Wednesday, 26 September 2012

Dear GPs

When someone with a history of depression comes to see you, please take the time to actually ask them how they are.  It is not easy to say you are feeling very low, it's not easy to relax your public mask and admit you are struggling.  How much more difficult do you think you make it by a brisk "What can I do for you?"  Clearly you are busy, clearly it is much more convenient for you to just write another prescription and move on to the next patient.  What does it matter that the person you've just hurried out of the door now feels even more worthless than she did when she walked in?  Do you care that she had to hide in the ladies until she had stopped crying enough to go home?  Do you care that she now thinks she is not important enough to be taken seriously?

It is difficult in these days of large surgeries for GPs to get to know their patients as they did when medical practices tended to be smaller.  Surely then it is even more important to ask questions and try and draw out from the patient the true extent of their illness than it was when the patient's demeanour could let you know they were not themselves?  Appearing "fine" is an art perfected by most people suffering mental illness; appearances alone will not tell even the most experienced of GPs how someone is coping underneath the surface.

Of course it would be easy to lay blame with the patient; why did she not just say how bad things are?  After all, the GP is not psychic and cannot be expected to know what is going on in someone's head.  What is the point of going to see a doctor and not telling them how you are?  This point of view totally discounts the difficulty many, if not most, of us feel when admitting we are not coping.  Simply making an appointment to see a doctor about a mental illness is a massive hurdle.  As the appointment gets closer it looms larger and larger in the mind and apprehension means that, by the time the appointment arrives, the patient can be paralysed by their internal turmoil; and yet appear outwardly "normal".

All it would have taken was the right question: "How are you coping?".  Giving an opening is all that is needed.  Let the patient know that they are in a safe place and you want to know how they are really feeling.  Less convenient perhaps, but surely convenience should not be the main focus of a GP's appointment?  Appointment time is limited and GPs often run late so the pressure is always on to keep consultation time to a minimum.  Having someone cry and talk about themselves is messy and time-consuming but if it makes the difference between the patient feeling cared for and valued instead of unimportant, useless and inconvenient is that not worth it?

Looking "fine" does not equate to feeling fine and taking the time to know the difference could not just make a difference to a patient's state of mind; it could, potentially save a life.  Depression may be the most common mental illness but that should not be taken to mean that it is an everyday malady and is not that serious.  Depression can be a severely debilitating and even life-threatening condition and, as such, should always be taken seriously.

So please, GPs, when you have someone sitting in front of you, take the time to ask them how they are.  If you don't ask they may not feel able to tell you and may just leave you feeling worse rather than better.

Tuesday, 25 September 2012

Bad Days

How do you cope with bad days when you have depression?  Everyone has bad days now and then but when you have depression a bad day can be anything from a general low mood; to hiding away from the world and hoping it goes away; to self-harming or self-endangering behaviour.  Bad days can also last far more than a day.  I don't normally blog when I'm in the midst of a bad episode but I thought this time I would try and convey what it actually feels like.

I have been suffering with a cold for a few days and this has depleted my already low resources, which isn't helping my mood at all.  Sleep has also been difficult for a few nights in a row now and lack of sleep always makes my symptoms worse.  So far this episode has not been too severe but my mood is low, I feel on the edge of tears most of the time, I'm tired, I have little motivation and I'm struggling to cope with my day to day responsibilities.  I feel worthless, useless and hopeless.  Parenting is very difficult when you are feeling this low and it gets difficult to hide how I'm feeling from the children.  The voice in my head tells me I'm a terrible parent and the children would be far better off without me.

How do I cope with bad days?  The simple answer is I don't, I just try to survive them until things improve.  Sometimes that means staying at home, seeing no one and doing little but if that's what it takes, that's what I'll do.  I'm tired, I just want everything to stop, for a while at least, to let me just be.  Life is relentless, wearing and difficult and there is no magic wand to make it better.  Bad days come out of nowhere, with no warning and take no prisoners.  I can't think straight or focus on a task for any length of time.  I can't cope with dealing with strangers or people in authority so leaving the house or even dealing with household business by telephone has to be put on hold until I feel more able to cope.

