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.