Freudian Script: Narcissistic Personality Disorder

Could you recognise a narcissist?

This highly topical Freudian Script explores Narcissistic Personality Disorder, and is brought to you by my friend and colleague, forensic psychiatrist Dr Bernard Chin.

DISCLAIMER: This blog post is designed for writers of fiction. If you are concerned that you or someone you know has symptoms of mental health problems, please see your doctor. Or your local government representative.

There once was a hunter from Thespiae, who was famed for his beauty. As he was so beautiful, many loved him. However, he only had disdain for those that loved him, as none could be as beautiful as he was.

He grew proud and one day he was drawn to a pool where he saw a reflection of himself. Not realising it was merely an image of himself, he fell in love with it (or perhaps coming to the realisation that he could only truly love himself) and was unable to leave the beauty of his own reflection. Losing the will to live, he stayed there, staring at his own image until he died.

His name was Narcissus.

What is narcissism?

Narcissism is a personality trait and Narcissistic Personality Disorder is a recognised mental disorder in the American Psychiatric Association’s biblical tome, the Diagnostic and Statistical Manual of Mental Disorders 5th Edition.

(The World Health Organisation did not include Narcissistic Personality Disorder in its International Classification of Diseases Version 10 as a distinct entity but instead chose to include it as almost a side-note in the Other Specific Personality Disorders category. Think of that what you will about the Americans.)

So what do we mean when we say someone is narcissistic? Do lay members of the public have a similar definition for narcissism as me, a forensic psychiatrist?

I work with people with severe and enduring mental illness as well as people with severe personality disorders who end up on the wrong side of the law – sometimes through a series of unfortunate events relating to their mental illness and sometimes entirely through their own devices completely unrelated to mental illness.

Narcissism as understood today was first publicised by the psychoanalyst, Otto Rank in the early 1910s, who linked it to vanity (egocentrism) and self-admiration. It is a descriptive term used widely in our daily lives. It is often used in a derogatory manner to indicate that someone is “full of themselves”, indicating that one has passed miles beyond being confident and self-assured into the realms of egotism.

We often use public figures as examples of “narcissists” – someone so full of themselves that they have essentially failed to recognise their own failures or absurdity. Case in point, a particularly “esteemed” Health Secretary or an exceptionally “bright” president-elect. Do these individuals have Narcissistic Personality Disorder? Many would like to believe so but it is dangerous to speculate without substantiated evidence or data to prove it.

Diagnosing someone with a personality disorder takes time – roughly three hours to interview the individual and a further two-three hours to locate and absorb any other information one can find on their background and relationship history.

This is, of course, if you are trained to diagnose individuals with a mental disorder in the first place. It also helps if one receives specific training to diagnose personality disorder, such as in the use of the International Personality Disorder Examination (IPDE).

But in a nutshell…

To understand Narcissistic Personality Disorder, we first need to ask what is a personality disorder? One explanation is included in this post on emotionally unstable personality disorder (EUPD).

To recap:

Personality is a set of characteristics that makes a person who they are. It is essentially the way that a person sees the world, interacts with the world and those in it. It also governs the way we feel and think about things.

Personality disorder (PD) is when our personality is different from what it should be, which then leads to the development of distress or conflict within ourselves or with others. It usually starts in our developing years due to some form of trauma which forces us to develop in such a way so as to protect ourselves whilst growing up.

Unfortunately, this may lead to a pattern of behaviour which is unhelpful when we are expected to be “fully functional” and “productive” members of society, despite it being helpful when growing up in a deprived or physically, psychologically, emotionally, and/or sexually traumatic environment.

Now that we have a rough understanding of PD, let’s delve into Narcissistic PD.

According to DSM 5, Narcissistic PD is:

A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognise or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviours or attitudes.

This can be someone who routinely overestimate or inflate their own abilities and accomplishments – appearing boastful and pretentious. They expect or assume others attribute the same value to their efforts and abilities and would often be surprised when they are not praised as they feel they deserve. They would also underestimate or devalue the contribution of others purely because they do not see the worth in others or does so to inflate their own achievements.

They can often be preoccupied with fantasies of power and unlimited success in whatever they do – love, beauty and so forth. They believe that they are superior, special or unique and they expect others to agree and recognise them as such. Often they will only mingle with the best of the best because only the “gifted” can understand them whereas the hoi polloi are just that.

However, these gifted people may be devalued themselves if they were to disappoint the individual with Narcissistic PD. Case in point – a patient of mine would rather speak to me instead of my junior doctor as I have more seniority but as soon as I disagree with him, my value immediately drops to just another doctor who isn’t the best in the country or the top expert in the field.

What causes narcissism and how does it manifest?

The narcissist’s overdeveloped sense of self and constant need for excessive admiration likely stems from an incredibly fragile self-esteem. They would constantly be preoccupied with how well they are doing and how favourably others regard them, constantly fishing for compliments using that great charm of theirs.

All this ego would of course be accompanied by a great sense of entitlement – they expect to be treated like gods. For, in their minds, they are nothing less and cannot understand why others do not or cannot see them that way.