The rambling nature of this post is an indication of my inability to plan and execute tasks as well as usual.  Thinking is difficult and trying not to just whine and sound self-pitying is virtually impossible.  I have had a lot of bad days over the past few months and somehow I need to convey that to the GP at my appointment tomorrow.  Talking about how I'm feeling is very hard and, as I wrote recently, I'm very bad at telling the doctor how bad things really are.  Maybe tomorrow I'll manage.

Monday, 17 September 2012

Happiness and Depression

This is a post I wrote as a Guest Post for the excellent Black Dog Tribe, the original post, and comments, can be viewed here.

Happiness may appear to be an odd choice of topic when talking about depression.  However, it is the happy times that can throw depressive feelings into the sharpest focus.  It’s ‘easy’ to be depressed on a grey day, when you’ve nowhere to go and no-one to see.  You can wallow in feeling low and distract yourself with your ‘white noise’ activity of choice, be that reading, watching television, dozing or, like me, surfing the net.  How much more difficult it is to be depressed on a lovely, sunny day when you are included in activity with family or friends.  Depression does not pick and choose the days to embrace you and, whilst that grey day may indeed invite depression in, it is just as likely to come knocking at a friend’s birthday party, at your parents’ anniversary dinner or even when you’re pushing your laughing child on a swing.

Never underestimate how difficult it is to feign happiness when your brain is a fog of despair and your heart is as heavy as lead.  Being amongst people who love you should feel safe and warm but it can feel lonely and stressful when your internal monologue endlessly reminds you that you are worthless and don’t fit in.  Smiling and making small talk can cause real emotional pain when every fibre of your being wants to run, run far away from these ‘normal’ people who must be able to see how fake you are, how false, how stupid.  Even those who think they understand and who treat you with care cannot see who you really are – or your own broken image of who you are.

Keeping up the facade of being happy when you are feeling dragged down by depression is not simply difficult, it is bone-crushingly exhausting and, in fact, depressing!  I have found it a good idea when surrounded by family or friends to try and take some ‘time out’ to rest from keeping up the appearance of ‘normality’.  Even if it’s just a few minutes in the bathroom to relax your facade or even shed a tear or two, it can help you cope for a while longer.

When others around you are happy they often feel the need to ‘cheer you up’ and this is particularly true of those closest to you who find your distress hardest to bear.  Explaining why their jokes, kindness and consideration don’t actually make you feel any better, no matter how much you appreciate them trying, gets embarrassing and exhausting so I often ‘pretend’ that yes, I feel better and thank them.  The dishonesty weighs heavily on my heart but I can’t see a better way out of the situation and so I’m back to painting on the facade once again and using all of my mental resources to maintain it.

A final, and perhaps the strangest, aspect of the dysfunctional relationship between happiness and my depression is the feelings I experience when I’m actually happy.  Even during my most severe depressive episodes I can have short periods of being happy or of enjoying myself and this brings on a complex mix of emotions.  I feel a fraud, for my depression can’t be all that bad after all; I feel afraid that if people see me smiling they will not believe I’m ill; I feel uneasy because the feelings of happiness do not sit easily amongst my more entrenched feelings of dislocation and hopelessness; and, above all, I feel sad because I remember a time when happiness was a norm for me and I yearn to have that uncomplicated relationship with happiness again, where I don’t feel the need to analyse or justify the feeling and can just let it happen.

Update 16th October 2012: I can recommend this blog post by The Depressed Moose on a similar topic

Saturday, 15 September 2012

Where is My Voice?

Mental illness is the poor relation of the health service.  I doubt that I could find a single person involved, whether service user (I hate that phrase!) or mental health professional, that would disagree with that.  A thought occurred to me recently that, glaringly obvious though it is, is probably not often thought about in this regard.  People using mental health services have, or have had, by definition, a mental illness.  Most mental illnesses are aggravated by stress.  How then, are people with mental illnesses supposed to get their voices heard?  How are we to campaign for better, more widely-available services?

For some considerable time last year I tried to join in campaigning against the planned cuts to disability benefits.  I wrote to my MP, I blogged, tweeted and generally tried to shake the general public into the realisation that these cuts would have a significant, detrimental effect on sick and disabled people.  I read article upon article, blog upon blog, trying to educate myself and to find ways of raising the profile of the campaign.  However, unlike many of my fellow campaigners, my mental health just wasn't up to it and my depression started to be exacerbated by the struggle to get people to listen and to take seriously the very real impact the planned benefit cuts would have on some of the most vulnerable people in our society.  I had to back away from the fight, reduce my area of focus and retreat into my own small, self-centred bubble of lonely safety.

