Adapted from a Presentation to the Royal College of Physicians of Edinburgh

In mythology the moon relates not just to madness, but to love. And that’s very convenient from my perspective, because I strongly believe that a deficit of love is what causes so-called madness, and the cure for which, therefore, is love.

So that’s what this article is all about: love. Not romantic love, as is normally associated with the moon, but taking it right back to our most formative experience of love or loveless-ness – from our parents – from which of course all later love derives. And to make it relevant to psychiatry and medicine per se – I’m going to show how the care and treatment of doctors towards their patients may be perceived as a form of love – making up to a greater or lesser extent for that which was lacking in our childhood – and how we, as patients, in turn, project the love we need onto our doctors. I don’t think I’m alone in doing this. In fact, it’s so common it’s even got a name: transference, and there are whole theories around it. But in lay circles it’s not something we talk about openly or even acknowledge to ourselves much of the time because it makes us feel so vulnerable – arising as it does out of our most primitive need for attachment and belonging from day one of our existence.

I’m going to turn the focus on my own experience now, to illustrate; and I have to admit that I have a lot of shame and trepidation in sharing this with you because it’s something I’ve struggled with for so long and so I fear being judged. I also worry you will think I’m blaming my parents for something that is ultimately my responsibility to fix. Most parents do their very best for their children, and I believe mine did their best for me.  Being a parent is the most difficult job in the world so in locating a source of mental distress within family constellations, I want to be very clear that I’m not blaming or attacking parents.

Our patterns of relating to our young are to an extent inherited from generations that have come before – add the trauma of two world wars into the mix and you get an idea of the sort of thing that can adversely affect family dynamics. These patterns are very difficult to break so parents need support and understanding – not condemnation when things go wrong. The situation is resolvable. With insight and concerted effort, will and courage to name the hurt for what it is and learn from it, we can begin to heal and grow. That, I believe, should be the primary focus of psychiatry: to help us to identify the source of our malaise and find a way through it with understanding and compassion.

The deficit of secure love that I experienced from my parents as a child was always going to render me moonstruck by a surrogate attachment. At the tender age of 17, who should happen to appear in my magnetic field with the promise of fulfilment, but psychiatry, no less.…. Yes, you’ve guessed, I was smitten before I’d even plumped myself down on the couch! But I don’t want to be flippant about the impact of what psychiatrists have meant to me. The deep desire for them to fulfil the parenting I lacked and longed for in childhood – a guardian that was protective, loving and secure – provided untold healing when it was fulfilled, and at times of perceived rejection and abandonment, caused me devastating heartache.

Whilst for much of my 28 years as a mental health patient I did receive a good measure of loving care from psychiatry and its related professions, ultimately it betrayed its indifference when I tried in vain to connect with the last of my psychiatrists, which is why in May 2017, the day after my father’s funeral, I did the unthinkable and discharged myself for good. The timing could hardly have been more resonant: in both instances the death of a parent or surrogate parent that had rejected, neglected and, in my father’s case, abused me, then finally abandoned me without acknowledging the hurt or saying sorry.

In the absence of a psychiatrist or CPN, my GP and practice nurse have done a sterling job of dealing with the fallout, but I know it can’t have been easy; that I am not an easy patient to work with or like – because I get far too attached to people who are kind to me and swamp them with my neediness, which, quelle surprise, earned me the devastating diagnosis of Borderline Personality Disorder in the past – a label that has made me hate myself all the more for needing love.

Now I reject that diagnosis wholeheartedly and I wonder what was going on for the person who considered my perfectly normal and appropriate response to trauma, abuse and neglect as evidence of a defective personality. Why did he feel so threatened or repelled by me that he would condemn me to a life of stigma and misunderstanding after spending only five minutes in my company? How could he be so confident of his opinion, knowing it would damn me thereafter in the treatment of his colleagues? We met as human to human but his label left me feeling like an alien species, something to pathologise and wipe his hands clean of when he’d closed the door on me. Some days I feel angry that he thought so little of me; other days I curl into a ball and cry, convinced that he was right. I am nothing more than a disordered thing, unworthy of love or understanding, just as I was taught to feel as a child.

