Hidden from view
Private Practice, Summer 2016

At the tail end of 2015 my brother died alone in an apartment in Costa Rica. He had a number of longstanding health issues – obesity, type 2 diabetes, high blood pressure, chronic obstructive pulmonary disease – and it appears that these conditions finally overwhelmed him. Two years earlier, a much loved cousin was horribly killed by a young man who was propelled by powerful voices – one of the hallmarks of paranoid schizophrenia – to attack a complete stranger. Mental illness was clearly the cause of my cousin’s tragic death, but it was also, more covertly, a huge contributor to my brother’s early death; in both cases a life ended because the impact of serious mental illness was not effectively identified and managed.

While it was a simple matter to identify my cousin’s killer and understand the direct and disastrous consequences of his illness, the link between my brother’s death and mental illness has been utterly obscured. Throughout my brother’s life he was repeatedly failed by a community that either couldn’t see or took no interest in the mental illnesses from which both our parents were suffering. Our father struggled all his life from an intense and often frightening emotional turbulence, which was usually ascribed to a deep conflict about his transgender identity. And while our father battled with himself, our mother sank into depression and a dependence on alcohol and cigarettes that eventually destroyed her health and led to a painful death from cancer.

For most of our young lives we were unware of these realities – it was the 1970s and people experiencing gender dysphoria were still often admonished to ‘get over it’. Our childhood and adolescence were punctuated by fierce emotional eruptions and periodic abandonments by our father, which left us bewildered, angry and scared. After one particularly violent outburst, our mother finally revealed the truth about our father’s painful self-loathing. Astonishingly, we were told not to talk about it, not to tell anyone, and no help or support for us was suggested or occurred. During this time, our father had regular visits with a psychiatrist, and our family GP was also made aware of his situation. Still, no one in the medical community reached out to help us, and both her doctor and friends apparently ignored our mother’s gradual descent into depression, dependency and ill health.

Lack of support and understanding

My parents both suffered terrible mental anguish, exacerbated by a society that failed to intervene, support or empathise. I want to be clear that I’m not suggesting that gender dysphoria is a form of mental illness. My father’s mental illness developed because of his difficulty integrating and accepting a truth about himself that was then neither condoned nor understood. Throughout his life he punished himself relentlessly, as do so many in his situation, for what he had been raised to believe was weakness, perversion and, at worst, madness. He left school early and talked his way into the army, where he welcomed the strict discipline and macho culture as an antidote to what he saw as his shameful affliction. He married my mother in 1942, and they tried for several years to follow the advice he had been given to just get on with being a man.

It didn’t work. Increasingly tormented by having to deny a fundamental truth about himself, my father became more volatile and temperamentally explosive. The effort of maintaining the deception was draining him of energy and making him paranoid and cruel. My mother quietly began to drink, consuming larger and larger quantities of alcohol, so that by early evening her words began to slur. If anyone noticed, they didn’t intervene. My brother and I learned to stay out of our father’s way and to put out the cigarettes our mother absentmindedly left smouldering in ashtrays. We colluded intuitively in accepting that the mugs left on tables and kitchen counters were full of coffee. We had not yet lived long enough to know that her quiet, withdrawn, defeated air was a symptom of anything; she was just our mother. We were fed, clothed and sent to school, but our exhausted mother struggled to manage the demands that children can make, and her remoteness gave rise to terrible anxiety. (For a thorough discussion of the impact of emotionally unavailable mothers, see Jasmin Lee Cori’s The Emotionally Absent Mother.¹) I developed a school phobia. My brother sucked his thumb into his teenage years. Our family became increasingly isolated. Friends rarely came over. There were never shared holidays. Eventually, in a final bid to escape himself, my father took a job overseas and we left for a new life where we knew no one.

The effects of chronic stress

By now we were teenagers, and the conflicts escalated as my brother and I fought back against the bewildering atmosphere of repressed shame, anger and condemnation. When my brother grew his hair to emulate the popular rock musicians of the day, our father’s rage was hideous. He flung pots and pans, shouted abuse and stormed out. Our mother shrank into the stunned vacuum he left behind and developed the suppurating sores common in pustular psoriasis – a condition now often associated with immune dysfunction brought on by acute and chronic stress.^2,3 She smoked more, drank more and talked less and less, spending hours staring into the middle distance. I would often find her at the kitchen table with a glass and a packet of cigarettes, just sitting. I used to berate her for abandoning novels, or chastise her for skipping to the end. It’s awful now to contemplate how dulled her interest in life had become.

