Sitting on the hospital bed, I breathe deeply into the paper bag. Watching it rise and fall and listening to the sound of it contracting and inflating helps me visualise my panic, and slow my breathing down.
Thankfully — eventually — I get hold of my anxious thoughts and stop hyperventilating. Panic over for now, I emerge into the corridor, only to find my boss talking about me outside. ‘You can send Natalie anything, nothing fazes her,’ she’s saying to another colleague. If only she knew.
For at the time of this incident, I was no patient in this hospital. I was a member of staff. And not just any member of staff: a trainee psychologist.
Often I represented the hospital’s entire emotional health and wellbeing service; the start, middle and end of many patients’ treatment plans, which typically extended across just six sessions over a few weeks.
Dr Natalie Cawley says all psychologists have to have therapy themselves while in training
In my career, I’ve treated many different patients: from men addicted to pornography to diabetics struggling with the psychological impact of losing a limb. My work often involves caring for the most vulnerable’s mental health needs, children among them.
Despite this, there have been many moments when I felt I was balancing two incompatible selves. One self had to be responsible, reliable. Yet my other self was known to resort to ice cream for dinner because of an otherwise empty fridge, or on occasion come to work wearing bikini bottoms under my trousers because I hadn’t done my washing.
I drank too much, stayed up all night, and had catastrophic relationships: one boyfriend was an alcoholic and cocaine user; another a pathological liar and fantasist; and one was an emotionally abusive, controlling narcissist.
The behaviour of these men deeply impacted on me, making me doubt my instincts, and left me hypervigilant and anxious. So much so that my psychoanalyst gently told me in one of our weekly sessions: ‘Your patient work is strong, but you seem to be hobbling along, getting by.’
Yes, that’s right — my psychoanalyst.
The fact is all psychologists have to have therapy themselves while in training, which I did for four years, with Kelli, a compassionate woman with a liking for bright lipstick.
Every week, I’d lie on her green velvet chaise longue as she delved into my subconscious. It may sound surprising to a lay-person that someone who is in charge of others’ mental health needs has their own issues. But the reality is that, while we are mandated to have therapy like this while training, it’s far from uncommon among psychologists and psychiatrists for us actually to need it, too.
Indeed, many keep up the therapy habit after training and long into their careers. I still have therapy. One of my tutors told me therapists are ‘wounded healers’ and I should ‘look for the wounds in colleagues and mentors. If you look carefully, you will witness their struggles’.
Sometimes I didn’t have to look too hard to see these wounds. One psychiatrist I worked with caused concern when, during a meeting, he refused to take off his blue surgical gloves.
It was also noted that all the items in his briefcase were vacuum-packed.
Concerns escalated just before his holiday, when he revealed he was paying for extra luggage to ensure he could take a full suitcase of bottled water as he couldn’t trust the water elsewhere.
It appeared to be a case of contamination-based obsessions. Because of my duty of care to his patients, I discreetly passed on my concerns to management.
More tragically, my supervising psychologist — a thoughtful, inspiring, can-do person who taught me so much — took her own life, such was her inner turmoil.
Psychologists and other medics of the mind might understand the mechanisms and symptoms of poor mental health and how to treat it, but this doesn’t necessarily mean we automatically know how to take care of our own. Psychologists and doctors are often seen as all-knowing and having it together. Patients need to see us in this way to feel confident in our ability as ‘fixers’.
But psychologists are as fallible as anyone else. There were several moments when I questioned whether I was a role model for patients I was advising on how to cope in a difficult situation.
But I’ve learnt it’s actually these very ‘wounds’ which allow us to connect with patients. That said, as a therapist, while you must step into your patients’ world and empathise with them, ideally, you leave your own behind.
You need boundaries to survive as a therapist, to protect yourself from absorbing each and every patient’s pain. You must retrain your brain to stay in the other person’s story and avoid linking it back to yourself.
Having therapy is vital to achieve this: it helps a therapist gain tools for reflection and resilience, and to be ‘the strongest person in the room’ with any patient. Our ‘issues’ have to stay at home.
