Psychiatry - A Labour of Love?
(A Journey in Search of No-Self)

Dr. Larry Culliford

• Introduction
• True Story
• Dimensions of love
• Love and psychiatry
• Giving up attachment to the ego-self
• Conclusion
• Acknowledgement
• References
• Discussion

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Introduction

Given the title, there is no way to avoid this being a substantially personal view. I hope you will not think it too self-indulgent. Be that as it may, I should like to begin with a passage from the recent College Newsletter by someone else - the College Registrar (Shooter, 2001). He writes:

'Given the current opprobrium heaped on psychiatrists… I must really love this job - because only a fool would do it otherwise.'

These sentiments echo those of an article in The Guardian in 1984, which was called, 'Are Psychiatrists Nuts?' in which the author describes his work and alludes to its benefits. I will say more about this later, but in the meantime, here is a true story. It is about love - and I find that I want today to explore the subject of love, especially the spiritual dimension of love, more than that of psychiatry, although I do of course want to tie them together.

True Story (from Whiteside (2001))

A man, Danny, fell in love with a woman. The woman, Elizabeth, fell in love with the man. This happened quickly, and there was soon a significant degree of trust and affection between them.

Elizabeth lived alone in a house and Danny often visited her there. After a time, for the sake of convenience, she had an extra key made for his use. Their relationship flourished. In time Danny proposed, and they were married. After Elizabeth moved in with Danny, she took back the newly redundant key to her former property and had it gold-plated, returning it to Danny as a symbol of their love. Elizabeth wrote a message for him in the card she gave him with the key: "There will never be any locks or barriers between us for evermore". Quite soon after this, however, she developed a serious illness, a cancer, for which surgical treatment was not completely successful. Three years later the disease had spread. Calmly and with courage, Elizabeth eventually died.

Danny was, of course, stricken with grief. The delay between diagnosis of the tumour and Lizzy's death had given him some opportunity to prepare himself, but the blow was a bitter one nevertheless. Little by little, though, he began to recover and to remember more of the happy times they had shared. One night five or six years after she had died, Danny had a peculiar dream. By coincidence a friend was staying with him at the time. This friend, John, was an experienced psychotherapist, and was used to helping people interpret their dreams. As they sat at breakfast, Danny tried to describe his experience during the night.

He recalled walking in the dream down a narrow street after dark. To his right there was a building behind a wall. It seemed like a large private house, but he did not feel particularly interested in it because he was intent on continuing down the road. Several people seemed to be waiting for him there, although he did not know who they were. As he passed by, he was just aware of a single light in the upper window of the darkened house, and it occurred to him that there might be a woman there. He thought perhaps he had a glimpse of her shadow passing quickly across the window, but when he looked up he could see nothing.

In the dream, Danny's attention now turned to the downhill curve of the lane and to the people waiting for him, but as he was leaving the house behind he noticed an upended brick on the path beside the wall. On top of the brick, he suddenly saw, was a key. In the dream, and as he spoke of it to John, he thought little of it, but John stopped him and asked about it. "Keys are often significant in dreams", he said. "Can you think about it some more? Could it somehow be connected to the shadowy woman?"

In a flash Danny remembered Elizabeth, and the gold-plated key she had given him. He even went to fetch the still shiny, precious golden object from its safe place in another room to show his friend. He remembered again Elizabeth's message, "There will never be any locks or barriers between us for evermore", and he remembered the innocence, the purity with which he had loved her, the joy and contentment, the mutuality, the total acceptance of each other between the two people.

It was a wonderful and powerful feeling, different from anything Danny had known before, even at the height of his love for Elizabeth. All the components of happiness were present and none of the painful emotions, but this time the feelings were not just connected to his wife. Somehow Danny knew that this loving sense of irrevocable inter-connectedness was present between all human beings, including all those that had died and gone before, and those not yet born who would come after.

Danny knew instantly - and unequivocally - that there are ultimately no barriers between people, except for those that we erect ourselves. He knew then that at the deepest level we are unified and interdependent, and that the nature of this unity is love. This was the true meaning of Elizabeth's gift. Much greater than a personal love between the two, it had now metamorphosed into a universal and enduring one between himself, herself and all people of all time. Utterly transformative, this momentous insight was to change his life for the better forever. (If you want to know how Danny reacted to this experience - an experience of healing and growth - you will have to get hold of a copy of my book.)

