I arrived at the psychiatrist’s office half an hour early, as instructed. They told me I needed to fill out some forms prior to seeing the doctor.
Standing in the hallway, I could see a woman sitting behind a circular desk. Her head shot up as I pushed through the glass doors.
She smiled. “Hello.”
“Hi.” I advanced to the desk, resting my elbows on the counter. “I have an appointment with Dr. Brace.”
“Grace?”
“Yes.”
“Great.” The receptionist began thumbing through stacks of paper until she found what she was looking for. She clipped the piece of paper onto a clipboard, attached a pen, and passed it over the counter. “I’ll need you to fill this out.”
I scanned the form and flipped it over. It was double-sided, containing dozens of questions asking me to rate my various moods on a scale of 1 to 5. Happiness, hopefulness, insomnia, family support, relationship with a significant other, relationship with friends, stress about money, anxiety, depression, suicidal thoughts.
I filled it out, then slid the clipboard back to the receptionist, smiling nervously.
“Have a seat,” she gestured. “Dr. Brace will be with you soon.”
I stood in the waiting room, unable to sit still. A young woman, covered in tattoos, was seated in the corner, her head down, looking at nothing. I picked up a pamphlet on suicide prevention and skimmed through it, unable to comprehend any of the words.
“Grace?” a voice boomed behind me.
I flinched.
“Sorry, I didn’t mean to startle you.” He was a tall man, early sixties, with wispy grey hair and a mustache. He wore round glasses and carried an extra twenty pounds in his midsection. “I’m Dr. Brace. You can follow me.”
I followed him down the long, narrow hallway, past open and closed office doors. I scratched my jawline vigorously. My shoulders ached, and I could barely hold my head up.
With each step, I thought: You still have time to run.
Left foot: Just turn around, Grace.
Right foot: You don’t need him.
Left foot: You know exactly what he’s going to tell you.
Right foot: You’re fucking crazy, he can’t help you.
He excused us as we stepped around a woman who was vacuuming the grey carpet.
Left foot: Too late.
I was standing in his office.
Dr. Brace shut the door behind us, quieting the noise of the vacuum and trapping me inside.
“Have a seat,” he said, motioning to an off-white armchair in the corner. I’d always imagined a couch.
Wheeling an ergonomic office chair out from behind his desk, he sat facing me, lifted a file folder and a pad of paper, and placed them in his lap.
“How are you, Grace?” He wrote the date in numbers and slashes at the top of his page before lifting his gaze.
“I’ve been better.”
He tilted his pad slightly upward, noticing my eyes on it. “I’m sorry to hear that. I see you’ve been referred to me by Dr. Jones,” he said, peeking at my file. He paused to read over the notes. “She said you’ve been feeling sad. Finding it hard to get out of bed. Haven’t been to work in weeks.”
This was something I’d grow to disdain. A medical professional reading to me from my file, using my own words against me.
“I guess so.” I ran my fingers through my ponytail, shaking the hairs that stuck between my fingers onto the rug.
He watched the strands of blond hair fall. “What else are you feeling?”
I knew exactly how I felt, but few ways to describe it.
“I feel like I’m disappearing.”
“Okay.” Dr. Brace straightened his glasses in mild anticipation, as though we were already getting somewhere. “Can you elaborate on that?”
“I feel like I’m not real.” There were three light bulbs in the room: two lamps and one overhead. “Like I’m watching my life from afar.” Four posters, each featuring some sort of inspirational quote. Each turned my stomach equally. “I’m afraid I’m going to disappear and no one will notice.” Three degrees, each stamped with a large red seal and framed in black.
“Are you harming yourself?” he asked. “Cutting? Burning?”
I tried to speak but I couldn’t.
He jotted something down on his pad of paper. I could no longer see what he was writing. I just stared at him.
It was chilly in his office, and my nose had started to drip. As I reached for a tissue, I noticed my fists were clenched so tightly that when I released them, my fingernails left half-circle indents on my palms. I pulled a Kleenex from the box on the table beside me and wiped my nose.
