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.

Three. A letter that won't be sent.

Dear A,

Tell me what to do!  I’m menstruating again and my hormones are all over the place.  We sat for an hour making uncomfortable conversation.  He said my message had been a bolt from the blue, and I said I thought his delay in answering might mean he wasn’t going to.  He asked me why – I had trouble explaining.  Eventually I said I thought he would be angry with me, for maintaining silence for so long and then breaking it pretty much on a whim.  He said that if it was anybody else, he would be angry.  I said that I’m nothing special and he said he begged to differ.

We had 20 minutes before I had to leave.  I said I felt sad, but I didn’t know why.  He put his arm around me.  Slowly,   he kissed me and I kissed him.  Bittersweet is the word that comes to mind.    At the ticket barrier he didn’t want to let me go.  A train guard who was watching us kindly suggested he saw me onto the train, but I declined.  I’ve invited him to come and stay with me next week, however.  Now I’m panicking about it.  I want him but when I don’t want him I DON’T want him, and if he stays with me in a city he doesn’t know we will have to be together  every hour of the day. 

My mother called, several times.  I usually call her when I’m on the train.  Today I didn’t.  She asked me what I had been doing, apart from seeing you.  I told her nothing much.  She was pleased when I broke up with M, and if I said I had seen him she would worry.   When I ask you to tell me what to do, I suppose I’m asking you to be someone other to me than you are.  Someone more deeply invested in my life than you are able to be. And when I really think about it, I don’t want you to tell me, because I assume you probably feel the same way about the situation as my Mum does.  I assume that to be the case, but if I knew it to be the case the therapeutic spell would break forever and I would hate you freely.  And yet, even if I believe you think differently to my mother you can’t win.  I felt two very odd and seemingly contradictory things towards you when I was with M.   Anger, linked somehow to a sense of abandonment.  And guilt – as if I had betrayed you.

I want to correct what I think was a misunderstanding in our session today.  I was confused when you suggested that my use of the word “brooding” implied self-absorption or self-interest on your part, because that wasn’t what I had intended.  I presumed I had used the word erroneously so I didn’t challenge you.  But according to the dictionary, brooding can simply mean “deeply or seriously thoughtful”, and by this definition its meditative quality is only as introspective as all thinking-words must be.  In my use of “brooding”, it was the “seriously” bit that I was getting at.  I do sometimes feel excluded by what I term your seriousness, but only because I don’t understand it.  I can’t see your thoughts to make sense of them; I can’t place you, or track you.  That doesn’t mean that I think you have lost me, that you are standing impossibly outside of me unengaged.  Most of the time, on balance, I have to conclude that you are engaged with me, but in a way that I can’t identify.  It is that which is so unnerving.

I know you will counter that by pointing out that there are certainly times when I don’t feel you are with me at all, and of course you are perfectly correct.  But you suggested the distance today when I didn’t feel it particularly, which makes me wonder.   Perhaps, probably, it is unfair of me, but I sometimes think you drag things into the room that aren’t there because you want me to keep them in mind regardless.  You pretend to see things that may well be part of my wider “clinical” picture but are not manifest at that particular moment in time, in order to educate me psychologically.   I know that pre-supposes that you are always aware of exactly what I am feeling, and exactly which way you should respond to it.  All the same, it grates on me how in discussion we always seem caught between the same binary oppositions – all or nothing, inside or outside, alone or overwhelmed…  You could say it’s because I am unable to get past the dualities within myself that they appear time and time again, but I wonder if the very idea of these oppositions is worth challenging.    I’m not sure I do always filter my perception through such a ruthlessly divided lens.   The binary may be internalised to some degree, but there’s an awful lot of external pressure to maintain it too.  If I comply (and catching myself in the act of this is the most aggravating thing of all) it’s because firstly it’s such a tremendous effort to see beyond it, and secondly because it promises to provide at least some structure to contain that which I fear cannot be contained, and is essentially meaningless.  It is a flawed structure but it is still alluring.  Much like my relationship with M, which fails to make sense of me but insists on being revisited just in case. If I could only completely surrender to another, or another’s idea, and exterminate my individual consciousness  - perhaps then I could be saved.

I was going to make some hideous joke here, to detract from the brooding – see what I did there? -  tone of that last paragraph, but God forbid I be accused of trying to entertain you.  Anyway.  I’ll see you on Wednesday.

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.

One.

Nosce Teipsum 

Can you?  Should you?  Is it an exercise of vanity to try to understand when ultimately we can only fall short?

Four years of psychotherapy on, the needles she pricks so gently are finally hitting nerves.  More garbage emerges nightly, as my dreams take on epic proportions.  Why now?  Because I've been eating pretty consistently, and my brain is nourished enough to make all those nasty connections I used to starve away?  Because there is a very real possibility that our time is running out, and I need to reach the bottom of this sludge before its too late?

I don't trust my motives.  How do you distinguish fantasy from reality when bits of you you haven't even met yet are getting anxious and clamouring to be heard?

Four years.  It sounds a long time, but it isn't.  Not in terms of how far we've gone.  The distance between us may have increased dramatically after I moved across the country for university, but in other ways I'm still as close to her as ever.  Same tensions.  Same anxieties.  Same fear of surrendering completely.  Writing helps.  She lets me write to her.  But when I let go of the words they're not really mine anymore.

I travel to London for weekly sessions.  They used to be twice-weekly, but train tickets from here and back are already ruinously expensive.  Expense is the problem.  At a beurocratic rather than a personal level.  She thinks its very important that I continue to see her, but since I live somewhere else now she has had to apply for funding from a different pct.  I know she'll do her very best for me, but in all likelihood it will go to a panel.  And judging from the current climate there's a decent chance it will be refused.

Tired now. 

Off for some more adventures.