I recently came across an essay by Dr. Lauren Slater, a psychotherapist in the United States. The essay opens with the case notes from the file of a patient which, describes a woman named, “Ms. Whitcomb.” The case notes state that:

“Ms. Whitcomb has had over 30 hospitalizations for suicide and self-harming attempts” and notes that the patient “experienced extensive sexual abuse, as a child.” The notes describe a current eating disorder and relates high levels of conflict with care givers having “fired over 70 social workers, psychologists, and psychiatrists.“ Ms Whitcomb is diagnosed with Borderline Personality Disorder.

The essay goes on to describe Dr. Slater’s reluctant acceptance of this case which begins with a phone call to Ms Whitcomb. Dr. Slater called to introduce herself and set up an appointment to see her new patient. The conversation ends with Dr. Slater calling 911 because the client has thrown up blood after 30 induced vomits that day.

A couple of weeks later, Dr. Slater receives a call from the psychiatric hospital where Ms. Whitcomb had been admitted. Dr. Slater was invited to come to a discharge planning meeting for the client. Slater writes

“…I should have been prepared, for eventually past meets present; ghosts slither through all sealed spaces.”

Dr. Slater tries to get out of going to the hospital for the meeting but in the end cannot avoid it.

Dr. Slater reveals that she had been a patient in this same hospital, five times. She speaks about arriving at the hospital and looking into the faces of the nurses and Dr’s to see if she recognizes anyone and hopes that none recognize her. She describes a moment, when a nurse is leading her to the meeting area and a patient asks when her Dr is coming. The patient complains that her Dr. is  always late and then swears at the nurse. The nurse turns to Dr. Slater and says, “Borderline.”  Dr. Slater writes,

“I responded, ‘They’re exhausting patients, the ones with borderline personality.’ I pause, ‘But I prefer them to anti-socials,’ I add, and as I say these words I feel safe again, hidden behind my professional mask. I am back on balance, tossing jargon with the confidence of a brahmin in a village of untouchables.”

“There is a betrayal here, in what I do, but in betrayal I am finally camouflaged.”

Lauren Slater speaks about her fleeting temptations, in meetings with groups of professionals, to say, “Guess who you’re looking at; guess who this is. The Borderline!” But she never does.

Lauren Slater alludes to her own childhood trauma which involved her abuser, her mother, who suffered from BiPolar I (Depression with mania, or, highs and lows) eventually, committing Lauren to the psychiatric hospital. She describes her thoughts in the present, at the same hospital she was once a patient in, only 8 years earlier, as the team of mental health professionals brief her on her patient.

“…while part of me sits in the conference room…For I have learned how to soothe the hot spots, how to salve the soreness on my skin. I can do it so no one notices, can do it while I teach a class if I need to, or lead a seminar on psycho-diagnosis. I can do it while I talk to you in the evenest of tones. ‘Shhhh,’ I whisper to the hurting part, hidden here, You can call her borderline- call me borderline,—- or multiple, or heaped with post-traumatic stress- but strep away the language and you find something simple. You find me, part healthy as a horse and part still suffering, as we all are. What sets me apart from Kayla or Linda or my other patients like George, Marie, Pepsi— what stets me apart from these ‘sick’ ones is simply a learned ability to manage the blades of deep pain with a little bit of dexterity.” 

She looks around the room and writes, “I do believe that nearly every person sitting at this oval table now has the same warped impulses, the same scarlet id, as the wobbliest of borderlines, the most florid of psychotics. Only the muscles to hold things in check- to channel and funnel- are stronger.”

“I have not healed so much as learned to sit still….”

Lauren describes being given the keys to the meeting room she will use to meet alone with her client. “Keys are the symbols of freedom and power and finally separateness. For in a mental hospital, only one side has the keys’ the others go to meals with plastic forks in their fists.”

Dr. Slater meets her patient for the first time, “Linda.” Lauren says hello and then fumbles for the key to their room. Before she opens the door she turns to Linda:

“You, you take the key. You turn the lock.”

The patient is confused and looks at Lauren as if to say, “who are you anyway?” Lauren starts to tear up and says to her again, “You.” Lauren writes, “Surely she’s never seen one of her doctors cry. ‘It’s okay,’ I say, ‘I know what I’m doing.’ And for a reason I cannot quite articulate at the moment, I make no effort to hide the wetness. I look straight at her. At the same time, for the first time today, my voice feels genuinely confident. ‘Take the keys, Linda,’ I say, ‘ and open the door.”

The essay ends with this line,

“My patient and I sit down, look at each other. I see myself in her. I trust she sees herself in me. This is where we begin.”

Here is the link to the full essay,  “The Three Spheres, by Lauren Slater.”

