How did I make that leap from them to us, or us to them? I was a patient, a not very active patient, but I had become part of that community. It was better than being part of nothing, and I was no longer working as a doctor, with no obvious prospect of returning. My options were limited.
To put it in context, I was a medical student by the age of seventeen and a doctor on the wards by twenty-two. I had always wanted to do psychiatry, but – and this is one of the hardest things for me to admit – I had failed my psychiatry attachment. I never knew why, and no-one ever explained; there was a possibility that there were some personal reasons around this, but I rejected that idea and decided that I was no good. So I trained in general practice without any problems, and was in my GP trainee year when it all went rather horribly wrong. I became pregnant, developed psychotic depression both before and after giving birth, and ended up an in-patient in the same unit where I had undertaken my ignominious medical student attachment. I had ECT, and took and untook various psychiatric drugs. For a while I was a revolving door patient, with a nasty This is Your Life feel to it. I thought I had a personality disorder; my doctors said not, but find me a person with a major mental illness who doesn’t develop resultant personality problems (especially when they have to stay in an in-patient unit), and I’ll be very surprised. Personality disorder should not be all or nothing – in my view, it would have been very useful to have acknowledged my less than helpful coping mechanisms and to have provided support for them. Denying things does not provide reassurance.
There was limited therapeutic optimism about my return to work, and I had a few aborted attempts, which reinforced this. However, after two and a half years I did recover sufficiently to get back. The jury is still out as to why – it could have been lithium, it could have been luck. But I applied for a junior hospital medical post and got it. No support, no phased return, full on-call. I can’t pretend it was fun, and I hope things are better now, although I don’t think this is always the case. I survived, and finished a further grim six months as a GP trainee – done! Except I didn’t really want to be a GP, and had a sneaking suspicion that no practice would take on such a risky financial proposition as me. I didn’t even bother applying.
I was sad, angry, devastated at what had happened to me. I suppose I’d reached an unanticipated personal rock bottom, and felt that I had nothing really to lose. This was the unlikely point at which I decided to cross over from patient to psychiatrist, or at least to try to. It wasn’t made particularly easy; my family was dubious (having seen psychiatry up close), and one of my treating psychiatrists advised against it. I applied for a local job, and wasn’t even short-listed. Rock bottom was starting to look as though there was a little more to scrape out. But I applied for a few more posts, all of which would involve commuting, and was offered a shorter contract than usual in one, and the normal length of contract in the other. I told both panels at interview about my illness; it won’t be a surprise that I took the second.
I don’t want to be too dramatic, but even I am surprised that I got through the next two years. I had a little child, I was working full-time (no other option), I was commuting an hour each way, and on the full on-call rota. I was also working for exams, and lost another pregnancy at twenty-two weeks, less than a year into the job. That was a terrible time. But I was stubborn and determined, and I didn’t want to fail. In many ways it would have been better – for everyone – if I had given up and done something else. It wouldn’t have been failure, but I couldn’t see it then. I am glad now that I got through, but I was too hard on myself, and on my family.
After this, life got a bit easier. I passed my exams, and was able to work part-time closer to home. This was a stroke of luck, involving a job-share. We each had to work six sessions so that we could attend the compulsory educational course, but were only paid for five – I am glad to say that that would not happen now. But at the time I would probably have worked for much less, as this closer job was in the hospital where I had been a patient, and I felt that I didn’t really deserve to work there, and that staff would think this too. I don’t know whether I was particularly over-sensitive, or whether others have also experienced this, and I would be very interested to hear. I have one particular memory of seeing a patient on a ward, who shouted – “she’s a doctor, but she used to be a patient, how’s that?” I had no idea what to say.
But I was lucky in the end, I have had great colleagues and friends, as well as family, and I have been able to become a psychiatrist. I felt shame, embarrassment, humiliation, but I stuck with it, didn’t avoid things, and it got easier. I don’t know what I would advise others – that it can be done, I suppose, but also that you don’t have to do it, and that it’s different for everyone.
A happy ending, perhaps, but it’s not been a one-way journey. My illness has continued, although I am fortunate that I am well between episodes. I live as a pendulum, suspended between patient and psychiatrist, moving one way and then the other. I still think it’s very hard to be both.
So given your enthusiasm for the diagnosis, are you now one of those doctors going round indiscriminately writing indelible PD labels on people, so they spend the rest of their lives struggling to get care?
No
that’s very good to hear
i am a bit concerned about what seems to be a belief that that everyone with SMI will have personality problems
i hope you’re aware that if you write that down, it can so easily develop, over time, via chinese whispers, into a full-blown personality disorder diagnosis
I share your concern. But I also worry about the stigmatisation of those who are given a diagnosis of personality disorder (however one views this). As someone who hasn’t been given this diagnosis I stick to the fact that mental illness has brought out unhelpful personality traits in me at times. And I am sad that the diagnosis of personality disorder can be so punitive and unhelpful
It needs to be both, not either/or IMO. We try and work out how to not treat people like shit who genuinely do fit well with PD criteria and benefit from the indicated treatment, and also stop indiscriminately diagnosing people for whom the diagnosis acts as nothing but a barrier to the treatment that would *actually* help, whether that’s drugs for their bipolar disorder, therapy for their psychological trauma or their social anxiety, adjustments for their ASD, help to escape the shit life situation they’re in that would make anybody superficially look like they have a mental health problem, and so on.
