bipolar-disorder – Patching the Soul

Forty years ago, Carol Gilligan, the veteran feminist psychologist wrote about how young women may lose their ‘voice’ during adolescence as they navigate the pressures of society. We women resist these pressures to disengage from our honest voices but are told that we must repress our anger and questioning selves and conform to societal norms if we are going to succeed in the world. We are told that it is wrong to resist.

Laura Delano’s world was a privileged one, but it was a life which nevertheless came with quite firm expectations. At the age of 13 she looked in the mirror and began to question what was happening to her in this somewhat gilded existence. ‘I had no idea who that girl was anymore. All I knew was that she was someone else.’

The tragedy of the next couple of decades is that, instead of having an opportunity to try and voice these thoughts, feelings and fears through conversations over time with a therapist skilled enough to both engage and work with her (she is sadly declared too serious a case for the one she does see), Delano is diagnosed with bipolar disorder by a psychiatrist at the age of 14 and given the bleak prognosis that she will need to take medication for the rest of her life. She is started on both Depakote (a mood stabiliser) and Prozac. This leaves her feeling betrayed, alone and ‘in a battle to protect myself’.

Reading about what happened left me feeling both full of compassion for her and anger that a fellow shrink could ever consider this to be good psychiatric practice. But that is only the beginning of this shocking story of multiple diagnoses and dangerous polypharmacy.

Oddly, I wasn’t surprised by the experiences Delano describes with each subsequent psychiatrist because I’ve read some similar accounts in recent years, notably Rachel Pruchno’s moving account of trying to help her daughter obtain good mental health care for bipolar disorder. I’m not going to pass any judgement on the diagnosis of bipolar that Delano received other than in my opinion coming to any such conclusion in one so young should take much more time and caution. Its also stunning how it sounds as though the diagnosis first provided is then taken as read – something that I was taught never to assume. Diagnoses are only working hypotheses which change over time, and as Allen Frances says, should be written in pencil. However, further additional diagnoses and medication are added to the list over the following years.

The period that Delano spends at McLean Hospital in the unit for Borderline Personality Disorder is however, for me, the most disturbing. It’s hard not to see this as some sort of place where it feels like attempts were made to overcome her resistance and get her to ‘behave’, in order perhaps to restore the ‘promise’ for society that she once showed as a New England debutante. I know many therapists will disagree but it’s a diagnosis some of us intensely dislike – rooted in a misogynist perception of how women and girls behave when extremely distressed, and here there are so many of them, collected together and regularly judged as to their ‘progress’.

The polypharmacy is chaotic and dangerous. I have some skin in the game here, both as a (now retired) psychiatrist and as a patient. I’ve prescribed many of those drugs but also taken quite a few of them too. I know about the side effects – the weight gain caused by Seroquel, the terrible thirst and tremor of lithium (I was never able to discontinue the thyroxine after lithium damaged my thyroid gland), the constant gut problems and the difficulties of coming off SSRIs and SNRIs. I’ve had episodic depression throughout my adult life, which at times has proved difficult to shift but I benefited from excellent care from colleagues in whom I trusted, and medication did help me to survive and thrive, even lithium.

One reviewer of this book has criticised it as a study in ‘black and white’ thinking. But I’m old enough to remember the change from ‘black’ to ‘white’ that came about in American Psychiatry, when it shifted from reliance on psychoanalytic interpretation to declaring the dawn of ‘decade of the brain’ accompanied by a hefty dose of psychopharmacology. Psychiatrists treating Delano seem to keep these modalities quite separate too. Never wanting to ‘see’ the whole person in the round – a young woman getting minimal benefit from treatment and experiencing what is desperate and suicidal anguish – to find out what she really needs.

However, Laura Delano did ultimately resist the ‘psychiatricization’ of her life and triumphantly survived to found the non-profit Inner Compass Initiative which helps people withdraw from medication. It probably goes without saying that I don’t share her view that psychiatry is the main problem though I’ve met people over my career, and some of my personal friends, for whom it certainly has been a significant part of it and who have only thrived when away from it completely. I believe it can do great harm but can also do much good too. In my professional and personal experience mental illness not only exists but can benefit from medication and psychotherapy. Some will say, of course I would say that, but I do also acknowledge the importance of the existence of the ‘other’, outside of psychiatry and mental health care, to whom people can turn if they need to, for advice, support and advocacy.