Dr. Slater speaks about the conflicting messages given to therapists, psychologists and other mental health professionals about honesty: “Go into therapy, but don’t call yourself one of us, if you’re anything more than nicely neurotic.” This message is designed to keep the, ‘us versus them’ rift embedded in the practice.  She notes the language used in mental health assessments which keeps non-professionals from making sense of reports or case notes that they may get access to.  Instead of saying, “so mad he want’s to kill her” we say “homocidal ideation.” Instead of “today he’s thinking clearly and knows who, what and were he is,” we say “oriented to all three spheres.”

In my experience, patients who use the language of professionals, or seem to know too much about their illness, are seen as ‘suspect,’ as trying to ‘play the system.’

It’s as if we, the ‘professionals’ are threatened by anyone who would see themselves as possessing the carefully held knowledge that we possess.

in our society, we focus on specialization and expertise. We encourage people to pick one very narrowly defined area of study or practice, become experts at it, and then market their unique knowledge or skill. This is a primary aspect of capitalism and it works for many people. It is useful in areas such as brain surgery and rocket science. It is specialization which has allowed for great leaps in technology, knowledge and innovation. It allows individuals to follow their passions.

However, as we carry on specializing every area of life, we risk losing our own sense of agency in areas that should belong to us. Many find that they cannot access the knowledge they need, as it is held so tightly by a group of professionals who will not share. Issues around copyright laws which result in unaffordable life-saving drugs, is probably one of the worst examples of this.

In some areas of society, the de-professionalization  is being undertaken.

In the area of birth,

midwives have advocated a return to patient/woman led care and non-medical interventions, noting that birth is a natural process and not a medical emergency. (See The Medicalization of Birth and Midwifery as Resistance). Midwives acknowledge the role of medicine and it’s importance in reducing maternal and perinatal deaths but feel that medical intervention has become overused and can cause its own complications along with disempowering the mother.

In law,

lawyers have been arguing for laws to be written in plain English for centuries. The premise being that citizens should be able to understand the laws which govern them. See “Drafting in Plain English”  or Alan Siegels’ Ted Talk for more on this.

In Psychiatry…

In an earlier post called “Saving Normal” I spoke about Dr. Allen Francis, the psychiatrist who helped create the DSM IV (the book used by psychiatrists, doctors and mental health professionals, for diagnosing mental illness)  who argues that psychiatry has gone too far, calling normal human reactions to stress and life circumstances, illness. He spoke about  the role of pharmaceutical companies in promoting “cures” to these so-called illnesses.

Social work has gone the opposite direction, professionalizing the field in hopes of better pay, field recognition and claiming that licensing will protect the public from poor practice. Social workers have debated about the pros and cons of professionalization for many years.  Concerns were voiced, that registration would permit a select group of people to decide who is permitted to use the title of social worker. At the time of debate, the group who was being considered for this role of licensers, was made up, primarily, of white, middle class individuals. The population being served, often Indigenous or newcomer, were not represented. Fear that individuals who had practiced for years, often in remote communities, sometimes using more traditional, or Indigenous methods and not mainstream schooling, might be left out. Individual social workers feared that the divide between client and social worker would be increased as social work’s status increased to something other than helpers, whose main goal is to work themselves out of a job.

As a registered social worker, who has worked as counsellor and a mental health worker, I have often sat with individuals who are responding normally to extraordinary life circumstances and are in dire need of someone to talk with who can listen and is supportive. They do not have this in any realm of their lives. They look to me for understanding and a listening ear.

I do not I have the ‘corner market’ on listening and supporting others.

Many people tell me that they are worried about burdening anyone else with their problems. Often, after some questioning, they will note they are the ones whom their friends go to for help. Because they know their friends have problems, they don’t want to burden their friends with their own problems.

I think we have forgotten how friendships work. I come to you for help and then you come to me. In this way we are equals.

We are supporting each other. We are there for each other. In this way, we’ve got each others’ backs. It takes risk to do this, but what are friends for? We need to get better at trusting each other. Your friend, who is going through something, may actually feel an increased sense of agency when you come to them for help, for once. They no longer feel like they’re the only ones with issues. Obviously there will be some who can’t help, are too overwhelmed by their own lives, but let them decide this for themselves. Ask if it’s too much, and if so, find another friend. Check out What do Adults do for Fun? to ensure that you have enough people in your life to give to and take from that there is balance. This is how we will all get better.

As mental health professionals and therapists I think we do ourselves, and others, a disservice when we hold so tightly to our roles that we can’t see ourselves in others, and they can’t see themselves in us. We can all learn to be supportive, non-judgemental, to listen deeply. These are skills that everyone needs to better care for themselves and each other.

For more on Mental Illness see Mental Illness – A Relationship Story

For more psychiatry and diagnosis see Saving Normal

See also A Good Time to Panic

And Are the Kids Okay? – Children & Mental Health