The Skeleton Cupboard (32 page)

He was right and I felt like an idiot.

We spent a while chatting, and while Tom was no less angry about the virus, he had decided not to kill himself.

“Are you happy with that decision?”

“What, to engage back into life?”

I nodded.

“Yes. And for what it's worth, you were right about what depression and anxiety were doing to my mind, and actually just knowing it helped: I didn't take any medication in the end. I guess you could say I have shifted my focus from dying to living.”

I smiled and suppressed the urge to hug this beautiful man.

“Yes. I am happy to be doing life again and designing like a lunatic.”

We laughed.

Tom reached into a bag. “For you.”

I opened the package slowly, wondering how I could tell him that receiving gifts from patients was frowned upon.

It was a small leather-bound Moleskine sketchbook. I held it in my hand.

“Look inside, for God's sake!”

Tom had given me a book of the most exquisite sketches that I had ever seen, each one a work of art. On every page there was a woman in an outfit that fitted her body perfectly.

“Do you know who that woman is, sweet cheeks?”

I shook my head.

“Look at her—she has curves and one fucking attitude.”

This was my style makeover. Protocol aside, I hugged my soon-to-be ex-patient.

“You are one fucking tough bird! Where'd that come from?”

The thin, still extremely beautiful man's face broke into a dazzling smile.

 

 

EPILOGUE

I qualified in 1992. The day of my graduation I celebrated with my girls in Central London. That evening, walking from the pub to the Tube station, I passed a heavily pregnant young woman who was begging, and mindful of how she might use any money I put into her cup, I went and bought her a sandwich and a hot drink.

As she looked up at me, her pupils constricted, and I instantly recognized this emaciated, drawn young woman—it was Mo.

She didn't recognize me and wasn't impressed with my offerings: “Fuck off and go look after someone who wants you to.”

So I did. I got a position in drug-dependency services and for a few years worked with a dedicated team while also completing my doctorate on the treatment of stimulant misusers.

One of my first jobs as a newly qualified clinical psychologist was to set up support groups, and I ended up working with pregnant users like Mo, whom I thought about often. Indeed, it wasn't until some years later, talking to Chris—who became a dear friend and to this day has remained my professional mentor—that I realized I had started my professional life back at the beginning of my own journey, age fifteen in my grandmother's living room, when she had been killed by a pregnant drug user. By the time I had qualified and was treating addicts, I had come full circle.

I have now been a practitioner for nearly twenty-five years, and I have spent twelve of them thinking about this book.

I have read many books written by people working in the field of mental health in which they've described cases they've worked. One thing that has always struck me is that the spotlight tends to be on the people being treated, never also on those of us doing the treating.

For me, this approach appears to collude with the prevailing and dangerous belief that there are people who are “mad” and people who aren't. It also elevates the role of the mental health practitioner unduly—we appear to observe, assess, formulate and treat from some distant vantage point. I don't believe that it works like that.

In these pages, I have tried to capture my own journey, to show how the differences between patient and clinician are often slight, merely a matter of degrees. In the cases I have written about here, I have tried to convey the journey from chaos to clarity that psychological therapies can offer. And as I thought back to my younger self, someone I'm not always proud of, I realized that I too was managing my own journey from chaos to clarity as my training progressed.

I could be anxious, arrogant and naive. I often had no more depth of insight than the people I was meant to be treating. I now realize that the understanding, perception and certainty I was seeking at that time come only through practice, through immersion in the experience and through people letting you into their lives. I owe a huge debt to the people I worked with in my early years for providing me an opportunity to become a skilled practitioner and, perhaps, a better person.

Some of those who generously read drafts of this book were surprised by my willingness to disclose my own, at times massive, ineptitude. Some, especially my mother, were worried I would come out looking like someone who should never be allowed near any person with mental health difficulties: “Aren't you revealing too much of yourself, darling?” she asked me.

Ever since I understood that my grandmother's murderer was a woman struggling with her own psychological troubles, I've wanted to challenge the way we stereotype those with mental health difficulties. I am passionate about destigmatizing vulnerable people grappling with the weight of their own distress, the fear that they are unable to cope with life and the terror that perhaps they are losing their minds. Revealing my own doubts and inadequacies when trying to help anyone with a mental health problem feels like an important part of breaking down the false barriers we've constructed between the “well” and the “sick.”

After all, where does sanity end and insanity begin? Some of us are lucky to be able to manage the challenges of our lives or within our support networks and make them work for us. We define ourselves as “successful” as a result. Yet, others of us manage to cope by living in denial or by finding people who will let us project our “shit”—our baggage and our insecurities—onto them.

Nurture is fundamental. Some of us are born into lives and families where the protective factors outweigh the risk factors, so we develop a stronger sense of self-awareness and self-belief; we have a strengthened base of resilience and an ability to weather life's storms. But others who endure early lives of abuse and neglect are often set up to fail from the minute they arrive.

Nature also has a key role in the narrative of our lives. Some of us may inherit an underlying predisposition to mental health vulnerability. When the stresses and pressures of life become overwhelming, we can be tipped into really debilitating mental health difficulties, repeating a family history familiar in terms of stories about previous generations.

We understand these difficulties using narrative. Often the key part of the journey from chaos to clarity is telling the
story
. Stories give us a handle on how we feel and an ability to tolerate and accept those feelings.

I guess it's fair to say that the characters in this book are the most challenging in terms of their stories and journeys—journeys I felt, and still do to this day working in my field, enormously privileged to be part of. They imprinted themselves onto my heart and my mind.