One of Dr Cawley’s relationships with with an emotionally abusive, controlling narcissist (file image)
And I had many issues. When I began training, I was young, naive and the man I thought I would marry had just dumped me by text message.
Devastated, I’d moved from my family home in Manchester to London to work, and soon rebounded into the disastrous relationships I described earlier.
I also felt insecure at first that I was ‘only’ a psychologist and not a ‘proper doctor’ like a psychiatrist. (Psychiatrists prescribe medications, psychologists cannot.)
So chaotic was my life, Kelli once told me I was so ‘immersed in and connected to those with emotional problems, difficulties or even pathologies, that they might have become the only people you feel safe to function around. They feel familiar to you, so maybe, subconsciously, in your personal life, you seek them out.’
And, certainly, I was surrounded by extreme emotional difficulties in the workplace. Some of the patients I was presented with were challenging — but in essence, they all needed the same thing. A connection to someone, to feel cared for and valued.
Take Bella, who had borderline personality disorder (BPD). Patients with BPD are often described as ‘the black hole’ and ‘difficult’ by many in the profession, and borderline personality disorder as ‘the dustbin diagnosis’ because of the many ways BPD exhibits itself.
They have such big emotions, that weigh so heavily they are difficult to mask — and are difficult to treat.
Bella, after a relatively long period of emotional stability, was having chaotic mood swings, flying into intense rages and then immediately breaking down in tears. She felt lost, overwhelmed and fearful that her emotions had taken over.
In our initial consultation, I drew a circle in the middle of a sheet of paper. At the centre of the circle, I wrote, ‘Me’.
Then I drew other, smaller circles all over the page at varying distances from the ‘Me’ circle, before passing the pen to Bella and asking her to write the names of her relatives in the smaller circles. The proximity of each relative’s circle to the ‘Me’ one often indicates the closeness of each relationship.
Bella began by filling in the circles with the names of all her children. There are a lot, I thought to myself. When I took a closer look, I saw the children’s names were not placed in the circles closest to her. Instead, the circles with her children’s names were positioned in a border around the edge of the page. Red flag, I thought. As she reeled off their names, I began to see a pattern. Jason, Freddie, Damien, Carrie, Annie, Norman.
Bella responded to the flicker of recognition across my face. Clearly, she had seen it before. ‘Yes, they’re all named after the villains in horror films. I used to be obsessed with those films,’ she told me.
Bella, who had nine children by then, went on to explain her compulsion to have another child. There was a pause and we looked at each other. ‘I’m in my mid-50s now though, so it’s a bit trickier,’ she was forced to conclude.
I’ve worked with several patients who feel almost addicted to having children. One had 18. For Bella, it was about ‘being needed’. She thrived on the sense that the baby was completely dependent on her, something we explored together.
Being needed and wanted was also an issue with Sam, a 17-year-old whose parents had mental health needs of their own. He was reliant on council accommodation after they threw him out.
Affectionately known in the staff room as the Great Pretender, Sam’s initial referral notes read, ‘hypochondriac and possible malingering’ — ‘malingering’ being a clinical way to describe a tendency to make out something’s wrong with you when it is not.
In our first consultation, he had a list of every possible side-effect associated with every medication he has ever taken and read them all aloud, describing how he’d been affected in such a way.
Without a hint of embarrassment, he even told me he had priapism, an extremely rare side-effect associated with an antidepressant, involving a painful erection lasting more than four hours.
He went on to discuss a man who sued his medical team after having an erection for 30 hours, and then declared his own erection lasted for 31.
When he reaches a muscle-twitching side-effect, Sam falls to the floor, shaking theatrically and intermittently glancing up at me with only one eye open.
Sam’s dependence on others for reassurance and comfort is clear — his performances are some sort of coping mechanism for an unmet emotional need, as he eventually admits himself.
‘If I get better,’ he says, his voice smaller, ‘you’ll only see me for six sessions and then you’ll leave.’
Peggy, a dainty-looking 16-year-old, also finds goodbyes difficult. This even extends to the end of our sessions. Her strategy is to make a ‘doorknob disclosure’ — a huge and distressing revelation as we approach 50 minutes, the point at which I’m ready to wrap things up. Peggy can’t see the clock, but has an acute awareness of when an ending is approaching.
