Friday, 29 November 2013

Wounded healer? A qualification without ceremony


Do professionals always have to wear a mask?
Image: kurogami.com
I innocently posted an item on Twitter the other day about Marsha Linehan, one of the world’s best known clinical psychologists and the creator of Dialectical Behaviour Therapy (DBT). Linehan caused a stir a little over two years ago when she announced that she, like so many of the people she has tried to help, had suffered from the experiences labelled as 'borderline personality disorder' (BPD). Admittedly, Twitter is a volatile medium in which people say many things free of the restraints that a less anonymous conversation might impose. But, even so, I was unprepared for the vitriol with which my tweet was greeted.

Service-users responded immediately and their views were unequivocal.
'It only took her 30 years to come out!' complained one, while another said that surely she could have helped more if she had revealed her own history of mental illness sooner. An attack followed on the merits of DBT, created by Linehan with the aid of insights provided by her own struggle. 



Whatever you think of DBT, it’s clear that when a mental health professional 'comes out', it will not necessarily go down well. The issue provokes interesting questions. Why don't professionals with so called 'lived experience' of mental illness and other difficult or traumatising experiences make known their histories more often or more easily? What might make them 'come out' and why would they choose to do so after many years of silent practice?


Linehan apparently spilled the beans after a service-user had asked whether she was 'one of us'. Linehan it seems, was used to answering such questions. But something about that question on that particular day got to her, and she let her secret be known. Her confession included details of frequent and protracted hospitalisation as a young woman, a misdiagnosis of schizophrenia and multiple electroconvulsive treatments. It was a risky admission.

More recently, the CEO of one of our local partner NHS trusts, Lisa Rodrigues, chose to make public her history of bipolar mood swings. Her confession received broad applause from what we might call 'the mental health community'. Nonetheless it was not without its detractors. Some service-users predictably thought it too little, too late. Others, including professionals, pointed to the fact that her imminent retirement meant that now was a safe time for coming clean.

The reasons for concealment might seem obvious. Stigma is frightening, and nobody wishes to invite it. But it's a sad fact that mental health professionals stand accused of colluding with it. Stephen Hinshaw in his book, Breaking the Silence suggests there is a status differential between those who give and those who receive care. The result is a tendency for those in professional and scientific roles to hold to an ‘us versus them’ approach in which users and survivors have the one-down position. Many professionals hide behind a facade of invulnerability and those with histories thus remain ‘other’. The fact that any one of us can develop a mental health problem given the right circumstances, may get lost.

There are many traps the other way, though.  While there may be merit in making wounds explicit, referring to a label can be a tricky business. Using it may invite others, including fellow professionals, to view user/survivor professionals through a particular lens. Do people think you understand their pain better? Or will they confer insight on you that you might not have? Psychiatrists might take the view that the disease is in remission. Once labelled, always labelled and that’s it. Do you then have the strength and resilience to cope with the work you do? As well as unease in the professional world, it may sometimes be difficult to be taken seriously as a user-activist if you’ve enjoyed the privilege of recovery and professional training. Both professionals and service-users may attempt to position a dual status professional in ways that can be both unhelpful and unrealistic.

Some of the most difficult dilemmas may arise from within wounded healers themselves. For some, the gift of recovery exerts what is felt as a responsibility to help those in distress, while for others it is an attempt at making peace with the past. However noble such agendas may be, dual status professionals will need to pay attention to motivations that may lead to unhelpful pressures from either themselves or colleagues. Hinshaw suggests that many individuals who enter the mental health professions do so at least in part to examine their own (or their family’s) psychological issues, vulnerability and pain. The psychologist Jung, who suffered serious breakdown, believed that it was a healer's own wounds that made the curative therapeutic journey possible. Wounds, he maintained, potentially bore within them transformative and curative power. Indeed, some believe that a therapist cannot necessarily guide a client anywhere they haven't been themselves.

Of course, this is a complex issue. Those with a history do not necessarily have the wherewithal to be healers, nor are they always ready to contemplate the rigours of clinical practice. Those who bear their own wounds may be terrified of being seen as too vulnerable, and training schemes may be afraid to take on those who confess to significant histories. What if they become a liability? At times I've heard colleagues say that it's okay to confess to a history of mental health problems so long as you were never hospitalised. Ironically, this ludicrous logic reveals that many don’t have much faith in recovery, or indeed the healing power of their own methods. The result is that many of those who could be most valuable to services are either kept out, or kept quiet. The controversial clinical psychologist, Rufus May, confessed to a history of psychosis only once he had qualified. Other wounded healers believe they need to clock up considerable years of practice and a record of reliability before it is 'safe' to reveal their dual status. It is a travesty that those who potentially have the most to contribute are pressured into lives of subterfuge. Arguably, successful transformation of one's own wounds is the highest qualification of all.

