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Tender is the night: The strain on family members of sufferers of mental illness
by Solomon Wakeling
There has been
much talk of the value of high literature in schools, so I thought it
appropriate to dwell on some that I've read. There is no better way to lead
than through example. Of course discussing literature should need no excuse.
Is there a more
perfect novel than Tender is the night?
When I first read this book I felt like it was the first real communication I
had received from an adult. That is how much it meant to me. I was shaken. I've
since read it over many times and each time I still find something new in it,
some extra layer of detail that I had not seen before. Each sentence is
exquisitely constructed, adding something extra to the whole. It has taught me
the value of a single sentence. I found in it a haunting, painterly and
hallucinatory quality which exists outside of the plot and characters,
deserving of recognition as a landmark in its own right.
This was all after
hating the book passionately, after having read only the first few chapters. In
the early parts of the novel, there is something intensely alienating about the
protagonist, Dr Richard Diver. This is the kind of book that requires
perseverance and advocacy, to ensure it is read in full.
By the end of the novel Dick Diver has undergone a complete change of character. In the first book he is viewed from the eyes of Rosemary Hoyt, a young actress who sees him with youthful idolatry. In the world of the novel, Rosemary is the prey, representing what everyone in the novel would like to have or to be. She is youthful, beautiful, talented and disciplined. In a way, there appears to be more of Fitzgerald in her than in any of the other characters. He sympathises with her search for something unattainable. No matter how hard she improves herself, no matter what she is willing to give, she is unable to receive the love of a father that is now dead.
The second and third books view him more objectively. He begins sober, observant, attentive and in complete command of himself. By the end he is an anti-social, brooding alcoholic who has driven his wife away from him and abandoned his children. Paradoxically, there is continual growth in maturity in his character as the novel progresses. His loss of confidence helps him to learn sympathies with those that he would previously have looked down upon. He loses his shallowness and becomes approachable, rather than alienating. Fitzgerald prophesies his transformation through the use of a nursery rhyme. "The best I can wish you, my child, is a little misfortune." Tragedy in the novel is seen as a complex phenomenon, containing brighter as well as darker shades.
I found myself going on a journey with Dick, at first repulsed, then intrigued and finally feeling a mixture of pity and love. The last chapter is seen through the eyes of his wife, Nicole, and we feel her sense of loss. Somewhere, we feel, something could have been done to prevent all of this.
Misfortune makes Dick grow, but in the end it breaks him. The plot of the novel, a man who is driven to alcohol by his schizophrenic wife, makes an obvious parallel to Fitzgerald's own tragic life with Zelda. There is no doubt Fitzgerald drew upon his own experiences in constructing the story but there is every reason to believe that Dick and Nicole were never intended to be Scott and Zelda. The unflattering portrait of Albert Mckisco, the scruffy literary man with his naive wife, better represents the two of them at that stage in their lives than the glamorous Dick and Nicole. Sheila Graham notes that Dick Diver was intended as the story of himself and Zelda, superimposed on Gerald Murphy. Fitzgerald has observed the vapid and leisure-filled lifestyle of the Murphy’s, and has imposed a tragedy on them that life had failed to do. It is a moral fable, but one that side-steps all clichés. There is no predicting the fate of the characters, yet once it is finally revealed, it seems inevitable.
Like Anne
Deveson's Tell me I'm here, the novel
deals with the under-valued effects of schizophrenia on family members who are
close to the sufferer. In my view, this is the most important aspect of this
multi-faceted work. Fitzgerald vividly describes a "hardening"
process that his protagonist goes through, "Sensing battle from
afar", even though he loves his wife dearly. Towards the end of the novel
Dick is clearly depicted as being both her doctor and her lover and stru
There is much talk of manners in Fitzgerald, almost as if manners were a form of morality. He sees decency in being social, as if it were a moral imperative. He longs for a way of life free of indulgence, excess or immaturity. This conflicts sharply with the reality of schizophrenia, with its messiness, its selfishness and its anti-social nature. The harshness with which he sees bad behaviour is almost a rebellion against insanity. Dick's life with Nicole is described late in the novel as being a "regime". He becomes unsympathetic to weakness and believes his wife's health is predominately a matter of her own will. At his most extreme point, after Nicole has endangered the lives of their children, he is described as wanting to "Grind her grinning mask in to jelly".
Ultimately it is a novel with a single theme: heart-break. The truest and most shattering sentence in the novel comes at the end of the first chapter at the close of book II. "He wanted to be loved, too, if he could fit it in." This sentence contains an ache, one that only occurs because we are aware of what is to come. As in Hemingway, who Fitzgerald treated as his artistic conscience, every indulgence is paid for by work. This contributes to the effect, also seen in Hemingway, of making the novel difficult to break in to, but ultimately moving.
