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.

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?

Four: When Doctors Grow Up

An odd dream last night has set my mind off along familiar tracks.

The scenario was a review meeting with a CMHT consultant and CPN, a meeting which in actuality is due to take place at 9.15 this morning.    If I don’t manage to drag myself away from the laptop and into the shower soon I’ll miss it, which would not be a good thing considering that the appointment has already been twice rescheduled, and after today the psychiatrist is on leave for a month.

It will be only the second time I have met this particular doctor, hence the reason why, for me, it is quite interesting that I should dream about him.  Even people I see regularly take a while to appear in my nocturnal fantasies – my therapist took a good few years – and I very rarely dream of acquaintances.  A bit of background:  the first appointment with this doctor took place after I moved here from London, and was referred on from one CMHT to another.  I think I wrote about it in the previous entry – anyway, it wasn’t fruitful.  I took away the feeling that there wasn’t ANYTHING they were prepared to do to help me, which was a bit of a shock to the system considering I have been under psychiatric care in one form or another for the past five years.  Then, the next appointment, twice rescheduled.  Although the new team had previously discharged me this was supposed to be a CPA meeting, made necessary by the fact that I had cut dangerously twice in one week (at this juncture, I’ll refrain from going into what happened in any more detail) and been placed under the Intensive Home Treatment Team – whose supervision I “escaped” by going back to London for the Easter break.  Before I left I promised them I would come back for the CPA a few weeks later, but when it actually came round to it I did not feel safe enough to travel up alone (being at my Mother’s saw a drastic decline in the cutting behaviour, since she won’t tolerate it in the house), and I gave them notice that I would not be attending only a few hours beforehand.  I spoke to the CPN who would be in the meeting on the phone.  She did not sound at all pleased, but said that they would go ahead and hold it without me, and schedule a review meeting for when I came back to university.

This meeting was supposed to take place last Friday.  I was in the right city at the right time for it, but I went to the wrong place.  I assumed it would be held where the initial assessment had taken place, since the letter regarding the review had been sent from this address.  Wrong.  Ergo, a pissed off CPN and psychiatrist whose time I had once again wasted.  Third time lucky?  In the dream last night, I told the doctor I am due to see today how contrite I was about the missed appointments, but he refused to believe me.  He said that psychopaths were incapable of remorse, and when I insisted that I was truly sorry, suggested that since such people are very good at saying what they think others want to hear this was just further evidence of my pathology.  I’m pretty certain the language in which the dream content manifested had something to do with this article, which I read yesterday.

The underlying conflict between patient and doctor, however, the tussle over truth which is the patient’s own but which must be relinquished to clinical authority, is an old anxiety of mine.  It was there right from the beginning of my “psychiatric career”, if I may so term it, but it seemed to grow more urgent with my transfer from child and adolescent mental health services (CAMHS) to adult psychiatry.  My experience of doctors at this time saw a dramatic turnaround within a matter of weeks – the time between leaving a secure child and adolescent unit and being referred on to a CMHT consultant, since I had turned 18 during the hospital admission.  During the 9 months I was in hospital my father had died, and the consultant I was under worked closely with me and was very involved in my care.  Admittedly, these were unusual circumstances, but even as an outpatient my community psychiatrist had been far more “on a level” with me than I could ever expect to find with those who worked in the adult service.  (Adult service, adult sector… my terminology has unfortunate connotations but you know what I mean).  Take, for instance, the issue of address.  Although I knew my psychiatrists’ surnames and professional titles, I was introduced to them by their first names, something which made them approachable and more inclined to win my trust.  On my first admission to an adult ward, which again took place no more than a month after I left the child and adolescent unit, I asked my consultant what his patients called him.  He was a nice man, friendly and more personable than many of the doctors I have seen since, but he reacted with astonishment to the question.

  “Dr [last name] of course”, he said.  “What else would they call me?”

A new boundary was established, one which I have never since transgressed.  The naming problem is but a small matter, however, symptomatic as it may be of the dynamics a patient may expect in such professional relationships.  Of far graver consequence to me was the treatment of my “illness”, which was now termed as such and given a formal diagnosis.  Indeed, this psychiatrist told me that it was a condition not only of my discharge but of everybody’s that a diagnosis was received – the computer system was set up in a way that demanded it.  I was incredulous of this at the time, and I’m still not sure it was entirely true.  During this and subsequent hospital admissions I encountered people who struggled with difficult social circumstances and sometimes had troubled histories, but who had never before come under the remit of mental health services. Once their “problem” was confirmed to be of a social rather than medical nature they left hospital as quickly as they arrived.

I had a different experience.  Although I was treated with a wide range of medications during my adolescent admission, including anti-depressants, anti-psychotics, so-called mood stabilisers (also used to treat epilepsy) and benzodiazepines, my psychiatrist refused to formally diagnose me with anything other than depression.  I had done some reading and noticed that one diagnosis, “borderline personality disorder”, seemed to describe me pretty well.  My doctor disagreed.  She told me that she was dubious about personality disorders in general, particularly “borderline” which nearly everyone could be said to display traits of, traits which were anyway particularly pronounced in young people.  Our personalities were still in the process of developing.  She said that there was a real danger that I would be diagnosed with the disorder by a CMHT psychiatrist, but this worried her and she would not pre-empt it.  At the time I did not understand why – I was in fact annoyed that she withheld from me a simple explanation of what was “wrong”, an explanation she could easily have provided.