Some people with Narcissistic PD have a predilection for the exploitation of others due to their great sense of entitlement and underdeveloped empathy. Friendships and romantic relationships are formed if it serves their purpose – to advance in society or somehow enhance their self-esteem.

They find it difficult to recognise the desires or feelings of others – children and “loved ones” become extensions of their selves. The only purpose these individuals served is to advance the narcissist’s own needs.

Envy is the emotion most often felt by those with Narcissistic PD – they feel that the successes of others are better served being theirs. They often come across as snobbish, disdainful or patronising.

Their fragile self-esteems make them particularly sensitive to criticism. Criticism may cause what psychologists term a narcissistic injury (essentially, an injury to the person’s ego and sense of self), leaving them feeling humiliated, degraded, hollow and empty. In order to repair or obliterate the injury, individuals with severe Narcissistic Personality Disorder may react with disdain, a defiant comeback or, on rare occasions, extreme rage. This could lead to social withdrawal, a façade of humility masking the grandiosity or sometimes, even violence.

That isn’t to say that overwhelming ambition and confidence has no place in society. On the contrary, these traits are useful and can lead to high achievement and progression if tempered with a suitable amount of humility and grounding.

Unfortunately, those with a disordered personality have difficulties managing their traits. The incessant need to protect their over-developed sense of selves may lead to avoidance of situations that would paradoxically lead them to achieving what they desire. If a narcissistic injury were sustained, the overwhelming feelings of shame and humiliation would often lead to persistent low mood and potentially a depressive disorder

Would you be surprised to learn that 50% to 75% of those diagnosed with Narcissistic PD are male? Probably not.

The core of the disorder is the intense fluctuation in self-esteem and the need to refer to others to regulate this and to define themselves.

Narcissistic PD in fiction

One example of Narcissistic Personality Disorder in fiction is Patrick Bateman, the titular character from American Psycho. He isn’t a pure example, although he shows certain traits one would find in a real life individual suffering from the disorder. Lacking empathy, utilising “friends” for his own goals to advance his self-esteem, grandiose sense of self-worth, associating only with “important people”, and highly sensitive to criticism and setbacks (for example – the business card scene as depicted in the movie).

Like in real life, there are features of other personality disorders evident in Patrick Bateman – Antisocial Personality Disorder being the other prominent feature. He is also likely suffering from a psychotic episode near the end of the novel and movie adaptation.

He is probably one of the more extreme and malignant examples I have come across in fiction. There are other examples that are slightly more benign and “played for laughs”, such as How I Met Your Mother’s Barney Stinson, although Barney’s attachment to his friends appear to be genuine friendship which goes against one of the more common traits in Narcissistic PD.

Narcissistic PD in reality

What are individuals with Narcissistic PD like in real life?

Depending on the severity of their personality disorder, they can be very much like you or me. There are certain points in my life when I thought that I displayed narcissistic traits. Whether I can be diagnosed with the disorder though remains to be seen.

As patients, people with Narcissistic PD can be difficult to manage. This difficulty stems from whether someone sees what he has as distressing to him or not. If I were told that I had a Narcissistic Personality Disorder and this was becoming a problem for other people but I do not see this as a problem for me, then I am less likely to engage in treatment. They may also have unrealistic expectations of the treatment, the service delivering the treatment, the outcome, the doctor that deals with them and a whole range of things.

I think what doesn’t come across well in fiction is the difference between narcissism and Narcissistic Personality Disorder. Narcissism is a personality trait which can be extremely useful in certain trades (such as mine) where overwhelming ambition and, to a certain extent, self-confidence and even a little bit of vanity can lead to a good outcome.

Narcissistic Personality Disorder is like it says on the cover – a disorder. There has to be a level of impairment or distress that goes with it (for the individual or for others in their lives, which would eventually lead to some form of impairment in their lives).

So, is America’s president-elect narcissistic? Oh god yes.

Does he have a mental disorder? I have no idea and I am afraid to comment… (wink)

Bernard Chin is a Forensic Psychiatrist with a background in genetics and psychology. He has worked with individuals diagnosed with personality disorders throughout his career in psychiatry and is specifically trained in understanding and assessing personality disorders as well as psychopathy. In his free time he enjoys torturing medical students and other junior doctor colleagues with lectures and role play. He also rants at the government on twitter (@berniebchin).

The Anti-Stigma Thesaurus: Rewriting the Language of Mental Health

Words taken from Rose et al (2007)

Despite how the nursery rhyme goes, words can hurt. They can also be used to reinforce mental health stigma, particularly in crime fiction.

Words are powerful – and “with great power comes great responsibility”. The longevity and influence of words can be epitomised in that one quotation, first used centuries ago and popularised by a comic book adaptation.

Words are the building blocks of the writer’s craft. They are our weapons and our tools. We can fuss for hours over the right choice of word to fit a sentence, a tone, a character. When it comes to fighting mental health stigma, we need to choose our weapons carefully.

The last time I wrote about this, I merely complained that writers should do better. This time, I’m going to do better.

The following words and phrases are all in common usage but have the potential to be harmful to people with mental health problems and reinforce stigma about them. I have here presented alternatives that will convey similar meaning but without the baggage.

