The following letter was written in response to our online play, Life in Boxes, created as part of Queen Mary University Conversations.

Maria Grazia Turri

Letter to a Mental Health Patient from a Psychiatrist turned humble

Dear Mental Health Patient

I am writing to you after seeing Life in Boxes, a play by Isabel Dixon, streamed live by The Space, a theatre I will surely visit in a post-pandemic world. While boxed in our homes to protect ourselves and each other from a deadly virus, we’ve had more time to reflect on what we’d like the world to be, once we’ll be free to roam it again. For my part, I’d like to see fewer lives in boxes and more stories told and listened to.

In Life in Boxes, a dead mother leaves as her legacy to her two daughters a secret identity hidden away in storage boxes. It made me think of the boxes you, my dear mental health patient, would leave me, should you be allowed to drop them at the door of my office. When we met, I asked you about mood, sleep, appetite and concentration, unusual beliefs and hallucinations, so that I could tick the boxes on my diagnostic checklist. You didn’t complain when I talked at you and not with you. How patient you were! You went along with it, obligingly, and let me be the expert about you.

Let me admit that, honestly speaking, I know nothing about you. I only know a lot, an awful lot in fact, about this ‘thing’ which I call your mental disorder. And the reason why I know a lot about it, is because I invented it. Well, not me exactly, some of my buddies who take the time to compile a big manual called the DSM (Diagnostic and Statistical Manual of Mental Disorders). The DMS is sometimes called the bible of psychiatry , and the name fits it perfectly, as we psychiatrists are its devoted clergy: in the DSM, and only in the DSM, we trust.

The DSM is a comprehensive catalogue of all the mental disorders to be found on planet Earth (and perhaps beyond, who knows). It gives every human suffering the great opportunity to be filed away in neat storage boxes: each diagnosis is a box, with a label on the outside and a menu of symptoms listed underneath. For each patient who comes to our office, we check their symptoms against each menu and we file them away in their matching box. So I filed you. And I apologise if, as I got to know you a bit more, and I noticed that your symptoms weren’t quite what they seemed at start, I had to take you out of one box and put you into another. In certain cases, I have to admit, a patient may have to be split and put into two or three boxes at the same time, but to no great inconvenience to them, we hope.

Well, all this boxing, that I carried out for so many years, even decades, has left me somewhat drained. Perhaps I realise it too late, but as they say, better late than never. Especially as I’ve come to know that there are other ways to talk to patients like you. I recently discovered the Power Threat Meaning Framework, a new tool for assessing mental health patients published by the British Psychological Society in January 2018. When we see each other again, I will be sure to use it, but should I forget, please help me remember.

You might have heard that this framework was highly disliked by some of my more illustrious colleagues. Some consider it a heresy. Others, perhaps tongue in cheek, have claimed that psychiatrists take the Power Threat Meaning Framework to Mean a Threat to their Power. For my part, I got going reading its 400 pages and I became aware of a great body of scientific knowledge that was mysteriously kept hidden from my sight thus far. There is an interesting parallel here, between you having to hide the truth of your story, and the hiding of the science that validates your story. But I will remember from now on, that your story and the way you tell it, is the only ‘Road to Damascus’ that can take us to the truth behind your suffering and show us the way to healing.

The DSM claims that we don’t know why you and so many other people are mentally ill, but if they had to put a bet on it, it would be molecules in your brain gone astray and gene mutations. Even now, with so much suffering going on behind the closed doors of isolation and anxiety for the pandemic, predictions are made of how many more brains and genes will fail to step up to the challenge. But I’ve had just enough of being the priest of the DSM. The Power Threat Meaning Framework document demonstrates that oppression, marginalisation, poverty, discrimination, racism (aka Power), trauma or the threat of it, be it physical, sexual or psychological (aka Threat) are the causes of mental disorders. I must say, it did not come as a surprise. Having worked in psychiatry for so many years, I never met a mental health patient who didn’t have something of the sort happen to them in the recent or distant past. But the DSM distracted me, it made me focus so much on symptoms, and labels for boxing patients in, that I forgot there was a story behind each.

