Chapter 4

I hope you have all had a lovely and relaxing Christmas. As 2026 approaches, I thought I would share the next chapter from my book, which will finally be published in mid-January 2026.

This month’s Layered Care newsletter focuses on Chapter 4, a chapter that deliberately slows things down. Instead of offering another framework, pathway, or intervention, it does something less fashionable and more difficult, it stays with lived experience. The chapter asks what happens when we stop treating distress as something to be observed, measured, and corrected, and instead begin with how it is actually lived.

Chapter 4 is grounded in phenomenology, which, stripped of academic excess, is simply the insistence that experience matters. Not how suffering appears from the outside, not how it is coded in a system, but how it is felt, endured, and survived from within. If you have ever tried to explain distress to a service that was more interested in ticking boxes than listening, you already understand why this matters.

The chapter begins with a refusal. We do not encounter the world as data. We encounter it as meaning. Pain is not just a cluster of symptoms; it is fear, memory, shame, relief, dread, and adaptation woven into a person’s life. Yet most systems are built as if suffering were a technical fault and people were machines requiring recalibration. Chapter 4 pushes back by asking a question services rarely want to ask because it is inconvenient, what kind of world is this person trying to survive?

This question is particularly urgent for people living with co-existing mental distress and substance use, CEMS. In practice, their lives are quickly flattened. Distress becomes “mental illness”, substance use becomes “addiction”, and the person becomes a problem to be managed. The dominant question becomes “What’s wrong with you?” rather than “What has happened to you?” or, more honestly still, “What have you had to endure, and how have you kept going?” Phenomenology starts there. It treats the person not as a malfunction, but as a meaning-maker under pressure.

One of the central moves in this chapter is rethinking substance use. Instead of beginning with moral judgement or brain chemistry, it begins with function. What is the substance doing for this person? What does it regulate, soften, slow, dull, sharpen, or make possible? When you start there, substance use no longer appears simply as the problem. It appears as an attempt at a solution. Often an imperfect one, sometimes a damaging one, but usually an intelligible response to something real.

Many of the people I spoke to did not describe their lives in clinical terms. They spoke through the body. They talked about waking up already flooded with panic, about living in a constant state of threat, about carrying an internal noise that never fully stops. For some, alcohol slowed the body enough to stop shaking. For others, heroin was not about euphoria, but about stillness, quiet, and relief from relentless internal pressure. Others described stimulants as the only thing that made the world feel real again after depression had flattened everything.

If you hear these accounts properly, something uncomfortable becomes clear. What looks irrational in policy language can be existentially intelligent in a life that has become unliveable.

This is where Merleau-Ponty matters. His central insight is simple but disruptive. The body is not something we possess, it is how we exist. We do not merely have bodies; we live through them. That means distress is not only “in the mind” or “in the brain”. It is often in the chest, the gut, the muscles, and the nervous system that never fully stands down. Trauma can live in the body long before it becomes a story that can be told neatly.

When you start from the lived body, a great deal shifts. A person pacing a corridor is not necessarily “non-compliant”; they may be trying to discharge unbearable energy. Someone drinking in the morning may not be “in denial”; they may be trying to prevent their body from spiralling into panic. Someone unable to sit in a waiting room may not be “manipulative”; they may be inhabiting a world that feels fundamentally unsafe. Phenomenology teaches us to treat these as meaningful signals rather than inconvenient obstacles.

The chapter then moves from embodiment to perception itself. Severe mental distress is not only about thoughts or emotions; it can be about reality coming apart. Time can collapse or stretch. Colours can intensify or drain away. Familiar places can feel unreal. The self can feel unstable and unanchored. This is not a metaphor. It is what it can be like when the structures that hold a person in a shared world begin to fracture.

R.D. Laing is useful here, not because everything he wrote should be revived uncritically, but because he insisted on something psychiatry still struggles with. What looks like madness may be a response to impossible conditions rather than an internal defect. Many people in this study described feeling behind glass, watching life but unable to enter it. Others described hyper-clarity, where everything felt too sharp, too intense, and too much. When services reduce these accounts to diagnostic shorthand, something vital is lost. Not just nuance, but recognition.

In this context, substance use often becomes stabilising. Not because it is harmless, but because it makes reality bearable enough to remain in. It can blunt the edge, slow the spin, quiet intrusive memories, or create enough distance to function. This is why abstinence-first approaches so often fail people with CEMS. They demand that individuals give up the only strategy keeping them intact before offering any alternative. That is not recovery; it is rupture.

This survival logic becomes even clearer when we consider time. For many people, time is a quiet structure holding past, present, and future together. Trauma can destroy that structure. The past can intrude without warning. The future can feel unreachable. The body can react as if danger is still happening because, at a nervous-system level, it is. When time collapses like this, life becomes profoundly difficult to inhabit.

In these conditions, substances often function as tools for regulating time. Benzodiazepines slow the night enough to make sleep possible. Opioids can pause loops that will not stop. Alcohol can soften a present that feels too sharp. Stimulants can force movement when depression has frozen everything. These are not just chemical effects. They are attempts to make time liveable.

The chapter returns briefly to Thomas De Quincey because his nineteenth-century account of opium use reads like an early phenomenology of trauma, anxiety, and temporal distortion. He was not celebrating decadence; he was describing control and relief in a life that felt unmanageable. His writing reminds us that narrative is not indulgence. It is a method. When people describe the texture of their suffering, they are not wasting time; they are offering the only data that really matters.

This leads to one of the hardest parts of the chapter: what happens when people do speak, but services cannot hear? Many try to explain that they drink to stop nightmares, that they use it to quiet the noise, that sobriety makes their body unbearable. Too often they are met with forms, scripts, and eligibility thresholds. “Come back when you’re sober.” “Come back when you’re stable.” Mental health blames substance use; substance services blame mental distress; the person is left outside both doors.

Over time, people learn to perform what one participant called “service speak”. They edit their stories to fit what systems can tolerate. Some underreport use to access therapy. Others hide distress to avoid exclusion. Others stop asking altogether. This is not poor engagement. It is adaptation to systems that reward legibility over truth.

This is where epistemic injustice becomes more than theory. When people are not believed, or cannot be understood because the system lacks the concepts to hear them, their knowledge is disqualified. Over time, this becomes a form of erasure. When someone speaks and nothing comes back, no recognition, no resonance, they begin to disappear from themselves.

The point of Chapter 4 is not to romanticise substance use or deny harm. It is to refuse reduction. It is to insist that behaviour is often coherent under pressure, and that care must begin by understanding the pressure being endured. Only then can alternatives be built that are actually viable, embodied, relational, and safe.

If I had to reduce the chapter to one line, it would be this: before we can treat people, we have to be able to hear them. Not just their words, but the body’s language, the world that has fractured, the time that has collapsed, and the relief they have found wherever it was available. When systems cannot hear complexity, they do not merely fall short. They recreate the very conditions people came to escape.

Next month’s newsletter moves into Chapter 5. If Chapter 4 asks us to listen differently, Chapter 5 asks why our institutions struggle to do that at all. It explores how systems translate suffering into categories of compliance, helpability, and worth, and how people are sorted, silenced, or excluded, not because they are beyond help, but because our systems no longer know how to listen.