Twenty: And then some

At the age of 22 it feels like I'm finally coming to terms with what it might be like to be an adult.

Being dependable.  Having people of my very own to look after, albeit only my boyfriend and our cat.  Visiting Ikea to buy wardrobes for his room.  Having to plan meals in advance and cook. Cleaning and doing laundry not because someone tells you to but because actually, if you don't, it starts to get to you.  Keeping in touch with family.  Learning to express your needs in moderation, and to give a fair hearing to those of others.  Leaving difficult situations in time to keep yourself safe when you feel overwhelmed.

Only four months ago things were very different.  Loneliness combined with perverse "coping mechanisms" I've had a lifetime to learn and perfect imposed a Jekyll and Hyde like structure onto my existence.  The days would be spent pushing down tempests of anxiety -  an almost compulsive fear that worsened if any sort of attention was paid to it. I felt, almost always, on the edge of calamity.  Danger lay in every unoccupied moment, and no matter how carefully I planned my day, there would always be more than one. My classes done, at night (or, on bad days, late afternoon), I dived into chaos.  I was exhausted and I just couldn't contain myself anymore.  The GP on campus had told me that if I continued to starve myself I would not be able to remain at university, and for once I had listened.   During the day I would eat enough to satisfy my appetite and give me the energy to work - but I managed this partly (and problematically) only by shutting my eyes to it. 

I knew the nutritional content of what I was eating.  I knew what constituted a healthy, balanced diet, and I aimed towards it.  My body, however, was aiming for more.  It was aiming for curves, periods, and everything else a healthy woman should have - but for me these things also possess unpalatable and still mostly unexplainable psychological implications.  As soon as it got dark I let go.  I would spend £10 to £20 on food and spend the next two hours eating and vomiting  - gorging also on the kind of trashy tv my day-time schedule would never allow for.  When I was done, and I was reassured that my stomach was entirely empty, I would eat a small meal and go to bed.  Ultimately I knew I couldn't afford to lose weight. 

But it was draining.  Sustaining any sense of self in the midst of a raging war between bits of you that you still don't really understand and  that insist on their fulfillment with ceaseless cruelty is difficult.  It's even harder when you're trying to work towards a first-class degree.  Luckily I was able to get through the term.  Two arterial bleeds and two visits to A&E in ambulance, days when I just couldn't muster the energy to get out of bed and clear up the mess (blood, food and vomit) of the night before and recommendations to take leave of absence from university -  regardless,  I got through.  But my God - it feels a world away from now.  I have enjoyed four of the most healthy months I have had since I was sixteen,  and I'm terrified - terrified - to let them go.

Term begins on October the 10th.  I may have more support  in York than previously, since the psychiatrist I saw on Thursday who works for the psychotherapy service thinks I do need psychiatric reviews and a support worker and is writing to the CMHT in support of both.  Briefly, I would say that this was the single positive of  a difficult and frustrating meeting.  More will follow later.

Eighteen: Recapitulation

I need to write here again, if for no other reason than that after three months essay writing-free I'm beginning to lose my grip on my grasp of the English language.  I'm perhaps three quarters of the way through the mega-reading list I set myself for next term, and I find when I'm annotating texts that there are words I need which were familiar once and now escape me completely.  Not so great if you happen to be doing an English literature degree.

There is still another month to go before I return to York.  As the weeks wear on I realise more and more that I need to cherish the time I have at university.  It is really very little.  Being that bit older than the other students on my course, with friends who graduated last year and are struggling to find their feet in a job-market that is smaller and more competitive than ever, I know just how lucky I am to have this opportunity. 

I don't feel particularly lucky at the moment though.  My reading distracts me, as does my boyfriend, as does the oblivion-seeking sex, drinking and occasional drug use I turn to when I'm really itching to hurt myself.  Apart from one cigarette burn inflicted in Poland I have been self-harm free for months now.  Tomorrow it will be 90 days since I last made myself sick.  I am a healthy 60kg for my 67 inch height, and I try to remember that I have made peace with my body.  But it was always a very tentative peace, and right now it feels particularly fragile.

