‘Mental health professionals have spent decades hiding behind a screen of hypocrisy’

Linda Gask is Emerita Professor of Primary Care Psychiatry at the University of Manchester. She is now retired and lives on Orkney. She has written extensively about her experience of seeing mental health from both sides, as a professional and as a patient. Annie Hickox met her.

In your recent book, Finding True North: The Healing Power of Place, you describe the important role that place or location, in the sense of being ‘home’, has had on your mental health and overall outlook. As an introduction, could you briefly describe the landscape of your early life? How do you feel that your childhood setting has influenced your views on depression and mental illness?

I was brought up in a working-class household in which my younger brother’s childhood onset of severe OCD profoundly affected our lives. My mother suffered chronic anxiety and my father, who died shortly after my qualification as a doctor, experienced periods of what I believe to have been depression. He was socially phobic… it went beyond shyness… he simply couldn’t go into shops even to buy clothes and shoes or into the library to choose his own books… but he never sought any treatment. He had a justifiably low opinion of mental health care given the quality of my brother’s treatment by services.

This background made me very aware of the impact of severe mental illness on family life. My brother was profoundly disabled. Yet he was treated by professionals as though he simply needed to try harder and discharged when he couldn’t. I came to recognise why helping people with common mental health problems, such as depression, anxiety, substance misuse, OCD and eating disorders in primary care, and fast and effective care, was so important. They can be as disabling as psychosis and destroy lives. Depression has seriously impacted my own life. However, over the last few decades my profession has retreated largely to working only with people with a diagnosis of psychosis. I’ve spent my professional life challenging this view of what psychiatry is about and reaching out to work with and support GPs.

Joan Didion once said, ‘we are well advised to keep on nodding terms with the people we used to be…’ When you look back, do you still feel a connection with your younger self, even though the trajectory of your career has taken you to such a different place?

Yes, I do. I’m well aware that my early life experiences enabled me to engage with my patients more effectively. However, each time I’ve embarked on therapy I’ve had to revisit aspects of my younger self, both to try and understand how my problems arose and to overcome them. This is true of both psychodynamic and cognitive behavioural therapy. My problematic ‘rules for living’ were adopted early in life and it can take a lifetime to overcome them.

You have talked about how your anxiety and depression developed initially in your teens and was perhaps accelerated by the major transition that going to university involves. Was this a particularly significant time for you as the first member of your family to attend university?

That was a very difficult time, with my brother’s illness and my teenage rebellion resulting in me feeling extruded by my family. I’d been close to my father, so felt his rejection painfully. I was desperate to get away and terrified of failure, so suffered severe examination anxiety. My mother seemed jealous of my opportunities rather than pleased for me. When I left home, I felt very much alone and heading into a new world I knew nothing about and with little support. It’s hardly surprising I had difficulty coping with my mood as a medical student.

The biopsychosocial approach to depression is the subject of a debate that shows no sign of dying down, but most mental health professionals agree that depression tends to arise as a combination of both vulnerability and stress factors. How would you describe the constellation of factors that led to depression in your own case?

My family history of mental health problems was certainly a vulnerability factor. Whether that’s genetic or environmental is a moot point, but I suspect it was both. Temperament is certainly heritable and important in predisposing us to depression. Both my parents were anxious, and I lacked secure attachments, leading me to marry young as I frantically sought support and validation. Stresses that triggered episodes of depression were almost always related to examinations and problems at work, on which I relied too much for my self-esteem. However, a major stress trigger was the sudden death of my father just after I qualified as a doctor which, given our complex relationship, led to a long period of abnormal grief with depression. My first long period of dynamic psychotherapy was central in helping me to overcome this and move forwards in life. Chronic physical illness – I was diagnosed with inherited kidney disease just after retirement – is now a risk for my mood.

In your book, you describe how shame and stigma about mental illness exist even among mental health professionals, both overtly and covertly. How did you experience this as a medical student, or later on in your career? What advice do you have for those who might be hesitant in opening up about their own mental health issues in the workplace?

The ‘hidden curriculum’ in medical education emphasises how difficult and stressful the job can be, and how being ‘strong’ and ‘tough’ is essential. It’s difficult to take time off when you know that your colleague will have to cover your work. However, I learned from my own experience and that of caring for other health professionals how important it is to seek help early before things get much worse, otherwise there is a risk of this interfering with your ability to practice. I wasn’t very good at hiding my difficulties from close colleagues, who were, on the whole, supportive, but there were a couple of instances when I was threatened with disciplinary action because of complaints about my ‘behaviour’ rather than this being understood as caused by stress impacting on my mental health. Find out who your friends and allies are and talk to them. Get help and support soon and don’t make key decisions about your future until you are completely well again. Remember that the ability to reveal vulnerability is actually a strength in our line of work.

The clinical psychologist, Kay Jamison has written in regard to her own concerns about writing about her experience of bipolar disorder: ‘whatever the consequences, they are bound to be better than continuing to be silent. I am tired of hiding, tired of the hypocrisy, tired of acting as though I have something to hide... I may be terrified to go forward but there is no question of going back’.

