This Book Will Change Your Mind About Mental Health Read online

  It is for precisely this reason that this book will use the diagnosis of ‘schizophrenia’ as the landscape from which to explore broader notions of health, suffering and the whole curious absurdity of being human. This terrain is far from peaceful. The heartland is the bloody battleground upon which the fiercest ideological disputes about madness and its meanings are fought.*

  Believe me when I tell you that these disputes are fierce. Many of the issues we will cover in this book are also right at this moment being debated by leading mental health clinicians and academics, and if you happen to take a cursory look on social media to find these debates you won’t have to scroll for very long before you encounter what Mental Health Today calls a ‘bitter adversarial dynamic’.4 Curiously, a great deal of this acrimony exists between two professional guilds that work closely alongside each other and that many people assume are one and the same thing. I’m talking here about the distinct but related disciplines of psychiatry and psychology.

  The lexicon of mental healthcare involves a lot of these ‘psych’ words. It’s a prefix that occurs in this book 343 times.† These words will, at least at first glance, feel familiar to most readers. They’ve found their way into common parlance through popular culture. However, they’re often misused and confused. And that’s for the very good reason that they’re confusing.

  So let’s spend a moment getting to grips with a few of them.

  Psychology

  Psychology is the broadest of all the ‘psych’ words that appear in these pages. It is the scientific and social study of all aspects of our mental and behavioural lives. It’s a discipline of enormous scope and diversity (if you’re thinking or feeling it, psychology has a theory about it).

  Clinical psychology is one of many specialisms within this field and is the one that is most pertinent to us here. It focuses on understanding, preventing and treating mental distress and dysfunction – often framed as ‘mental illness’. Clinical psychologists must do an undergraduate degree in psychology and a further three-year postgraduate training at doctoral level.

  The main method of treatment employed by psychologists is called psychotherapy (yet another ‘psych-’ word). Sometimes we simply call this ‘talking therapy’. There are countless iterations of talking therapies, ranging from psychoanalysis, as developed by Sigmund Freud in the late 1800s, to the currently more fashionable mindfulness-based therapies and Cognitive Behavioural Therapy (CBT).

  Many of the professionals that we will hear from in this book are clinical psychologists.

  Psychiatry

  In contrast to psychology, psychiatry is a medical profession. Psychiatrists are medical doctors who do the usual five-year training at medical school before going on to specialise in mental health.

  They are similarly concerned with mental distress, though they often place a greater emphasis on biological causes and medical treatments. In other words, they frame mental illness – at least in part – as the consequence of chemical imbalances within the brain, which other chemicals might be used to redress. Psychiatrists (unlike clinical psychologists) will therefore frequently prescribe medication, although it’s important to add that many psychiatrists offer talking therapies too.

  In the UK, psychiatrists are also charged with making more decisions regarding the detention and enforced treatment of people under the Mental Health Act.

  In the NHS – and in most western healthcare systems – it is a biomedical approach, as most closely associated with psychiatry, that has become the dominant paradigm for conceptualising and treating serious mental distress.

  This has not always been the case. In our long history of trying to get to grips with human madness, different ideologies have enjoyed their moment in the sun. Go back far enough and we inevitably encounter demons and spirits (which still feature in some cultures, of course).

  Even as recently as the twentieth century, the newly conceived profession of psychiatry wasn’t overly concerned with biological mechanisms.‡ Or rather, after an initial and ultimately fruitless effort to find madness spelled out on the physical matter of the brain, it turned its attention instead to psychoanalysis, and for many years a person’s life history and childhood were deemed to be most significant when trying to understand and treat them.

  It was only in the decades after the Second World War, crucially coinciding with the invention of new medications and the publication of a now legendary classification system for mental disorders (more on these things later), that modern psychiatry nailed its colours to the mast as a truly medical discipline, in the sense that we understand the term today.

  Many people – including numerous psychiatrists, other health professionals and people who use psychiatric services – believe that this represents good progress and is a clear sign that we’re heading in the right direction.

  Many other people – including numerous psychiatrists, other health professionals and people who use psychiatric services – are profoundly critical of this, and fear we’re doing more harm than good.

  Psychosis

  Of all the ‘psych-’ words in this book, the one most loaded with popular misconceptions is psychosis. It’s an important one for us, not least because it’s generally considered to be a defining feature of so-called schizophrenia.

  I remember the first time that I encountered this word in a clinical setting.

  I was nineteen years old and was beginning my career in mental health as a health care assistant, providing short-term cover for wards with staff shortages. HCAs are often highly skilled and well-trained members of a hospital workforce. I was not. My interview for the job, such as it was, can’t have lasted more than ten minutes and was mostly concerned with my availability. My point is that I knew nothing. I remember arriving for my first shift. It was at a psychiatric hospital on the outskirts of Bristol, in the green and leafy grounds of an old Victorian workhouse and lunatic asylum. A crackly intercom on the locked front door instructed me to head to the nursing office. I hesitated. With all the usual anxieties that come with starting any new job there was something else in the mix. Until this point my only real experience of so-called serious mental illness had come from the stuff I’d discovered second-hand, from books, films, TV and the tabloid newspapers that my parents read throughout my childhood. My head was filled with preconceptions and misconceptions about mental institutions, asylums, madhouses and the kinds of people in them.