I think it’s very problematic to say “find me a person with a major mental illness who doesn’t develop resultant personality problems (especially when they have to stay in an in-patient unit), and I’ll be very surprised”, because characterising those difficulties as problems of *personality*
a) implies those problems are intrinsic to the person
b) suggests they’re longstanding, rather than situational and responsive; if you were to say they’re pre-existing and latent, and that the pressures of mental illness merely brought them to the surface, then unless you think that mentally ill people become ill *because* they have personality problems, that would lead me to think that if those traits are brought out in *all* mentally ill people, then they also likely exist in all humans, so it’s unreasonable to give them a label linked with pathology; and if the problems weren’t pre-existing but were instead caused by events or experiences that are part of having a mental illness, you’d have to remove the stimulus for the development of the problem (e.g. the illness itself, the abusive aspects of treatment, the stigma from staff and public), and provide help to come to terms with the experiences people have been through, before you could declare it’s changed their actual *personality*
c) implies there is pathology involved in those problems by linking them to an established category of mental illnesses.
Surely if you’re seeing these kinds of problems in *all* people with serious mental illness, you need to reconceptualise them not as “personality” issues, whether you construe that in the clinical or the nonclinical sense, and instead acknowledge these problems as an almost universal human response to these kinds of experiences, and include therapeutic input for this type of problem as standard for all those with SMI, without having to insinuate that there’s something wrong with their personalities.
By personality I mean behaviours that are not considered to be directly due to major mental illness. These are often attributed to personality by psychiatric staff, and not in a positive way.
But I do think that major mental illness is a significant trauma that has long term effects on personality, good and bad.
Thank you for engaging with me on this. It’s been interesting to hear your views.
Of course, any major illness is going to affect your personality, but the language of “personality” has an utterly different set of connotations when applied to a person with mental illness, as opposed to, say, someone with MS or cancer or arthritis. It would be, perhaps, more helpful to separate out “personality” as a concept, and instead discuss whether the person has developed suboptimal coping strategies, and ways is thinking about the world and themselves that might cause them problems.
“Personality” in the nonclinical sense is a nebulous concept, where self-perception is always different from that of others and where people disagree as to what parts of someone behaviour and thinking are attributable to it. “Personality” in the psychiatric context is a toxic set of heterogeneous ideas used to obfuscate, to discriminate, and to deny treatment.
If I were a psychiatrist who wanted the best for my patients I would do what I could to avoid using the word altogether, as the risk of harm to the patient from attaching the word “personality” to them in a psychiatric context is just too high.
*ways OF thinking
Thank you both.
I am trying to extract what your words might mean for me. I have been given a diagnosis of bipolar based on my behaviour over time. Behaviours are secondary to my feelings and thoughts. Surely all 3 define my personality to a large extent?
Behaviours can be seen and noted down but only I can know the feelings and thoughts in my head and can’t express these sufficiently coherently for others; psychiatrists or family/friends.
I tend to think of my issues as part of my personality, a different style of coping compared to others being an example. I don’t think I can “blame” all on bipolar. Friends say “that’s just the way you are”.
(One psychiatrist gave serious thought to a personality disorder saying “I don’t think so as you haven’t disrupted your career”.
My feeling now is that my personality is bound up too conveniently into a label of bipolar (convenient for others and recently convenient and helpful to me). Yet my personality is often unhelpful to my functioning. I have a problem with it even if it is not a “disorder”. It may be true “that is just the way you are”, but I have learnt that I can at least modify behaviours if not underlying feelings and thoughts with therapy.
Sorry, I know this doesn’t help you but you’ve both given me an opportunity for reflection.
Thank you
I take your point.
I feel, though, that sometimes “personality” is used as an excuse by psychiatrists to avoid having to work harder at treating the mental illness. Residual symptoms after treatment are often put down to “personality”, but for me, whenever my medication has actually been fully working I’m completely symptom-free. And it can be hard to persuade doctors of that; when I’m suffering symptoms I can tell them till I’m blue in the face that I need a medication review and they’ll still go for the easy option of saying it’s just personality.
Which is wrong. It’s a lazy option really, I agree
I think you’ve described really clearly some of what I’ve been thinking (perhaps not so clearly…). Thanks for this!
Hello Doctor Rebecca L. You are right, certainly it is not easy to be both. But the experience is priceless. The added advantage is that you are a doctor and you developed coping mechanisms, so during episodes, it is easier to treat a doctor than a random patient. You are tough. God bless you. Keep helping patients overcome mental challenges. Thank You
Were you ever worried that being around psychiatric patients or in a psychiatric hospital would trigger negative mental reactions within yourself? I have struggled with severe depression and anxiety in the past, and sometimes I worry that being around depressed clients might decrease my mood and spiral into depression myself. Did you find there was a clear mental and emotional barrier between your experiences and your clients?
Usually, I think so. It’s partly why I work in addiction psychiatry rather than general adult psychiatry. But sometimes I do see people who trigger something, or remind me of my own difficulties. I think the most important thing for me is to recognises this, and if necessary talk about it with a colleague. I think I’ve got better at it with age. The hospital itself has been an enormous trigger – I used to become very anxious coming near. But by not avoiding it, it has got much better.