Ten: Marsha Linehan

Dr Marsha Linehan, renowned for her creation of a pioneering treatment for bpd, has spoken out about her own mental health difficulties. 

I was surprised, more at the revelation itself than her announcement of it.  Since I was first made aware of it maybe five years ago, I have held a rather disparaging attitude towards the therapy programme which became known as "DBT", or Dialectical Behaviour Therapy.  Primarily, my experience of this therapy took place during my admission to the Crisis Recovery Unit of the Royal Bethlem (Maudsley) Hospital.  The philosophy of DBT underpinned much of the work staff at the CRU tried to engage patients in, some more successfully than others.

It didn't work for me.  I resented what I saw as the "holier than thou" top-down way in which groups were conducted and the ward was run, and failed to see how I could be educated to better regulate my emotions when I felt I had perfect insight into my thought patterns and did not agree that splitting them off and beginning to change them could have any real impact on the way I felt.  Moreover, I was wary of the intentions and motives of the staff and was at times extremely defensive -  I was prone to "intellectualising" and could not resist getting into endless arguments over the logical fallacies I noticed in the cognitive exercises we were asked to perform.  I was (and still am) skeptical of the principle that changing behaviour can make profound and long-lasting changes to attitude and mood, particularly for people who have great difficulties with trust and find a six month admission period insufficient to form the relationships necessary to really engage in the work.  It is for this reason that I think the consistency and prolonged duration of psychotherapy has been most helpful in getting me to discover and examine parts of myself that lead me to self-destruct.

But back to Marsha.  Her admission that she had, as a young woman, struggled with the very difficulties she subsequently attempted to treat, made me wonder if I should reconsider my view of DBT.  At the very least, I am no longer able to understand it as the arrogant, proselytising model of good "health" I had so despised before.  I find it impossible to overstate the importance that feeling really heard and understood has for me in trusting someone enough to let them help me.  I am able to recognise this in psychotherapy, where A's integrity (or otherwise) is a constant feature in my assessment of our work.  That she has more or less consistently managed to sustain a genuine connection with me accounts in my opinion for much of the change she has helped me to achieve.   Since it is emotional work, I suppose it is unsurprising that "emotional" reactions not only to individuals but to treatment models themselves could play a large part in determining the responsiveness of patients, particularly those as wary as myself. 

This is well and good in hindsight. Unfortunately, at the time of my CRU admission, I was unable to recognise, or voice, the part of my frustration with the treatment that  emerged from distrust.  I only hope Marsha's courageous decision to speak out about her own experiences will help others to accept help, and feel less alone.

Nine: Four years

It's the fourth anniversary of his death today.  I don't feel much. Numb.  Anxious that I'll stop feeling numb.  My session at the Tavistock was not terribly gruelling.  I spoke minimally about my Dad, more about my relationship with my boyfriend which feels a more immediate issue.

In short I made it through the 55 minutes without crying, and I felt relatively okay until on the way out, I crossed paths with the inpatient psychiatrist who saw me through the whole ordeal four years ago.  I have seen her maybe once since, also at the Tavistock, and although I think she did nod at me on that occasion I had no expectation that she would engage in conversation with me if we encountered eachother again.  Perhaps it was the date that made her response today seem particularly heartless.  I know she noticed me, as I saw her scanning my face.  When I reached the bottom of the stair case (she was ahead of me on the floor below) she turned round to look at me again, and I said "hi".  That was all.  But she didn't nod at me, or smile, or do anything else to acknowledge the greeting.  She just walked away. 

It hurts.

I've been staying with my boyfriend for the past 6 days, during which time I have not cut myself or vomitted once.  I do however have to go back to my Mum's tomorrow, at least until Monday, and I'm not sure at all how I'll manage.  I'm trying to live very much in the present, and not let a moment's anger or sadness spoil the next.  Tonight we're going out for a Thai meal, and I know I'll feel safe at least until tomorrow night.  If not, the poster campaign I keep noticing around York may (with a certain irony) serve to remind me of why I should not hurt myself:

A visit to A&E costs on average £117 per patient, so Dr Lethem tells us.

Eight: A Cigarette is Like a Kiss

A return to the personal.

A cigarette is like a kiss.

Each toxic puff wastes dizzyingly

Into the stratosphere,

The light getting shorter, you fight for breath

Alone in the fag-end of morning.

