From Psychiatry Is Driving Me Mad: “Insight in mental health is pretty much exclusively thought of as the insight or lack of insight in people with mental health difficulties and how this affects our health and engagement with services . . . Rarely when someone discusses mental health and insight do we think about insight in mental health professionals, and how their insight (or lack thereof) massively impacts on people’s care, experience of services, and clinical outcomes.

. . . I have been praised for my insight when agreeing with clinicians, and immediately castigated with ‘lacking insight’ when I have disagreed. Insight in this context is nothing to do with the individual, their mental state, or their actual insight into their health, it is usually about convenience or clinical arrogance. The patient doesn’t agree, while the clinician feels they are absolutely correct and aren’t willing to compromise or even spend the time trying to further explain their reasoning. In this context the ego of the clinician is revealed as they measure their patient’s insight against their own understanding of the world. The importance of this should not be overlooked. By using their own personal subjective understanding of reality as a yard stick for everyone else’s insight, the clinician is anointing themselves with some kind of ultimate power of insight – like a god . . .

While the insight of patients is under permanent scrutiny, the reverse is not true at all. In fact, it seems clinicians go to great lengths to avoid scrutinising the underlying motives of their own feelings, thoughts, words and actions . . . When I have feelings about my clinician, those feelings are attributed to me and my past. When my clinicians have feelings about me, they are ALSO attributed to me and my past. Somehow, the clinician ceases to exist as an individual who has their own experiences and emotional reactions, and the patient becomes some kind of all-encompassing emotion monster, whose feelings are so enormous, they fill up the entire space, including the clinician.

. . . There is no situation in which a person seeking help should ever be faced with a clinician who blames, excludes, and turns their own inability to cope back on their patient. In a profession where staff are certain to experience negative and difficult emotions in relation to the people they work with, emotional insight is an absolute necessity. It is vitally important that staff are able to recognise when their feelings and responses to a patient are actually based in their own difficulties. To illustrate this, I thought I would describe a situation I encountered a few years ago, where my GP’s lack of insight put me in an extremely unsafe position.

I was seeing my GP regularly . . . while going through a very severe period of depression with mounting PTSD symptoms. Initially, my GP did all the things in her GP handbook on how to support someone in my position . . . But I didn’t get better, in fact I got much worse and became extremely suicidal. She reached the end of her list of things she could do and from my perspective this seemed to challenge her professional identity. She was a helper, that was her life. She had gone to the same medical school as me and we had spoken a lot about her progression through medicine. She was very enthusiastic about her job and had this very obvious passion for helping. But unfortunately in this case, she felt powerless to help me . . . after a while, she couldn’t cope and directed her distress back at me. Her manner changed entirely. Suddenly she was deeply frustrated, angry even, with my lack of progress. Her perceived failure to help me was turned around and became my failure to accept help. Despite trying absolutely everything she suggested, I was no longer ‘compliant.’ Despite me openly thanking her for her help and recognising that this was a struggle for us both, she expressed immensely upsetting statements, to the effect that I was being extremely ‘challenging’ and ‘difficult’ on purpose. I wasn’t. I was suicidal, my whole world was ending, and eventually I would decide to make an attempt on my life… but my GP’s poor insight into her lack of control over the situation, her perceived failure at her job, her struggle to understand why she couldn’t help me, turned into this incredible anger at my failure to stop being ill . . .

The emails between her and my psychiatrist (which I obtained via a SAR) were so revealing – two people comforting each other, for their own perceived failure and their struggle to cope with witnessing my pain, by dragging my name through the dirt. They felt bad, and it was easier to blame this on me, to suggest I was just ‘too much for anyone to cope with,’ than really think about what was happening for them. I think my GP was really truly aware that I was growing more and more likely to die, and by indulging in this anger she was also creating a distance between herself and me, to protect herself if I died.

. . . this complete failure to consider her emotions only served to make me more unwell. Not only was I desperately clinging to life, but now I had to deal with downright unpleasant interactions with someone who had previously been a huge source of support. My pain and my emotions had taken a back seat, to accommodate those of my doctor. I struggled to cope with this and decided that it would be best for us all if I discretely changed GP. I’m sure that sounds absolutely bizarre to many clinicians reading this – a patient managing their clinician’s emotions and changing their entire system of care to accommodate the clinician. It’s neither bizarre nor unusual. Mental health patients are not pieces of furniture. We are living, breathing, thinking, feeling people (gasp!) and are often excruciatingly aware of the feelings of the people tasked with our care. I personally don’t know anyone under services who has not acted in some way to protect staff – perhaps from fear, anxiety, uncomfortable truths, protected them by censoring the graphic details of past trauma, protecting them by using euphemisms for suicide and self-harm etc… The sad thing about this is, firstly, this usually goes entirely unrecognised (to the point of it being spun the opposite direction where clinicians actually perceive their patients as being deliberately provocative) and secondly, this takes energy. I should not have had to contend with my GPs emotions during a period of crisis. I should not have been forced into the position of lying to her, telling her I was suddenly better, and then switching to a new GP practice. This cost me emotionally. This took the focus off me and my safety, and in the end, almost cost my life.

. . . There is a desire in medicine for professionals to see themselves as objective spectators. This seems particularly strong in mental health services, as little objective evidence exists in support of psychiatric disorders or the psychiatric model. But healthcare professionals are not objective, and in a specialty like mental health where interactions and relationships are so central, insight into how your feelings, experiences, and understanding of the world affect your interactions and relationships is absolutely vital, and potentially life-saving.”

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