NOTE: I have made some assumptions about the intention behind the use of these words. The alternatives will not fit every situation. If you have a question about options in context, please feel free to comment or contact me for suggestions.


The Anti-Stigma Thesaurus

asylum/loony bin noun
mental health unit, psychiatric hospital

bipolar adjective
capricious, changeable, fickle, flip-flopping, oscillating, unstable

commit suicide verb
complete suicide, die by suicide, kill him/herself, take one’s life
(For more guidance on writing about suicide, see Samaritans’ guidance. For a personal and professional perspective, see this note from Dr Alison Payne in the BMJ.)

crazy/insane/mad/mental/nuts adjective
1. general use
i. bizarre, eccentric, odd, outlandish, peculiar, strange, unbelievable, unusual, weird
ii. amazing, astonishing, awesome, incredible, outrageous, stunning, unbelievable
2. referring to mental health:
rephrasing is preferable – e.g. “person with mental health problems” or “he has a diagnosis of depression”
(See the “Time to Change” guide to language.)

demented adjective
absurd, nonsensical, ridiculous

OCD adjective
exacting, fastidious, finicky, meticulous, neat, tidy

psycho adjective
1. general use
violent, unpredictable, unstable, wild
2. crime fiction – referring to a murderer
cold-blooded, cruel, detached, remorseless

retard noun
idiot, imbecile, moron
(NB: The words I have chosen here are all archaic words for a person with mental health problems, but they have lost that connotation in modern usage)

schizophrenic adjective
conflicting, contradictory, incongruous, inconsistent, indecisive


Do you have suggestions for other words to include in this list? Please leave your ideas in the comments.

REVIEW: Pulling the trigger by Adam Shaw and Lauren Callaghan

Pulling the trigger: The Definitive Survival and Recovery Approach for OCD, Anxiety, Panic Attacks and Related Depression

ptt-cover Adam Shaw spent his life running away from the terrifying thoughts which tormented him. This lifelong struggle with mental illness ultimately lead him to a railway bridge and the brink of suicide, and it was at that point that he met psychologist Lauren Callaghan and was finally able to get the help he needed.

They share this practical approach in their new book, Pulling The Trigger: The Definitive Survival and Recovery Approach for OCD, Anxiety, Panic Attacks and Related Depression. The book, divided into two helpful parts, provides both first-hand evidence for sufferers that recovery is possible, and a user-friendly blueprint for mental health support and recovery.


For my review of this book, I enlisted the help of Huw Davies, football journalist and OCD sufferer. Davies has written about his own experiences with OCD for publications such as The Guardian and ShortList.

huwdavies-icon People with obsessive-compulsive disorder, perhaps more than others with a mental health issue, often feel they’ve heard it all before. I know I have, after experiencing various treatments and coping strategies for my own OCD over the years, as well as interviewing people when writing about the condition. For some sufferers it’s mere ennui, but for others it can feel more like despair.

So it’s refreshing to read about a new approach – or, at the very least, an approach presented in a new manner. To my mind, there’s nothing revolutionary about most of the tasks, both physical and mental, that psychologist Lauren Callaghan sets. However, the focus on compassion as well as practical solutions, emphasised by Callaghan and OCD sufferer Adam Shaw alike, is something often missing from books outlining a treatment.

rosieclaverton-icon During my work as a psychiatrist, I have helped treat a number of people with OCD, including at the National Specialist Service in South West London. I therefore have a good (if inexpert) knowledge of the diagnosis and treatment approaches in OCD.

While there is nothing novel about the “Pulling the trigger” approach, the combination of Shaw’s personal story with Callaghan’s professional commentary really aids understanding of OCD. The book also deals with the common mistakes in attempting to self-manage OCD, and gives an accurate impression of the impact of the disease. The Accept, Embrace, Control model is also easy to remember and understand.

huwdavies-icon The book’s biggest asset is its accessibility. In the first section, Shaw recounts his lifelong battle with OCD in a memoir that will engage the vast majority of its target audience (although as much as he strives to be neutral, Shaw’s own experiences inevitably paint other approaches to treatment in a negative light). Callaghan interjects regularly to explain Shaw’s malfunctioning thought process and how she helped him to tackle it head-on. It’s enlightening and occasionally a little shocking: more than a few OCD sufferers reading the book will gulp as she persuades Shaw to hold a knife to her neck, even as she feels safe in the knowledge he will not enact on his fears of being violent to others.

rosieclaverton-icon While very accessible to its intended audience, the PTT approach is quite vague – for example, it doesn’t go through breaking down the worries into a hierarchy, as would be common in OCD management (and cognitive-behavioural therapy in general), and then tackling them in a stepwise fashion.