This story sets the scene for us on the subject of psychiatry as a labour of love. Stuart Johnson, co-author with me of 'Healing from Within' (Johnson & Culliford, 2001), recently told me about a 72 year old man in a psychiatric hospital saying, 'I feel God's love deep inside of me - and it's what keeps me going'. Stuart said that the man also felt the love of the church, and that that too made an enormous difference to him.

As well as divine love, this man feels support from an institution that he perceives as caring. To what extent do our patients experience the institutions of medicine and psychiatry as similarly loving and compassionate? We can discuss this point later.

Like Stuart, I also frequently ask my patients with long-term problems, 'what sustains you? What keeps you going?' One, a woman in her early forties, estranged from her family because of repeated, severe and prolonged bipolar episodes, recently gave me her answer: 'It is the love of my husband and daughter. Even though I don't see them, hardly ever, I always remember how they loved me.' She also had a belief in what she referred to simply as, 'something greater', which sustains her. She wears a crucifix and other charms, which symbolise particularly her reciprocal love for her daughter, and clearly gains a kind of spiritual comfort from this.

Let us try and look a little closer at what this love really is.

Dimensions of love

I have found that in order to do full justice to something, we must examine all its different dimensions.

} - Main focus
] - Additional focus

Starting at the bottom of this hierarchy, love's physical dimension - presumably to do with the endorphins and such like - does not concern us much here today. Neither really does the biological dimension, its neuro-humoral basis and so on. I am not even going to say much about sexuality, important though it undoubtedly is, except to note that it too has biological, personal, inter-personal and socio-cultural dimensions, separable but also somehow intimately integrated.

Already we have spoken of love between individuals, love in the context of institutions, the universality of love between people, and of God's love. These belong to the top three dimensions, but also hint powerfully at seamless interactions and inter-connections between them.

This, I think, is the point of love - it is dynamic. It both flows and unites. It forms the living matrix of creation.

Mature and immature love

But there is an important distinction to be made, I think, between mature and immature love. I mention this here as a prelude to talking about personal growth. I have listed some of the distinctions in the following diagram.

Love and psychiatry

The quote from the College Registrar indicates a truism, that love is not defeated by opposition, but strengthened. I have written in 'Happiness - The 30-Day Guide' (Patrick Whiteside is the author's pen-name), about a possible mechanism for this involving a new checklist of emotions, both painful and pleasurable, (that some here will have heard me speak of before), all of which are called into play by the inevitable experiences of threat and loss following any attachment.

To simplify this process - one of healing - sadness heralds the acceptance of a loss and with resolution come not only better feelings, but also personal growth in terms of improved equanimity and emotional resilience, improved creativity and spontaneity, a greater capacity for wisdom, discernment, joy, calm, tolerance, humility, compassion, kindness, generosity - and love. We can call these spiritual benefits.

There is a point here about healing and personal growth going together. Cure does not necessarily involve growth. This is one of the distinctions between 'cure', an aspect of the medical model, and the more holistic 'healing'. The paradigms of cure and healing can be placed on adjacent continua as shown below.

Figure 2. Health within illness - Trent's two continua.

(adapted from Swinton, 2001 and reproduced in Culliford, 2002)

To quote from the WHO definition of health, 'Health' is more than the absence of disease.

Giving up attachment to the ego-self

The most intense and tenacious attachment of all is to the self, more specifically to a person's psychological representation of him/herself, which we may call the ego-self, comprising all that with which (and with whom) one identifies, consciously or otherwise.

The greatest potential for emotional pain and psychological injury therefore arises when this attachment is threatened - but equally, the greatest potential for growth is there too, through the judicious and necessary weakening of this attachment. And we can train for this. We can learn and continually improve our spiritual skills, for example through meditation, yoga and other forms of spiritual practice (perhaps including regular devotion and worship), and not least by doing 'good works'.

This partly explains a central principle of what may be called 'spiritual' care (see Swinton, 2001), that offering it benefits both giver and receiver.

We cannot function as psychiatrists without having to let go, little by little, of the burden of our attachment to the ego-self, and without working towards the kind of universality Danny achieved through his gift from Elizabeth, that golden key. When Stuart Johnson told me of his 72 year old who felt the love of God and of the Church, he added about himself, 'It is so wonderful to be trusted with that kind of information. You actually get so much back from that kind of interaction'.