My crisis has faded a bit now, although I am still fragile and have good and bad days, so again I have started to blog.  This time however, I have been blogging not about campaigning for better services or cuts to benefits, but about my actual illness; what it's like, for me, to live with depression.  One of the hardest things about depression is trying to decide where, in the spectrum of illness and disability, you actually fit.  I have no physical disability and I look 'fine' so no one coming into contact with me would guess at my illness unless I tell them.  I make no secret of my depression, but neither do I wear a placard announcing it to the world.  It's difficult to demand treatment when you feel that you're 'not ill enough' to deserve it. I know there are many far worse off than me, so how can I justify wanting to utilise a scarce resource (therapy) that others need more?  My own, internal, self-critical voice silences my militant, political, campaigning, demanding, public voice.  My voice is not only silenced by the ignorance and lack of interest of others, stigma and discrimination; my voice is silenced by my own illness and lack of self-worth.

I attend my GP appointments every few weeks like a good girl and just manage to stop myself from the stock "fine" answer to her usual "how are you?".  But do I actually tell her how I am?  No, in my usual not-wanting-to-make-a-fuss fashion, the best I can manage is a self-deprecating "not that brilliant actually".  Why?  Why don't I tell her that most days I have at least one episode of internal screaming and fear it will never stop?  Why don't I tell her that I suppress my feelings so much for the sake of others that I feel I will literally explode?  Why don't I tell her that at least once a day I feel so tired of the struggle to keep going that I just want to give up and stop living?  Why don't I tell her that I spend so much of my time trying to be what everyone else wants or needs me to be that I've completely lost sight of who I actually am?  Why don't I tell her that I cannot look to the future at all, never mind do so with any hope?  My voice is silenced by my own need to 'act appropriately', to 'not make a show of myself', to 'be in control'; my voice is silenced by my own self doubt that my illness is 'deserving' enough to demand better treatment.

I am just one person whose voice is unheard.  How many more people are there, people like me, whose voices are lost?  People who struggle from minute to minute; hour to hour; day to day.  People who have not got the energy, strength or platform to make their voices heard?  Who speaks for those that cannot speak for themselves?  Of course there are charities like Mind, SANE, The Samaritans, The Black Dog Tribe and Rethink Mental Illness that all do excellent, valuable work and try to give us a voice; but we need to be heard as individuals and as people deserving of adequate treatment.  If people suffering cancer, heart disease, diabetes or any other widespread physical condition were routinely turned down for the one treatment that could mitigate their symptoms or even cure them there would be a national outcry.  This happens to people with mental illness every single day and no one knows; no one shouts; no one cares.  Having an invisible illness does not just mean that your symptoms are not visible; it means that you are invisible; it means that your voice is not heard.

Tuesday, 11 September 2012

Online Support

I have suffered with depression for, I think, about 9 years.  I can’t pinpoint exactly when it started as you don’t just wake up one day with depression; it creeps up on you unawares.  What I can do is pinpoint the exact moment I realised I needed help.  One day I went into the local village shop after dropping the children off at school.  The lady serving that day was a friend and she greeted me, as she always did, with a warm smile and a welcoming hello.  Her easy cheer stopped me in my tracks and I was in tears before I had even made it out of the shop.  I cried all the way home and it was all of a sudden glaringly obvious to me that my reaction to someone else’s happy, relaxed nature was completely abnormal.  I was way more than unhappy; I was so desperately low that someone else being normally, every-day, happy threw my own feelings into such sharp relief that I could no longer ignore them.  I called the doctor as soon as I got home.

I was severely depressed by the time I sought help.  I had been sinking lower and lower each day for months and months and by the time I realised I was virtually catatonic.  My condition was made worse by the fact that I also had extremely low iron levels in my bloodstream, which rendered me physically exhausted in addition to the mental maelstrom I was experiencing.  Each day I got up and got the children fed, dressed and ready for school.  As soon as I’d taken them to school I’d go home and often either go back to bed or sleep on the sofa until it was time to collect them.  After the day I was woken by a phone call from the school fifteen minutes after I should have collected my youngest, I always made sure I set an alarm, even if it was 9.30 in the morning when I went to sleep.  I’d collect the children and then play ‘Mummy’ until after tea, when I’d crash again and my husband would take over for a while.  During this time I tried very hard to ensure the children were cared for.  I always kept the washing up to date and made sure there was food in the house, although going to the supermarket was, and still is sometimes, extremely traumatic for me.  I am conscious though that they did suffer during this, my darkest period as I was not able to interact with them as I should have and I regret that deeply.

