstructing the mythology around the use of antidepressants which we inherited when Prozac was so inaccurately introduced to the nation as a ‘lifestyle drug’ all those years ago.

More of a concern is that, despite Government promises of extra resources being poured into talking therapies in the Improving Access to Psychological Therapies initiative, I have patients who have been waiting over a year to see a counsellor. In Surrey the counselling service is in its worst state than at any other time I have known it over the last 10 years. Any wait over three months becomes a treatment for trying to help someone stay well, rather than something that might get them well. If I am reduced to only one treatment for a certain condition, don’t be too surprised if I use it.

The decision to use antidepressants is a complex one, which requires careful consideration by doctor and patient working together, balancing benefits against harms. Medication is certainly no cure for unhappiness, but it is an effective treatment for a distressing illness, and deserves to be freed from the shadow of stigma. And what we must remember is that, unlike drugs like statins, behind each and every one of those prescriptions is a person who actually feels unwell – this is good old-fashioned doctoring in action, that outdated notion of trying to heal the sick.

Will Exercise Help Your Depression? Only You Can tell

The long-held belief that exercise can be beneficial in treating depression was brought into question last week by a study, published in the BMJ and widely reported in the news, which reported that exercise did not improve recovery in patients suffering from depression.

Exercise
Exercise can take many forms, but will it help depression?
Image courtesy of freedigitalphotos.net

As you can imagine, the study has prompted much debate. Can such a definite statement be made about so complex and varied a condition as depression? (probably not); how do you define exercise? (your guess is as good as mine); is that really what the study showed? (not really, it just showed that patients encouraged to undertake a programme of exercise got better at the same rate as those who did not). Interesting and erudite as these discussions might be, they are not really relevant if you have depression and want to know whether or not to get your trainers on – because you don’t want to know if exercise will treat depression, you want to know if it will help withyour depression. Thankfully there is another clinical trial you can refer to – the ultimate clinical trial where n=1 – that means there is only one patient (you) trying one treatment and seeing if it works.

We do a lot of n=1 trials in medicine. Every time we try a cream for a rash, a medicine for indigestion or an antibiotic for tonsillitis we are essentially conducting an experiment: Here’s a symptom, there’s a treatment, see if it helps. If it doesn’t, try something else. It’s not great science, but it is good medicine.

Of course, an n=1 trial won’t work for everything in medicine. Firstly, you need to be sure that the treatment you are about to try doesn’t carry a significant risk (which is why frontal lobotomy as a cure for depression has somewhat gone out of fashion), and then you need to be able to know if it has worked, and in a reasonable timescale. For this second reason, a trial of treatment is not much help when it comes to deciding many of the big questions in medicine – like whether or not to take a statin for cholesterol, or to have your PSA measured to try to detect prostate cancer – for these dilemmas there is no escaping the need for large-scale clinical trials to help guide us. A statin is not going to make you feel better, so how would you know it was working? Even if it lowers your cholesterol, how do you know that this will do something that actually matters to you – like stopping you having a heart attack? There’s no value in a ‘try it and see’ approach here.

Exercise in depression, however, is ideal for an n=1 trial. Exercise is clearly a safe treatment to try – more than that, we know it has many health benefits beyond any help it might be for depression. What is more, there is good reason to think it might help lift mood – whether it is just the benefit of feeling fit, effects on serotonin levels or the magic of endorphins it seems worth looking into. What is more, those who testify to its benefits report that they actually feelbetter soon after exercise – no need for a 2-6 week trial like there is for antidepressants. Of course, you may have to try it a few times to get a feel for it. You might overdo it one day and feel worse, or find one form of exercise works better for you than another, but the message is clear – if you are going to benefit, you will feel the benefit of your experiment sooner rather than later.