Human beings need love as much as oxygen or food. Without it we perish. It might be a desperate leap off a bridge or cliff – as I resorted to in the past – or a slow tortuous demise of isolation, loneliness and fear. We see this all around us; or, rather, it is there to see if only we would open our eyes to the suffering that most people prefer to call mental illness. So, I’m going to keep talking about love, even if it’s a bit embarrassing, because I believe it is what we all most need, whether we have a diagnosis or not, and if so, whatever that diagnosis may be.

Our consumerist crazy world indoctrinates us to believe that we can buy love or find it in a quick-fix pill, or any manner of addiction, obsession or distraction. But actually, we only find it in soul connection – which, sadly (for some of us), doesn’t come with a price tag. We need to work at it tirelessly throughout our lives because, for most of us, it’s an elusive thing. We struggle even to love ourselves – perhaps that’s the thing we struggle most of all to do.  

If we struggle to ‘find’ or love ourselves it’s probably because there was a deficit of secure love in our formative years; perhaps it was withheld, conditional, critical, dismissive or confusing; arrested through abandonment or trauma, or not appropriate to our needs. And so, as adults, we try to recreate the conditions in which we will be loved. I guess that was what I was doing all those years I was hanging around with psychiatry. I believe that’s true for most, if not all, of the patients I’ve ever come across. For some of us it’s more obvious than others, and because that makes us uncomfortable to be around, for fear we’ll swamp them with our need, we might end up with a pejorative punitive label like Borderline Personality Disorder. Everything we say or do is then used to justify the label, which makes us feel crazy, and we get caught up in circular patterns of relating to care-givers: simultaneously hating them, fearing them, idolizing and appeasing; desperate for their love and understanding. It’s like speaking foreign languages. Despite our best efforts to relate there’s a gulf of understanding that can’t be bridged until we take the time and care to learn each other’s language; or in other words, develop empathy.

When we are met with empathy and understanding, when we feel that someone really cares about us, the potential for healing is limitless. Love is a force more powerful than any other. It is, literally, what makes our worlds go around. And it’s what brings us back to a place of sanity and belonging. So, I’m going to honour that now by sharing some poems on aspects of what love has meant to me in the context of psychiatry. My first poem starts at the end of my treatment, expressing the hurt and abandonment I felt that drove me to discharge myself.


Closure

I’ve just buried my father
The last thing I need is a bureaucrat
asking me formulaic questions,
testing my patience with textbook expressions…
Sympathy masking indifference, boredom
Customary platitudes I’ve come to expect
Not a shred of authentic response to detect

He can see I’m upset, feeling misunderstood,
that I’ve disengaged – clear ingratitude
In a last-ditch attempt to appeal to the man
I ask him what he understands of my story
His answer reveals not a word has sunk in

Two years of his ‘care’ and I’m still a statistic
The trauma I’ve disclosed reduced to a tick list
I’m nothing but a multiple diagnosis,
a difficult patient whose transient psychosis
is typical of many on his caseload

Exasperated, he thinks to himself:
She’s angry with me, it’s her BPD
Unrealistic expectations of what I can offer
I’m being kind to her, what else can I do?
I’ve said I’ll see her again in a month.
It’s not my fault she’s taken the humph

Little does my psychiatrist know
I don’t expect him to be a superhero,
Just a human being without a mask
Is it really so much to ask
that he treats me as an individual,
takes the trouble to get to know me at all?

We go through the motions till the end of my stint
The saddest twenty minutes I’ve ever spent
I decide on the spot to discharge myself
My impromptu announcement has made his day
No half-hearted attempt to persuade me to stay
Glad you’re doing fine now and Take Good Care
The end of an era of laissez faire

But though I am hurt, it’s not fair to blame him
We’ve both been let down by a system
that prizes efficiency over love
And now my psychiatrist has nothing to give


Reverting now to the start of my treatment as an outpatient at CAMHS, or the Young People’s Unit, as it was then known… I was referred by a guidance teacher during my final year at school and started to see a psychiatrist there for weekly sessions, which, in a sense, blew my mind, because it was the first time I had ever really been listened to:

My First Psychiatrist

For Dr Fiona Forbes

Pretty, young and glamorous
with fiery hair and funky clothes,
a princess of Bohemia rolled out on a magic carpet
just for me

An hour each week to talk about myself!
Far-fetched as cherries on an acorn tree

I grew within those sessions from a girl into a woman,
left behind my school days, took up university –
a guise from going mad

Dr Forbes absorbed the pain within our sessions,
listened without question of my need to cry

We delved the caverns of my childhood,
twists and turns so perilous
with only my psychiatrist for oxygen
as traumas resurrected like the corpses of a horror film

Throughout the maelstrom of distress
she trudged the quagmire with me hand in hand,
sure-footed as a shepherdess who’d guide me home

The tinderbox she opened
like a cage of butterflies released into the wild

I look back on the child I was with tenderness and pity
as she taught me,
strip the layers of self-disgust to free the love within

My first psychiatrist,
such kindness in an adult I could not conceive
I loved her like a mother
Now I thank her for the gift of being the first one there for me

As is often the case when you open a can of worms, the contents spill out and take off in unwanted directions. It was not long before I descended the slippery slope of psychosis and despair – as countless members of my family had done before. Interestingly, familial prevalence is often taken to be evidence of genetic susceptibility to mental ‘illness’, but actually I think it is more sensibly understood as indicative of intergenerational trauma, dysfunctional patterns of relating and learnt adaptive strategies to stress – be they conscious behaviours or autonomous ‘symptoms’ such as flights of mania, depression, paranoia and hearing voices – as manifest in my relatives and in my own experience.

Suicide presented itself very early on in my childhood as a possible escape from this unbearable distress. My uncle - diagnosed with schizophrenia – killed himself by jumping out of a window when I was seven; and my mum, thought to be bipolar, made several attempts on her life as I was growing up, for which she was hospitalised and often ran away. My brother and several cousins also spent years in hospital, diagnosed with schizophrenia or bipolar – all of which perhaps made my own dual diagnoses of schizoaffective disorder and BPD too neatly justifiable. I wonder now if instead of asking people, or telling them, “What is wrong with you”, professionals might more helpfully concentrate on exploring “what has happened to you”.

The paediatrician, analyst and attachment theorist Donald Winnicott described the absence of secure love in our formative years as an experience of being ‘infinitely dropped’, to refer to the chasm that is left, which can never be fully repaired, though services, admittedly may do their best. Healing requires time as well as love, so, commensurate with the level of deficit or trauma, our journeys through the psychiatric system can be tortuous and long.

Unsurprisingly, I was to spend four years of my late teens and early twenties in hospital, with many more admissions over the next decade and beyond. I encountered both humane compassionate treatment at the hands of my custodians, and deplorable abuse, including violence, punishment and rape. All of which served to compound my childhood trauma and neglect, leaving me both angry, yet grateful for what scraps of kindness I was lucky to receive. As such, the kind compassionate treatment stands out in my mind, and that is what I would prefer to focus on. This next poem was written for my consultant psychiatrist in the Young People’s Unit, where my feral attempts to elicit and repel love were at their most extreme. The title is somewhat painfully resonant of what I needed him to be:

The Consultant Who Cared Like a Father

For Dr Robert Wrate

I liked you the moment I met you
So I told you to fuck off.
I shrugged my shoulders in defiance
when you asked me what was wrong

We skirted round the edges
till the boxing ring grew dull,
another way of saying
you had earned my trust by now

And then one day I tested you,
I threw my ‘T’-shirt off.
You gently gave it back to me,
turned your gaze away,
asked me please to put it on,
You understood my shame

Nothing I could say or do
would tempt you to mistreat me
so I banged my head against the wall
to make you understand
that I was nothing but an animal
to be abused by man

I ran away so often
from your fatherly protection;
threw the pills back in your face,
pissed upon your section

I never told you then
or in the years between
that your perseverance freed me
from the prison of my teens

Clearly this demonstrates how much attachments matter. As I’ve also suggested, our experience of the past is hugely relevant to the present. So-called ‘symptoms’ should never be seen in isolation but perhaps as threat responses to the pressures of our environment or the absence of love. We are also part of a wider community – subject to socio-economic pressures – such as rampant consumerism, increasing inequality and insecurity of income, which I believe are at the root of much of our malaise, and why the incidence of mental illness, or distress as I’d prefer to call it, is on the rise. In shooting for the moon have we outdone ourselves and landed with a crash back down to Earth?