However, please don't think the people I've described represent all those with mental health difficulties. Such difficulties exist on a spectrum of severity, a spectrum we all sit on.

I suppose I should now give this book a neat and tidy epilogue: What did I learn? What happened to those I worked with? I should let you know that they all got “better” and lived on in greater happiness. But the reality is that I can't. Unlike in physical health, where fundamentally there is a diagnosis and hopefully a cure, in mental health things are just not that clear-cut. In mental health we see patients getting better as being able to function with an improved quality of life—often this is a process that continues and completes long after treatment has ended.

We tend to say that, in general, a third of those we treat will get “better,” a third will stay the same and a third will get worse. We can't “cure” everyone, and this is not only because some cannot be “cured”—sometimes we just don't know how to. In fact, the term “cure” can be detrimental in our understanding of the best way to support those with mental health difficulties.

And of course there are people who just aren't ready or willing to be helped. There are those for whom their mental health difficulties are part of who they are and how they will continue to live. And sometimes there isn't an end to their stories because, however much we want to, as practitioners, we may not hear about them as they move on in their lives and we move on in ours.

Sometimes we meet patients we can see will have to fall—to deteriorate brutally—for us to be able to get in and help them; waiting and watching for that to happen is really tough.

What this means is that as practitioners we can become pretty hardened. The personal-professional boundary becomes nailed down, and we learn to cut off from the despair of not being able to help everybody. We learn to soldier on. This is one of the most crucial lessons I was forced to learn in my training years. With patients like Harold, even Ray and Mo, I had to acknowledge that there was little I could do to “fix” them and that my fantasies of rescuing them were just that—fantasies.

But acknowledging our limitations as therapists can also be dangerous. Many of us resort to gallows humor to brush away the horror of what we see or hear in our work—like the joke told after Imogen was released from her noose. Cynicism can become a useful defense mechanism.

Sometimes we struggle to engage with those we treat because we've been verbally or physically abused by them. Patients often lash out when they feel threatened and in distress, which leaves the therapist feeling the same anxiety. It is not rare for us therapists to identify the parts of ourselves that frighten or challenge us in our patients. It's difficult when we're forced to confront aspects of ourselves we'd prefer to ignore. So we make it the patients' issue, not ours, and hide behind the patient label, relishing the notion that it's them, not us.

In telling these stories, I didn't want to cause distress, but I do feel strongly that to get past a diagnosis, a label, we have to see the real human being who sits underneath and acknowledge how bloody sad that person's story can be. Edith and her sweet vulnerability; Imogen, the child with a secret so dark it is almost unbearable to contemplate; Tom, the wonderful man who was angry and dying. Real people, real lives.

I have also included the stories of people for whom it can be more difficult to summon immediate compassion. Martin and Elise, struggling with intimacy; the frustrated and controlling mother Daisy; Jess, the top-earning city girl shoving coke up her nose. These individuals came from privileged backgrounds, so it's easy to question their struggles. But a comfortable lifestyle often provides a mask of sanity for some very vulnerable people … It's something I see often.

Then there is Mo and her DDU cohort, and young Paul, the former dweller of the stained sleeping bag—what do we do with our feelings about them? In my experience, as a society we tend to discard these people. Angry, aggressive kids; marauding, thieving drug users—why do they deserve our understanding and compassion? Surely all that does is condone and justify their antisocial behavior and stop them from getting on with “sorting themselves out”?

But I don't like being part of a society that feels comfortable with discarding people who do not express their vulnerability in a way that we can accept, understand and tolerate. We will reach out with compassionate arms to Imogen and Mollie as they withdraw and cower in the corners of their lives, but not to angry Mo and physically aggressive Paul. They challenge us, frighten us, take from us and, yes, sometimes harm us.

And then there is Ray. What do we do about people like him—those perhaps considered to have a “personality disorder,” occasionally considered by default as untreatable? Do we lock them up in case they do something antisocial because they have no empathy or understanding for the needs of others? Or do we respect their civil liberties and let them live their lives?

Listen, just to be clear, if I had ever met the woman who smashed my grandmother's head open, I can't say for sure that I wouldn't have had a strong urge to take a poker to her. But my grandmother's murderer was a damaged, vulnerable woman, something I try hard to remember.

In the twenty-five years since I began my training, I've learned that there are no easy answers to these questions. I often find myself conflicted, split between my cool professional head and my more visceral emotional response based on my experiences as a mother and granddaughter. It is all extremely complex; there are no neat answers.

What I do know is that the mental health profession—even society at large—has made great strides in the way we view and treat those we consider mentally ill. But we have not reached the place of destigmatization and compassion I long for. Marion's, June's and Frank's stories show how our segregation and marginalization of people considered mentally or morally deficient at an earlier time in history hasn't really changed. We no longer take a day-trip to the asylum as an entertaining outing, but we still enjoy the voyeurism of staring at people in crisis, whether on callous TV programs where we can shout at them and tell them to “sort their lives out” or in our insatiable desire to read about people who are breaking down. And we rejoice most when the breakdown happens to someone who “had it all.”

Did June and Frank want to remain institutionalized because they would then continue to live in a place where they were accepted and appreciated for who they were, where they had an identity? For them, that was perhaps a better solution than moving into the community, a community that does not care.

Nothing has changed. We don't like mental illness. We don't want it in ourselves because it frightens us. We have no time or desire to engage with it in others except as something to gawp at and to define ourselves against. We expect people to be mentally ill in ways that are comfortable for us, or we discard and disown them. We buy into a model of health that requires mental illness to be cured within prescribed time frames and narrow parameters.