From what information is given in the book, PTT appears to be based on a basic CBT model, though without the typical emphasis on preventing a response to the exposure, such as strategies to resist rituals. I therefore feel it would be difficult to design your own programme of OCD treatment solely by reading the book.

huwdavies-icon There’s arguably nothing much radical about “Pulling the trigger”, but then Shaw and Callaghan call it “the definitive survival and recovery approach” – not “an entirely new one”. Most sufferers will have heard their advice before, dressed in different robes. But perhaps because of its compassion element, readers of the book are still likely to feel more confident about recovery after reading it.

rosieclaverton-icon “Pulling the trigger” is not without its problems. The repetition of “you’re not going mad” supports OCD sufferers at the expense of people with other mental health problems, reinforcing old stigmatising stereotypes. The section on exercise, while framed as useful encouragement, does not address issues of ableism by exploring exercise alternatives or support available.

While adopting a healthy attitude to medication, the book perhaps overly emphasises independence of the OCD sufferer from the wider healthcare system. This is perhaps because Shaw took this approach, due to his inability to access NHS services.

Overall, “Pulling the trigger” is a good background book to help understand the experience and management of obsessive-compulsive disorder, but I feel it needs further development to be used as a standalone self-help book for people with OCD.


Pulling the trigger: The Definitive Survival and Recovery Approach for OCD, Anxiety, Panic Attacks and Related Depression by Adam Shaw & Lauren Callaghan (CPsychol, PGDipClinPsych, PgCert, MA (hons), LLB (hons), BA) (Trigger Press Limited, 1st September 2016)

Find out more at Pullingthetrigger.

INTERVIEW: Sara Barnard on Mental Health in YA and Beautiful Broken Things

In Freudian Script, we love to hear how authors tackle the accurate and sensitive portrayal of mental health problems in fiction. Sara Barnard, author of Young Adult novel Beautiful Broken Things, tells us her tale.

beautiful broken things cover

What led you to explore issues of mental health in Beautiful Broken Things?

I was interested in the aftermath of trauma and violence, and how these experiences can affect young people as they grow and develop. In a lot of cases, unfortunately, people recovering from past pain go on to struggle with their mental health. It struck me that we don’t see much of this in YA fiction – stories tend to focus on the traumatic event itself and not what comes next – and I wanted to change that in a very small way with the book I wrote.

I was also aware of how mental health is so often used as The Big Issue in YA, as if it is the defining feature of a character. So I wanted to also feature a character who had mental health issues that were incidental to the actual plot, to show that living with a condition like bipolar disorder – as Caddy’s older sister does – can be part of everyday life instead of a big drama.

There’s a lot of stigma around mental health. What do you think are the best ways to combat it?

I think fiction can be really important in this area – in books and on TV, we should be seeing truthful and authentic portrayals of a range of mental health issues. For many people, this will be the first (and sometimes only) time they are exposed to a particular mental health condition, so it’s important that it’s not one-dimensional or stereotypical. It also shouldn’t be used as a transparent plot device – this is one of my biggest bugbears with mental health in TV and books.

As a writer, would you recommend any particular films/TV shows/novels that do a good job of portraying mental health that other writers could use as inspiration?

Holly Bourne’s novel Am I Normal Yet? contains an amazing portrayal of a teenager struggling with OCD. She’s in recovery but is fearful of relapsing – this is also something we don’t see enough of in books or on TV.

What would you like to see more of in terms of young adult characters?

It would be great to see a little more of characters living with conditions rather than a story being based entirely around them “discovering” they have a condition, if that makes sense. Mental health – and physical health – is about so much more than the initial diagnosis, and it would be nice to see a bit more of that reflected in fiction. Though I think we are getting better.

What one piece of advice would you give a person struggling with their mental health?

Talk to someone. That doesn’t have to mean in person, or even someone you know personally – those of us who struggle with mental health are very lucky in one important way, which is that we’re living in the age of the internet. Taking that first step of finding help can be as simple as opening a webpage.

And what advice would you give to writers looking to portray that struggle accurately and sensitively?

Ask! Again, the internet exists, so there’s a whole world of information available on so many aspects of mental health. Research is so important, but I also think that should be done with the character in mind, rather than as something separate from them. So rather than “How does bipolar disorder affect teenagers”, for example, it would be “How does bipolar disorder affect MY character, with this life and this family, with these character traits?” etc. Just like people in real life, a character doesn’t begin and end with their mental health. If you are true to the character and their struggle, it will follow naturally that the portrayal will be accurate and sensitive.

But having said that, I’d recommend finding a beta reader you trust to check your novel specifically to give you feedback on the mental health aspect.


sara-barnard-author Sara lives in Brighton and does all her best writing on trains. She loves books, book people and book things. She has been writing ever since she was too small to reach the “on” switch on the family Amstrad computer. She gets her love of words from her dad, who made sure she always had books to read and introduced her to the wonders of secondhand book shops at a young age.

Sara is inspired by what-ifs and people. She thinks sad books are good for the soul and happy books lift the heart. She hopes to write lots of books that do both. Beautiful Broken Things is her first book and a dream come true.

Freudian Script: Work-Life Balance

Another junior doctors’ strike, another blog post from me!

My theme, however, is one that is relevant to all professionals but particularly writers of all stripes. I am talking about the mythical work-life balance.

rock-balance What is work-life balance?

