It’s always tricky reviewing a book written by a friend, which is what I hope Linda would call me although we have only ever met online, so of course I come to this review admitting bias. If someone asks me to review a book I suspect will be bad I simply say no, as I would hate to have to tell someone that I think all their hard work has resulted in something that wasn’t very good. But I didn’t think twice in this case and reading The Other Side of Silence: a psychiatrist’s memoir of depression has been an honour and a pleasure. I’ll share my thoughts below but after that I want to try something a little different so I’ve set Linda some questions for a Q&A. Once I’ve hit publish the “floor” will of course be open for comments but I will be out of the country for the next week or two so I may be slow in responding.
Linda is a psychiatrist by training and spent years in the NHS, working her way up the ranks before moving into the academic world. She is now semi-retired, giving her more time to write (you can visit her blog here). The sub-title of her memoir explores what is so unusual about her situation – she has practiced psychiatry for most of her adult life despite suffering from severe depression. Research tells us that doctors have a high rate of depression and that many hide their suffering from colleagues, with staff in mental health teams particularly fearing the consequences of disclosure. It is clear that being a mental health service user and a psychiatrist has been a very tricky tightrope to have to walk on a daily basis.
The book weaves together Linda’s lived of depression, the ghosts from her past that have contributed to her condition, the treatments she has sought, her life as a clinician and the learning she has taken from patients. I hesitate to use the phrase “case studies” when referring to the patients described as that sounds too cold. Perhaps “stories” would be better, but in any event Linda has shared her experience with a number of patients, some of whom she saw decades ago, which are woven into her personal narrative. Patients with whom she felt out of her depth as a newly qualified doctor. Patients who taught her what it means to listen properly and carefully. Patients who took risks, opening up in the consulting room, sharing their stories of past abuse, inability to love, or unresolved grief. All reminders that doctors have as much to learn from patients as patients do from doctors. learning that Linda passes on to junior doctors bound for psychiatry or general practice.
I don’t really like it when people call my writing “brave”. I don’t know how Linda feels about the word but it is a brave piece of writing. Even in life writing many people consciously or unconsciously present a less flawed or less damaged version of themselves. To focus as much on therapy as Linda does in the book is to acknowledge being a work in progress, that no matter successful a person might appear they are very much human and very much fallible. Linda however goes further, turning over a some very heavy stones and examining what is underneath, things that were at the time (and perhaps still remain) a source of shame, difficult to admit even to a therapist. Linda continues to be very open online as @suzypuss) not only about her personal difficulties but about her use of antidepressants. quietly but firmly seeing off those who see psychotropic meds as a dangerous plot cooked up between Big Pharma and psychiatrists.
I won’t say too much more, because I would encourage you to head on over to Amazon to buy a copy to read yourself! But to give you more a few more reasons yo do so I’m going to put Linda on the spot by asking her about the aspects of the book I found most interesting.
Doctors can often appear quite impersonal to patients. Did you set out to make doctors appear more human, or was this just a side effect of sharing your own experiences?
I didn’t set out to do that. I tried to be honest about the kind of interactions I’ve had in my life, both with the doctors who treated me, and with my own patients. If that makes doctors appear more human, that’s good- because we are! However, not all doctors I know seem human (I’m pretty open about the fact that there are quite a few of my colleagues I would not wish to consult) and I suspect I’ve not always appeared that way to patients either. Appearing human without sharing too much of yourself inappropriately can be a difficult balance to achieve.
Quite early on in the book a colleague notes that you will be a good psychiatrist because you were the most sensitive person he had ever met. At the time you wondered whether you were sensitive or just thin-skinned. Is this a question you have ever resolved? And do you think now that sensitivity did play a part in having a career in psychiatry?
I think am both! Quite easily on I realised I was able to pick up on how people were feeling and that helped me in deciding to do psychiatry. However I am also thin-skinned. A thicker skin would have been helpful in my career- and I might have lasted longer in it, and been more successful as an academic and manager. But I’ve come to terms with who I am.