On one occasion, at minute 49, she says: ‘Have I ever told you I was raped?’
It’s hard to pack that away with, ‘we have come to the end of our time’. So instead I say, ‘I know ending the session feels hard and I want to hear you and support you in full at the next session, next week.’
The root of all this is Peggy’s very difficult relationship with her mother. As she explains to me, ‘when people let me down, it makes me feel worthless, so I hurt myself sometimes’.
Indeed, Peggy is a prolific self-harmer, on one occasion swallowing five razor blades, which thankfully caused her no significant harm. She has also swallowed batteries, glass, screws — anything that could wound her.
Dr Cawley says she was left doubting her instincts, hypervigilant and anxious because of the behaviour of some of the men she dated (file photo)
In one session, she asks if she can show me her scars. I ready myself to respond before she lifts one of her sleeves. For a split second, I assume she has a sleeve of tattoos. Then I take in the intricacy of silver and red lines with jagged edges and coarse seams. Her arms are a patchwork of pain.
Peggy nonchalantly explains she poured petrol on to her arm and set it alight, resulting in multiple skin grafts and painful operations.
A lump rises up in my throat and I fight tears. The injuries on her tiny body are profound. The shock registers across my face and Peggy sees it; she holds my gaze as if to ask: ‘Can you handle this?’
I compose myself and look straight back at her. I try to explain to her some of the complicated emotions children endure when they are let down and not protected from abuse by those who should protect them.
I point out to her that, in order to combat the helplessness, and the unpredictability of their environment, children will try to take ownership. They locate the blame within themselves to make them feel they have some control in an out-of-control situation. I’ve heard many heartbreaking statements from children, such as, ‘maybe if I am very quiet and don’t make a mess, it won’t happen today’.
This self-directed blame can lead to self-punishment and self-hatred, acted out as self-harm.
When I explain this, Peggy seems relieved to think her actions have a survival component, that they make sense and she isn’t ‘weird’.
Peggy is stuck in the self-harm feedback loop. Someone with unstable emotions feels compelled to seek connection with another person, but lacks a strategy to do this. They soon learn that doing something disastrous to themselves can be a ‘quick fix’.
With a self-destructive act, they receive a short-lived or pseudo-connection with someone else: a loved one will have no choice but to show up for them when called by an A&E nurse.
Failing this, hospital staff represent a caring connection, albeit transiently. This gives the behaviour a function, makes it more likely to be repeated.
A supervising psychologist of mine in my early days of training once said something I have carried with me ever since: ‘If someone needs attention that badly, for God’s sake, give it to them.’
With help, Peggy eventually moves to group therapy sessions and even starts a college course. Her troubled emotions start to heal.
The lesson patients like these have for all of us is summed up neatly by Kelli, when discussing my own disastrous emotional relationships, as follows: ‘You may think on some level that you don’t need intimacy, or that you’re scared to have it in case it ends or betrays you, but the truth is that we all need it.
‘We are attachment beings, hardwired for connection and bonding. The point is, Natalie, none of us can cope alone.’
Working with my patients, I’ve seen how, in times of stress and suffering, we are all susceptible to developing maladaptive, chaotic ways of coping — unhelpful behaviours we feel ashamed about or see as abnormal.
I’ve learned how I can support patients by removing the shame and sense of aloneness in these seemingly odd responses and helping them to find more adaptive ways to cope. My string of relationships with men struggling with their own issues was my way of coping. I was focusing on their needs to deflect from my own.
I was also seeking connection. But there is no shame in that. Connection is the mother of all coping mechanisms. It’s how we regulate our emotions and feel secure within ourselves. Now I can see that the foundation for all our emotional pain is disconnection.
- Adapted from Just About Coping by Dr Natalie Cawley (Pan Macmillan, £16.99). © Natalie Cawley 2024. To order a copy for £15.29 (offer valid until 10/08/24; UK P&P free on orders over £25), go to mailshop.co.uk/books or call 020 3176 2937.