Diary entry, 3rd August 2011 (I was still in Poland):

It just keeps getting better.  After a call from Dr S of York Psychotherapy Services, in which I was informed that my therapy at the Tavistock would cease to be funded in October, I found out from A (my therapist) that even this may be in question.  There is something of a row developing between the Finance Department of the Tavistock and York, who are apparently refusing to pay for any of the psychotherapy I have been having at the Tavistock since I moved from London. (I have since been told that the reason they are giving for this is that the Tavistock have prevented me from engaging with their local services - the only problem with this argument being that said local services proved on several occasions to be unwilling to engage with ME).  I don't know quite how this will affect me, but it does mean that money-wise my therapy with A is even more in the shit than before, and it is unlikely that the Tavistock will themselves finance any extension to the October deadline.  I did feel a glimmer of hope when A (I called her from Poland when I received the news, and we had a brief conversation over the phone) hinted at our previous discussion about paying (her?) privately.  But only a glimmer.  I'm sure A will think of a dozen different reasons before I see her again at the end of August as to why this arrangement would be unworkable.

As I understand, A is still fighting to build a case as to why my therapy with her needs to continue.  I have been invited to a meeting in York on Thursday with Dr S (consultant psychiatrist/psychotherapist) and a therapist to discuss whether the group therapy or individual therapy they may be able to offer me would be suitable.  Talking to these people is not at the top of my wish-list at the moment, to say the least.  I envisage throwing things - if not objects, then hard words.  It's childish.  But I am not inclined to give them any more of my time.  There are a number of reasons why I do not think it will be beneficial for me to either enter group therapy (again) or establish a new, short-term psychotherapeutic relationship.  Experience has taught me however that my opinion falls on deaf ears - if anything, it will be seen as further evidence that I am refusing to co-operate, possibly as a result of an unhealthy dependency on my therapist in London.  My boyfriend wants me to go to the meeting, and has said he will accompany me. I still haven't made my mind up.

This brings me to the question of what WILL happen if my therapy at the Tavistock is terminated at the end of October.  A has tried to discuss this with me in our sessions.  She says we need to talk about our options.   I am,in effect, stonewalling her - it's just to painful.  I cannot see any "workable" options being made available to me - rather, in anticipating the conversation I see my last hope, of her agreeing to see me privately (at a cost I would be able, if only just, to afford) being crushed.  Again, M (boyfriend) says I need to have a frank conversation with her.  Not knowing is draining me.  I don't know how much longer I can go on in this state without resorting to the ways of coping I swore (sort of) to forsake once and for all at the beginning of the summer.

I dread Sundays, because they signify two full days until Wednesday, when I have my session.  I dread Mondays and Tuesdays proportionately more.  A keeps apologising to me for what is going on.  It doesn't help.  I have a lot of rage inside of me - rage I do not want to direct at her, but which seems to be blocked whenever I aim for more appropriate channels.  I cannot help but feel that I am just not being heard.  I have come so far, and I refuse to give up something which has helped me so greatly -something that has given me my life back and which I believe needs to continue to fully restore me to health - without a fight.  But there seems to be nothing to take on but smoke and mirrors - the thin veils of bureaucracy.

If there were a God I could believe in, I would ask him to help me through this.  For the lack of one I must try to believe in myself, and my strength - which has surprised me before and may surprise me again.

                                                           Street art, Wrocław Poland.

Seventeen: In brief

Very, very annoyed.  I managed to delete the post I've spent the past hour writing just as it was autosaved.

Take two will be greatly limited, seeing as it's already two o'clock in the morning and I have an early start ahead of me - we leave for Poland on Thursday (I'll be away three weeks) and there's lots still  to sort out. 