I had always been a good student, but while my grades slipped only imperceptibly, I had no interest in the subjects I studied; it’s hard to be excited and passionate when your energy is drained away by anxiety and fear. We know now that chronic stress elevates levels of cortisol which can interfere with cognitive function, specifically undermining our capacity to create memories and therefore to learn.⁴ As I struggled to stay engaged, my brother slipped away from school to work in bars, trading the suffocating and claustrophobic reality of our home, for the dark, insalubrious caverns of nightclubs. I soon followed, retreating to my room and to the temporary distractions of fiction. No one pursued us as we both increasingly withdrew, and as a result of our family’s chronic isolation, there were no extended family or friends to fall back on. My brother started to drink, overeat and take recreational drugs. He began what would become a lifelong pattern of intense relationships, searching desperately for a partner who could find something in him to value and cherish. He became increasingly unable to tolerate the occasional periods when the love and support he craved was inadequately returned, and would retreat into bitterness and despair.

My own teenage withdrawal from life finally roused my mother from her depression, and I was seen by an austere and authoritarian psychiatrist who told me I was struggling to accept that I wasn’t special. He showed no interest in why this might be the case, or what my life was like. He was uninterested in my faltering attempts to talk about my parents, and at that time I had little awareness of how increasingly unreal our home life had become. My father had been removed from his job at the university and was at home on antipsychotics, and yet I was left with the feeling that my difficulties were due to my being a difficult, self-absorbed adolescent.

Shame and self-loathing

This feeling of being the one who is flawed, of terrible shame at an inability to thrive, learn and develop, is a frequent concomitant of early trauma.⁵ There is a constant struggle to maintain the fiction of having value and worth. Again, there is a terrible sense of isolation in this. To the outside world the individual may be highly regarded by colleagues, appear accomplished and confident, and enjoy the companionship of good friends. My own friends think highly of me. I’m valued by many work colleagues, and my two sons return my love and devotion (albeit through the prickly thicket of late adolescence), and yet my own internal experience is jarringly different. I have had to work painfully hard to overcome powerful feelings of self-loathing and shame. It can be hard for others to make sense of this: how can appearances be so deceptive?

A recent tragedy provides an apt visual metaphor: a building in Taiwan mysteriously collapsed during an earthquake, even though neighbouring buildings, similarly shaken, survived. During efforts to find survivors in the rubble, rescue crews discovered that the foundations of the building had been weakened due to the use of tin cans as fillers.⁶ Once the building was completed, no one could see the tin cans or guess at the vulnerability of the foundations that the earthquake so tragically revealed. Sue Gerhardt describes this phenomenon in her book Why Love Matters: ‘There is an inner, invisible handicap which operates at both psychological and physiological level. In the past, this has been understood in terms of character flaws or genetic make-up, but we now have to take seriously the substantial contribution made by early experiences.’⁷

The importance of early intervention

The mental illness with which my parents struggled in isolation had a profoundly destabilising effect on my brother and me. It contributed to his early death at 58 after a life of frantic and often desperate consumption, and drained me of energy in young adulthood that I might well have used in more personally and socially constructive pursuits. But the real tragedy is that the outcome could have been so different had there been some support and timely intervention from our community.

In recent years we have been repeatedly advised to be alert to the possibility that members of our community may be radicalised by jihadist organisations.⁸ We’re told how early intervention can halt the radicalisation process, thereby avoiding potential danger to the community and rescuing the individual from the clutches of a ghastly and inhumane ideology. And yet the reality is that far more people are threatened daily by the awful impact of untreated mental illness. Where are the constant admonitions to look for the signs of people struggling to free themselves from the grip of mental illness? Why aren’t we told to intervene early so that untreated mental illness doesn’t destabilise a family or a community? We praise the bold, courageous individuals who challenge potential terrorists, but we’re all still too timid to risk enquiring about the wellbeing of those around us, in case we are thought rude and interfering. Is it possible that our scrupulous regard for personal privacy hides an unwillingness to bother ourselves with a problem that doesn’t require heroic gestures, just ordinary interest and concern? For example, the recent inquiry led by Dame Janet Smith unearthed a culture at the BBC of ‘a reluctance to rock the boat’ and a ‘culture of not complaining or of raising concerns’.⁹

Demonising the weak

And perhaps most devastating of all, there are still those among us (and they appear in these troubling times to be on the increase) who manage their own fears, anxieties and anger by demonising the weak and vulnerable. Look at politics: ideological splits are on the increase all over Europe and in the US. The political right, driven by the electorate’s anger,¹⁰ chooses to blame and shame: according to Donald Trump, the US can only be great again if it builds walls, reverts to torture, arms its citizens and ‘bombs the hell’ out of its ‘enemies’.¹¹