This term is most commonly used when talking about the proportion of life spent on employment compared to family, hobbies and rest. It is most often applied when talking about how jobs can be all-consuming and gradually take over your entire existence, like a life-sucking parasite. Ahem.

One of the reasons the junior doctors’ contract negotiation is so emotive is the discussion of Saturday working – is Saturday a normal working day or is it special? Retail jobs, for example, mainly consider Saturday a normal working day, as do the police. Professional jobs consider Saturday a non-office day in the main, but people may be working from home. Schools and childminders definitely consider Saturday a non-working day.

Writers do not enjoy such demarcation lines. Professional writers can write any time, any place – 3am on Sunday is the same as 10am on Tuesday. Meetings, studio commitments, and play rehearsals might occupy more conventional hours, but writing is 24/7.

For writers with day jobs, we are looking at the balance of work-life-workagain. Bank holiday weekend: three days dedicated to the family, or to the novel?

This is where a broader psychological framework may be helpful in understanding how balance can be achieved.

Mastery and Pleasure
When therapists look to rebuild a life ravaged by depression or another serious illness, they look to balance from the outset. If you are starting from a wide-open schedule with nothing in it but sleep and TV, filling your days can be daunting and anxiety-provoking.

The theory goes that what makes life fulfilling is not merely the pursuit of happiness, but the balance of mastery and pleasure. In plain English – we want to feel useful and we want to enjoy ourselves. You can’t have one without the other. Having a purpose for the day is equally important to having a good time.

Doing household chores is good for you. Taking a walk is good for you. Doing only one of those things without looking to the other isn’t going to lead to satisfaction and contentment. This is why many people get antsy at the end of a holiday.

Boundaries
The other problem is those lines between work and leisure time are increasingly blurred. When your smartphone can fetch your email at any time, and we rarely turn the things off, when are you not at work? Am I at dinner with my husband, or am I also answering my email, Whatsapping my friends, and checking the cricket score?

The current investment in mindfulness, both in healthcare and the wider public consciousness, is partly fuelled by our need to escape distractions. The idea is very simple: be completely in the moment. The execution is very difficult, however, unless you’re a practised yogi. Focussed on breathing and your immediate environment, acknowledging but not engaging with your worries and thoughts, is a powerful experience but not a template for life.

However, principles of mindfulness can carry over well to the everyday. How about this: concentrate on one thing at a time. For example, watch TV but don’t check your phone. Eat dinner, and don’t check your phone. Talk to your partner – and don’t check your phone.

(Aside – I am terrible at this. This blog post has taken me twice as long as it should because I CAN’T STOP CHECKING MY PHONE. Reminder to us all: the “Do Not Disturb” setting exists for a reason.)

Work-life balance in practice
So, how can you improve your work-life balance?

The answer is to look at your life and be honest about what parts are necessary features and what parts of it are bringing what benefits to you.

We have to sleep and we have to eat. We have to work to pay the bills, or have some other purposeful activity in our lives. We have to spend meaningful time relating to other people. We have to do things that we enjoy. These are the building blocks of life.

Here are some simple take-home tips:

Make an activity diary: Look at a week or two and see what you’re doing with your time. Are you spending two hours on Facebook because it’s bringing you joy or because there’s nothing else to do? Did you try to work on that screenplay but were distracted by that Tweet you sent three hours ago that’s had more favourites than you can shake a stick at? Prioritise the things you want and need most.

Recognise what you enjoy: I like going out to dinner, watching my favourite TV shows, practising yoga, reading books, and taking long hot baths. These activities are restorative. Your list probably looks completely different. Recognise these activities and use them to help yourself decompress.

Invest in relationships: You don’t have to spend all your time and energy on a person to have a good connection to them. Yet the time you do put into those relationships means you can rely on that support at more fallow times.

Turn off your phone: I’m not talking about a digital detox, because I think the idea is unsustainable and unrealistic. We need to adjust to having these always-on, always-connected devices in our lives. How important is it to be able to answer your email at any time? Can you afford to put your phone on silent for two hours?

The answer is probably yes. If it isn’t, maybe your work is actually a life-sucking parasite.

How do you strive towards a work-life balance? What strategies work best for you? Is the whole idea an impossible dream? Tell me in the comments!

Junior Doctors: Their Lives in Your Hands

2016-02-10 10.05.49
When I wrote my New Year post, I was ready to leap into frequent updates, including on the important topic of self-care for writers.

Then life happened.

As most of you know, in addition to being a screenwriter and novelist, I am also a junior doctor. On 3rd February, I started a new job as an Advanced Trainee in Psychiatry – also known as a Specialist Registrar, or a psychiatrist who is becoming more specialised in one particular field.

Medicine is a professional vocation that was once very popular, well thought of, and attractive to bright young things looking to make a difference. In many ways, it is still that – but it’s also becoming harder.

Let us count the ways:

Cuts to NHS funding
One of the first things you learn as a newly-qualified doctor is how to use the fax machine. As a twenty-something in 2010, I hadn’t the faintest idea why we were addicted to this technology, but we still cling to it. Since then, I have added to my repertoire: scanning reports, posting clinic letters, answering the telephone, manning reception, and fixing the photocopier.