One kiss is never enough.

Cling to my lips in familiar grip,

Cling and never let me go.

Who hears  our kisses,

Who holds us to account?

An-ever changing sky watches, receives,

Arranges its clouds in storm-spun silence.

Taste, and taste again the death of morning.

Let you into my heart, my mouth, my lungs

You burnt out too fast for a possible last time -  

But It  did happen.

I  have the smell of you.

The Personality Police would be happy with this one, I think.  It ticks all the borderline boxes.  Which is fine, since it’s a nonsense diagnosis anyway.  Is it not the case that I feel only what every other bloody human being on this planet feels?  I love my transience and despise it at the same time, I want to hold on to all that keeps me fixed and safe,  but I have to let it go or risk a living death.  Somewhere in the holding on or the letting go lies the problem.  It is a problem for me.  But I won’t accept that it could ever be solved – no one has the solution, just the offer of a thicker skin.  And that will come to me in time.

Last week (when I wrote the above) was an angry one.  From (another) letter that I didn't send, the following:

I am horrifically angry at the moment.  I feel let down by everyone and everything.  It disturbs me how angry I am.  I’ve been having some really nasty, graphic thoughts.  Violent images that seem to leap into my mind from nowhere like dreams (I wish they were).   One of these flashes involved me turning up to the Tavistock in a wheelchair, having amputated both my legs.  In another I saw myself  slash one of [ my consultant psychiatrist in the adolescent unit's] arms.  Possibly exhaustion is the cause.  My conscious mind doesn’t usually make such savage leaps to the unacceptable – of if it does, it contains the violence firmly within the boundaries of my own body.  I enact my fury bodily without ever really having to confront it.  Sometimes I think self-harm is the safest outlet for me after all.  The safest for the people who I co-habit this planet with too.  Something must insulate the live wire, or impede the flow of current it conveys.

I come to this conclusion, and then I remember Dylan Thomas: 

Do not go gentle into that good night.

Rage, rage against the dying of the light.

Rage for raging’s sake, even if all I will ever have to make a fuss about is a storm in the smallest of tea cups?

Instead of sending the above to my therapist, as intended, I ended up writing a letter to the psychiatrist aforementioned.  When I left the adolescent unit, she told me that I could write to her and that she would always write back.  Over the years, I have written less.  I had sent her one letter previously this year.  But we are now well and truly in anniversary month (My Dad would have turned 52 today, and next wednesday is the 4th anniversary of his death), and I wanted to send her a card.  Enclosed in the card was a letter, mostly focusing on my achievements and other positive aspects of my life, though I couldn't resist whinging a bit about the psychotherapy funding situation.

I'm still reaching out, however cautiously.

Seven: "Ghosts in the Machine" - Locating the Soul in the Bionic Age

Parts of a group presentation I'm giving tomorrow, for my "Bodies and Minds" module.  Since I ended up writing nearly the whole thing myself (which I'm bloody annoyed about, but hey, these things happen...), there shouldn't be a problem with me putting it up here.

Metropolis - Fritz Lang, 1927

The phrase "ghost in the machine" was coined by the philosopher Gilbert Rye in his book, “The Concept of the Mind”.   Rye criticised Descartes' mind-body dualism, arguing that the terms "mind" and "body" should not be considered as belonging to the same category, and that mental and physical states are inseparable.   In the film “I, Robot”, the phrase is used to refer to inexplicable actions by robots that possibly hint at the existence of a soul or mind that works beyond their mechanical bodies.

As a group, we examined our own beliefs about the soul, or more generally, what it is that for us separates man from machine.  Of those that we examined, we selected the ability to love and make ethical decisions as the most “human” of human aspects, or those that a machine would find hardest to imitate.  As our presentation will demonstrate, however, the increasing sophistication of Artificial Intelligence problematizes this assumption.  

We have placed the examination of these issues within the context of the "Bionic Age", which we define as an age in which machines and mechanical parts are used by humans to carry out tasks that are difficult, intricate, or dangerous.  The question of where and how we locate the soul as man and machine become ever more closely linked continues to be explored in science fiction film and literature, and across the fields of science, philosophy and psychology.