  I feverishly scribbled down notes as, one by one, nurses from the previous shift came into a cluttered office to hand over relevant details about the patients they’d been working with, and what needed to be done during the rest of the day. I’d never written the word ‘psychotic’ before. I wasn’t even sure how to spell it. But now I was writing it over and over. I didn’t know what it meant, but it came with a feeling attached – a physical feeling, a perceptible tightening in my chest.

  During that first shift, I spent most of my time sitting in a dreary smoking room, drinking tea with ‘psychotic people’, and wondering what I was meant to say. I remember meeting a woman who was recovering from a first episode of what may have been ‘bipolar disorder’ – she was getting better, but she was terribly shaken. She took a long drag of her cigarette and told me that before she came onto the ward she hadn’t known such places really existed.5

  Me neither, I thought.

  *

  Though not an especially precise term, at its broadest and most simplistic psychosis describes the phenomenon of a person losing contact with reality – or, at any rate, losing contact with what most other people perceive as reality.

  It’s not considered to be an illness or disease in and of itself, though it can certainly be symptomatic of disease. It’s a typical feature in most forms of dementia, for instance.

  Many of us will experience psychosis at some point in our lives; we may even actively pursue it. It’s the desired effect of numerous recreational drugs. If you try LSD and it doesn’t radically distort your experience of reality,
then I suggest you find a new dealer.

  Importantly, what we call psychosis can also be a response to extreme stress or trauma. As we’ll revisit later, for many people it might best be understood as a kind of psychological adaptation, a coping strategy gone awry or a form of storytelling carried out within the mind as a response to unbearably painful life events. Whatever its cause, psychosis is commonly experienced through hallucinations and delusions. Hallucination is the medical name given to false sensory experiences, such as hearing voices or seeing things that other people can’t. Delusions are usually false and bizarre beliefs that are held with conviction and are unresponsive to evidence proving them to be wrong. Amit’s belief that we were contaminating the water supply to his bedroom could be described as a delusion. It might also be described as an understandable response to what was happening to him.

  Most people who are diagnosed as having schizophrenia experience this kind of detachment from reality. Often – though not always – this is deeply distressing and can lead to strange behaviours as the person tries to navigate and survive in their altered, hostile world.

  *

  Psychosis may be a major feature of so-called schizophrenia, but it’s by no means the whole picture.

  Other symptoms can include: a disintegration in the process of thinking; disorganised speech; disorganised behaviour; flattened or incongruous emotional responses; impaired attention and significant social withdrawal.

  These are often sub-categorised (a little confusingly) into positive and negative symptoms. In this case positive doesn’t signify a symptom being beneficial or good, but rather that it’s an addition to a person’s consciousness. Hallucinations and delusions are therefore positive symptoms, whereas social withdrawal, avolition (a lack of motivation to accomplish purposeful, even pleasurable tasks) and poverty of speech are negative symptoms, as they each represent something that has been lost.

  In a popular TED talk, Professor Elyn Saks, an expert in mental health who herself lives with a schizophrenia diagnosis, asserts: ‘The schizophrenic mind is not split but shattered.’6 It’s also a surprisingly common phenomenon. A statistic bandied around for years is that worldwide it affects around one in every hundred people, though this distribution is far from even.7 The rates of psychotic disorders, including so-called schizophrenia, are higher in men than women. They are also higher in younger age groups, and in racial and ethnic minorities. And there’s huge variation, not only by person but by place. More on that later.

  *

  I mentioned that not long after I’d finished my training and began working as a registered mental health nurse, I also started to try to write a novel. There’s a nice Peter Cook quote that pretty much sums up my experience of this: ‘I met a man at a party. He said, “I’m writing a novel.” I said, “Oh really? Neither am I.”’

  Yet a mere nine years after I’d first sat in front of my computer to stare hopelessly at a blank page, my novel was – by some miracle – finished and on the shelves.§ A lot can happen in nine years. I’d left frontline nursing to work in mental health research at the University of Bristol. I’d also had a baby daughter, got married, and was wondering whether I should maybe try and write another book one day and if my own mental health would survive it. Then the emails arrived through the contact page of my shiny new author website.

  They were from people I’d never met but who had read my fictional account of a young man with ‘schizophrenia’ and had taken the time to reach out and share their own stories – true stories – sometimes because they were similar; sometimes because they were wholly different.

  And this conversation grew as I continued to meet more people through my work writing and speaking about mental health.

  Many of the stories told to me were upsetting, others hopeful. Rarely did they have the kind of neatly conceived beginning, middle and end that as a novelist I had the luxury to craft. A truth about the strange phenomenon we call mental illness is that it’s messy and chaotic; it can be extremely difficult to make sense of, but that doesn’t mean we shouldn’t try. There’s a fragility to the mental health of everyone. It serves us all to be part of the conversation.

  That’s what this book is: a part of the conversation.

