October 2015 – Patching the Soul

At the recent Cheltenham Book Festival, The chair of the mental health panel on which I was appearing to talk about my new book asked me perhaps the most difficult question that I’ve been asked so far.
‘So, there is a scene towards the end of your book where something quite shocking happens. Is it alright with you if we talk about it?’
I felt my chest tighten, as I knew exactly what he referred to. It was the moment in which I confronted my mentally ill brother about why he could not get out of bed. It was, I’m still terribly ashamed to admit, the moment that I hit him. I didn’t hurt him, at least not physically- but I did it, I had written about it, and now I was having to face that moment again- only this time in front of an audience.
‘Yes, you can,’ I replied, feeling my anxiety level rise even more, I knew I couldn’t avoid it.
‘So, can you explain how, given your profession as a psychiatrist, you raised your hand in anger and brought a stool, was it?- down on your brother who was clearly mentally unwell?’

It’s one of those moments when you are forced to really admit your thoughts and feelings. Why did I do it? What on earth was going through my mind? I remembered how upset, frustrated and annoyed I was that he seemed completely unable to help himself, whatever I tried to do to support him. He had spent three days in a room and could not get himself dressed. Instead many of his clothes had been torn up and lay on the floor around him. By that time neither of us were functioning in any rational way. I was no longer thinking as the trainee psychiatrist I was at the hospital down the road. I was an exhausted, tearful and desperate person trying to care for someone who seemed to be refusing anything I offered; And I knew what was going through my head: I really thought he was simply refusing to do anything for me; he was perfectly capable of it, he was just ‘putting it on’ to thwart me. In that moment I treated him like many others had in the past. I was acting as though his problems were not real.

In a recent article in the guardian a medical student also admitted ‘before working in psychiatry, I didn’t think mental health problems were real’. I’m sure that is what many people think- that those who complain of mental difficulties are probably just acting in some way, or are simply weak-willed. That certainly seems to be the prevailing view of those who think that people with mental illness can be forced to find work and financially sanctioned if they do not. Logically this can only work if you believe they have considerable control over most of their symptoms and problems-which infers that they must be, to some degree, ‘putting it on’ doesn’t it? If you are responding to voices or convinced of something that is labeled as delusional, your problems may become more real, but then you may simply invoke fear (‘these people should be put away’); or pity, (these poor people need some assistance) an emotional response I have seen in those mental health workers who are sympathetic to people with more severe mental health problems, but still appear to view them as simply the more unfortunate ones in society- much deserving of charitable help, fascinating in an academic kind of way, but not somehow as their equals- real people with lives, dreams and desires of their own.

And those of us with ‘common’ mental health problems, anxiety disorders, OCD (my brother’s problem) and depression? Well we are almost certainly believed to be responsible for our actions and quite capable of changing our behavior. This viewpoint is in many ways reinforced by the fact that many treatments require us to actively change our behavior and confront the very fears we are paralysed by. ‘Response prevention’ works in OCD (Obsessive Compulsive Disorder) but it is extraordinarily hard, at least initially, to stop yourself doing something- the very compulsive behaviour that has for many years relieved your anxiety. Similarly activating yourself in Behaviour Activation works in depression, but you may have to force yourself very hard to start doing it. Small goals are helpful at first, like simply being able to get out of bed; but even that can seem impossible. My brother couldn’t do it. He was stuck in his own loop of intense anxiety. Unfortunately therapists can sometimes be remarkably unsympathetic too- if you cannot comply you are sometimes labeled as ‘not motivated.’ The responsibility that the therapist has for helping to motivate you is disregarded.

I’ve learned a great deal since that awful moment in my spare bedroom thirty years ago. Some of it I found out quite soon when I confided in a colleague who was a clinical psychologist. He helped me to understand how my brother had, paradoxically, been able to get out of bed, dress and leave the house when I insisted, despite having been quite unable to do it for the previous few days. That didn’t mean he hadn’t been struggling- desperately trying to deal with the anxiety that manifested itself in obsessional behavior; but he was, temporarily at least, quite disabled by it. I’ve known that helpless feeling too in the times I’ve been unable to get out of bed, get dressed or open a book because I couldn’t find the energy or interest to even try. Sometimes, when I am well, I stop and wonder if I have been putting it on too, because if I can sit here and type a thousand words in an hour this evening, then there cannot be anything wrong with me surely? (despite the number of pills I’ve had to swallow today). One of the many reasons people with mental health problems are stigmatized is that they are not believed when they say how difficult it is to do normal everyday things. It’s patently obvious to anyone with common sense that they can just get on with it- can’t they? I know this is how people think, because I can honestly say that even with my expertise and own lived experience, there are times that I have thought this too. I’ve been there. Real empathy and the power to confront stigma that comes with it, means not only believing that isn’t so, but acknowledging the times you too haven’t wanted to understand why a person with mental health problems cannot do what you would prefer them to do, and why.