When the photocopier ran out of ink before Christmas, we ran up the stairs several times a day to use the only other copier/printer in the building. No new ink arrived because our temporary admin had left and we had failed to hire another one. All other administrators were rushed off their feet, reduced in numbers by a third. Like our community nurses and social workers. Because we have to make yet more savings to our budget.

When I have time, I practice medicine. When there’s no one else to do it, I fix the photocopier.

A Considerate Employer?
Riddle me this: what job do you apply for without knowing where it is, what you’ll get paid and what hours you’ll work? Welcome to being a junior doctor.

I found out the location of my new job in November – an half-and-a-half drive from my new home. I found out what I was getting paid last week. I received my work duties for March yesterday.

When I got married in 2012, I had just started a new job. The medical staffing department in my new hospital couldn’t guarantee that I would have my wedding day off work, and refused to consider accommodating me.

When I finished my last job, I was meant to be working night duty. I would’ve finished work at 9am in one hospital and started at 9am in another. Without my friend’s generosity, I would’ve been scuppered.

Morale is low when your employer isn’t interested in you as a person.

A new contract
You will have read in the media that doctors are getting a pay rise and they’re after more money, the greedy so-and-sos. You may also have read that medics are “militant”, that doctors are ensorcelled by the BMA, and that you should Google your child’s rash (DO NOT DO THIS).

Many others have said this better than me, but I will say it again: if the government want an all-singing, all-dancing seven-day NHS (as opposed to the current seven-day NHS we have for urgent care, emergency care and hospital inpatients), they have to fund it. You cannot take the money for five days’ worth of doctors – and the actual doctors themselves – and spread them over seven days. You may get more doctors on the weekend, but you will necessarily have fewer doctors all the rest of the time.

And we need other professionals. We do not work in isolation. We need investment in allied health professionals – the nurses, social workers, physiotherapists, occupational therapists, psychologists, radiographers, porters and administrators. Or all those “extra” doctors will be pushing trolleys and fixing photocopiers.

How you can support us
Firstly, thank you for reading this post. Being better informed about the issue helps you to be a stronger ally.

Secondly, please support your doctors on the picket lines today. A packet of biscuits or a cup of tea is greatly appreciated, but a word of solidarity or a signature on a petition is even more valuable.

Thirdly, and perhaps most importantly, support doctors’ voices and challenge dangerous ideas about the NHS that are being spread by those in charge. There is a reason I write a disclaimer on my posts when I talk about mental health in fiction. There is a reason we have peer-reviewed scientific journals and not press releases from the Health Secretary. Be good internet citizens, and spread good information.

Thank you.

Hello 2016

Happy 2016! It’s that time of year again. The one in which I tell you about the exciting things that are happening in my writing life right now, and we can anticipate them with glee together.

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New Amy Lane novels
The wait is almost over! Captcha Thief, book three in The Amy Lane Mysteries, will land on 4th February. And that’s not all! The fourth book in the series Terror 404 is due for publication in August.

As these will be out in paperback (paperback!), keep your eyes peeled for bookplates and swag and giveaways as the due date nears – the newsletter and Facebook Page are always the first to know.

If you can’t wait that long, check out the Amy Lane short story Car Hacker.

CrimeFest 2016
After the success of last year’s CrimeFest, I will be returning to Bristol this May to do more panels and sign aforementioned books. I’m really excited to part of this festival again and meet so many enthusiastic authors and readers.

Mental Health and Writing
Building on my work combating mental health stigma and #psywrite, I am going to be looking more this year at how writers can look after their own mental health and how awareness of how we tick as creatures can help us create better. Watch this space!

Coming Home
I am also delighted to finally be returning to my beloved Wales. My husband and I are moving back to Cardiff early this year, so I will be languishing in Culture Cymraeg for my future writing endeavours. Happy authors make for better books.

And Much, Much More
As always, there are a number of things I can’t shout about yet, but I look forward to sharing them with you this year.

2016 is going to be a thrilling ride. What are you looking forward to this year?

One Flew Over The Cuckoo’s Nest v Modern Psychiatry

There is no doubt that One Flew Over the Cuckoo’s Nest is one of the seminal films in mental health fiction. Its legacy is still strong forty years later – barely a week passes without one of my patients mentioning the film, usually comparing it to the ward or my proposed treatment plan.

One Flew Over the Cuckoo's Nest

But it is exactly that legacy that haunts the fight against mental health stigma. This film has so permeated the public consciousness that when folk think of mental health, they think about One Flew Over the Cuckoo’s Nest.

So, how accurate is it? Are mental health units full of Nurse Ratcheds? What conditions do the ward’s patients suffer from? And is electroconvulsive therapy really that barbaric?

But first:

It is 2015, not 1975.

Why is this point important? Because medicine’s approach to mental illness has changed dramatically over the past forty years. A lot of the problems I identified with One Flew Over the Cuckoo’s Next stem from it being a product of its time. It is partially reflective of psychiatry in the sixties and seventies. Like all contemporary pieces, it is unfair to judge it with a modern eye.

Yet what I hope to do is correct misconceptions that have carried over into today’s thinking around mental health.