So what should you do if you have a negative trial – if you give exercise a go and feel as flat as ever, or maybe even worse? Well there is still a more general principle that will work for everyone, and it is this: When you are depressed there will be some things that, when you do them, help you to feel a little bit better. Whether it is exercise, gardening, music, art stroking the cat or just getting up on time in the morning doesn’t matter – whatever it is, you’ll feel better if you do it, so try to do it more!

Fear According to Pi

From time to time, you come across a piece of writing that is so compelling, so beautifully written, so resonant with what matters to you that you want to shout it from the rooftops – to call to anyone who will listen and declare to the heavens: “Look at this everyone! Stop whatever you are doing! Just stop for a moment and read this!”

So with Yann Martel’s marvellous novel Life of Pi, and more specifically chapter 56 – a single page offering that is the most powerful, emotive and yet eerily accurate description of fear that I have ever come across. It is worth quoting here in its entirety. If you have ever experienced the overwhelming power of panic, you will relate to every word and find relief that someone can so reliably describe how you felt. If you have never been to the depths of fear, it is worth reading all the more so that you can  understand better those that have.

I must say a word about  fear. It is life’s only true opponent. Only fear can defeat life. It is a clever, treacherous adversary, how well I know. It has no decency, respects no law or convention, shows no mercy. It goes for your weakest spot, which it finds with unerring ease. It begins in your mind, always. One moment you are feeling calm, self-possessed, happy. Then fear, disguised in the garb of mild-mannered doubt, slips into your mind like a spy. Doubt meets disbelief and disbelief tries to push it out. But disbelief is a poorly armed foot soldier. Doubt does away with it with little trouble. You become anxious. Reason comes to do battle for you. You are reassured. Reason is fully equipped with the latest weapons technology. But, to your amazement, despite superior tactics and a number of undeniable victories, reason is laid low. You feel yourself weakening, wavering. Your anxiety becomes dread.

Fear next turns fully to your body, which is already aware that something terribly wrong is going on. Already your lungs have flown away like a bird and your guts have slithered away like a snake. Now your tongue drops dead like an opossum, while your jaw begins to gallop on the spot. Your ears go deaf. Your muscles begin to shiver as if they had malaria and your knees to shake as though they were dancing. Your heart strains too hard, while your sphincter relaxes too much. And so with the rest of your body. Every part of you, in the manner most suited, falls apart. Only your eyes work well. They always pay proper attention to fear.

Quickly you make rash decisions. You dismiss your last allies: hope and trust. There, you’ve defeated yourself. Fear, which is but an impression, has triumphed over you.

The matter is difficult to put into words. For fear, real fear, such as shakes you to your foundation, such as you feel when you are brought face to face with your mortal end, nestles in your memory like a gangrene: it seeks to rot everything, even the words with which to speak of it. So you must fight hard to express it. You must fight hard to shine the light of words upon it. Because if you don’t, if your fear becomes a wordless darkness that you avoid, perhaps even manage to forget, you open yourself to further attacks of fear because you never fought the opponent who defeated you.

This ‘wordless darkness that you avoid’ is the hallmark of fear. The key question to ask if you suffer from anxiety is this: Do you avoid anything that most people see as routine? Avoiding activities such as bungee-jumping is most people’s idea of common sense, but what about using a lift, getting on a train, going into a room with a spider in it, or having an MRI scan? The military analogy works well here; fear is like an invading army that can annex part of your life if it is left undefeated. The greater the fear, the more restrictive the occupation can become, and negative phrases like ‘I can’t’ and ‘I don’t’ become commonplace. Avoidance behaviour seems so natural and logical that it often creeps in unnoticed and unchallenged over years.

It is possible to reverse this trend, to reclaim the occupied land and plan a strategic advance into enemy territory. It is not easy, as it involves facing up to fear and staring it down until eventually, like any bully, it reveals itself to have less substance than first seemed (it is, after all, ‘but an impression’). Each victory over fear, no matter how small, diminishes its power – making the next step in the campaign seem possible, and ultimate victory a realistic goal.