This post includes the opinions & experiences of the author, who wishes to remain anonymous.
Like a lot of the people posting to this blog, I never thought I’d get onto the STP either. When I applied, I almost balked at the competition ratios. I felt like I didn’t deserve to be there, and doubly so after how I’d felt the interview went. But I did get in – to the training institution I wanted, nonetheless. And it was one of the biggest surprises of my life.
The brain is a funny thing, in that it is great at tricking you into thinking you haven’t earned where you are, and that you don’t deserve it. Somehow, you have fooled everyone into thinking that you’re a person who is capable of the enormous responsibilities of a clinical scientist over countless others. Some people never feel like this and can cruise through life happy as a clam. Most, I think, do at some point in their lives, but experience eventually quietens the voices as they become increasingly competent at what they do. Some others are like me where, no matter how many things they achieve, they remain convinced that they’re there by some miracle. This way of thinking is, of course, very frustrating for mentors and advisers who try in vain to convince them that no, they’re fine, don’t be daft, they’re good, so on and so forth. I’ve had countless such conversations.
There’s been posts about imposter syndrome on here already which are very good, so I won’t repeat them here (I’ll link some resources at the end that I’ve personally found helpful), but I wanted to lead with it as it is so relevant to my STP experience, which I’ll talk about in a bit. My imposter syndrome in part stems from a mental health condition I have, which I struggle even now to talk about due to the lack of understanding and stigma surrounding it. In fact, I was so frightened of having to declare it on my application for the STP, as I was worried that I would be considered mentally unfit for the role by Occupational Health. Times have changed considerably in recent years in the understanding surrounding mental health (and I knew that I was protected under the 2010 Equality Act) but that didn’t stop the internal doubts creeping in.
Emotionally Unstable Personality Disorder (EUPD)
My condition is called emotionally unstable personality disorder (EUPD, otherwise known as borderline personality disorder, or BPD). In basic terms, EUPD is a disorder of emotional control, but it is so much more than that. An individual EUPD sufferer’s experience is profoundly unique, and there are roughly 256 possible symptom combinations. To meet the criteria for a diagnosis, an individual must match at least 5 of the 9 characteristics:
1) frantic efforts to avoid abandonment,
2) a pattern of unstable relationships,
3) unclear self-image,
4) engagement in impulsive and self-destructive activities,
5) self-harming and suicidal behaviours,
6) extreme shifts in mood,
7) chronic feelings of emptiness,
8) explosive anger, and
9) paranoia, dissociation and being out of touch with reality.
It is unclear what the causes of EUPD are, but it is thought that it stems from developmental issues caused by difficulties in childhood, with genetic factors also playing a role. It is also more common than people may realise – although not necessarily a representative sample, of the approximately 800 or so STP trainees in England, around 5-16 may meet the diagnostic criteria for the condition. Although it can be effectively treated with specialised talking therapies and medication, success rates in terms of a cure are mixed and the condition is usually lifelong. Without effective access to treatment, roughly 10% of EUPD suffers die by suicide.
For people uninformed about EUPD, they often think the sufferer is being overly-dramatic, dishonest, insincere, lazy, moody, over-sensitive, ignoring them when they give advice and that they’re not trying hard enough. Worse still, there are those who avoid people who struggle with EUPD, or are overtly exclusionary and cruel because of the unfair reputation EUPD sufferers have. The media (as a whole) paints an extremely negative picture of EUPD, where images of Glenn Close in Fatal Attraction, or Dennis Reynolds from It’s Always Sunny in Philadelphia spring to mind. Although these stereotypes aren’t necessarily wrong for a minority of sufferers, the symptom combinations for EUPD are so numerous that they are in no way reflective of the majority and are, in fact, overtly harmful. There is no talk of the extreme vulnerability to abuse, nor the incredible empathy and kindness sufferers often exhibit, nor the trauma which many sufferers have endured behind their pathological emotional worldview.
