Out of mind

"You're going to think I'm dreadful," said Alice—a middle-class girl in her late twenties—to the young psychiatrist. "But I met this man on the bus and agreed to sleep with him, I don't even know his name." She looked meekly towards the doctor, holding the hem of a denim miniskirt tightly over bare legs. "I can only talk to you about it."

Of all the relationships he was developing with his growing list of patients, the one with Alice was the most difficult to get right. She had been to Birmingham University and then to drama school in London, but things hadn't worked out so far. Although she said she was writing a novel, most of the time she temped at a mental health charity where she filled time writing blogs on the internet, taking on various identities; a mix of fact and fiction. In reality, between the ages of seven and 11, after her parents divorced, the father of her best friend Katie had sexually abused her. Initially she encouraged his attention. She blanked out the pain she felt, even at times helping him inside her. And though she wanted him to stop, it wasn't until puberty that she fought him off. During her teens she had lived between parents, neither of whom were much good at talking about emotions.

Alice's relationship with mental health services was fraught. Since the age of 15, when her father had taken a job abroad, she had begun cutting herself—superficial cuts that scarred her forearms and required stitching. Then, at 17, she took her first overdose of 20 co-codamol tablets after the boy she was seeing tried to sleep with her. Things got a bit better at drama school, but then declined into a cycle of relationship failures, self-harm and inner emptiness.



To the young psychiatrist, Alice fitted the category of borderline personality disorder. The origins of borderline PD lie in psychoanalysis, but the diagnosis managed to become standardised in modern psychiatry—despite the ambiguity of its definition. Rather than a particular state of mind, it is a trait of personality. It denotes a pattern of behaviours that spring from a problem in forming relationships. If a neurotic person forms pathological relationships, and a psychotic person can't form any, the borderline personality lies in between—constantly forming and breaking relationships. It's a pattern that gets repeated in the consulting room.

Sometimes Alice would come to the clinic unable to speak, almost dribbling and infantile, requesting admission or antidepressants. At other times she would be hateful, slam the door and threaten to throw herself under a train. And then, like today, she could also be seductive, dressing scantily and telling the young psychiatrist that only he could save her; even seeming to invite a transgression of clinical boundaries.

Empathy and boundaries: these were the twin poles of the therapeutic relationship that the young doctor had been taught. But encounters with Alice were stressful and he often found himself retreating to the safety of the objective clinician, emphasising the need for regular medication. Over ten years, different doctors had tried to treat Alice, suggesting she had recurrent depression or bipolar disorder and trying various drugs. Antidepressants, mood stabilisers, even antipsychotics were tried, but the effects were minimal. Both psychiatrists and patients want something they can name and treat. You can fight a biological depression or bipolar disorder. You can't fight a disorder of the self.

As each clinician became exasperated, the professional consensus—not shared by Alice—tended towards the sticky and sometimes pejorative modern label of borderline PD; and the best evidence pointed to psychotherapy. Various clinicians had explained the benefits of a long-term stay on a personality disorder day unit—groups, analytic psychotherapy, a focus on relationships. But Alice wouldn't agree. "I have depression, that's all."

She agreed to try cognitive behavioural therapy, with a nice psychologist called Tom. He initially agreed to see her for ten sessions, but ended up seeing her weekly for two years. He said he would give her tools to manage her emotions. But, devastated when Tom left the trust, she took a massive overdose of paracetamol and cut her wrists before calling an ambulance. That was almost a year ago; since then she had been in a general psychiatric clinic, seeing the young psychiatrist about once a month.

A couple of days earlier, she had again turned up in A&E, this time on a Saturday night, claiming she had taken another overdose of paracetamol. Staff had checked the level of the drug in her blood, found none and asked if she was telling the truth. Furious, she had told them all to fuck off; that they didn't care. She had stormed out of the department. The letter from the casualty doctor was now on the young psychiatrist's desk.

"I understand you went to A&E on Saturday? Was that because of what happened with the man on the bus?" She flared up. "Fuck you," she spat, "you don't even look old enough to be a psychiatrist." She was heading to the door. The young psychiatrist felt he should follow her, knowing that there was a 1 per cent chance that a patient like Alice would kill herself. He felt an impulse—a need—to try and save her, but stopped himself. Empathy and risk were important, but so were boundaries.