Before my finger slipped, I had basically written out what took place at my meeting with the psychotherapy service in York last Thursday.  The psychiatrist I saw is only involved in CBT work, so he said he would discuss with his team what we had talked about and meet me again possibly with a colleague who knows more about psychodynamic work.  Though he gave me no clear indication as to what at this point he thought he was likely to advise the commissioners regarding my treatment, we discussed the various options and he agreed with my boyfriend's mother that it is extremely unlikely that funding for open-ended therapy as provided by the previous Trust would be granted.  There is a possibility that I could be assessed for psychotherapy in York, though this would last a maximum of two years and I did say that I was ambivalent about whether it would be beneficial for me to pick up the work with someone else.

He said that resources for mental health are very stretched at the moment - for instance in York no patients are being sent to private treatment centres any more.  I asked him about the CMHT consultant's claim that the view of the psychotherapy service is that the only effective type of therapy is short term and goal oriented, and he said that although he cannot speak for individual practitioners this is largely true.  His own personal view is that therapy needs to be conducted in short, repeated bursts and he told me that there is no research whatsoever to evidence that psychotherapy "works" (this infuriated M's mother, when I repeated it to her later).  He also said that he was incredibly surprised, given my history and his own experience, that I had managed the transition from twice weekly to once weekly therapy, commuting from York to London.   He commended me on what I have achieved in managing to maintain my weight and keep myself well enough to be at university, considering everything that has happened.  In his view my psychiatric history is extensive - he said that he had had to take notes from my notes before meeting me.  He asked me about the intention I had expressed a few months ago of wanting to open an artery, and when I said that I had in fact managed it seemed slightly amused.  He told me that if I was to do it again our discussion would be futile, as there would be no point in discussing therapy I wouldn't be alive to undergo.

All I can do now is wait.  And not think.  I'm sick of thinking and agonising over something that I really cannot change.  While I'm away I want to focus on building on and consolidating the things that I have been able to change recently, particularly regarding my eating.

On my way back to the station after the meeting I saw a painting on the side of the house that would have offended me not too long ago, but makes me smile a little (if wryly) now:

It's a strange World.

Fourteen: Awaiting a second opinion

Tomorrow (actually today in eight hours) I have to catch a train to York.  At 12 I have an assessment with the psychotherapy service as requested by the Consultant I saw at the CMHT, who wanted a second opinion as to whether to the mental health commissioner should be advised to grant funding for continued psychotherapy.

I have reached a dead end in Anxiety Street.  I feel I should be going over in my head what I need to say, rehearsing and perfecting my argument, but I cannot suppress a conviction that it hardly matters what comes out of my mouth tomorrow.  My inner pessimist warns me that the matter has already been decided, and that a favourable outcome is extremely unlikely.  Warring against this faction is the part of me that is still desperately hopeful, a part that I indulged this evening in requesting a meeting with M's mother.  Although she works privately, and I knew it was clutching at straws, I did feel an informal chat with another psychotherapist might be helpful - at least in taking the edge off the worst of my nerves.

It wasn't a waste of time.  She understood that all of this is mainly bureaucracy and politics, machinations against which I have little agency, and agreed with what I had felt -  that the letter sent to the psychotherapy service by the consultant I saw, stating that he was "torn" about whether or not he felt continued funding was necessary, had given me a false sense of the potential influence I have on the panel's decision.  This said, however, she did give me some advice about how to best present my case.  One thing in particular that she mentioned, that it was important for me to state that I do want to work towards an ending with A, but as there is still work to be done this needs to be prolonged, seemed especially relevant.  If the PCT has some sort of time-scale around which funding could be arranged, with a definite end date in sight, they may be less likely to dismiss it out of hand.  She also thought I should play up the destabilising effect a too abrupt ending would have on my mental health, but I have already decided to steer away from tried and tested threats.  I think it is a far better idea to concentrate on the important changes that my therapy has helped me to make, despite ongoing difficulties, without forgetting that my therapist and I both feel there is work still to do within a perhaps more specific time frame.