Institutionalisation
One Flew Over the Cuckoo’s Nest takes place in what the sociologist Goffman termed a “total institution”, where a group of people are confined in a controlled setting for a prolonged period of time.

Its features include all activities of daily living taking place in the same location, with a large batch of people all conforming to the same schedule and rules. There is also a marked divide between staff and community members – in this case, patients.

This heightened control becomes obvious in the film when McMurphy (Jack Nicholson’s character) tries to change the ward’s schedule for the baseball World Series. While there is a show of democracy in the voting, the act is rigged by the staff. The belief that order and schedule is vital to mental health is being applied here by force and against autonomy.

The other most obvious point is the institutionalisation of the characters. McMurphy is stunned to find out that most of his fellow patients are voluntary and not compelled to stay on the ward. Then why do they stay?

Because any total institution equips people to survive in that environment and not to grow beyond it. This effect is also widely seen in prisons and the military. These patients have grown so used to the ward that they don’t know how to leave it.

However, psychiatry emptied its institutions in the 1980s, moving towards a “care in the community” model and later to the recovery model. Which basically means wanting people to live their own lives on their terms, with support given to achieve those personalised goals. It is basically the polar opposite of institutionalisation, though we do still cause this in some mental health units – e.g. in forensic mental health services, and in patients who stay for a long time.

Mental illness
One of the questions the doctors ask of McMurphy is whether or not he has a mental illness. It is a question we could also ask of the other patients on the fictional ward of One Flew Over the Cuckoo’s Nest.

Again, we must look at historical psychiatry. The vogue in the mid-20th century was that institutions were the preferred method of delivering mental health services. Therefore, if you had any sign of a mental health problem, into hospital you would go. It was partly based on the scientific thinking of the time, and probably more realistically on the fears within the community of what mentally ill people do if left unsupervised.

Fast-forward forty years to a modern mental health unit. One – given the current state of NHS mental health funding, you’ll be lucky if we can find you a bed at all. Two – only the most severe episodes of mental illness require hospital admission.

I still have older patients asking me if they can come into hospital “for a rest”. Respite admissions were very common in the institution era. Now, I can hardly think of a place less restful than a mental health unit.

Of the main patient characters in One Flew Over the Cuckoo’s Nest, I can’t identify one who requires hospital admission. The so-called “chronics” may require highly-supported living arrangements, but not hospital.

Because all these people are relatively well, they may have problems that could be addressed by long-term therapy, robust medication, supported accommodation, or just a more understanding community.

Not one of them has a definable, recognisable mental illness. Especially not McMurphy.

Nurse Ratched
I had heard terrible things about the iconic Nurse Ratched before watching this film. And yet I found nothing terrible about her.

One-Flew-Over-The-Cuckoos-Nest-Nurse-Ratched

Here is a woman doing her job in an institution that completely defines that role. She is as much a prisoner of this system as they are. In fact, at times, I realised that I would enforce the boundaries in exactly the same way she did.

Does she make some questionable decisions? Absolutely. I found the dynamic between her and Billy particularly troubling. I also thought the nursing staff did absolutely nothing to de-escalate a situation unless they felt their authority was being threatened, not when they felt their patients were suffering emotional or physical harm.

But do I think she had a vendetta against McMurphy, or wished to bully the patients? No, I don’t. I think she genuinely thought she was doing the right thing.

And those people make for the most terrifying villains.

Treatments
Never do I hear as much about One Flew Over the Cuckoo’s Nest as when discussing electroconvulsive therapy, or ECT. It is undoubtedly controversial – for one, it is the only form of treatment that requires consent or a second opinion under the Mental Health Act.

And in the 1960s, it went down pretty much as you see in the film. In 2015, however, it is a very different beast. ECT always takes place under general anaesthetic. A muscle relaxant mutes the effects of the seizure on the body. And it’s only given in the most severe episodes of depression and psychosis, usually when people are dying from dehydration and malnutrition.

It is definitely not used as a punishment for bad behaviour. It’s also not used for tranquillisation.

The medication ethics are also pretty shit in One Flew Over the Cuckoo’s Nest. When McMurphy asks what tablet he’s being given, the nurse patronises him and then Nurse Ratched threatens him. Even when compelled to receive treatment, people should be informed about what it is you want them to take. We are trying to move beyond the paternalistic model of medicine where you just do exactly what your doctor says – because why the hell should you?

See also group therapy. Is group therapy for everyone? Nope. Should you be compelled to do it? Probably not. The evidence suggests that any compelled therapy will be pretty much useless. It requires consent and active participation. It requires a trained facilitator who won’t use the threat of your mother against you (and should instead be looking into those mother issues, because that seems a significant factor in this case).

Verdict?
I’ll be honest: I really enjoyed this film.

It shows people with mental health problems as individuals, with in-depth characters, dreams and desires. It didn’t do psychiatry a lot of favours, but then 1960s psychiatry didn’t do itself a lot of favours.

I find it difficult that so many people still turn to One Flew Over the Cuckoo’s Nest as their benchmark for what mental health and psychiatry are actually like.