Survivors and service-users know this, hence their feelings of betrayal when a wounded healer belatedly 'comes out'. Professionals know it too, despite their collusion with an us-them hierarchy. As a wounded healer myself, I believe aiding others is most potent when practised from a position of common humanity where all are regarded as fellow travellers on this difficult journey of life. This is no easy task, for it requires that we not only gain intimacy with our vulnerabilities, but ceaselessly and courageously confront them. It is the only standpoint that is genuinely authentic in a world in which suffering is inevitable. What we need is an honest appraisal of the issues, so that clinicians like Marsha Linehan and executives like Lisa Rodrigues needn't risk censure when they make known what might be of profound value.

As always we ask contributors to enter into discussions on the comments thread over the next few days. You can also follow Angela on Twitter @cyberwhispers.


9 comments:

  1. A therapist I saw when I was really struggling with some difficult issues, disclosed to me that he had also suffered from depression. It gave the interaction a very 'authentic' feel to it and enhanced my respect for him enormously. I've seen other therapists since, but the quality of relationship has never matched that first experience. When professionals hide behind a mask of invulnerability it's easy to end up feeling as if you're just another patient.

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  2. There are so many views about whether it is a good idea to self-disclose and it is useful to see them brought together in this thoughtful post. I would only add a couple of extra perspectives to the mix; I have been warned in training that self-disclosure should only be undertaken if it is conceivably a benefit to the SU. A MH prof may feel an urge to self-disclose but should ask whether it helps the person with whom they are working or puts them in the position of feeling like they have to listen to the woes of the very person *they* have come to disclose *to*. As this latter feeling is likely to be different in different people (some people may be very happy to hear a prof's self-disclosure; others may quickly feel fed-up) I would err on the side of caution. In short, it is generally better to spend the majority of the time listening to a person in psychotherapy and the minority of the time telling them about you.
    Another consideration is that MH diagnoses are generally applied to fairly heterogeneous groups. I would always want to question whether the diagnosis received by one person really picks out the same group of experiences as it does in another. There is undoubtedly some commonality of experience among people with the same diagnosis (if only because they have had the experience of receiving the same DSM label) but we should exercise caution in making assumptions about how far that stretches. At least some of Linehan's reticence could have been motivated by a desire to not seem to be trying to attain "guru" status and claiming to understand people with a BPD diagnosis more than one individual sensibly can. There is wisdom in letting her intervention speak for itself.

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    1. Interesting points. Feel that last sentence may be making it's way into some teaching quite soon! Thanks for the thoughts. John McGowan.

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  3. Linehan has never spoken out about that vile diagnosis and how people are abused in it's name by mental health services, as for DBT, it's behavioural dog training, I have zero respect for her.

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  4. Thanks for this piece, you have been very honouring of wounded healers. I have two points I would like to make, one about woundedness and one about the anger directed towards Marsha Linehan. I think the world is wounded by us, by our consumerism and our pollution and our unequal societies. I think because we are part of this world that wound is carried within all of us. If we look at it like this anyone helping others is a wounded healer. I wish in training to help others, in the West, we learned more about self awareness and looking after our emotions and needs. Then the lived experience of sadness and confusion would be something we would all talk about. There would be no need for coming out!

    I was thinking if Marsha Linehan had integrated her experiences into her work helping others earlier she may have promoted a more collaborative respectful approach to therapy. Many have found her Dialectical Behavioural Therapy helpful but many others have found it is very top-down, judgmental and controlling. I think that explains a lot of the vitriol. For example in many DBT groups you have to sign a contract not to form friendships with other group members. To me, this implies people cannot be trusted to choose their own friendships and it undermines community building possibilities. It is understandable to choose to keep quiet but like same sexual interest (homosexuality) it only became less judged when people became open about it. Perhaps someone should organise a wounded healers gathering open to all of course. I would support it : ) Rufus May

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  5. How could you be a healer if you weren't wounded? It's those who would claim not to be wounded that I would be much more worried about - empathy is the key to understanding the human condition and talking to someone who can connect with dark and difficult places is what we all need when troubled - it's simple: if you have a mind you have mental health issues Martin Seager