Tomorrow is not the be all and end all.  My mother's advice was simply "que sera sera", and in a way she is right.  I will survive a premature ending to therapy, as distressing and difficult as it might be, and as horribly unfair as it might seem.  After tomorrow I will try to put the whole thing out of my mind.  I've fought a good fight and I'll see it through to the end, but at some point I do have to let go.  Not everything is within my control.

Eleven: Verbal battering

I.e the London Review of Book's "Conference on the Literary Essay", held at Queen Mary's.  I had tickets for both days this weekend, but sheer exhaustion prevented me from returning on the Sunday - Friday I was up at 6 to collect our ten week old kitten, and I had to be up again at 6 on Saturday to get to East London for the conference.  Two friends from Ireland came to stay on Saturday night, so I couldn't catch up on sleep in the evening.   My boyfriend also suffered a massive sleep deficit, due to work deadlines left till the last minute.  He stayed up all night Friday working and keeping the kitten company, and was functioning better than I was the next day, despite my fears.  He has manic depression, and though he has been stable now for a good eighteen months I am on constant alert for signs that he's getting ill again.   One of these is sleeplessness.  Sleep deprivation is one of several factors that have precipitated episodes in the past.

Had I been more awake, I would have got more out of the conference on Saturday I think.  I was alert enough to pay attention to the three speakers I had most wanted to hear: Hermione Lee ("Dreams and Clouds: Lamb, Woolf and the Essay"), Adam Phillips ("The psychoanalyst and the essay") and Andrew O'Hagan ("The Essays of Robert Louis Stevenson").  Of the three, Adam Phillips' speech was the worst delivered but the most entertaining.  His discussion was based around why psychoanalysts seem to avoid the essay form, and why, when it is used it seems somewhat rebellious.  He posited that psychoanalysts write very much for other psychoanalysts and are anxious about communicating beyond their own circles, partly because they are insecure about approaching domains usually reserved for other fields and partly because their is something about the  essay that is inimical to the "science" of psychoanalysis.  Although an essay drives towards definitiveness, it is by definition an attempt, something uncertain that does not reach completion. For writers of fiction or critical literature,  this impossibility of completion creates the freedom of exploratory space.  But for psychoanalysts, this can feel threatening.  As Phillips said, Freud insists that we are ambivalent creatures - and yet no psychoanalyst will admit to being ambivalent about psychoanalysis!

Phillips went on to discuss Freud's own use of the essay form,  which he suggests Freud used to investigate our desire for an ending, as well as to indulge his own literary tendencies .  The abundance of footnotes, particularly in his three essays "On Sexuality" reveal the author's search for the "something missing" in the theory he felt compelled to revise time and again.  The essay form may seem appropriate for such a search:  Phillips notes that like psychoanalysis, the essay encourages digression whilst there is still a point to be made.  Indeed, Freud never seems to lose faith that there is a point worth making, but significantly, at the end of "On Sexuality" he admits the impossibility of finding an all-encompassing, satisfactory explanation for the mystery he set out to uncover .

I am unsure what conclusion to draw from this, or if there is a conclusion to draw at all.  It may be relevant that at the time of writing, though Freud was of course jealous of his reputation, psychoanalysis as a profession was in its infancy and there was far less competition between different "talking cures" to prove the most effective than there is today.  In our time, psychoanalysis though not perhaps universally threatened, does in the UK at least seem to have to work a lot harder to fight its corner against quicker, more "cost-effective" treatments.  In this climate, perhaps it is no wonder that most psychoanalysts prefer to steer clear of what can seem a potentially subversive form, and one that undermines the scientific credentials of the profession.

I have my own meeting with a consultant psychiatrist and psychotherapist in York coming up in July.  This is the meeting requested by the CMHT psychiatrist after I persuaded him to at least consider supporting my case for the Tavistock therapy to continue.  If I can be equally persuasive on the 21st, the doctor may advise the mental health commissioner that the therapy should continue, and that instigating another sort of treatment for me in York would be inappropriate to my needs.  It is a lot to hope for, I know.  But at the very least I may have won myself some more time. 