I have known people who have been diagnosed with severe mental illness who have been able to come off all medication and live a drug free life, and others for whom this was quite impossible. I still take duloxetine to stay well and often wonder what I would be like if I didn’t. The medication free me is a person I’ve not known for many, many years. But having reduced the pills considerably I know that last few milligrams will be hard to withdraw from given the decades for which I’ve taken it. Support is vital, and, even if we disagree, ‘inside’ and ‘outside’ psychiatry might benefit from working together for the very sake of those we are trying to help.

Laura Delano fought to rediscover her voice.

Even if you disagree with what she has to say, it is indeed a powerful one.

*Laura Delano Unshrunk : How the mental health industry took over my life and my fight to get it back. Monoray 2025.

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is published by Cambridge University Press and is a PROSE award winner (American Association of Publishers) in the USA.

It was utterly shocking to read Scout Tzofiya Bolton’s description in the Guardian a week ago of how she was re-diagnosed from having bipolar disorder to having a diagnosis of emotionally unstable personality disorder (EUPD), and, excluded from care then ended up in prison.

And yet, sadly, wasn’t.

Because many women and girls have told me similar stories during my research for Out of Her Mind.

We know it’s remarkably easy to be given this diagnosis. Women are three times more likely to be given it, and some are very clear about how easy it is to receive it. Challenging a doctor’s views, as Scout did, is one way.

When I was training in psychiatry ‘borderline’ or ‘EUPD’ wasn’t a recognised diagnosis but difficult women were usually labelled as having ‘hysterical personality disorder’ until they received sufficient time and care to be able to tell their story to someone who would really listen. It can take years to get a diagnosis of bipolar disorder, especially if you are a woman perceived as behaving ‘outrageously,’ and you can be rediagnosed easily too, as Scout’s story demonstrates.

However, we don’t seem to be any better now than we were 40 years ago at listening to women with complex problems and finding out what is needed to help them. Now we have the diagnosis of borderline personality disorder and undoubtedly, as clinical psychologist Jay Watts says, some with this diagnosis are suffering from missed bipolar disorder, are autistic or have premenstrual dysphoric disorder. The vast majority have experienced trauma, if not before they came into mental health care, certainly afterwards. I’ll discuss the issue of complex post traumatic stress disorder cPTSD versus BPD in another blog, but I’ve made no secret of my desire to put ‘borderline’ in the bin – and that is a change of opinion from my experiences of listening to women.

What we do know is that a majority of those with this diagnosis who take their lives when under mental health care are women. Not only are they unlikely to get an adequate assessment but they have great difficulty accessing appropriate psychological therapy. We hear about them quite frequently now at inquests and/or there are investigations into the quality of their care, after which we are told that ‘lessons will be learned.’

Surely, in mental health care, and society too, we should be paying more attention to this? Yet when I recently shared my views in a psychiatry teaching session, several (male) colleagues told me I was mistaken. It was a helpful diagnosis – for them. And I felt like I was once more being a ‘difficult’ woman. That’s familiar.

We also know that women are regularly victims of sexual violence in mental health care, though without the fact that the majority of victims are women being mentioned.

Many women who end up in in-patient care have already experienced trauma of one form of another. In mental health care, be it from the lack of respect, kindness and compassion from staff that women described to me (and was clearly visible in the BBC Panorama report) or the risk of sexual violence, women are being retraumatised every day.

All-in-all its not so very different now for women in hospital from what I described in The Other Side of Silence of my experience as a new consultant in an old asylum in 1990. I didn’t name the hospital, but everyone who knows me can guess where it was. We closed those places, but the culture sadly hasn’t changed.

In the focus on men’s mental health in the last decade, we have failed to pay attention to what’s been happening to women in the mental health system. I know that many of these problems happen for men too, but being ‘gender neutral’ is not helping to address the very specific problems that women are facing.

We need a women’s mental health policy.

And if that’s at the risk of offending men, well so be it. Something has to change.

My book: Out of Her Mind: How we are failing women’s mental health care and what must change, is out now.