Towards the novel's close, Fitzgerald reveals his trump card. With a single sentence, "Doctor Diver was now at liberty," we are given an extraordinary revelation. Until that time we feel that Dick is lost and completely out of control of his own life. For a second we come to understand that underneath this, he was quietly planning his escape. Having withdrawn himself from his wife he slowly transfers her over to another man, who had something to give her when he had nothing left. He doesn't simply leave, he assures her security, even though the thought of which makes him "physically sick". After his escape, he is unable to do anything else but to repeat the pattern, over again. He has been trained in to healing hurt wherever he sees it, not really knowing how to do anything else.
At the close of the novel, Nicole is substantially free of her illness, finding happiness with another man. The tragic figure of the novel is not the sufferer of mental illness but her spouse. Without proper support, there may be more truth in this scenario than fiction. The question I want to ask the forum is: what can be done to ease the burden on family members of those with mental illness, by governments, the mental health system and by the community at large?
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Another life gone
Today’s SMH reports that on May 29 a man stood in front of a train and ended his life. He had suffered from paranoid schizophrenia since the age of 16 and had made five attempts on his life in the previous six months. On the day he died he was refused admission to hospital.
This is just another life lost due to the breakdown of mental health services in this country. I have already expressed my strong views on this on this thread. The system is totally broken and despite the commitment of some 1.8 billion to fix it, little has as yet changed.
I fear that the money allocated will be spent on bandaid measures with little long term benefit for the mentally ill. For instance, spending money as proposed on making counselling and psychologists' fees rebatable under Medicare is not going to change much. In my view that is money down the drain which would be better spent on providing accommodation and supervised care, and in particular case workers in the community so that the mentally ill do not slip through the system.
From my experience counselling does little to help the seriously mentally ill. Many cannot even understand that they are ill, let alone accept a need for counselling. To turn these people away from hospital, only to see them take their own lives, without hope, without care and without medical help is a scandal.
To expect such people to live in the community without support is simply to leave them to flounder, till they do something desperate as this man did.
I feel desperately sad for the family of this man, and those who suffer similar loss. Many families have struggled under enormous and unrelenting pressure for years, battling the dysfunctional mental health system, only to have it all end like this. Such families live for years in dread of that phone call in the night. And such anxiety over a long period of time is detrimental to anyone's health so there are many collateral victims.
Suicide not only takes the life of the sufferer of mental illness. It leaves families shattered by the horror, by a sense of personal failure and grief that knows no refuge.
Where there is suicide there is mental dysfunction and illness of some form or another. Tragically many who die are young people. When a child dies as a result of a violent crime, some solace may possibly be found in anger, and a desire for justice. When a child disappears, there is always some hope that he or she may be alive, somewhere. But when a child takes its own life, there is nowhere to go. There is no solace to be found, anywhere. Family members cannot comfort each other for they find it hard to even comfort themselves. Relationships fail and the extended family system is shattered, often permanently.
Economic loss though lost work days, even jobs, and forced early retirement as individuals struggle to cope, is an inevitable consequence of suicide in any family.
The youth suicide rates reached a peak in 1997 and the Government advertising initiative may have helped lead to the decline from 1997 to 2001. However no statistics appear to be available since that year, but young people are still taking their lives in unacceptable numbers. Gifted children are often overly represented and for every child that dies, there are large numbers who attempt suicide which masks the full extent of the tragedy. Clearly there needs to be on going initiatives to reach children in crisis and one would hope some of the funds will be committed to programs in this area of mental health.
There is also a high rate of suicide amongst country people (double that in the community in general) and many of those are also in the 15-24 age bracket. The growing attendance at rural seminars on depression is a sign that the current drought is taking an enormous emotional toll on families. I know only too well, having seen my family go through several long and severe droughts, just how great the pressure can be. Long hard days of physical work, followed by nights of worry over financial pressures is a catastrophic mix. Then there is the added trauma of seeing animals suffer and die. Often the depression last for years after the drought ends, as the financial pressures continue for those same years.
Rural communities, especially in the wheat sheep belt in NSW and Victoria are in decline and I see evidence of that all around me, with all the families now gone in a 15 km stretch of our road in the past 8 years. Hence the support that neighbours could give to each other is often now absent, with abandoned homesteads common. That in itself is a depressing sight and increases one's sense of isolation and loneliness.