Six: Funding Battles

90% of the review meeting I had with the CMHT psychiatrist turned out to be about the Tavistock funding issue.  He began by saying that given the current economic climate, and the dire shortage of money available for out-of-area treatment, it was not a question of IF I stop seeing A, but when and how it is managed.  Since he is also of the opinion that the *only* truly effective therapy is short-term, goal oriented work, he would not be supporting my case.  Apparently this is also the opinion of the entire psychotherapy service in York.  I brought up the fact that the consultant psychotherapist I have been seeing for 4 years has a very different opinion, and thinks it is important that our work continues.  He said that if either she or the Tavistock were funding the therapy that would be fine, but since they’re not her view is inconsequential. 

I asked him whether he had arrived at this from a clinical or a financial perspective, and he said that for him the two were inseparable.  I pointed out that if the Tavistock treatment is withdrawn and no adequate replacement found quickly enough, there is a risk that I would be turning up A&E more frequently or requiring an inpatient admission if I am unable to manage, costing the NHS more money than the price of the therapy itself.  Since this year, with the support continuing, I have already had to receive medical treatment for injuries and be assessed by the on-call psychiatrist at A&E on seven separate occasions, two of which involved ambulance transportation, that this would be the case is not wildly improbable.  The doctor agreed that I had a valid financial argument, but explained that the problem is that the funding of the NHS is not quite as cohesive as it would need to be to recognise this.  It’s a question of different pots of money for different services. 

The economic problem is very real, and it’s not his fault.  I understood what he was saying, and I also know that the treatment I receive impacts on that which is available for everybody else in the region.  I have been very lucky to have had the therapy on-going for so long – it isn’t available to most people who could profit from it.  What I did take issue with, however, was his idea that A plays a completely “supportive” role in my care, suggesting that since I am not symptom-free, the work has not helped me to make any real lasting changes.   I vehemently disagree with this – and I asked him to leave alone his general views about therapy for a moment and just LISTEN to me.  It really isn’t a matter of being attached to a particular therapist, and not wanting to let her go simply because it will be painful.  A too is of this opinion.  In the past four years, things have changed quite radically.  I am no longer in and out of hospital every few months (my last admission was over a year ago), I have maintained my weight for almost a year and I am  stable enough now to be able to complete a degree course – something which I have wanted to do ever since life interrupted me at 17.

He did listen, finally.  And something positive came of it.  Although it is still extremely unlikely the funding will be granted, he thinks it might help my case if I talk to the psychotherapy service here in York and get them to recognise the value of my treatment at the Tavistock and agree that the short-term therapy they could offer me would not be appropriate.  He said he would refer me to a colleague at the service so the conversation could take place.  I also told him about the psychopath dream, which seem to amuse him.  He said he didn’t even need to turn up to my appointments – a cardboard cut-out would stand in for him just as well!  On a more serious note, he wanted me to know that all of this had nothing to do with the way he or others in the service perceive me.  It is not a case of personal dislike getting in the way of providing me with help.  As I told him, I do know this, rationally.  Emotionally it is another matter.

Therapy yesterday was tough.  I spent most of the session crying.  A has begun to use the past tense when she talks of our work together.  We discussed what would happen when the therapy ends – she suggested the option of paying privately for psychotherapy, though since I have no income I would have to talk to my mother about this (who, I might add, is not likely to help).  I asked if she meant paying to see her, and she said “yes” – “or someone else”.  Ideally of course I would love to keep seeing her, even if I have to pay for the privilege.  But realistically it’s not likely to be affordable, since I would also have to pay travel costs.  Introducing the money aspect more overtly into our relationship is also likely to change it drastically.  I’m sure she is aware of this, and although she conceded it as a possibility that I could pay to see her I am not sure she really thinks it would be the best option for me.

We are coming up to a month of anniversaries – my father’s birthday and the day of his death.  Not the best time to be dealing with this.  But is it ever?