In the context of work, for me, the symptoms of EUPD manifest as severe anxiety (generalised and social), depression, low self-esteem, tiredness, hypomania, sleeplessness, severe procrastination, working odd hours (because of procrastination), a desperate desire to be accepted by and liked by others, paranoid thought patterns, black and white thinking (where everything is either sunshine and roses, or an unmitigated disaster), emptiness, perfectionism, thought spirals, suicidal thoughts, highly negative self-talk, people-pleasing, self-isolation and fast, severe mood swings (often, several swings or more per day). As to how extreme the latter can be, I’ve gone from relatively alright one minute to having a crying fit in the bathroom as I’ve thought I’ve offended someone, or that I’m rubbish because I’ve had a bit of negative feedback.
EUPD & the STP
In my first year, I struggled to fit in with the trainees I began the STP with. I was in the midst of specialist therapy every week that took me away from my training. As a result, I felt like I would never keep up, trying to make up the extra time and becoming increasingly exhausted. It felt like it was a dirty secret going to therapy – I felt as if I couldn’t really talk about it and whatever I was struggling with at the time was no excuse to be behind, or for it to affect my attitude at work. While I managed to make a few friends, I still felt incredibly lonely and like I was constantly putting my foot in my mouth wherever I went. As a result, I used to struggle going into work, preferring to isolate myself away from others. If I was down one day, I couldn’t explain to my colleagues why – the group therapy I partook in on a weekly basis was incredibly emotionally exhausting, and trying to switch my brain from mental health outpatient into professional clinical scientist wasn’t always possible.
As difficult as it was to adapt, home-working during the pandemic really helped. I felt as if I had space to breathe, and could piece my head together while trying to push through university work and competencies. Therapy stopped during the pandemic, and I managed to use the skills I had learned (as well as a lot of support from friends) to push through and stay on top of what I was doing. I received positive feedback from my multi-source feedback (MSF) (after being terrified to open it), passed all my exams and managed to get through all my first-year rotations in good time. Despite all of that, though, it never really felt enough. The self-flagellation still continued.
I enjoy my training overall – although it can feel enormous in terms of the avalanche of work to get through, I have felt myself improving and becoming more confident. One of the things that brings me joy is the sense of achievement I get when I’m able to explain something I couldn’t before, or keep pace with a technical conversation. But still, trying to fight with my brain on a daily basis while trying to explain why I’ve not gotten to something, or why I’ve left the room to try and regulate my breathing when things get too busy, or trying desperately to just be ‘normal’ when I’m in the midst of an emotional maelstrom during a meeting is really hard. It feels like I’m wearing a mask – every single day – where I’m gritting my teeth and forcing a smile. Some days, it’s easy. Other days, it’s impossible.
As you can probably imagine, trying to keep my condition quiet is exhausting, as it often involves suppressing symptoms primarily to maintain the comfort of others. Although I have informed my direct employers about my condition, none of my training officers know. Several of them know I have anxiety and depression, but they are not aware of the underlying broader cause. This has been a personal choice of mine thus far, predominantly as I worry that I will be treated differently (I should stress that they have not indicated that they would), that I will have to explain my condition to them or worse, my competence will be called into question. This fear predominantly stems from past experiences in my life where I have been open about my condition and had a bad experience as a result. It is something I need to work on personally, which was one of the reasons I chose to write this post; the other reason of course being to reach out to others with mental health (including complex mental health struggles) to let them know that they are not alone (and that they’re amazing).
Where I am now
A painful change in personal circumstances a few months ago (which I couldn’t hide at work and drove me towards a breakdown) has presently made it harder to self-manage and has affected my performance enormously. When this began to happen, it was then I decided to reach out and use the resources at my GP, work and university. Although waiting lists can be frustratingly long and there may feel like an endless number of hoops to jump through, it can be worth accessing them due to improved accessibility to talking therapy (sadly, compared with most local NHS services). Most Trusts should offer a staff counselling service, and universities acting as academic providers for the STP should have their own internal counsellors as well. I would still recommend in any case to speak to a GP if you suspect you may be struggling with mental health issues, especially if you feel you may need more specialist therapy (such as Cognitive Behavioural Therapy (CBT), Mentalization-based Therapy (MBT) or Dialectical Behaviour Therapy (DBT)) or medication.
