Tag Archives: psychiatry

Anger, violence and mental health: a response to Deborah Orr

I’d noticed some outrage on twitter about a comment piece by Deborah Orr, published on Friday afternoon, but had avoiding reading it until this morning. The headline is incendiary enough, but it was a sentence in her final paragraph that made me really furious:

It seems to me that lack of mental health, not gender, is the defining motivation of all violence.

At its most basic level, this statement is unsupported by evidence. Women are 40% more likely than men to have mental health problems, and yet over 85% of perpetrators of violent crime are men. If there really was a causal relationship between poor mental health and violence, we would expect women to be the majority of perpetrators of violent crime.

It’s in attempting to make such simplistic causal links that Orr’s analysis falls down. Fifteen years ago, Lori Heise proposed the now widely used ecological framework for explaining violence against women. Heise’s model recognises that men’s use of violence cannot be explained by identifying a single causal factor, but that it is the interplay of personal, situational and socio-cultural factors that result in violence.

Ecological model | Image from Centers for Disease Control and Prevention, 2004. Sexual violence prevention: beginning the dialogue. Atlanta, GA: CDC.

The ecological framework doesn’t discount poor mental health as a factor, but it makes it one tiny piece of the puzzle. And like any puzzle, one piece can’t operate on its own. When a person – usually a man – makes the choice to use violence, that decision is a product of factors at the individual, relational, community and societal level. In a country where the state is sanctioned to use violence to resolve conflict through overwhelmingly male military and police forces, where perpetrators of violence against women are rarely convicted for their crimes, and where sex and relationships education isn’t mandatory on the curriculum (let alone education about consent), identifying poor mental health as the primary causal factor for men’s use of violence seems absurd.

So Orr’s argument frustrated me in its absurdity. But it made me furious because it’s personal.

I was diagnosed with Borderline Personality Disorder in 2004. The first time I’d ever heard of it was when my male psychiatrist gifted me with the label. The diagnostic criteria for BPD is changing, with the publication of the DSM-5 last month, but in the previous version (DSM-IV) there were nine criteria. One in particular stood out and made me believe the diagnosis was incorrect: “inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).” I was being told that not only was I angry, I was potentially violent. That I was a danger to others.

Earlier this year, I requested my patient file from all those years ago. It shows that we discussed the diagnosis over three sessions and although I strongly resisted the diagnosis, after three sessions the psychiatrist’s notes still recorded that I met 6 of 9 criteria for diagnosis and a letter was sent to my GP informing her of the diagnosis. The barely legible scribblings over the many following sessions contain notes like “gets angry – self harm”, “holds anger in onto self”, “showing anger by rebellion, appearance; passive aggressively; repressed.”

And this leads me back to Orr. The pathologising of my anger and being told that I was potentially dangerous to others was about the least helpful thing anyone could have done for me. While my psychiatrist interpreted my anger in his notes, I did my best to avoid addressing my anger in therapy, because I didn’t want to meet the diagnosis I’d been given. I dropped out of psychiatric treatment after 18 months and got on with my life. But I never dealt with my anger.

Nearly ten years later, I’m back in therapy again. I have another diagnosis: moderate depression – an improvement on the BPD, major depression, alcohol dependence and anorexia nervosa I was labelled with last time. Hopefully older and wiser, I’ve found a female counselling psychologist through Mind who I know doesn’t do diagnosis. And what have we been working through over the past several sessions? Finally, after all these years, my anger.

So guess what, Deborah Orr? I’ve got a mental health problem and I’m angry: but I’m not violent. I choose not to be. And that choice has nothing to do with my mental health and everything to do with hundreds of overlapping personal, situational and socio-cultural factors in my life.

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Today is the day.

Today is the day: my first counselling session. I would like to write about how I feel, but truthfully, I don’t feel anything. It’s been nearly five months coming, and today, I feel much like I did five months ago. Numb. Empty. And exhausted. Exhausted by the daily grind of depression, the heaviness of trying to get out of bed, the dissonance of putting on an enthusiastic face for the outside world, and the pressure of wanting to be ‘getting better’ for the people in my life who were so relieved to see me getting professional help.

I ran out of citalopram a week ago and can’t find the prescription slip to order a repeat. I could go back to my GP to get a new prescription,  but I’ve explained to myself that since I didn’t want to be on medication anyway, this is a good opportunity to see whether psychological treatment alone is enough. That’s the rational explanation. The truth is, the thought of seeing him again makes my heart beat through my chest, so I’m avoiding it.

Now today, I have to talk. But what to say? My life is good. I have a well paid, interesting job; a partner who I love deeply and have fun with; a nice flat in an area lots of people wish they could live in; good relationships with family; and lots of friends who I love and who care about me. There is no good reason for me to be unhappy. I could dig out supposedly traumatic events from throughout my life, but in my experience, that’s true of pretty much everyone. So that leaves me back where I started: what to talk about? In my last go at psychological treatment, I remember endless silences because I didn’t know what I was meant to talk about.

A couple of months ago, I requested a copy of my patient file from the psychiatrist I saw in 2004-5. It was hard seeing things written down about myself, things that I didn’t recall being spoken in the room. Words like “anorexia nervosa: partial remission”, “drunk today”, “borderline personality traits: see for further assessment”. There were also the letters between my psychiatrist and my GP, which I’d not seen before.

I feel she is suffering from a mild to moderate Borderline Personality Disorder. She describes a long history of labile mood, and has been self lacerating for the 2 years. She also bites her fingers to cause pain, and can also be reckless with spending and sex.

And a year later:

If she remains engaged in therapy she should continue to make slow but steady progress.

I dropped out of treatment a month after that last letter was written.

I feel reassured that this time I am seeing a counsellor without an official referral from my GP, so they won’t share information about me. But I know I suggested in an earlier post that it would be useful for them to share information. The point is, I want information shared in a way that includes me. I want professionals who are collaborating in my treatment with me. If they communicate, I should be copied in. Instead, I get a choice between uncoordinated treatment from two separate professionals who don’t know what the other is doing, or coordinated treatment in which I have no voice.

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