The medication the GP prescribed me, antidepressants and iron supplements, gradually dragged me out of the worst of the dense fog but I reached a plateau in my recovery after about six months and I felt I needed more than just medication to help me.  I was fortunate that I was able to (not quite) afford the private psychologist that my GP referred me to.   He was great and really helped me to address some of the issues that were contributing to my illness.  Sadly, part of this process led to the end of my 18 year marriage, which was incredibly painful for all concerned.

I have never returned to that absolute depth of long-lasting, non-functioning depression but nor have I succeeded in achieving the recovery that my GP assured me was possible all those years ago.  I have had periods, some as long as several months, of being relatively symptom free but by and large my depression has stayed with me, colouring all aspects of my life.  I have good days and bad days and have pretty much resigned myself to living with depression for the rest of my life.  I am no longer in a position to be able to pay for therapy and, as therapy on the NHS is virtually non-existent, having online support has really helped me to cope with my condition on a day to day basis.  There is, of course, no joy in knowing that other people also suffer with an illness that drains the pleasure and energy out of them most days, but to know that others understand exactly what you mean when you describe how you are feeling can take some of the pressure off.  Having my feelings validated, affirmed and understood makes me feel more able to keep pushing for the help and support I know I need. 

My illness can often make interacting with people face to face extremely difficult, or even impossible, for me so access to support online has proven invaluable.  I read a lot of mental health blogs and follow many people on twitter that also have various mental illnesses and all of them have helped me at one time or another to feel more ‘normal’ and less isolated.  Online forums, organisations like Mind and SANE and projects like SANE’s Virtual Black Dog all comprise an online community for raising awareness, sharing experiences and providing support.  Certainly for me, support from people who have, or have had, similar experiences to mine means so much as I know it comes from a place of acceptance and understanding.  I am blessed to have a wonderful, close family who try very hard to understand and support me but, as I have written before, sharing too much with those closest to you is not only difficult, it can cause other, knock-on problems that affect your relationships and the dynamics within them.

Blogging is a good way of exploring my own feelings and experiences and to try and make sense of them.  Very often I have started to write a piece thinking it will go in one direction only to discover, as I write, that it veers off at a completely unexpected tangent.  This has occasionally resulted in me revealing perhaps more of my personal experience than I had originally intended, but it almost always helps me have a new insight into how events have impacted on my illness and emotions.  In a way, it’s like the more positive experiences I have had with therapy, in that the process itself can help me to see solutions for myself, rather than having them suggested for me.  I blog mostly for myself, exploring events in writing is a well-known way of coping with difficult situations and emotions, but also for others.  I have had so many positives from reading other people’s stories and from interacting with people online and I hope that reading my blog will make someone else feel that maybe, just maybe, they are not as alone as they thought.

Wednesday, 5 September 2012


What do you think of when someone mentions bullying?  Physical punches, kicks, beatings?  Or threats of physical violence unless favours are given?  Stealing of trainers, school bags, dinner money?

What about name calling?  Isn't that just normal childhood behaviour?  Is it really bullying?  Surely it can't actually hurt anyone?  Well, yes, it can, and does, hurt people, far more than you might think.  I was bullied relentlessly throughout my years at primary school.  I couldn't tell you when it started, I don't really remember it ever not happening.  I was never physically assaulted, unless you count filling my wellies with snow or a bit of jostling, but the verbal abuse was constant and it wasn't just one or two people, it was nearly everyone in the class, and some that weren't.  What marked me out as a victim?  I doubt I'll ever know really, but once the pattern was established there was no going back.

Every single day of my school life, every break, every lunchtime, walking to and from school and any time I was seen by my classmates, or other children I didn't even know on several occasions, I would have to negotiate name calling, taunts and teasing.  Why?  I wasn't a nasty child, I didn't smell, I didn't wear glasses (then), I was just a little girl that for some reason, everyone decided didn't fit in.