It turns out I didn’t have long to wait.  I was indeed discharged from that first admission to the adult psychiatric ward with a diagnosis of borderline personality disorder, a label which in my view has led to many assumptions and treatment decisions which have been ineffectual, if not detrimental to my so-called mental health.  That, however, is a story for another time.  The title of this blog entry was “When Doctors Grow Up”, which is supposed to suggest  the strange phenomenon whereby as a mental health patient your transfer from child to adult services pre-supposes not only a radical progression in your own development, but an abrupt change in the people around you and the way you must relate to them.  Strangely, given that the treatment I received as an adolescent was more intensive and thorough that that which I received from both inpatient and outpatient adult services, there seemed to be more room in CAMHS for development and growth.  More “wait- and -see”, more “maybe you’re like this now, but your current difficulties do not have to define you or the life you will go on to lead”.  I can only speak from personal experience of course, and the treatment of children with, for instance, psychosis-based illnesses may well be different. 

But back to my dream.  There was certainly no wriggle-room in the fantasy doctor’s condemnation of me to psychopathology.  Furthermore, this diagnosis implied not only that my current behaviour was pathological, but that there was a right and “well” way to behave, and that a responsible practitioner’s job involved hypothesising an illness to show the patient how he or she had deviated from the prescribed path.  Psychiatry as a form of social control is by no means a new idea – Foucault amongst others wrote far more sharply on the matter than I am ever likely to be able.  But if it is true that doctors in adult psychiatry take on a more controlling, educative role, based on behaviour based medical theories than those in child psychiatry, there seems to be an issue still to address.  My treatment as a “child” seemed far more modern and progressive than that which I have received as an adult.  Whether it was more successful in terms of outcome, I don’t wish to speculate.   I only know that I sensed the people I worked with had belief in me and hope that I would come out the other side – that I wouldn’t be stuck inside their box forever.

Two.

This blog, which is barely a blog (consisting as it does of a whole two entries) is already presenting me with problems.  When I made it I was very aware of not wanting create a public “journal”, a space to whinge about and cling on to issues that have served only to disfigure my life and threaten my future.  This year is in many ways a turning point for me – I have finally, at 21, made it to university.   I have been discharged from nearly all psychiatric care, and… dare I say it… I have started to enjoy life more often than not.   I have moved back in with my mother during the holidays (she evicted me when I was 18, and discharged prematurely from a self harm unit for losing too much weight), and slowly, slowly, my friends and family are starting to trust me again.

I am cautiously ambitious.  I would, eventually, like to go into academia.  I know I will write, and I hope that during the three years of my degree my literary interests will develop in a direction that I will be able to take further.   The course I am on is everything I could have wished for.  I know I am in the right place, and I want to stay here.  I will fight to stay here.  The trouble is, I may have to.  I enjoyed a lot of support in London – as well as psychotherapy twice a week at the Tavistock I had a care-cordinator who I saw weekly, a consultant at the CMHT, a dietician and another psychiatrist at the eating disorder unit.  There is nothing like that available here – although I was referred to the CMHT, they were able to offer me very little.  My experience has been wholly negative – one consultant who assessed me remarked that “frankly, I am very surprised that someone with a personality disorder of your severity is able to do a degree”.  This being the case, however,  he  wouldn’t be seeing me “just to monitor your sertraline”.  Of course, I determined to prove him wrong, and with the support of the GP on campus I did rather well, up to the last few weeks of the spring term.   Stress, weight-gain, fears of losing my therapist and whatever-other-excuses-I-can-come-up-with combined to send things spiralling out of control.  Arteries were opened, ambulances were called and it was all just one big mess where I was being advised to take medical leave of absence, an option that was impossible because I would a) be homeless b) be unlikely to receive any more help than I am currently getting and c) be deprived of the structure of university life, which has been hugely important in keeping me well.

They could not, however, force leave of absence on me unless I was sectioned – and luckily I was able to get a grip on the situation before that became a likelihood.  Over Easter I rested, got back to work, and handed in essays that received a first and a 2.1 respectively.  But what I am trying to say is that however much I would like to erase the past, forget how I have survived it, concentrate purely on my studies and make a blog that deals exclusively with the “un-personal”, the literary, the sophisticated analysis of current affairs,  I cannot do it.  Not quite yet.  At times the two sides of my character seem to be mutually anatagonistic and incompatible.  I must either be wholly sick, or wholly well.  I am either  the determined, “gifted” student with an exciting career ahead of her, or I am the girl who’s spent the last five years in and out of hospital, the  girl whose father killed himself when she was 17 but who was fucked up before then anyway, the girl who hurts herself and those around her again and again and never learns, the girl who by rights really shouldn’t be alive.

Well, isn’t this cheerful!  I  have actually had rather a good weekend.  Booked  a ticket to see Andrew Motion when he comes to York to give a reading in a few weeks, and also secured a place at a conference on “The Literary Eassy in English” being held at Queen Mary in July.  Hermione Lee, Andrew O’Hagan and Adam Phillips (who was actually visiting professor at York last term) are amongst the speakers.  There IS a world outside the stagnant, deadly jungle of my introspective head, and I will dare to take my place in it.  One slightly less self-absorbed blog post at a time.