The McGill Daily - - Contents - Art and Es­say By Bee Khaleeli

con­tent warn­ing: self harm, eat­ing dis­or­der, sui­ci­dal ideation, sex­ual as­sault

It’s late spring when a friend of mine in­forms me that my for­mer clin­i­cian — let’s call him Doc­tor X — with­held a di­ag­no­sis from her when she was his pa­tient. She learns this dur­ing a cri­sis ap­point­ment with a dif­fer­ent psy­chi­a­trist, who flip­pantly men­tions a note on her chart which sim­ply states: “per­son­al­ity dis­or­der, not oth­er­wise spec­i­fied.” A land­mine doc­u­mented in med school hand­writ­ing, still ac­tive even af­ter two years of con­ceal­ment. Un­sur­pris­ingly, she re­sponds to this in­for­ma­tion with a panic at­tack. She is asked to leave the of­fice, to “re­turn when she has calmed down.”

She sub­mits com­plaints against the clin­i­cians in ques­tion. De­spite this, they both re­main em­ployed and con­tinue to treat stu­dents.

Mcgill Psy­chi­atric Ser­vices charges a dol­lar per page when pho­to­copy­ing a pa­tient’s chart, with a max­i­mum charge of $25. My re­quest takes a week to be pro­cessed. I pick up the thick white en­ve­lope at the re­cep­tion desk. Debit or credit, no cash.

One of the first doc­u­ments in my chart is a client eval­u­a­tion form com­pleted on Fe­bru­ary 9, 2017. Sec­ond se­mes­ter of my sec­ond year. I came in for a cri­sis ap­point­ment. It is stated that I have “re­cur­ring night­mares about sex­ual vi­o­lence.” It is stated that “[they] think [they were] as­saulted.” One header on his page of notes is ti­tled “PTSD(?).” His hand­writ­ing is dif­fi­cult to de­ci­pher.

My wait time for a fol­low-up ap­point­ment with a psy­chi­a­trist is four to six weeks. Five days later, I am hos­pi­tal­ized for self-mu­ti­la­tion. The notes from my med­i­cal con­sul­ta­tions in the Psy­chi­atric Emer­gen­cies Unit state first that I likely have an “un­spec­i­fied per­son­al­ity dis­or­der with border­line el­e­ments,” and then that “BPD is a prob­a­ble di­ag­no­sis.” These notes are for­warded to Psy­chi­atric Ser­vices, and then passed onto my soon-to-be-clin­i­cian, Doc­tor X, for fol­low-up. Dur­ing a sec­ond cri­sis ap­point­ment on Fe­bru­ary 27, a psy­chi­atric nurse un­der­scores this, ad­vis­ing my fu­ture clin­i­cian to “rule out [whether I had] BPD or bipo­lar-ii.”

Border­line per­son­al­ity dis­or­der, or BPD, is es­ti­mated to im­pact 1% of the gen­eral pop­u­la­tion, and 10% of those di­ag­nosed will com­plete sui­cide. It is char­ac­ter­ized by un­sta­ble in­ter­per­sonal re­la­tion­ships, emo­tional dys­reg­u­la­tion, and a shaky sense of self. BPD has a high rate of her­i­tabil­ity, and is preva­lent amongst in­di­vid­u­als with trau­matic child­hood ex­pe­ri­ences, such as ne­glect, aban­don­ment, and abuse.

I meet with Doc­tor X the next day. He does not in­form me of this di­ag­no­sis, though he makes a small, brief note at the bot­tom of the page fol­low­ing our ini­tial meet­ing: “BPD.” An­ti­thet­i­cally, he states that my pri­mary di­ag­no­sis is for gen­er­al­ized anx­i­ety dis­or­der. I ex­press a de­sire to fo­cus on my PTSD, which he re­jects – it is the anx­i­ety, he claims, which is im­pact­ing me most sig­nif­i­cantly. He gives me a script for es­c­i­talo­pram, an an­tide­pres­sant. He rec­om­mends me to a cog­ni­tive be­havioural ther­apy spe­cial­ist.