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  6. Angela Gilchrist2 December 2013 19:21

    Interesting comments so far, thank you to those who have contributed. There are a couple of points I would like to respond to. Firstly, the issue of disclosure in psychotherapy is a very tricky one and there are no hard and fast rules beyond the idea that disclosure (of any kind) should always be in a client's interests and not an indulgence on the part of a therapist. Perhaps what is being brought to bear though, is the idea of disclosure to colleagues and a profession. If this was not as difficult as it indeed is in the mental health professions, we would not be having this discussion. There is no suggestion here that people should be compelled to compromise their privacy or confidentiality around their own health issues if they don't wish to. There is a suggestion, though, that there should be more choice about this than is currently the case. The fact that personal histories are often concealed is a function of stigma more often than it is a function of confidentiality. If mental health histories were not stigmatised, there would indeed be nothing to disclose in the same way that gay people would not feel that they had to 'come out' about their status if there were real equality of sexual orientation. In the addictions/alcohol field it seems to be universally recognised that a history of addiction/alcoholism may be one of the best qualifications for the field. While a complex issue it is sad that there is no potential recognition of this in mental health work, even though we know that many of us are drawn to the helping professions as a result of our own wounds.

    Rufus, I agree with you that potentially we are all wounded healers. As we go through life we will all suffer 'woundedness' of various kinds, whether it be in the form of serious illness, bereavement, disability, the caring responsibilities we have towards others; and so on. All of these things will affect our practice in a myriad of ways and can potentially be used to assist us in understanding the pain of others.

    Indeed, it will be a great day when we merely refer to 'health' rather than 'mental health' and 'physical health'; just as it will be a great day when it is no longer a matter of any significant interest when a gay person, famous or otherwise, reveals the status of their sexuality. When this is the case, terms like 'coming out' and 'disclosure' may have no bearing on the issues we are currently discussing. I agree with the comment that 'anyone who has a mind will have mental health issues'. To that extent, we are all in the same boat as wounded healers.

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  7. For me - "healing" is about the desire to mend something and help it work better - I started mending things early with my toys, who got bandaged and splinted, one horse got an artificial leg so it could stand upright again. I don't think it is necessary to be "broken" in order to feel the need to "mend" something.

    Admitting to bipolar disorder has been a career damning move on my part, and has probably also meant that my book - MoodMapping has been taken less seriously than it might otherwise have been, at least by the establishment.

    However, if I had not been ill, I would almost certainly be a neurosurgeon, which is where I started, earning squillions and not having time to think about the important problems in medicine and mental health.

    People come to me largely because they know I have bipolar. We share experiences, which is great and we both learn from the experience - a Shamanistic model.

    People hate hypocrisy - not disclosing who you are. I didn't realise that Linehan had had mental health challenges. I can fully understand why she didn't disclose. Had she done so, it is doubtful that DBT would have been taken seriously.

    All credit to her that she has now revealed her past. There is stigma and prejudice out there, one way to succeed as a woman/black person/mental health patient is to be ten times better than the opposition. The alternative - since a level playing field is not easy to imagine, is affirmative action. Not sure I want that - personally I would rather win through against the odds rather than having standards lowered to let me in ;-)

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  8. Thanks for this post Angela. Really good stuff.

    As someone with prior experience of mental health difficulties now working as a clinical psychologist in the NHS, I can certainly relate to much of this. Too often you can feel that your past experience is judged by others (many of whom are often just ignorant) as being a hindrance rather than a strength - and yet, as a therapist, I find that my past experiences of being in distress, and being helped through that distress by other people, provide the cornerstone of my therapeutic work. Technique is important of course, but what ultimately underlies that technique? For most of us, it is our personal experience (in one way or another) and how we make use of it.

    It also takes time, I think, to develop the confidence to be true to your experience. Especially when you feel people want to put you in box in that often arbitrary, and false, dichotomy of either/or, professional or service user. Rates of disclosure of mental health problems are still far less common in mental health staff than in other occupations, including other health sectors, demonstrating that we still have some way to go here.

    There definitely needs to be more discussion around the role of personal experience in therapeutic work - both the experience of being someone in distress and the experiences of being helped to work through this distress - as well as how people manage their dual identities. I think this blog provides a good platform for these discussions, so thanks again Angela.

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