We will, I fear, continue to pay dearly as a society for the failure to put adequate and appropriate resources into mental illness, and alleviating stress and depression in rural communities. How the available funds are spent remains to be seen, but unless these are properly targeted then little will change in my view.
Fiona: Jenny, we live in the luckiest country in the world. We are experiencing a time of unprecedented prosperity. If people are having these sorts of reactions to the restructuring that we have to have in order to be part of the global economy, surely it is their problem, not ours? (Forgive me, Jenny, you know that my heart bleeds too. I truly do not know what it will take for those who espouse the view that I parodied to see their error. A Damascene revelation? If only.)
Living in crisis
That it will take1.8 billion to try and rectify the crisis in mental health services in this country speaks for itself. But I have little confidence however that that money will be spent in a way that will make any real difference. The system as it currently exists fails the sufferer, the family and the community and to me is a national disgrace.
The average stay in hospital for even the dangerously ill paranoid schizophrenic is now just 8 days. It takes up to six weeks for there to be any real beneficial effect of medication, during which time the sufferer is out there in the community, or in the home, suffering, and while doing so, wreacking emotional and often physical havoc on the lives of those around him or her. If he or she is living alone, then their families come to dread the sound of the telephone, not knowing how bad the news will be, but always expecting and fearing the worst.
Crisis intervention teams are understaffed, stressed, over worked and often have to rely on a reluctant police to assist them when mandatory detention is clearly required. There is no cohesion in terms of follow up by the mental health authorities once a sufferer is released from hospital, and most times no follow up at all. Too often the follow up is expected to be at the initiative of the sufferer, when the sufferer is totally incapable of exercising that initiative. This simply means relapse after relapse with families lurching from crisis to crisis.
As for family support, there is none. I know of people in their seventies struggling to support and care for seriously mentally ill adult children (one woman has three with schizophrenia) and one wonders just what will happen to all these mentally ill people as their carers age with the general population, and become increasingly unable to cope. Who exactly is going to care for these people? We can be sure that the aged care industry with its eye on profits will not be stepping up, as most mentally ill people have few assets or financial resources.
For the seriously mentally ill I do not believe living in the home with family should be the only option but that is the option that many face, and their families also have little choice in the matter. Roger, you are quite right. Families cannot make much difference to the outcome for the schizophrenic sufferer. Hope has no place. And love is crushed under a load of stress. The home becomes an emotionally barren landscape for every interaction is as you say, dysfunctional.
Three months home care, with two weeks mandatory care to give respite for the family. Well many families I know with a mentally disabled adult relative just want out and out permanently, especially where the illness is schizophrenia. Not because they do not care, but because they cannot cope with the enormous emotional stress and because they do know that what they do rarely makes any difference. They are mortgaging their lives for no return and they know it. What they want is full time care in the community, by the community, thus giving them some freedom in their own lives. And if Roslyn Ross is correct, and I think she is, giving the sufferer a better chance of assuming some semblance of control over their life and their illness. Families can in fact be in the way of the mentally ill person in terms of their ability to manage their own illness and lives. They need assistance, but family members are not necessarily the best persons to give that assistance.
With children it is somewhat different, but ultimately the dysfunctional child grows up and at the time when most parents are seeing their children leave home, those with the mentally disabled child face a terrible dilemma. Without the option of quality community care they face mortgaging the rest of their lives for that now adult, and often violent and abusive child, and as they age, the fear of what will happen to their child after they go dominates their lives.
Clearly what is needed is not short gap measures such as short term respite care. Such a remedy is predicated on an assumption that families want to go on living with their mentally disabled relatives and I do not believe that we can make that assumption. In most cases, I suspect the opposite is true. What is needed is long term community care facilities along the same lines as the aged care facilities with appropriately trained staff.
Mentally ill people are just that. They are ill. And for their illness there is yet no cure. Many of them require life long care, and that care should be provided for them by the community. Families have a role to play but it should not have to be one of full time carer, unless they chose it. Today they have little choice in the matter. It is either that or see their loved one leading an isolated lonely life in a housing commission flat, or worse living under a bridge or on a railway station. Many of course, simply finish up in gaol.
Mental health crises
David Candy: "But if interactions with police lead to criminal charges or the killing of a person who has not broken the law what should I do next time?"
David, I have also recently been involved in a situation where police were called after a mentally ill friend expressed suicidal intentions to me on the phone and the ambulance I called were unable to find her. I am thankful that they handled the situation pretty sensitively and my friend is somewhat better now after a couple of weeks in hospital. My husband is a GP so I have had the luxury of his advice backing me up in the months I have been attempting to convince my friend to accept help.