And this, I think, is possibly why people like our College registrar love their difficult jobs. There is nothing foolish about it. Why have each of you entered medicine and chosen psychiatry? I look forward to hearing you discussing this point in a minute.

I must now confess that it was I who wrote the article in The Guardian in 1984. Towards the end it reads as follows: 'To the question, "Don't you find the work depressing?" the answer is "No…." We (psychiatrists) are by and large tough people, tough in the sense of resilient. The work makes us so, and perhaps that is why we are attracted to it.'

'Every day in others I see anxiety, anger, bewilderment, guilt, shame, doubt and sorrow - often in painful intensity. Often, I feel these emotions myself. But equally, every day, I also witness tranquillity, acceptance, understanding, forgiveness, self-esteem, self-confidence, self-control and joy in those around me.'

Perhaps I was a bit naïve 18 years ago, but I hope you will at least partly agree with my observations. My closing words were: 'every day I see people growing - patients, colleagues and all. This is my life. I am alive…and I love my work.' This is true for me, even today.

In the practice of psychiatry, both individually and collectively, we are engaged in very challenging work. Setbacks occur frequently, if only because, according to Swinton, 'The reality for a significant number of people is that certain forms of mental illness are interminable', also of course resistant to treatment. Therefore, he says, the aims and objectives of health care professionals are: 'To enable a person to find enough meaning in their present struggles to sustain them, even in the midst of the most unimaginable storms.' Thus it has to be a labour of love. And I would say that there is a duty we ourselves have - to achieve resilience, emotional stability and spiritually mature ways of living and coping. It is a duty but as we make progress, it is also a joy and a blessing. We grow thankful that the work does demand this of us, and gives us life.

Conclusion

To finish, and explain that comment, I would like to quote one of my favourite spiritual guides, the Trappist monk Thomas Merton, who died in 1968, from his book, 'Love and Living'. Merton is asking, "What is love about? How do you think about love?" He says:

'Love is the revelation of our deepest personal meaning, value and identity - but this revelation remains impossible, as long as we are the prisoner of our own egoism.
Love is the transforming power of almost mystical intensity, which endows the lovers with qualities and capacities they never dreamed they could possess.
Where do these qualities come from? From the enhancement of life itself - deepened, intensified, elevated, strengthened and spiritualised by love.
Love is only a special way of being alive. It is the perfection of life. He (or she) who loves is more alive and more real than he was when he did not love.' (Merton, 1985)

For me, psychiatry has been and continues to be a labour permeated by this kind of love. It gives my life much of its meaning and purpose. I feel somehow genuinely chosen to be a psychiatrist, rather than that I chose the profession.

I should like to add that part of our task is undoubtedly to value, care about and support each other and I am pleased to say I feel especially supported within the College and by this group. Our task is also to try and educate - to draw out - those who wish to follow. It has been a privilege to speak to you today. Thank you for coming along and for giving me your attention.

Acknowledgement

Extract from HAPPINESS - THE 30-DAY GUIDE by Patrick Whiteside published by Rider. Used by permission of The Random House Group Limited.
http://www.randomhouse.co.uk

References

Merton, T. (1985) Love and Living. San Diego: Harvest Books.

Johnson, G.S. & Culliford, L. (2001) Healing from Within. South Downs Health NHS Trust.

Swinton, J. (2001) Spirituality and Mental Health Care. London: Jessica Kingsley Publishers.

Whiteside, P. (2001) Happiness - The 30-Day Guide. London: Rider Books.

Discussion

Reported by Dr. Daphne Wallace

The discussion explored the potential rewards of working in psychiatry, and the difficulties that can arise. One participant drew attention to the difficulty of the Christian concept of 'sin' (implying badness). It was suggested that the right word is 'wound'. We are all wounded people. Psychiatry can transform the wound to love. Other members connected this to the concept of 'the wounded healer'. The current challenge is to be able to step back from the pressures and statutory regulations in order to see love.

The source of the pressure was felt to be partly down to sheer numbers, but also due to societal dynamics. There has to be someone found to blame. There is much anger and anguish but due to the pressure we cannot let go and grieve. Society promotes instant solutions and many social problems come to the psychiatrist who may feel powerless, or else feels driven to 'go the extra mile', which may not be practicable. There is a danger that we resort to a more 'textbook' approach as a defence against criticism. This led to a discussion about the real nature of the loving therapeutic relationship.