Yet, aren’t you going to be worried that the Power Threat Meaning Framework may only be another trick to box you into new labels and categories? I promise it will not, as the things I’ll ask you when you come to see me again, will be: What has happened to you? How did it affect you? What sense did you make of it? What did you have to do to survive? What are your strengths? What is your story? It will always be about you and what you make of what happened to you (aka Meaning): you’ll be the expert in your own story. I will be there to walk by your side and help you through your journey of recognition and recovery. And I will have things to say, perhaps even expert things, but I will always check with you that my suggestions, my advice, my prescriptions even, make sense to you and that you are interested in trying them out.

In Life in Boxes, two daughters are gifted with an opportunity to question themselves through the discovery of their mother’s secret boxes. Thinking of your secret boxes, I questioned myself as a medical doctor and I rushed to look up the definition of medicine in the Cambridge English dictionary. This is what I found. In definition number one, medicine is the treatment and the study of illness and injury. In definition number two, medicine is a substance (liquid or pill) that is used as a treatment for illness or injury. I wonder when, as a doctor of medicine, I became a doctor of pills instead of a doctor of treatment in a more generous sense of the word. Listening can be treatment, understanding can be treatment, comforting can be treatment, educating, advising, guiding, supporting, assisting, succouring.

When did medicine in psychiatry come to mean dispensing pills? When did treatment in psychiatry reduce itself to pills, liquids and injections? I don’t know, I’ve lost track, but I guess it has got something to do with the DSM. For each patient there is a DSM label, and for each DSM label there are matching boxes of medicines. Let’s say that the psychiatry I have practised so far is like a bleak warehouse: in come people to be put in label boxes and out come people holding a number of boxes of pills to be swallowed, digested and boxed within their bodies for the rest of their lives. And all under the pretension that what causes mental illness is some molecule that goes astray within the braincase. Another box, the skull, holds the brain, the focal point of interest for research into mental illness. We do like boxes in psychiatry!

And yet, if the mental refers to the mind, there is so much more to the mind than the brain. Studying the brain to understand the mind, is like studying a leaf to understand a plant. There is no leaf that can function in isolation from the rest of the plant, and no plant that can function in isolation from its ecosystem. So far I was scared. Scared of being shamed for not understanding that mental health pertains to medicine and biology. It took me so long to appreciate that being against the DSM and against the equation between brain and mind does not mean I’m against the bio-medical model of mental health. It is only just to be against a mistaken definition of what biology and medicine mean. Biology is always ecology, as there is no isolated life, only life within an ecosystem. And medicine means studying and treating illness, not dispensing pills. I’m not against biology, nor medicine, only against a dull restriction of what they stand for.

Thanks to the Power Threat Meaning Framework, I will put my study and treatment of your suffering in the context of your ecology, your mental health in the context that makes it possible: family, friends, work, housing, finance, social class, past history, current joys and concerns, dreams and dreads for the future. Who cares for you? Who do you care for? What do you care about? What concerns you? What gives you joy? What do you need help with?

But there is more to it. If it is true that… No, wait a moment, no ifs or buts. Because it is true that oppression, marginalisation, poverty, discrimination, racism, trauma and the threat of it, be it physical, sexual or psychological, are the causes of mental disorders, then the cure for mental illness is first and foremost prevention of those social ills. If we are serious about fighting for better mental health, and if mental health is a human right, then we must prevent oppression, marginalisation, poverty, discrimination, racism, trauma and threat. Take the metaphor of a council that leaves its roads wrecked and cracked, and the people breaking their legs in the hundreds, taken to hospital, put in a plaster. Would you agree that if the council invested in repairing the roads, there would be much fewer broken legs, much less needs for hospitals and plasters, and many more happy citizens overall?

As you can see, Life in Boxes has given me lots of things to think about, and one more. It’s made me ponder how actors and playwrights and artists know the human mind more than anyone else. To invent characters you need to know them from the inside, know their stories, what happened to them, what sense they made of it. Those questions which I will ask you, using the Power Threat Meaning Framework instead of the DSM, may be questions an actor employs to learn her role, or a playwright to write her script. I believe this is the attitude we call empathy, and we need so much more of it in psychiatry and beyond. And you know what? Although I am sure that a trip to the theatre, or a book, or a visit to a gallery may do you good, I will not give you arts on prescription. You’re as clever as I am, and you’re probably writing, or painting, or making music already, despite never telling me, because you thought I didn’t care. In fact, what I’m going to do, is to give myself some arts on prescription. Send psychiatrists to the theatre, to learn a thing or two about the mind, their patients, and how to be human again. Send us to the theatre to be unboxed.

With my very best wishes, your psychiatrist turned humble.