Legally, a person whose mental illness is at the point where they are a danger to themselves or others is detainable. In my state (SA) any doctor can initiate a detention and I think it would be the same elsewhere. Initially the person would only be detained for a short time unless it is confirmed by a psychiatrist. So my advice would be to get your neighbour to a doctor, one way or another. My state has a 24-hr mental health crisis phone number and I imagine other states would have similar lines available. They are happy to provide advice in the sort of situation you faced, but I can't imagine them telling you to do anything different to what you did, given your neighbour was in the process of putting suicidal plans into action.
respite care can't be mandatory
Roger , I think respite care in hospitals at regular intervals would be extremely beneficial for families. The caveat I would place on it is that I don't think it should be mandatory. I think unless someone is acutely unwell, then there is no justification for detaining them. At present, you can book yourself in as a voluntary patient and I think this should be encouraged but not forced. I can also see some practical difficulties in wanting to incarcerate someone who doesn't want to be; They may have to be forcefully sedated, which seems to be a grave road to walk down unless it is absolutely necessary.
Roslyn, I take it you were referring to my comments and not Roger's<. I'm sorry for misreading your comments re too much love. I can well understand how a carer may see their role as simply trying to keep the peace. I think in many situations they would have their hands full just in managing that. I think the best strategy is not simply to make sure that the person is "controlled" but to teach them methods of self-control. I think drugs can help a person regain control of themselves, which is why I support their use.
Problematic
Solomon, I understand what you are saying. My concern is that a voluntary system is a system that breaks down under the abuse it ultimately fosters. The point to mandatory respite is that its main concern is for the primary carer.
We have mandatory attendance requirements in many government initiatives. It is not a matter of punishment or overt interference but one of providing balance to the ongoing treatment of mental illness sufferers. It would also be continually under review with periods of mandatory hospitalisation reducing with improved mental health.
Last night
Last night I went to supermarket at 8pm. Found neighbour with garden hose attached to exhaust pipe of his car (my Dad euthanised himself this way four months ago). Talked to him and "asked what are you doing?". Told me bullshit so went to supermarket calling an ambo on the way. Got home as 3 x Police cars and 1 x ambulance arrived. Neighbour had disappeared. Came and complained to me after police left (was hiding) so I rang police to tell them he was ok. Got him and police to talk to each other. Police kept him talking until they arrived a second time. Thought they had taken him to hospital.
This morning.
The guy ran from Police and was arrested and charged with resisting arrest. I called ambos so police wouldn't be involved. I suppose he was lucky he wasn't shot.
Now I have a belief neighbour is a criminal. I rang ambos not police as a result. My concern was his life (of someone I avoid).
He had committed no offence (that the police knew of). Police were concerned for his safety (as they should be). But if interactions with police lead to criminal charges or the killing of a person who has not broken the law what should I do next time?
The dual dance
Solomon: A thought-provoking post. In terms of what can be done to 'ease the burden' I would suggest the first thing which needs to be addressed, and which often is not, is the 'dual dance' which takes place between the person who is mentally ill and those around them.
My experience has shown me that often 'mental illness' is not just aided and abetted by partners and family members, it is at times re-inforced because it is required. Albeit unconsciously.
My mother became mentally ill when I was nine and never regained mental wellness of any lasting nature for the next 45 years until her death. My mother-in-law also experienced severe mental illness for nearly twenty years before her death. During that time I was instrumental in working with my father-in-law, because my husband was an only child and we lived in another State, in trying to get help.
A part of the problem in securing adequate help was a lack of anything beyond incarceration, short-term basis only, and drugs and a reluctance on the part of my father-in-law to change his way of relating to his wife. I would add, he spent most of that twenty years caring for her at home: feeding, washing, dressing..... as she lay almost permanently, face down on the bed.
He was absolutely wonderful but he was also a part of her problem, as was my father with my mother.
My observations over that time eventually led me to 'see' that the relationship, particularly that between husband and wife, although also between parents and child, is a core factor in what sort of mental wellness, if any, the person regains.
It is an acknowledged psychiatric fact that some people in family, or partnership situations, become 'coat hangers' for the emotional, psychological and even spiritual dysfunction of other family members.
I also believe that these 'coat hangers' are usually the most sensitive, 'thin-skinned' or psychically vulnerable members of the family.
This is a complex subject and I can only agree with you that support is needed but we need to be careful about who we are supporting in doing what.