The Government response is not to cure this ill with love, but to punish the poorest and most destitute – who are least to blame - with austerity, driving more and more of us to prison, homelessness, hospital, alcohol, obesity and drugs. The prominent physician and addictions expert, Gabor Mate, has likened our individualistic behaviourist approach to treating problematic attachments as akin to experiments with lab rats, whereby they are lured with sugar or deterred with electric shock towards a desirable goal – i.e. not making ‘choices’, as they are deemed to be, that disrupt the aims of the experimenter, or in our case, the established social order.
 
So, how should health and social services respond? I’d like to share with you this quote from Gabor Mate: “Healing is a highly subversive act in our culture. Whether in a medical or more direct psychotherapeutic sense, our work with people is about subverting their self-image as isolated, simply biological or simply psychological creatures, and helping them see the connections among their existence, the nature of the culture we live in, and the functioning of all of humanity. It’s about challenging the idea that someone’s value is dependent on how well they fit into an abnormal unhealthy culture” In other words, I would add: not reducing them to a diagnosis, but seeing their distress in context and treating it with understanding, kindness and compassion.

Labelling someone mentally ill may bring them comfort and seem to offer an explanation for the intensity of their suffering. But ultimately it diverts them and the clinician from the more helpful task of identifying the source of their pain and the means to make it better. It also further alienates them from the rest of humanity, thus compounding the problem, for the experience of mental distress and indeed its cause is one of profound alienation.

In terms of treatment, the first port of call for most of us experiencing a breakdown in our mental health, is not psychiatry, but General Practice. GPs play a vital role in looking after our mental health, and in my opinion, they don’t get enough thanks or recognition for doing a difficult, demanding job. Some of them go the extra mile, and this final poem is for the one who’s travelled furthest with me and made the biggest difference. Fittingly, Dr Calvert won the prestigious title of Doctor of the Year at the 2018 Scottish Health Awards for her legendary kindness to her patients at Bruntsfield Medical Practice in Edinburgh.

The Generous Practitioner

For Dr Caroline Calvert

The lovely things you say and do to show you really care
The tenderness I feel from you, a gift beyond compare
Instinctively, you understand the healing that I need
The bounds of expectation which you constantly exceed

By listening without prejudice, it’s clear you never judge
By giving extra time, you know I’d never ask too much
When darkness threatens to engulf, you shine a torch of hope
Make me feel courageous, give me strategies to cope

Attentiveness and gentleness, your voice such welcome balm
You help me find perspective, keep me measured, safe and calm
I look to you for guidance and you never fail to prove
That wisdom manifests in my capacity to soothe

Your timely counsel in response to problems I can’t solve
A reassuring word from you and all uncertainty dissolves
With every new appointment, I grow healthier than before
Discover strength within me which you urge me on to more

The life force you inspire in me, the deep respect and love
The gratitude I feel – no words can render it enough
The medicine you practice touches body, mind and soul
The doctor that you are – extending far beyond your role


So, there you have it – the essence of love in a therapeutic context: feeling held and being healed. That’s what makes the sun and moon to shine on us alike.

If you’re a practitioner, I hope my exploration of love and mental health has helped you reflect on how important it is to treat your clients with humanity and kindness. It may have made you rethink whether diagnosis has any place in the treatment of mental suffering. I certainly hope it will make you think again before giving someone who has been hurt enough already a label of personality disorder, which, to my mind, is the antithesis of love.

By Jo McFarlane

To accompany the exhibition
‘Moonstruck: 500 Years of Mental Health Treatment in Scotland’
Currently showing at the Royal College of Physicians in Edinburgh