“How long have you been cutting?”
“A couple of months,” I finally stammered. “I guess.”
He turned the pad face down in his lap and placed his hands on top. “It’s okay,” he reassured me. “I only want to help you. But I need you to be honest with me.”
I nodded, crumpled the dirty tissue into a ball and clutched it.
“When was the last time you cut yourself?”
At that point, I wasn’t familiar with the way the mental health–care system worked. I didn’t know then that you learn to lie or embellish to avoid getting what you need.
“Last night,” I whispered.
“Where do you usually cut yourself?”
With my head down, I followed the ecru rug’s circular pattern with my eyes. “My wrists.”
“Have you ever had to go to the emergency room?”
When I wasn’t looking at Dr. Brace, I became more aware of his voice. He used very little inflection, a performative tone that was meant to soothe. It made me uncomfortable. I shifted in the chair, uncrossing and recrossing my legs at the knee.
“Grace?”
I shook my head.
“Can I see your wrists, please?”
No one had seen my wrists in months. I was careful to wear only long-sleeved shirts. Since it was winter, this didn’t appear unusual. I was cognizant to never roll them up while washing my hands, letting the fabric dampen and gradually dry against my skin.
Slowly, I pulled back the sleeve to reveal my left wrist. I was naïve; I thought I had to do whatever he said.
Thirteen ridged slashes, one after the other, like lines of cocaine. It was always thirteen. Lucky number thirteen. The cuts were horizontal, starting at the base of my palm and ending just below the crease of my elbow. The whitest and most delicate part of my skin.
I studied his face, hoping for a reaction.
Nothing. He was good.
“Thank you.” He regarded the notes in his lap, jotting something down.
My cheeks reddened as the anger surged and the shame built. I yanked my sleeve back to cover my wrist.
“Why do you cut yourself?” he asked, searching my eyes for some sort of tell.
I needed to see my blood to make sure I was real. I liked the way it felt as it trickled down my arm. It was punishment. It was a way to feel something. It was an outlet for my fucked up thoughts. A level of control was required. Never too deep, otherwise you might have to go to the hospital, but just deep enough to feel that release. The warmth of blood soothing the sting of the freshly exposed wound. I would use anything I could get my hands on. A razor blade, a pen, a nail, a needle. I preferred something that made a clean cut. Precision was key. I was always surprised how little it hurt. I hardly felt it.
“I don’t know.”
Dr. Brace sat in silence, an attempt to intimidate me into saying more. I stared at the exposed parts of the floor, counting the tiles. Thirty-two.
The clock on the wall ticked, drawing my attention like a baby crying out for its mother.
“I’m going to prescribe you an antidepressant, something to make you feel a little better.”
It wasn’t a suggestion. This strange man, whom I had just met, knew what was best for me.
“And let’s set up an appointment for you with a psychologist.”
mental status examination
Grace on a one-to-one presented as a somewhat seductively dressed 18-year-old. Her affect was clearly anxious. Her mood, she described as depressed. When symptoms of depression are reviewed, indeed she describes significant mixed insomnia, tendency to be withdrawn and show little interest. She has significant feelings of tiredness and low energy. She feels that her concentration is poor and she is unable to relax, with excessive worrying or nervousness. She describes classic anxiety symptoms of a panic type with panic attacks occurring approximately once or twice a week. She has been prescribed Ativan to be taken on a permanent basis.
Client did spend a period of time partying when she came to university (i.e. drinking alcohol). She drinks a lot and has not moderated this by her own report. She smokes marijuana daily. She has done so for the last couple of years.
Client denies suicidal ideation or intent. She does, however, cut herself and has done so over the past four or five months. These are relatively superficial and I examined some superficial scarring on her forearms today. She claims she doesn’t know why she does this.
diagnostic formulation
Axis 1 (Major Mental Illness):
- Generalized anxiety disorder
- Major depressive episodes
Axis 2 (Personality Features):
Significant borderline tendencies.