How do we combat that? We include more characters with mental illness in our dramas, our comedies, our documentaries. We tell the truth about mental health now.

What did you think of One Flew Over the Cuckoo’s Nest? Leave a comment!

REVIEW: The Other Side of Silence – Linda Gask

As a psychiatrist, I walk a fine line of understanding. While I can try to empathise with the people I see in my clinics and on my ward, I cannot truly know their experiences. Sometimes that helps to give me the distance of objectivity, and sometimes it leaves me lacking.

other-side-silence-linda-gask
Linda Gask has a markedly different perspective. She is a psychiatrist and academic who has experienced mental health problems from both sides – that of a clinician and that of a patient.

In her book The Other Side of Silence: A Psychiatrist’s Memoir of Depression, Linda draws on both her professional knowledge and personal experience to take the reader on a “guided tour” of depression – using her own life and anecdotes about patients to illustrate the complexity of this illness and its manifestations.

What I love about The Other Side of Silence is that it sets aside the traditional, medical model of psychiatry and instead embraces a whole-person, holistic approach to the illness. It looks at depression not as a disease of neurotransmitters and recovery models and care programme approaches, but as an experience that happens to people and affects their lives. We see up-close and personal the effect it has on Linda’s life and the course it takes.

However, she also retains the perspective of the psychiatrist. The reader is left in no doubt that they are in the hands of a doctor, a professional with clinical expertise on this subject. Linda’s narrative moves effortlessly from a psychiatrist’s analysis to a patient’s point of view. She shares encounters from both sides of the table – her own work with patients and her own experiences of being tended to by professionals.

I highly recommend The Other Side of Silence if you want a real account and contemporary understanding of depression, particularly with the supporting knowledge of a medical perspective. I can also recommend it if you have a personal experience of depression and are struggling to understand it, or are already on that journey. I think it is particularly relevant to professionals and those trying to maintain or reclaim the functioning of their lives. In fact, I recommend it so highly that I have already lent my copy to a friend.


Linda Gask (MB. ChB, Msc (Psychiatry), PhD, FRCPsych, FRCGP) was born to a Scottish mother and English father and brought up on the east coast of England in Lincolnshire. She trained in Medicine in Edinburgh and is now Emerita Professor of Primary Care Psychiatry at the University of Manchester. She has worked as a consultant psychiatrist in the North of England over the last 25 years. Now semi-retired, she lives with her husband and cat in a stone house in the Pennines and also spends an increasing part of her time in Orkney. You can follow her blog at www.lindagask.com and on Twitter as @suzypuss.

You can buy The Other Side of Silence: A Psychiatrist’s Memoir of Depression at all good book retailers. Here are a few to get you started:
Amazon
Google Play
Hive
iBooks
Waterstones

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#WriteInclusively – We Can All Do Better

Yesterday, the news broke on Twitter that SC had been removed as co-host from Query Kombat and Nightmare on Query Street, popular query competitions designed to help win an agent or editor.

The reason? His “passion for the Write Inclusively campaign may be unsettling or umcomfortable for people who don’t write from the POV of ethnic characters, or who don’t portray ethnic characters as ‘honestly’ as [he] would like.”

Okay. I’m not going to talk about the decision, as many articulate people have already commented on Twitter. I am going to talk about my personal struggle to write diverse books and why we should strive to do better.

I have written before about my difficulties identifying as a queer woman of colour, and about feeling responsibility for writing diverse books.

My first novel Binary Witness is shit on diversity. Despite having a female protagonist, it doesn’t even pass the Bechdel Test. One of the only queer characters is a victim. There are no prominent people of colour. It does work to accurately portray mental health issues, because that is a significant fever of mine, but that is all.

The worst thing is that I didn’t even realise it. It was only about six months after publication, when I was talking about diversity in fiction, that I realised how I had unconsciously written an all-white, heteronormative world. In my defence, the real Cardiff isn’t a hotbed of diversity, but it’s certainly moreso than my novel would suggest.

In Code Runner, I decided to do better. I introduced a woman of colour who I intended to replace a white male recurring character. I included a couple of microaggressions towards her. However, she was largely in the background – she smiled and did her job. It was a start.

In my latest WIP The Deaths of Miss Gray, I was determined to work hard. My nineteenth century London must include real people. I have queer characters of differing stripes, who flaunt their sexuality based on their privilege. I have characters of colour who suffer prejudice and discrimination, though I could’ve done more with this. I have women front and centre.

And yet still I can do better. In Amy Lane book 4, I can include more of Indira’s experience as an Asian woman in Wales. In Deaths, I can explore what happens to the black performer Cassandra when she ventures into the white, well-heeled parts of London.

We can all do more. We can all do better.

The point is that we have to be willing to accept we need to grow and learn. The writers that feel uncomfortable at being told their portrayals aren’t accurate? Those are growing pains. You need them to become a better writer.

We need to tell each other when we fall short so that we can all do better. And that is why we have #WeNeedDiverseBooks and #WriteInclusively.

Right now, my books don’t meet the threshold for #WriteInclusively – and I’m asking myself why. Are you?