You have often been described as brave and courageous in your willingness to talk and write (both in your blog and your books) with such candour about your own lived experience. What are the risks of being so open, and what are the benefits? 

I didn’t publish until I had retired from clinical practice. That wasn’t because I didn’t want my patients to know I had experienced mental health problems – some did. It was to do with the very personal information about my life that I share in my writing which I didn’t feel should be public until I had finished work. I don’t feel particularly brave. It seemed to me that we as mental health professionals have spent decades hiding behind a screen of hypocrisy. Being experts who tell other people how to live their lives, yet failing to reveal how we often have so many of the same problems in living. This was very much the theme of my first book, The Other Side of Silence

I was well aware that many colleagues had problems too, but almost no-one was talking about it. That has changed and I hope I have contributed to that within my own profession at least. In Finding True North I continued with writing about the knowledge I gained from my clinical work, and my own depression, to explore how to go about recovering and what that really means. In academic life these days mental health is dominated by clinical trials, yet as someone who originally wanted to be a psychotherapist, I became more interested in qualitative work. Finding out how and why people became depressed and how to help them. I realised the value of my own implicit experience, and how that might have power to make a greater difference to people’s lives through writing.

In many ways, the love between you and your husband, John, is woven through the book and seems integral to your wellbeing. How does your depression affect your relationship, and how does your relationship affect your own emotional balance?

Finding True North has been described as a love story, and it is certainly as much about our relationship as my mental health. Both of us struggle at times with our mood and we have learned how important it is to spend time apart as well as together. However, my husband has provided immense support over more than 30 years. His view is that our relationship has survived because I’ve had good treatment for my depression – which is probably right too! Moods can be very destructive to relationships and it hasn’t always been easy, but I think his insight into the difference between me when I’m functioning and well, and when I’ve been despairing and depressed is crucial. We never stop talking to each other.

As a lifelong feminist, what relevance do you feel that feminism has within mental health services? What progress do you feel we still need to see?

I spent much of my professional life both treating women and latterly in an IAPT service, working with women. We have repeatedly failed to address the particular problems that women face. There is a lack of service provision for women who have experienced abuse and trauma and need longer periods of therapy. Instead, they are told they have Borderline Personality Disorder and may get discharged or ‘off-rolled’ from the case-lists of community mental health teams; young women who self-harm are still treated abominably in emergency departments when they seek help; we still have mixed in-patient wards; is it a coincidence that eating disorders services are so underfunded when there is a majority of women who suffer from them? Finally, there is more funding for maternal mental health, but there is so much more to do. We do have to begin to take women’s mental health seriously. The focus has been on men and their high suicide rates, but I do think it’s high time we thought about women too, many of whom are suffering at the hands of men. We need to listen to the stories that women are telling about the trauma they have experienced not only in the past, but now, in their interactions with health care. This might be feminism – but it’s also a question of social justice too. 

How does your writing affect your psychological state and how does your psychological state affect your writing? Is there ever a conflict between, say, writing and living/doing?

Writing helps me to make sense of the world and organise my own thoughts, but I need to be a good place to be able to concentrate. There is always a conflict between sitting down at my desk and getting on with life! Getting the balance right is difficult, and too much time at my desk isn’t good for my mood either. I try and schedule times when I’m going to work, stop for a break and drink tea, read (essential for writing) and get on with life. Sometimes my husband has to prompt me move into the ‘getting on with life’ part of that sentence.

On a final note, now that you appear to be genuinely ‘at home’ settled in Orkney, and still engaged with writing and work projects. How do you picture the landscape of your future, in terms of place, creativity and mental health?

Less frenetic, with more time to enjoy writing about what interests me, ponder the view from my desk, and observe the ever-changing weather.

-       Our interviewer, Dr Annie Hickox, is a Chartered Psychologist with over 35 years of clinical experience in the NHS and private practice. Find her on Twitter @dranniehickox  

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I always find these narratives fascinating. In particular, this one by Professor Gask could almost, with a few minor adjustments, have been written by myself. I, too, experienced very similar problems in childhood and also in going to university. Writing about experiences helps us to understand them and also helps other who may be going through similar situations. Although I appreciate that not everyone will want to read about practitioners who, themselves, suffer from mental health problems, such as my former tuor Dr Lindsay ("enough is enough", The Psychologist, letters, February 2017), I do think that they are very useful. Interestingly, I did indeed suffer from an ingrowing toenail whilst I was an undergrad, so I may be partly to blame! But, I digress. I recognise that value of using personal experiences to inform one's work. I don't need clinical trials and research data to tell me that my own experiences have made me a better therapist for my clients. The successful outcomes and the genuinely grateful responses from clients and their families, the fact that they recommend me, and will return to me for further therapy if needed, tells me that I must be doing a pretty good job. Empathy and genuine understanding are what clients appreciate in their practitioners, as in any profession. I wish Professor Gask well, and look forward to more interesting articles about mental health.