The first cylin­dri­cal plas­tic bot­tle of es­c­i­talo­pram costs me four dol­lars, thanks to my Stu­dent­care cov­er­age.

The next two months are a dis­so­cia­tive blur. De­spite my con­sis­tent com­plaints vis-à-vis the neg­a­tive ef­fects of the pre­scribed med­i­ca­tion, Doc­tor X makes no note of my de­clin­ing men­tal state. My dose is in­creased at whiplash-in­duc­ing rates. I am ex­hausted, para­noid, and emo­tion­ally la­bile. I am manic, ir­ri­ta­ble, im­pul­sive. I have delu­sions about the sup­posed risk of leav­ing my apart­ment. I don’t eat, and I rel­ish the feel­ing of my ribcage un­der shaky hands. There is less body left for me to drag around half-heart­edly. I spend hours in bed, keep­ing track of the wall mould­ing’s in­tri­ca­cies. I buy pot­ted plants and let them dry out on my book­shelf. Chipped mugs ac­cu­mu­late on my bed­side ta­ble. Wa­ter glasses. Bobby pins. At any given time, my body feels as though it is five feet away, un­in­hab­ited and su­per­flu­ous. I dream about be­ing vi­o­lently as­saulted and wake up in a cold sweat. The idea of pain — feel­ing any­thing again, re­gard­less of how trau­ma­tiz­ing — seems mar­vel­lous.

Doc­tor X’s notes of our ap­point­ments rarely ex­ceed five two-word-long lines, and tend to­wards il­leg­i­bil­ity. The tight, or­derly struc­ture of his writ­ing is some­what pleas­ing when it doesn’t st­ing. Briefly, he men­tions the “ques­tion of bipo­lar­ity,” with no fur­ther de­tails. He refers to me as “gig­gly.” He de­creases my dose. On April 13, 2017, he quotes me as say­ing: “my brain is try­ing to kill me.” This is all that he writes. He in­creases my dose. Five days later, he re­ports that I am “fine now.”

I re­mem­ber that ap­point­ment clearly. I don’t re­mem­ber much of that year, but I re­mem­ber that ap­point­ment, be­cause I cried for ten min­utes straight while telling Doc­tor X about how much I wanted to kill my­self. He seemed at a loss, un­mov­ing in the face of my sad­ness. Our ap­point­ments – booked for an hour-long time slot, as they al­ways are at Psy­chi­atric Ser­vices — never ex­ceeded ten min­utes. I would al­ways cry. He would usher me out at the ten-minute mark. I was not fine.

Less than a week later, I am hos­pi­tal­ized for the sec­ond time.

One as­sess­ment doc­u­ments the fol­low­ing: “pa­tient sit­ting on bed. Ap­pears well groomed, wear­ing ap­pro­pri­ate cloth­ing. Short hair, large glasses. Thin. Mul­ti­ple fresh cuts on fore­arms (~30 on left, ~3 on right). Fac­ing win­dow. In­creased level of psy­chomo­tor ac­tiv­ity (run­ning hands through hair, mov­ing fin­gers). No eye con­tact. Co­op­er­a­tive but seemed frus­trated at hav­ing to re­peat [their] story... Anx­ious, la­bile... Deper­son­al­iza­tion: ‘ does not know how to make [their] body feel real.’ Good in­sight.”

And then an­other: “self-harm with strong BPD traits.” I am de­scribed as “help-re­ject­ing,” likely for hav­ing stated that I am un­com­fort­able speak­ing to a male doc­tor. “Keep overnight for safety (vol­un­tary).” No­body of­fers to clean off my fore­arms.

The next morn­ing, I wake up to flakes of dried blood on my stan­dard­is­sue sheets. “I be­lieve the main di­ag­no­sis is BPD, along with PTSD. Af­fect is fully re­ac­tive. Smiles. Has sense of hu­mour, en­gages well. Copy of chart to be faxed to Mcgill.” At this point, they in­form me of my per­son­al­ity dis­or­der di­ag­no­sis.