My book ‘The Other Side of Silence- A Psychiatrist’s Memoir of Depression, published by Summersdale, is out now.

‘Resilience’ is one of those words its hard to avoid at the moment. No one seems to be quite sure what it means, but one suggestion has been that it refers to a person’s ability to maintain or regain a state of mental health in the face of significant adversity or death; in which case it is a quality in which I am undoubtedly lacking. I am very sensitive to the ups and downs of life especially loss. I get anxious and depressed; I’ve had periods off work. I may have successfully survived a lifetime of work as a psychiatrist and an academic, but I’ve also had to use mental health services to keep afloat. Life in the NHS is challenging and I’ve not got through my career without some serious wounds to show for it.

Before the word ‘resilience’ achieved common usage, and its current prominent space on the buzz word bingo board of healthcare, I understood it broadly to be inversely related to the degree of vulnerability conferred by a combination of genetic heritage (see Goldberg & Goodyer)- which influences our temperament, personality and susceptibility to some types of mental health problems, early life experiences and social learning in childhood. If a group of people are exposed to the same degree and type of stresses most will cope, they will demonstrate resilience, but a minority will not. We all have differing degrees of it. Some will develop common mental health problems like depression and anxiety in response to traumatic events, and others less common ones, such as psychosis, but many others will get through relatively unscathed.

The General Medical Council (GMC) with whom I am still registered, although I no longer practice psychiatry, has recently decided that the current generation of doctors is less resilient than those in the past and students need to undergo resilience training in order to be tough enough for the job. I have a number of problems with this view:

As an excellent review of the topic by Balme and her colleagues in BMJ Careers recently stated ‘there are no consistent definitions, no standardized, valid or reliable measurements; and no robust studies into what resilience is, what the predictors of resilience are, and whether resilience is related to better patient care.’

So if you intend to screen for it please check out this first. If I were starting medical school now (and I still dream I haven’t yet passed my finals) I would want to know, as will others, exactly what it is I am lacking in (given that I tend to get depressed I will likely feel guilty and even more insecure) and whether being without it is going to be of harm to anyone but myself. We don’t screen out people with diabetes from being health professionals. Why should we even consider doing that with people who might be vulnerable to depression.

Because in an increasingly hostile working environment the reality is health care professionals are going to experience more mental health problems. They are human beings like the rest of us, although they are not encouraged to admit they need help, for fear of appearing weak. The culture is tough enough already.

Please don’t dress up this quality called ‘resilience’ as something for which they must take full responsibility (I have a problem because I lack resilience) rather than the NHS (I’m not very well because I do not work in a supportive and caring workplace). As Balme et al. point out resilience is always contextual – it’s a complex interplay between the person and their environment.

Please don’t assume that attending a few short workshops would increase my resilience much either. The evidence for the effectiveness of resilience training is patchy at best, and though there is a suggestion of some positive outcomes, these are mainly from self-report in studies lacking rigorous methodology. It might be more effective to address these problems I have in relating to the world and coping with stress much earlier in life before any thought of being a health professional is even a twinkle on the horizon.

What I would need is help to identify coping strategies like problem-solving. There is evidence that this works for people with depression, and those who self-harm in response to life stresses. I wish someone had taught this to me in childhood, it might have helped me earlier. I would need things I can rehearse to put into action at times when life gets tough. But I’m also going to need to be encouraged not feel too ashamed to ask for support and how to identify I might need it earlier rather than later, as so many health professionals who have consulted me have been unable to do. Fast and confidential access to help and support too, not having no choice but to consult a service that I work in, which happens to so many people now in mental health services in the UK.

And finally, please don’t assume that just because I’m not as tough as the GMC would perhaps like me to be, I would not be a good doctor. Since my book was published a month ago, I’ve heard from medical students who have feared for their future because they have experienced mental health problems at medical school, worried that they will not be strong enough to cope. Yet these very young people, who have experienced what its like to be a patient can bring a very special dimension to their work. Like me, they know what its like to be on the other side.

We all differ in our ability to deal with traumatic events and the stress of work, yet within that spectrum of abilities lies the potential for us to learn to listen, support and care for each other: as friends, colleagues, some managers and a insightful and proactive occupational health service did for me; supporting me through my sometimes difficult career.

My memoir about experiencing depression during my career in psychiatry is out now: The Other Side of Silence: A Psychiatrist’s Memoir of Depression ‘published by Summersdale.