You may be asking what the school did about this consistent bullying?  Well, the answer would be nothing.  Not because they were incompetent, nor did they not believe me.  The reason they did nothing was that they didn't know.  I told no-one.  Occasionally there were instances when I did tell, once, whilst I was still in the infants, my mother noticed I complained of a sore stomach one Friday each month and had to stay home, though by mid morning I was fine and would happily go back to school after lunch.  She spoke with the Head Master and found out that once a month there was a longer playtime to enable staff meetings.  I was scared of the children playing some kind of chasing game apparently, although I have no recollection of this.  Action was taken to ensure extra supervision during these breaks and my Friday morning stomach aches disappeared.  Another time was when I was seven and had broken my arm falling on ice in the playground.  Being slowed up by a plaster cast meant I was bullied during break times even more and I must have told on that occasion as I was allowed to stay in school for breaks until the cast was removed.

Never though did I tell anyone just how persistent the bullying was.  Looking back I think there were several reasons for this.  Firstly, what could I actually say?  Oh, so-and-so called me this or that name?  They wouldn't let me play their games?  They don't like me?  Even at such a tender age, I knew that anything I could say would sound lame and hardly like 'proper' bullying behaviour.  Secondly, I was happy at home, I had a family that loved me and siblings that I fought and played with as all children do.  Nothing about my home life was like the loneliness and isolation I had elsewhere.  Why, then, would I want to bring those feelings home to my safe place?  Possibly too, there was the chance that I may have thought I wouldn't be believed or taken seriously, or that there was nothing that could be done to stop it.  In truth I think telling anyone just didn't cross my mind.  While the bullying wasn't actually happening I shut it out, not wanting to think about it, let alone talk about it.

Moving on to secondary school things did improve, there were fewer comments shouted at me across the street and the name calling pretty much stopped.  However, I had been irrevocably affected by the bullying and I found making friends difficult to say the least.  I felt that no one would want to be my friend and that I was basically unlikeable.  I was awkward with people I didn't know and assumed people would forget who I was if I didn't see them for a while.  In second year I made friends with a girl in the year above me, someone who hadn't known me from primary school and knew nothing about me being 'the one that no one likes'.  I met her through the school choir and, through her, joined an amateur dramatic society outside school.  She probably saved me from ending up far worse than I have, and she is still one of my best friends, although she lives overseas now.

You might think that knowing the root of a lot of my self esteem problems would mean that I could leave them behind and move on.  Sadly, that has not been the case.  The bullying throughout much of my formative years has left me believing still that I am intrinsically unlikeable, unloveable and unattractive.  Even when face to face with evidence to the contrary in the form of people who take the time to be with me, and even someone who is the love of my life who actually wants to marry me, I cannot believe that the opinions of all those children all those years ago were wrong.

This is the legacy that bullying leaves.  It changes you.  It breaks you.  Never think that name calling or verbal taunting are not 'proper' bullying.  The scars they leave are deeper and more long lasting than any punch or kick.  If your child tells you someone is calling them names and being mean to them, please, don't tell them that old lie about 'sticks and stones'.  Words can hurt you.  Words do hurt you, and they can keep on hurting you long, long after the bruises from sticks and stones have healed.

Monday, 3 September 2012

How ill is ill enough?

I read this excellent blog on the Time to Change website about where depression fits into the spectrum of disability, if at all.  The blog made me think a lot about my own illness and my own feelings about the 'legitimacy' of my claim to ill-health.  I know I'm not well, I know the limitations my illness puts on me and my ability to function productively but still I feel embarrassed by claiming to be ill when, physically, I am relatively healthy.

The everyday experience that is my depression impacts on every aspect of my life.  My relationships, my children and even who I am are all coloured by the black cloud of depression.  When I laugh I feel guilty; when I'm down I feel pathetic and, yes, guilty again; when I'm out walking, especially if the street is quiet, I feel self-conscious, unattractive and cripplingly conspicuous; I hate to eat in front of anyone, unless they are also eating and even then I am on edge and make sure I don't eat more than others; I cannot handle confrontation without crying and feeling totally inadequate; if my children are less than acceptably behaved I blame myself and feel like a useless parent; and then of course there is the ever-present, all-pervading, brain-numbing exhaustion.