This need to hate what offends us, to destroy it or shame it, permeates our lives. All around us we see evidence of people being shut out, pushed away, rejected and blamed. When we encounter the weak and the vulnerable, it takes strength and resilience to understand that we don’t need to destroy them in order to safeguard ourselves. If our self-esteem and psychological wellbeing rest on a need to eradicate, shun or ostracise those who cause us discomfort, or even distress, then we will create a society of intolerance, rigidity and fear. Learning to tolerate the anxiety that others cause us, seeking to understand rather than reject and demonise, is what makes us civilised and humane. If more of us could do this then we truly would be a stronger, more resilient society, where those who are sometimes weak and vulnerable are helped and supported rather than blamed, shamed and shunned.

In recent months a report on the parlous state of mental health services in the UK was published.¹² The report is alarming, indicating as it does that more and more people suffering from a variety of mental illnesses are going untreated. More and more people are taking their own lives; waiting times are longer than ever; appointments are cancelled due to lack of staff. The report is a sobering read. But we can all do something positive about it. We can develop the capacity to care about our neighbours, colleagues, friends and acquaintances. We can show an interest in their wellbeing, notice when they seem tired, stressed, anxious, irritable or absent. We can’t change the difficult circumstances that some people experience, but we can offer compassion and kindness. We can ensure that suffering doesn’t have to be borne alone, and that we no longer blame the vulnerable for their distress.

Ellen Bow is a pseudonym.

Ellen Bow is a psychodynamic counsellor and registered member of BACP. She works in both private practice and as a volunteer counsellor for a charity that provides free, open-ended counselling for teens and young adults. Her name has been changed to protect her ongoing client work. In a previous life she was a magistrate, reference librarian, literacy support assistant and editor.

References

1. Lee Cori J. The emotionally absent mother: a guide to self-healing and getting the love you missed. New York, NY: The Experiment; 2010.
2. Gaston L et al. Psoriasis and stress: a prospective study. Journal of American Academy of Dermatology 1987; 17(1): 82–86.
3. Darian L, Corfield D. Why do people get ill?: exploring the mind-body connection. London: Hamish Hamilton; 2007.
4. Suor JH, Sturge-Apple ML, Davies PT, Cicchetti D, Manning LG. Tracing differential pathways of risk: associations among family adversity, cortisol, and cognitive functioning in childhood. Child Development 2015; 86(4): 1142–1158.
5. Cozolino L. The neuroscience of psychotherapy: healing the social brain (2nd edition). London: WW Norton; 2010.
6. BBC News. Taiwan earthquake: felled building used ‘tin can fillers’. BBC News 2016; 8 February. [Online.] http://www.bbc.co.uk/news/world-asia-35515749 (accessed 25 February 2016).
7. Gerhardt S. Why love matters: how affection shapes a baby’s brain. London: Routledge; 2004.
8. Weale S. Nursery staff urged to look for signs of radicalisation. The Guardian 2016; 5 January. [Online.] http://www.theguardian.com/uk-news/2016/jan/05/nursery-staff-radicalisation-children-parents (accessed 23 February 2016).
9. Smith Dame J. The Dame Janet Smith review: opening statement of Dame Janet Smith. 25 February 2016. [Online.] http://www.damejanetsmithreview.com/wp-content/uploads/2016/02/Opening-Statement-of-Dame-Janet-Smith-25.02.16.pdf (accessed 27 February 2016).
10. Allen N, Sherlock R. Why is America so angry? The Telegraph 2016; 10 February. [Online.] http://www.telegraph.co.uk/news/worldnews/uselection/12147570/America-Barack-Obama-Donald-Trump-Why-is-Americaso-angry.html (accessed 25 February 2016).
11. Pilkington E. Donald Trump: ban all Muslims entering US. The Guardian 2015; 8 December. [Online.] http://www.theguardian.com/us-news/2015/dec/07/donald-trump-ban-all-muslims-entering-us-san-bernardino-shooting (accessed 23 February 2016).
12. Boffey D. Leaked report reveals scale of crisis in England’s mental health services. The Guardian 2016; 13 February. [Online.] http://www.theguardian.com/society/2016/feb/13/mental-health-services-crisis-britain-revealedleaked-report?tm_source=esp&utm_medium=Email&utm_campaign=GU +Today+main+NEW+H&utm_term=156689&subid=13159165&CMP=EMCNE WEML6619I2 (accessed 18 April 2016).

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