A few weeks ago, I saw a GP for an urgent re-referral back to Consultant care. I was embarrassed by my plight. “I just feel like these unseen, malevolent forces are trying to thwart me at every turn,” I told her, crying at the thought of it. “I mean, obviously I know that’s not true. But I believe it is. And I feel like I’m going into crisis and I’m scared.”
“Don’t worry,” she said. ”I’m going make an urgent re-referral back to the community mental health team and I’m going to make sure that happens today. I’m here until four o’clock, so if you’re struggling this afternoon, come straight back, OK?” She reached over and put her hand on my arm. “And you’re very self-aware, so you’re going to be OK.”
Ah, my old friend self-awareness. I distinctly remember the first time I realised that knowing how much pain I was in would make professionals take that pain less seriously. I was 25 years old and acutely depressed, mother to a tantrum-prone two year old and a newborn baby with colic. My GP threw antidepressant after antidepressant at the problem with no success, and asked the Health Visitor to drop round. She asked how I was feeling, so I told her the truth: like the world’s worst mum. “Oh, you’re not!” she said, looking horrified, “you’re a lovely mum! But I think we’d better just do this Edinburgh Postnatal Depression Scale.”
As you are pregnant, the form began, or have recently had a baby, we would like to know how you are feeling. Thank God somebody did. I looked down the list. Had I been able to laugh and “see the funny side of things?” Well, you see, I really wasn’t sure what funny side it was I was meant to see, trapped in a house with two completely dependent children I felt incapable of caring for. Had things been getting on top of me? I ticked the box marked, “Most of the time I haven’t been able to cope at all.” Yes, I’d had difficulty sleeping. Yes, I was miserable and crying most of the time. I paused at the last question, but carried on regardless. Yes, the thought of harming myself had occurred to me “quite often.” I handed the form back and the Health Visitor totted up my answers. “Hmm,” she frowned, rechecking the score, “you’ve come out very high. But I think that’s just because you’re so self-aware.”
I totally get that from a medical perspective, the person who is depressed (or manic or delusional or whatever) but has insight into their condition is easier to treat. It is going to be much simpler to get them on board with a treatment plan, reducing the risk that coerced treatment will be needed. From my perspective, however, knowing exactly what is happening me does nothing to reduce my distress. In fact, having to accept that I am ill again and knowing what is likely to happen next can be terrifying. Have you ever had an experience such as falling over in the street or being involved in a vehicle collision? You know that sense that time suddenly runs very slowly, that you can see precisely what is going to happen? Do you have awareness of the situation? Yes. Can you control the outcome? No. Knowledge is not power, not if it’s without control.
My self-awareness may be a comfort to my care team. For me, it means there multiple layers to my distress. There’s the primary pain, the fear of paranoia or despair of depression, or the desperation of mixed mood. Overlaying that is the knowledge that things may be about to get a whole lot more distressing, because no matter how hard I try and manage my condition, by the time I get to this stage things can only get worse before they can get better. And on top of that is the shame and the embarrassment, shame that I have “let” things get this far, the indignity of the contents of my thoughts and beliefs, embarrassment that I proudly “called” recovery a few months ago and yet here I am, back at the CMHT.
Having marvellous insight is no comfort if the self you’re aware of is not the self you want to be. Very rarely have any of the professionals I have worked with noted that it must, in fact, be scary to realise your mind is yet again being hijacked by your illness. I am aware, as I type this, that I am hypomanic. I am aware too that there are lots of things I can try to counter this. Yet I am also aware that sometimes I do everything right, and things still go wrong, and that next week I could end up back in front of that same GP with the same kind of issues, having my self-awareness praised.