Key to the Skeleton Cupboard

In The Skeleton Cupboard: Stories of sanity, madness and hope, Tanya Byron describes her training as a clinical psychologist some 25 years ago through the stories of the people she met on clinical placements, both patients and staff. Ostensibly that is. But as she tells us in the introduction and again in the epilogue, the people she so vividly describes are entirely fictional, inspired by the real people she came into contact with.

She is a good writer, and the stories she tells are exciting, challenging and thought-provoking. This is a very enjoyable book to read. If Tanya Byron felt like a change of career, then writing fiction is well within her compass.

How much does it matter that the material is made up? As I have argued many times, good fiction can convey truths better than facts. This is true here too. A reader can learn much about anorexia and family dynamics in the case of Molly, for example, or the care and challenge of those dying young from AIDS in the case of Tom. I too have written a memoir in which I fictionalised real cases, but there was a difference. I always stuck to the facts of the referral, the assessment, the therapy, the nature of the therapeutic relationship and the outcome. Byron does not tell us if she did this. We do not know if there was a real Molly or Tom or whether they are entirely a work of her imagination. The people feel real, but that is what good fiction writing can do.

Despite this uncertainty, I thought the book illuminated what a young and inexperienced psychologist might find when in some tricky clinical encounters. To her credit, Byron does not shirk from showing her foibles and failings as well as her successes. In her account of her younger self, she comes across as a naive, stubborn, engaging, personable, empathic, friendly, fashion-loving, arrogant, self-doubting, self-believing 23-year-old woman with a flair for personal relationships and the courage to tackle big issues and to make mistakes. It is a vivid self-portrait.

There are some striking omissions. Given this is about her three years of clinical psychology training, we hear nothing of the training course itself, her fellow trainees, the academic programme, the different tutors she met, and only passing asides to the relentless demands of the course, such as the final-year dissertation, course essays, case presentations and exams. From this book you would think that the only important training took place on clinical placements. Perhaps that is the message. But I cannot believe that the bright young Tanya was not also caught up in the many other aspects of training.

There is a curious elision. Chris, the one tutor she does describe at length, with whom she has a warring and engaging relationship for three years, is both the clinical tutor who organises her placements and her clinical supervisor on every placement! But trainees have a different supervisor on each placement and the roles of the clinical tutor and clinical supervisor are not the same. Where are Byron's clinical supervisors and why are they not in the book? In my experience, supervisors play a huge part in shaping the experiences of trainees. Did they not do so for the young Tanya, I wonder? 

This is a work of fiction that is drawn from the young Tanya Byron's experiences during training. It shows how personal clinical psychology is and how tricky it can be for a young person. Its often dramatic and heartfelt stories will resonate for a long time after reading. I strongly recommend it. 

Macmillan; 2014; Hb £18.99 Published now in paperback by Pan Books
Reviewed by John Marzillier who is a writer and clinical psychologist based in Oxford

What follows is the book's introduction, reproduced here with kind permission of the publishers and author.

MY GRANDMOTHER'S FRONTAL LOBES

Frontal lobe n. (pl. frontal lobes)
1. Each of the paired lobes of the brain lying immediately behind the forehead, including areas concerned with behaviour, learning, personality and voluntary movement.
2. A region of the brain that influences higher mental functions often associated with intelligence, such as the ability to foresee the consequences of actions, planning, comprehension and mood.

I first became fascinated by the frontal lobes of the human brain when I saw my grandmother's sprayed across the skirting board of her dark and cluttered house. I was fifteen.

A young woman – eight months pregnant, I discovered much later, and a heroin addict – had battered her about the head with an iron fire poker. She was an ex-tenant of my grandmother's. Th is woman knew that her former landlady, a German Jewish refugee recently converted to Christianity, had treasures and cash galore stashed among the chaos of her large house, the top two floors of which she rented out.

A few blows to the head, a quick rifle through purses and drawers, and the woman was off, cash in her pocket to pay off her dealer and secure her next hit. My grandmother lay on the carpet of her front room, bleeding from a large head wound. I don't know whether she was conscious or not. I do know exactly how she died: by slowly asphyxiating, choking to death on her own blood.

Asphyxiation: that was the problem, of course. If only she'd died instantly from the head trauma, the crime would have been treated as murder. If only she hadn't been a stubborn, wilful woman – a woman who had fled Nazi Germany pregnant with my father, a woman who had lost many of her family in concentration camps, a woman who never took anything lying down, except when she was beaten with an iron fire poker.