I eat break­fast with a plas­tic fork and knife. Too volatile for real cut­lery. A slice of ba­con stares at me, drip­ping grease onto Sty­ro­foam. I don’t eat meat. A med stu­dent en­ters the room as I am chang­ing out of my hos­pi­tal robe, breasts ex­posed. “Did the sero­quel help you sleep?” he asks.

Given my friend’s ex­pe­ri­ence with Doc­tor X, I con­sider re­ceiv­ing my di­ag­no­sis dur­ing this so­journ at Mon­treal Gen­eral to be a god­send. He with­held it from me for two months, but what if I hadn’t been hos­pi­tal­ized a sec­ond time? Would I have waited two years? Would I have never been in­formed of my di­ag­no­sis, never been re­ferred to the life-sav­ing prac­ti­tion­ers that I’ve been lucky enough, insured enough,

un­threat­en­ing enough to pa­tron­ize? The re­al­ity of my sit­u­a­tion is that sui­cide was a real pos­si­bil­ity, as it is for count­less in­di­vid­u­als with BPD, es­pe­cially in the ab­sence of ap­pro­pri­ate psy­chi­atric treat­ment. How do you make sense of per­son­hood af­ter sui­ci­dal­ity? I have never known how to pic­ture my­self in five years, but I know that I will carry that feel­ing of con­stant pre­car­ity for­ever. I was nine­teen and I was ready to die. I could have been get­ting bet­ter. I should have been get­ting bet­ter. I re­peat­edly told Doc­tor X that his treat­ment plan was fail­ing me, was hurt­ing me. He didn’t lis­ten. That a clin­i­cian could have de­nied me a chance at re­cov­ery should be seen as noth­ing less than a slap in the face to my au­ton­omy and agency — as a pa­tient, as a per­son.

I be­gin to see a new clin­i­cian at Psy­chi­atric Ser­vices. I am weaned off es­c­i­talo­pram. The with­drawal pe­riod is like pulling teeth. I am tired. I am ir­ri­ta­ble. I look up di­alec­ti­cal be­havioural ther­apy prac­ti­tion­ers. I am re­ferred to the Per­son­al­ity Disor­ders Pro­gram at the Al­lan Memo­rial In­sti­tute. A week and a half passes, and my body has ad­justed to life with­out SSRIS. Doc­tor X avoids eye con­tact with me in the lobby of the Brown Build­ing. Some­times I pass by his of­fice and feel a swelling tide of dread, a vis­ceral urge to vomit.

In Septem­ber of 2017, I meet with the co­or­di­na­tor of the Per­son­al­ity Disor­ders Pro­gram, let’s call him Doc­tor Y.

He asks me about my eat­ing habits, and I de­scribe a con­sis­tent pat­tern of re­strict­ing my caloric in­take. “I am un­sure,” I say, “whether this ac­tu­ally counts as anorexia.”

He writes: “never had full anorexia, but keeps [them]self very slim.” My ribcage braces it­self against taut skin, jut­ting through my T-shirt. His of­fice is too cold.

He does not doc­u­ment my dis­clo­sures of sex­ual vi­o­lence.

He writes: “con­sid­ers [them]self a Mus­lim, and car­ries a bag with a state­ment against Is­lam­o­pho­bia.” He writes: “men­tal sta­tus: tat­toos, rings on the nose,” as though these could be mean­ing­ful mark­ers of trau­matic life ex­pe­ri­ences or neu­roses.

I do not dis­cuss my sex life at length. I men­tion my bi­sex­u­al­ity. I men­tion be­ing in an open re­la­tion­ship. I men­tion my mi­nor in gen­der stud­ies, of all things.

He writes: “very in­tel­lec­tual, jus­ti­fy­ing prob­lems on ide­o­log­i­cal ba­sis (e.g. [their] promis­cu­ity, which is some­what im­pul­sive and des­per­ate, is framed as polyamory).”

I meet seven out of nine cri­te­ria for BPD. He tells me that my val­ues and in­tel­lect will be the pri­mary bar­rier to ef­fec­tive treat­ment. I won­der if he has ever said this to a man.

Border­line per­son­al­ity dis­or­der is strin­gently gen­dered. This is, in part, be­cause of dif­fer­en­tial rates of ac­cess­ing care — men, on av­er­age, seek psy­chi­atric help more in­fre­quently.