R.U.R

Karel Capek coined the term 'robot' in his 1920 play "R.U.R." in defining his artificially created creatures, the word 'robota' in Czech literally meaning "work", or "labour". Traditionally, "robota" was the term used for the work period of a serf, an unpaid member of the lower classes required to work for their superiors. Serfdom was banned in Bohemia in 1848, but this obsolete term would have carried its meaning across to Capek's early 20 century audience. This immediately colours the way in which the artificial beings of R.U.R. are viewed, reduced by the concept of slavery. They are introduced as "goods"(p3), and are a highly demanded product: willing slaves in attaining the ultimate human ideal of an elevation to a god-like status where "Man will do only what he loves doing, free and sovereign, with no other task than to better himself"(p23), unfettered with the need to labour. From Domin's point of view, this is ethically sound. The robots' intended purpose is to work; they are "without will, passion, history or soul"(p20).

However, young Helen arrives, adamant to dispute this. She is determined to see their usage as exploitation, her "League of Humanity"(p17) extending to the "liberation of the Robots" (p20). Immediately the audience is posed with a contradiction. The robots seen are apparently soul-less, unable to comprehend human emotion, yet their complete assimilation of outwardly human manifestations staggers her. "Can't tell the difference, eh? Feel this hair we gave her! Soft and blonde! M-mm, lovely!" (p11). JD Humphries, in his introduction to "The Robots are Coming", draws attention to the problematic nature of " 'other minds' ". Humans "cannot be directly aware of any other consciousness in other human beings […] One has, therefore, to assume, in terms of similarity of appearance and overt behaviour, that other people are in fact much the same as oneself." (p18)

 Helen is unable to come to terms with the fact that "they're not bothered what you feed 'em […] And no-one's seen them laugh yet!"(p20), when they appear so absolutely human. By her understanding it must be unethical to treat those who appear so similar to ourselves with such flippant disregard for their welfare. Yet apes are similar to humans, and we treat them also as soul-less. Humphries continues his introduction by stating that "Theologians argue that though man's thinking processes may be similar to those of an ape, the man possesses something extra - his 'soul'. In “R.U.R” it seems unethical to treat the robots as if they have no consciousness, or personality, or however our sentient conscious "soul" is defined, yet unless the existence of such a soul can be empirically proved, their status as slaves cannot be contested.

Play – intro. 

One possible way that we could attempt to measure and quantify the soul in articulate beings is via the “Turing Test”, an idea introduced by Alan Turing in 1950.  Designed to  discern intelligence, a human judge engages in conversation with one human and one machine, programmed to appear human.  If the judge cannot correctly guess which is the machine, it is assumed to be an “intelligent” entity.   The concept of the test has inspired the short play that follows, in which we attempt to distinguish human from robot by posing a series of ethical questions.

                                                                *****DRAMA*****

Class questioned.

                                                                              Play – conclusion

As our scenarios illustrate, finding a universal definition of what it means to be human is exceedingly difficult.  It is not possible to say that being able to adapt to new situations, communicate and interact with others, feel love and empathy, and respond appropriately to ethical questions are characteristics shared by all humans. If it were possible to create an organic, intelligent robotic being, would we be able to differentiate it confidently from one of ourselves?

 LOVE.

As we have tried to do with ethics, could we design a Turing Test for love?  If a machine behaves in a way that suggests loving emotion, should we assume that it is capable of loving, whether it is itself, other robots or even human beings?

In understanding how our attitudes towards robots who love are shaped, it may be helpful to examine the ways that love is conceptualised in Western philosophical tradition. 

Rousseau’s second Discourse, in which he discusses the views of Thomas Hobbes, proposes three different kinds of love:  amour- propre (base self-love), amour de soi (gentle or at least benign self-love), and charite (love of God and things public).

In stating that charité is a "natural repugnance at seeing any sentient being, and particularly those similar to us, suffer pain or death",  Rousseau placed the capacity to suffer above the ability to reason in describing what makes creatures worthy of compassion. 

This view is one that is widely held today, but love in the philosophical tradition has not always been held to emanate from compassion.  In the thirteen century, Thomas Aquinas picked up on the Aristotelian theories of friendship and love to proclaim God as the most rational being and hence the most deserving of one’s love, respect, and considerations.  Accordingly, in the Summa Theologica, he states: “Each human being has a share of the eternal reason, whereby it has a natural inclination to its proper act and end: and this participation of the eternal law in the rational creature is called natural law” ( Summa Theologica, 1a2ae, 90.2)

 Could YOU Share a bed with your Robot?