There she lay, refusing to die, until she choked on her blood. The woman who had beaten her was sentenced to only three years for manslaughter with diminished responsibility. She had her baby in prison and was out within eighteen months.

OK, to be honest, I am not entirely sure that my grandmother's brains were on the skirting board when I went into her house that day at the age of fifteen. Is that a direct memory or something I told myself later on? In fact, I'm not sure I remember much of that day at all except two things: a massive bloodstain on the carpet and my father making a noise like an animal caught in a trap.

In that moment I became the rational coper. My darling father howled, but I just shut down and began to try and understand how and why.

Had she died in pain? Did she know she was dying before she died? What had compelled her murderer to smash her head in? Had the woman planned it? Did she want to kill my grandmother or merely maim her so she could plunder?

All these questions about the shit end of life, at a time when I should have been unthinkingly hedonistic. At fifteen years old, my frontal lobes were in a post-pubertal stage of reorganization, which meant I should have been taking my own risks and thinking bugger all about the consequences.

But on that March morning it was only and all about frontal lobes: my grandmother's on the skirting board (perhaps), her murderer's – clearly under-functioning – and mine, clicking into a precocious place of calm rationality that I now believe began my journey into the profession of a mental health practitioner.

This book tells the story of my clinical training. It takes place over the course of three years from 1989 to 1992, when I was in my early twenties, during which I underwent a series of placements in diff erent mental health settings and worked with several distinct kinds of patient: troubled children; families in crisis; men and women dealing with the encroaching effects of dementia; those struggling with drug dependency, eating disorders, sexual dysfunction and terminal illness and, in one case, a sociopath.

After completing my BSc in psychology at the University of York, in the north of England, I had moved back to live in a flat in London, the city in which I grew up. My childhood had been busy, creative and exciting. My father was a successful TV, film and theatre director – a brilliant, highly emotional, inspiring man. My mother was a senior nursing theatre sister and occasional model. My sister, Katrina, only fifteen months younger than me, and I grew up surrounded by art and culture – which I loved – and went to a highly academic all-girls school – which I hated. Life was full of interesting people coming through our house; dinner conversations were always lively and passionate; my mother was a calm, steady presence in the busy, sometimes manic world of the creative people who worked with my father.

I never intended to be a mental health practitioner; I wanted to work in film and TV, making documentaries about social issues. Quite unexpectedly, I managed to get onto a postgraduate clinical training course and decided that a further three years would allow me to make authentic films and TV programmes about mental illness. I wanted to demystify and destigmatize it.

Almost twenty-five years on, I still practise clinically alongside writing, journalism, broadcasting and policy advising. Best of all, I am the mother of two fantastic teenagers, Lily and Jack.

Although I have written books about child development and parenting, I have never felt able, until now, to write more fully about the experiences of working in mental health. It's taken this long to distil the experience of working with some of the most amazing people I have ever known – people who trusted me enough to tell me about their lives.

I am going to start at the beginning and tell the stories of my training as a well-meaning but inexperienced young woman. I had to learn on the job: half the week at University College London, receiving lectures and training in models and approaches in mental health, writing essays, case reports, a dissertation and taking exams; the other half of the week on a series of six-month placements, attempting, with regular supervision, to apply this learning.

The training took place within the National Health Service, and I spent time in hospitals, clinics, mental health units and GP surgeries. I saw patients referred to me by many different specialists in health and mental health – people struggling with acute, chronic and at times profoundly debilitating mental health diffi culties. Some were mildly impaired, others dealing with long-standing difficulties. Occasionally there were patients who presented such a degree of risk to themselves or others that they had been sectioned under the Mental Health Act.

Over three years I was given six six-month placements, structured to provide a complete training experience across the age span and full spectrum of mental health issues by the time I qualified.

There is no other way to narrate the training of a clinical psychologist than to tell the stories of those I encountered, so the book is inspired by the cases I worked and my experiences treating people as a new and naive mental health practitioner. However, because confi dentiality is a core principle of my profession, while all I describe is drawn from real clinical practice, the characters I write about are not modelled on real individuals. They are constructs, infl uenced by the many incredible people I had the privilege of meeting during my training.

I dedicate this book to them.

Tanya Byron

London, April 2014

About the author:

Tanya Byron is a clinical psychologist and a professor in the public understanding of science, specializing in working with children and adolescents, with twenty-five years' experience. Tanya has authored an independent government review and advises governments nationally and internationally. She writes regular columns for The Times and Good Housekeeping and is a broadcaster for BBC television and Radio 4. www.professortanyabyron.com