How­ever, there are other fac­tors at play. Due to misog­y­nis­tic per­cep­tions of women’s symp­to­mol­ogy, they are three times more likely than men to re­ceive border­line di­ag­noses. Sim­i­larly, many psy­chi­a­trists have as­sumed the ex­is­tence of a link be­tween gen­der dys­pho­ria and BPD. Ad­di­tion­ally, child­hood sex­ual abuse and vi­o­lence — both of which are dis­pro­por­tion­ately ex­pe­ri­enced by girls and young queer and trans youth — are con­sid­ered to be po­ten­tial causal el­e­ments in the de­vel­op­ment of BPD.

Misog­yny is the thread which ties to­gether this labyrinthine mess of psy­chi­atric mal­prac­tice. I think of Doc­tor X sug­gest­ing that we fo­cus on my anx­i­ety, rather than my PTSD. Did he jus­tify this, per­haps, with the as­sump­tion that my rape was nei­ther trau­ma­tiz­ing nor se­ri­ous? I think of every note from a con­sul­ta­tion or ap­point­ment where my sur­vivor­hood is not men­tioned. What does it mean that Doc­tor Y saw a fa­cial pierc­ing, or the shape of my body, or a patch on my back­pack as more note­wor­thy than rape? In “Car­togra­phies of Si­lence,” the fem­i­nist poet Adri­enne Rich writes: [Si­lence] is a pres­ence it has a his­tory a form do not con­fuse it with any kind of ab­sence. Omis­sion is telling. It may let us un­der­stand what an au­thor has taken for granted in their cre­ation of a source. Why do we al­low prac­ti­tion­ers to dis­miss rape as a re­al­ity in their pa­tient’s lives? Where does that leave sur­vivors?

I ask my new ther­a­pist about the ra­tio­nale be­hind with­hold­ing a BPD di­ag­no­sis.

“The only real rea­son would be the risk of fur­ther desta­bi­liz­ing a pa­tient who was al­ready volatile.”

I was ask­ing for help, wasn’t I? I was ask­ing in all of the ways that I could. I wanted med­i­ca­tion that worked. I wanted ther­apy that worked. I wanted a psy­chi­a­trist to see my hurt, to say “you have been hurt,” and to act ac­cord­ingly. In what world could that be read as volatil­ity? I was ask­ing as clearly and loudly as pos­si­ble, but I was re­ceived by clin­i­cians as a dumb, petu­lant lit­tle girl. A hys­teric.

“For what it’s worth,” he as­sures me, “that co­or­di­na­tor at the Al­lan has ter­ri­ble re­views on Ratemds.”

This is com­fort­ing for a split sec­ond, be­fore I re­mem­ber that Mcgill is prob­a­bly still pay­ing Doc­tor Y six fig­ures a year.

My ther­a­pist thinks that writ­ing this ar­ti­cle will be a good out­let. We switch top­ics.

It is late sum­mer now. I re­fill my pre­scrip­tions for ser­tra­line and clon­azepam at Jean Coutu. Lit­tle yel­low cap­sules, flat white tablets. The phar­ma­cist asks if I am preg­nant or breast­feed­ing. “God, I hope not!” A joke.

Af­fect is fully re­ac­tive. Smiles. Has sense of hu­mour.

My new psy­chi­a­trist says that I no longer meet enough di­ag­nos­tic cri­te­ria to qual­ify for a BPD di­ag­no­sis — just “traits.” She weighed me at our first ap­point­ment, and im­me­di­ately re­ferred me to a di­eti­tian for fol­low-up. I had a BMI of 16.2. Keeps [them]self very slim. My psy­chi­a­trist as­signs me read­ings. I com­plete them with­out fail.


Months later, in the lobby of Psy­chi­atric Ser­vices, I ask Doc­tor X why he with­held my BPD di­ag­no­sis. “I don’t re­call do­ing that”. I tell him that I saw my chart. “I don’t re­call you ever ask­ing if you had this di­ag­no­sis.”

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