Perhaps the real question is not whether robots, possibly the most rational creatures of all, are able to love, but whether we, as humans, have an appetite for robots to have this capability.

Extolling the virtues of sexbot cyborgs trained to help humans improve their sex lives, David Levy hypothesises that marriage with robots will be legalised in some countries by 1950.

Even if this rather outlandish prediction is fulfilled, however, our creation of beings that are allowed access to our deepest needs and desires has profound implications for how we understand ourselves as human beings.

As Sherry Turkle says, in her book “The Second Self”,

"We ask [of the computer] not just about where we stand in the world of nature, but about where we stand in the world of artefact.  We search for a link between who we are and what we have made, between who we are and what we might create, between who we are and what, through our intimacy with our own creations, we might become".

The darker side of robotic, soma enhanced and psyche reduced love is explored in Aldous Huxley’s 1931 novel, “Brave New World”, where soulless, impersonal love is a form of social control.  Unlike R.U.R, the protagonists of Huxley’s novel are all ostensibly human, and yet in Brave New World it is only in the past that “there was a thing called the soul and a thing called immortality”.  The tragic irony at the heart of the novel is that the marginalised “savages” appear more human than those that inhabit the civilised, sanitised world where physical pleasure is maximised and love forbidden.   The novel warns of the danger of a creator becoming engulfed by his creations – where love is deemed redundant and unnecessary, there is no place for a soul – it is literally destroyed by the machine of society.

In recent years, attempts have been made to tackle our anxiety and distrust about machines that too closely approximate humans.  In Pixar’s Wall-E, the love between two robots (Wall-E and Eva) is redemptive, and leads to the recolonisation of Earth.  The film does not attempt to deny the robots’ mechanical nature, incorporating it instead into the way they communicate their love for each other.  Despite this, it must be acknowledged that the degree of anthropomorphic animation of the robot characters that the film-makers indulge in does not really challenge popular, human-centric notions of what it is to love.

Conclusion

Whilst our terror of hypothetical “ghosts in the machine” must be balanced against the growing needs and demands we have for artificial intelligence and the ways it can serve humanity, it is important to remember that the problem does not end here.  It is not simply a question of whether ethical and loving robots could live alongside their human counterparts.  As we make the transition from the post-modern to the bionic age, we must use the privilege that human status grants us wisely to negotiate the ethical and moral dilemmas we will face in the coming century. We must accept that as we adapt and change the world around us, our conception of ourselves will inevitably change too.     Some of us, none of us or all of us may have souls in the bionic age –but if we are to retain them, they must be guarded fiercely.

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?

Five - A taste of my own Medicine

Last night, my phone alerted me to a text message at 1.30 in the morning.  It was from a girl on my course who I have got to know slightly over the past few weeks – let’s call her Ellen.

The message read: 

“I’m in hospital, taken an overdose”.

Ellen and I originally got talking when she sat next to me in our first workshop of the current term.  She was in one of my classes last term too, and she told me she had been really worried about me when she saw a bandage on my arm.  Apparently she had tried to catch me up after class to ask if I was okay, but I was walking too fast (I do, particularly when I’m on edge.  Ellen has bad knees so she didn’t really stand a chance).   I was surprised that she had noticed, and rather gratified that she cared enough to worry.  Despite the very obvious signs of self-injury I display, including one memorable day last term when I was really out of it and walked around campus with clothes soaked in the arterial blood I had spilled the night before, no one here has asked any questions.  I do appreciate the respect of my privacy, but for me there is a fine balance between an intrusive and an uncaring reaction. The fact that not a word was said by anyone about the scars on my arms had an unexpected isolating effect.   In some ways, I think I have grown reliant on remarks from others about the scarring to affirm my more hidden suffering.  I have felt for a long time the existence of a “split” in myself, the emotionally unstable hurting core armoured by a shell of social enthusiasm, rational capability and intellectual interests that seeks to distract and divert attention from the “real” me.  But while this attention is terrifying, I also crave it.  It proves that I exist, or at least, that the part of me that is often overlooked exists.  When this recognition or “attention” does not take place, it has a greatly destabilising effect, barely discernable at first but increasingly apparent over time – last term, it got to the point where I felt SO divided, SO unacknowledged that I began to doubt my sanity.