All of these symptoms and more can leave me unable to function effectively at all some days, others they just make me slower than I ought to be, less able to 'put myself out there'.  I don't work as I am a registered carer for my son, who has an autistic spectrum disorder.  In reality, I hide behind my son's disability.  It's true that it would be very difficult for me to find work as he needs supervision at all times and has to be taken to and collected from his special school daily as we live too close to qualify for transport.  That said, the main reason I don't work is due to my illness, I just don't need to admit that publicly too often as I have the ideal smokescreen of my son's disability behind which to hide my own.

Whenever I try and explain my illness to anyone I feel as if I'm over-dramatising and yet at the same time under-selling my symptoms.  I shy away from discussion of suicidal ideation, even though it's an ever-present demon lurking in my mind, as I don't feel I have the right to admit to feelings I have no intention of acting on.  There are few days that pass without the thought of ending my life, or at least my life coming to an end, crossing my mind at some level.  How legitimately can I tell anyone that when I know it's an avenue that is simply not open to me?  I have very limited experience of suicide but what I have experienced has taught me that it is not something that can ever be confined to the person committing the act.  The ripples of suicide are far-reaching and long-lasting and those left behind suffer far too much for me to ever feel able to take that route.  I have seen the effect that the death of my baby son had on my family.  I have flashbacks to the horrific telephone call I had to make to my parents to tell them and to the heart wrenching, devastating, unbearable, unprecedented sound of my father crying at my son's funeral.  Inflicting pain like that once in my lifetime is enough, I cannot, no matter what happens, willingly do it again.  I know also that children of suicides very often feel guilt for their parent's actions; how could I possibly do that to my children?  My children are approaching adulthood having had a fairly rough time over the years and I am so proud of the people they are turning out to be.  No way can I forestall their personal growth in such a traumatic way.

The removal of the ultimate conclusion of my illness as an option is, in itself, a factor in exacerbating some of my symptoms.  The fact that I cannot have a 'way out' means that I am trapped in this life and that way, as the saying goes, madness lies.  On bad days, when I want to escape but cannot, I can 'see' myself inside my head; running from door to door, searching for a way out where there is none to be found.  Those times are when I feel insanity taking hold of me and the fear and desperation can be unbearable.  The vision I have is literally of my inner self trapped inside a room that is my mind; there are many doors but none lead anywhere safe.  I can feel the panic taking over me as my heart rate quickens and my breathing speeds up.  Left to myself, without someone to hold me and calm me down, I hit myself to stop the pain.  I've never told anyone that, no one knows unless they are reading this now.

When all of my symptoms, difficulties and experiences are written down I can almost believe that I do deserve help and that I am really ill but at the same time I know there are so many people more deserving and more in need than I am and I struggle to feel justified in asking yet again for help.  I managed to secure some short-term counselling earlier this year, despite the assessor telling me that the service I had been referred to was really for those with more "serious and enduring" mental health issues.  I think the reason I was allowed to access the service was twofold; first of all, my reaction to the "serious and enduring" comment was distress and despair and begging that I'd been ill for more than eight years, how much more enduring did it have to be before anyone would help?; secondly, I told the assessor, truthfully I may add, that the last time I had tried to access psychological therapy was a couple of years previously.  On that occasion I had been referred to a psychiatrist who saw me every so often and increased my medication each time because I wasn't getting better.  When I asked to be referred to a psychologist he claimed I was too ill to benefit from therapy.  I struggled to control myself over the course of a few sessions and eventually I was given an appointment with the consultant psychiatrist ... who told me I was too well to be referred as  I would never reach the head of the prioritised waiting list.  The assessor was clearly shocked by this, which I have to admit pleased me as I had always thought my treatment had been unacceptable, and I think this was a major contributory factor in her deciding to allow me to access some counselling.

The counselling helped while it lasted but it could not, or did not, help me with my underlying issues.  It was great to be able to 'off load' to my therapist on a regular basis and to talk through situations I'd found difficult and have my feelings validated but I don't know what, if anything, would help me rediscover my ability to function more effectively.  I often feel like I'm a lost cause and that I'll never recover.  I don't look far into the future and can't picture myself in ten or even five years' time; I just cope with each day as it comes and hope that one day things will get better.  I suppose I feel like I am ill enough to not be well but not ill enough to be judged deserving of any help other than the pharmaceutical variety.  I hope one day that will change, sadly I don't much mind whether that means getting better or worse.