  *

  I’d like to introduce you to some people that I’ve been fortunate enough to meet. I’m going to tell you their stories and after each story I’ll reflect a little on what it might teach us and what questions it raises.

  We will consider such topics as stigma (and why the current conversations around stigma could be missing the point); diagnosis (and why psychiatric diagnostics is on seriously shaky ground); the causes of ‘mental illness’ (and why nobody can say with absolute certainty what makes any given individual become ‘unwell’); delusions and hallucinations (and how these are a part of all of our lives, all of the time); and psychiatric medication (including the things that ‘patient information leaflets’ don’t tell us).

  In debates characterised by increasingly polarised positions, we’ll attempt the more revolutionary approach of trying to keep an open mind.

  In this way, I hope that we’ll untangle a few of the more pernicious myths and stereotypes that the very word ‘schizophrenia’ so stubbornly evokes, and also that we’ll arrive at some clarity about our own mental wellbeing and that of others.

  The Mad Hatter (the one from Batman, not Alice’s Adventures in Wonderland) once explained that trying to understand madness with logic is ‘not unlike searching for darkness with a torch’.8 Putting aside that he was an evil supervillain, and maybe not the best exemplar of mental health portrayals in fiction, he still had a point. The logic of scientific research – which will certainly form a part of this book – can only take us so far. There is another part of the thing we call ‘mental illness’ that will for ever exist beyond the reach of statistical analysis, probabilities and distribution curves, or the otherworldly pictures of neurochemical imaging.

  It is the person. It is their story.

  Sitting in that hospital smoking room during my first shift as a care assistant, I was too nervous to open my mouth. I had no idea what to say, which by chance meant I probably did the best thing. I listened. It’s not always possible to find the right words but we can still be part of the conversation. We can walk with people for a bit, sit with them, hear them.

  Notes

  1 For an interesting debate about what is the most appropriate collective noun to describe those of us who use mental health services, read: Christmas, David M. B., and Sweeney, Angela, ‘Service User, Patient, Survivor or Client … Has the Time Come to Return to “Patient”?’, British Journal of Psychiatry 209 (2016), 9–13.

  2 Filer, N., The Shock of the Fall (HarperCollins, 2013), 233.

  3 Goodwin, G. M., and Geddes, J. R., ‘What Is the Heartland of Psychiatry?’, British Journal of Psychiatry 191 (2007), 189–91.

  4 ‘Psychiatrists and Psychologists Pledge to End “Bitter” Adversarial Dynamic’, Mental Health Today, 27 November 2018. https://www.mentalhealthtoday.co.uk/news/mental-health-profession/psychiatrists-and-psychologists-pledges-to-end-bitter-adversarial-dynamic

  5 In describing my first day of working on a psychiatric ward I have quoted from my own BBC Radio 4 documentary, The Mind in the Media. https://www.bbc.co.uk/programmes/b08hl265

  6 Elyn Saks’s TED talk is ‘A Tale of Mental Illness – from the Inside’, www.ted.com/talks/elyn_saks_seeing_mental_illness/She also describes her experiences in extraordinarily vivid detail in her memoir, The Centre Cannot Hold (Hachette, 2007).

  7 For a heartbreakingly poetic take on the ‘one in a hundred’ statistic, read: Uninvited Guest by Jenny Robertson (Triangle, 1997).

  8 ‘Mimsy Were the Borogoves’, Detective Comics 1, no. 789 (2003).

  * I first read about schizophrenia being referred to as the heartland in The British Journal of Psychiatry. It’s an emotive, strangely territorial description. It’s not a phrase used today, but it remains apt to describe w
hat is a highly emotive and proprietorial debate.

  † To put that in perspective, it’s 340 times more often than Ant McPartlin and Declan Donnelly implored us to watch them ‘wreck the mic – psyche!’ in their 1994 debut studio album Psyche.

  ‡ Psychiatry was officially created in 1808 when the German physician Johann Christian Reil had the neat idea of joining together the Greek terms psyche, meaning ‘soul’ or ‘spirit’ (and so casting Ant and Dec’s later work into its truly philosophical context), and –iatry, meaning ‘medical treatment’.

  § So yes, needless to say, I found writing a novel really, really, really difficult and frequently responded to this by not writing it. This is a well-established technique for the first-time novelist and one that I wholeheartedly endorse.

  THE JOURNALIST

  The fugitive

  UPON BEING NAMED BRITAIN’S most wanted criminal, twenty-nine-year-old Molly went to her local supermarket, where she bought a bottle of bleach to drink.

  She stopped briefly to look at the rack of newspapers and her worst fears were confirmed. The Daily Mirror – a newspaper she had previously contributed articles to – had launched a hate campaign against her. The other papers each carried headlines and stories pertaining to her crimes. These included the false imprisonment and sexual assault of a friend she knew from her university days; her suspected role in the unsolved murder of a young man at a London squat party; and her involvement in a conspiracy to detonate a bomb in Canary Wharf shortly after 9/11. There were other crimes, too numerous for Molly to recall. Her double life was coming to an end. The police were closing in. Helicopters circled the night sky.