This is a rather long-winded way of explaining that Ellen’s interest was valuable to me, and that I felt disposed to encourage a friendship between the two of us. There was (and is) however, a complicating factor.  Ellen of course has her own problems, problems which I have come to realise she presupposes I can intimately identify with. I have come to expect the appeals “You know how it is, you know what it’s like” to pepper a sizable proportion of our conversation – which, more often than not, is about her.  Ellen is diagnosed with Asperger’s Syndrome, as well as depression, and I do wonder if the nature of our exchanges has something to do with this.  It may be a case of pot and kettle to suggest that she is particularly self- absorbed, but while I too tend to feel my existence as particularly isolated, I (perhaps overly) compensate for this by showing a pronounced interest in other people when I spend time with them.  Ellen feels that she “does not exist” when she is alone, that she needs other people to make her exist.  When I am on my own, I am all too real – it’s the rest of the world that disappears.  If it is possible to form such a comparative hypothesis, perhaps then this  explains why Ellen is “larger than life” (she has informed me that people have told her she comes across as “intense” and “frightening”) around others,  the only time she is able to realise the concreteness of her existence, whilst I am overwhelmed by other people’s needs when I engage with them, to the extent that in order to recuperate, I have to cut off from a recollection of these completely when I am alone.

The more I think about it, the more it sounds like two sides of the same coin – though I do not think I fit the diagnostic criteria for Asperger’s, I think Ellen could quite easily be diagnosed with BPD.  The irritation, as well as concern I felt when I received her text message was an important reminder of how my poorly integrated outside and inside worlds have worked to cause a lot of damage to my relationships, hurting those who I fail to realise (until too late) love me.  Ellen is fine.  The overdose she took does not sound substantial enough to have caused any damage, if her reports of the lack of medical treatment she was given in hospital are anything to go by.  Ellen, I think, wants me to help her, if only through the understanding she thinks I possess of how she feels.  She offers, unasked, details of her self-harming behaviour and watches closely for my reaction.  I cannot help but be responsive, but I am very wary of getting too involved.  For various reasons, which I won’t go into now, I think some of her recent behaviour has been modelled on what she knows of my history.  A few days ago, before her recent overdose, she told me she had once again taken a few too many of her citalopram pills.  I was bemused, and asked her what she had wanted to achieve – assuming she knew, as I do, that (whilst not a great thing to do) a small SSRI overdose is not particularly dangerous.    I can’t help but wonder if my reaction played some part in the fact that last night she appears to have taken paracetamol as well as citalopram.

I am annoyed partly because I hardly know her, and in some ways I do feel the text was an imposition. I was also angry because it took no account whatsoever of my possible feelings, and gave me only enough information to make me feel worried (disproportionately, considering the situation wasn’t in the end dangerous) and powerless.  It did make me think, though, of how my own self harm and suicide attempts must have affected those close to me – if I felt the way I did about Ellen, who after all is only really an acquaintance, how much worse it must be if you have a greater personal investment in someone who seems to behave towards themselves, and towards you, in such a cruel, careless way.  Those are emotionally loaded words, and my anger towards Ellen was almost entirely an emotional response.  While it may not be the most useful reaction, it is human – it is human to hurt when someone, particularly someone you love, hurts.  My experience of re- gaining consciousness in intensive care, hooked up to a million tubes, my mum, her face ashen, standing over me; or of my mother telling me how my Dad (he was still alive then) had cried when I was being treated for my first serious overdose and they were still waiting to find out if I would pull through, has a flip-side.  A flip-side which is at heart no less caring, but requires more insight, and in my case personal experience of being on the other side, to understand.

It is the frustration with a friend who has once again put herself in hospital, the friend you were relying on that weekend to come to see you on your Erasmus placement abroad.  It is the bewildered, frightened fury you feel when she goes out to celebrate a birthday with you only to spend an hour vomiting in the toilets of a bar and then sits down in the middle of the road, and you have to call an ambulance.  It is my mother’s terror, as she finds me hurting myself once again – the terror that provokes a hysterical “you don’t have to kill yourself; I’ll do it for you”.  It is my therapist's questioning of why I am “tormenting” her by making her watch me lose a dangerous amount of weight, yet again.   It is all this, and so much more. 

Thank you, Ellen, for helping me to see.

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.