Treatment
Roger Fedyk, everything I've read points towards community/family care as the preferable option to institutionalisation or hospitalisation. This would be in conjunction with professional help, rather than placing the whole burden on individuals and their families. I think this kind of system takes the best of both worlds. That is if the person receives any treatment at all. 62% of people with mental disorders don't recieve any treatment at all.
Roslyn Ross , I think you raise an interesting point. Too much love could in fact be counter-productive. I think that in such a situation, community education on how to treat people with mental illness would be useful. I think that the ideal approach is to try and maximise their independence, whilst taking in to account that they may need assistance from time to time. Sometimes it is better to help people help themselves.
A Worthy Aim
Solomon, I agree with the general concept of family care and think that it should be combined with a form of hospitalisation which provides respite for home carers at regular intervals.
This would allow the sufferer to have professional assesments done in a regular pattern of treatment while allowing carers to refocus and re-energise their private lives. Something along the lines of three months home care followed by two weeks of in-hospital care is one suggestion that I have heard. It needs to be mandated and not voluntary with the proviso, that as a sufferer improves, the length of home care stay lengthens.
Alternately should the sufferer's condition deteriorate, the length of hospital stay would increase. The necessary pre-condition is to have medical and hospital staff of sufficient training and independence to make assessments based on clinic evaluation and not on financial constraints.
In today's world everything predicates on money. But it is a false economy to skimp on proper treatment when the carers are at risk of being also added to the pool of sufferers by the burdens placed on them.
Roger: I wasn't inferring
Roger: I wasn't inferring that the problem was necessarily 'too much love' although this can be the issue. I think the problem is often 'fear'. Fear of change, fear of feeling, fear of lack of control, fear of dealing with the 'untidy' and potentially 'traumatic' experience of being other, or acting in a different way.
Human beings in relationship tend to take on roles and these roles become entrenched more easily where mental illness in a partner or family member is involved. I think this is because people instinctively fear mental illness; it is in fact much more terrifying than physical illness because for most people it is so hard to understand. More than that, it seems so far beyond anyone's control.
The terrible thing about loving someone who is suffering in this way is that, unlike a physical injury, you cannot comfort them. Often you cannot help at all and your efforts to help are rejected. In addition, the person who is suffering cannot be comforted as he or she could be with a physical condition. The sense of helplessness is so much greater with mental illness that it magnifies the sense of fear.
A lot of the time, the carer or carers want only to keep things manageable, to keep things as ordered, peaceful, calm, as sane as possible and this, very often, is not in the best interests of the 'ill' person even though it may be in the interests, or appear to be in the interests of the carer.
But this attitude reflects society. What do we do with the emotionally traumatised, particularly women I might add? We drug them. A woman hysterical over the body of her child is led off and drugged to the eyeballs. The grief is then 'locked' into her body and her mind but those around her feel better because she has been calmed. Things have been controlled.
The human psyche is messy. Mental illness is evidence of that chaos and disorder. It scares people. We have improved because at least now people will talk about it. My mother lived in shame all of her life because she had grown up believing that mental illness was shameful, and, like Down's Syndrome children, something to be hidden.
We still, I think, seek to 'hide' mental illness in terms of its raw, seeping reality, if not its actuality. And that is why the ill often remain ill. Their road to wellness threatens to be far more traumatic for those around them than their place of illness.
A Case For Sainthood
Solomon, your post raises many issues, the most important of which, after trying to restore mental illness sufferers to health, is the ability of the non-afflicted family member/s to cope or contribute.
The most striking facet of mental illness, irrespective of its causes, is the dysfunction that it brings to all interactions with the sufferer. As such, it is an exceptional person who is able to cope for any length of time.
Parents are the ones who have the biggest burden to carry but all family members are affected. We see just how difficult caring for sufferers is by the very fact that institutionalisation has been the standard community response until very recently.
Today, as we know, spiralling health care costs has seen governments move away from involvement in care or services for the mentally ill. I am implying no criticism, as the government is us, and our representatives are far more tuned into community sentiment than we give them credit for.
Mental illness sufferers have been returned to the community and family with the ill-founded hope that the community and family can provide a better quality of care. Unfortunately, it makes the problem of long-term care and treatment, an invisible problem. The emotional and financial cost on family is enormous and the fact that government policy actually mirrors what the wider community accepts often has serious and sometimes tragic consequences.
In the case of schizophrenia, it is beyond the ability of any non-professional to make a real difference in outcomes. The illness itself is not amenable to hope or prayers or best wishes. While it is true that family interaction, assuming that it is loving, will help assuage the feelings of alienation that a sufferer has, it is not treatment.