You make it clear in the book that you consider depression to have complex origins including biological vulnerability and particularly unresolved grief and loss, themes that run through the book. Could you say a little more for readers about how depression differs from a normal grieving process?
Grief is a normal human process we all go through when we experience loss. Feeling low and depressed is a normal part of that – but it usually resolves over time. We cry, desperately miss the dead person, and feel unable to do much other than think about the person we have lost and what has happened. There is no rule about how long this last before we begin to take up our lives again and don’t let anyone tell you “you should be over it by now.” Crucially it just gradually feels a little easier as time passes. If grief however is complicated the process can get stuck. You begin to feel worse, have ideas about suicide, wanting to join the dead person. This then becomes very hard to distinguish from depression – and is usually treated in a similar way. Grief can get complicated if you have had a difficult relationship with the dead person, like I did with my father, or, for example, if it was a sudden or really traumatic death or the person was never found.
If you are vulnerable to depression – for example if you’ve had it before or have a family history, the loss alone can also result in a relapse of your depression. The depression associated with grief resolves as you move through the process of grieving. A person who develops depression experiences more persistent low mood, sleep problems, weight change and all the other things we recognise, along with lack energy, hopelessness and suicidal ideas. If these continue week after week, or become very severe, thats not grief, that’s depression.
You’ve shared some deeply personal things about yourself and your family, especially your father and your brother. Did you discuss the writing of your memoir with any family members still living?
You may be surprised but – no. While I was writing the second draft, my mother died. I haven’t mentioned it in this book. We had been estranged for many years, and I’ve seen very little of my brothers in my adult life. Apart from my husband and friends I’ve been very much alone. I’m in touch with my youngest brother now a little, after decades, and I’m not sure how he will receive it, as he was closest to my mother. However it was a therapeutic exercise for me to write it, and completing it has been an important task for me. I will let you know in time!
I was struck by how often you took on patients for psychotherapy rather than just offering medication or self-help skills. It seems quite rare now for psychiatrists to administer talking therapies. How do you feel about that, and do you feel it’s a component of the exceptionally long waits service users face for therapy?
When I was in training, and in my early period as a consultant I did see patients for psychodynamic psychotherapy with supervision, and I supervised trainees. I wanted to be a psychotherapist then, but got tempted into academia instead. Many of my psychiatric colleagues are trained in therapies which they do not have time to practice – they are increasingly expected to refer on to others and simply review medication. I think this is a terrible waste of their skills. However if I had become a consultant psychotherapist I may well have had problems retaining my job. Psychotherapy services have been savagely cut – and its almost impossible to get the longer term psychodynamic therapy I practised as a trainee, or received myself in the past, without going privately now. There’s been a huge loss of expertise, and I think that is so short-sighted. This contributes to the long waiting time for therapies other than CBT [cognitive behavioural therapy] such as dynamic psychotherapy and DBT [dialectical behaviour therapy]. Even CBT is hard to get, because many people who are waiting for it, might benefit from other short term help – but instead end up on long waiting lists with no support at all. You can see what gets me angry!
You describe having found antidepressants helpful and indeed having taken them for decades. What reaction have you experienced to this openness?
All types of reactions! I’ve had a lot of support from many colleagues over the years especially when Ive not been very well, but I’ve had others who look embarrassed when I reveal I take them as though I really shouldn’t be talking about that. I’ve had a person on twitter tell me that I would be positive about them, wouldn’t I, because I’m a psychiatrist! I found that reaction the hardest one to accept! I haven’t stayed on antidepressants for any other reason other than I need to take them to stay well – certainly not to prove a point. Some colleagues have told me how comforting it has been to know other mental health professionals take them too especially if they work in settings where there are strong beliefs that medications don’t work, and find it hard to admit their own experiences.
So there we have it! Big thanks to Linda, who I hope enjoyed answering the questions as much as I enjoyed writing them!