I also spoke with the national school about my condition, current feelings and present circumstances (I am fortunate that the training I receive in my centre is generally very good, so I cannot speak on behalf of those who have contacted the NSHCS regarding centre-based training issues). The training support case manager was extremely kind and supportive – not once did they make me feel as if I was a burden, or as if I did not have a valid case. They listened attentively and followed up with me, offering advice on the extension process if it was required. As difficult as it may feel for those in a similar boat to myself, they really are there to help and I would encourage anyone who is suffering with their mental health to reach out and see what services or resources they may be able to offer.
Finally I spoke to Occupational Health at my workplace, who made recommendations for workplace adjustments to my immediate managers. To access Occupational Health services, you may need to either self-refer or be referred by a relevant line manager. This was originally a source of fear for me, but the Occupational Health doctor was very encouraging and ensured me that I was not alone. They will not share any information with managers (unless in very specific circumstances, such as safeguarding concerns, and will outline these to you at the beginning of the consultation) and will take into account any previous adjustments you may have had that have worked in the past. For me, I requested deadline flexibility and a general awareness to be made that I was struggling. The Occupational Health doctor did not disclose my condition, saying that: ‘people might Google it, put two and two together and end up with five’.
None of my managers have since discussed the report with me or reached out (aside from an off-handed remark as I walked into the room), which made me feel frustrated and further isolated. While I am aware that there is a general fear of ‘saying the wrong thing’, it is better to do so than pretending that the problem does not exist. I am not encouraging individuals to offload their entire personal life stories to their colleagues in a professional setting, but I feel, especially in this day and age, that we can and should do better concerning mental health in the workplace. At my training centre, for instance, we received no guidance regarding how to access services, nor how to apply for extensions, nor where mental health first aiders in the Trust are located. The STP is an intense training programme, so it was surprising to me that individuals involved in training had not taken the time to communicate these to us.
Some final thoughts
I’m not suggesting that the workplace is necessarily a place to offload deeply personal information – but being informed about resources for employees, encouraging them to access those resources, having more awareness of common mental health conditions/how to speak to colleagues who may be struggling (e.g., in the form of mandatory basic training) and encouraging a more open environment is something that we should all strive for. One in four of us have a mental health problem and, in high pressure environments such as healthcare and academia, that number is probably an underestimate. Mental health struggles should not be a source of stigma or weakness – rather, they should be viewed as a source of diversity and inner resilience. We should strive for better, take responsibility for looking out for one another and nurture those who struggle, rather than falling into silence.
If I had a few suggestions as to how things could be made better in the context of my STP experience, they are:
- Training officers should undertake annual mental health first aid training as a part of their role. If this is not possible, they should at least be encouraged to educate themselves on resources for trainee wellbeing and be aware of the mental health first aiders at the Trust.
- Wellbeing resources for trainees and staff should be signposted at the beginning of employment and then regularly thereafter (e.g., quarterly).
- Senior figures should encourage open discussion about mental health, engage with staff on a regular basis and advertise training opportunities. This will hopefully have the wider effect of encouraging an attitude change.
- Output ebbs, especially those which are not characteristic of a trainee, should not be viewed at the first instance as a sign of ‘laziness’. This also goes for direct trainee progress comparisons. Training should be given to spot the signs of when trainees (and employees as a whole) are showing signs they are struggling with their mental health.
- The NSHCS should place more pressure on, and encourage, training centres to implement these changes, especially those who have a track record of struggling trainees. The wider Trust should also audit individual departments to ensure that they are yielding positive results for their staff.
Cognitive Behavioural Therapy (CBT): https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/cognitive-behavioural-therapy-cbt/overview/
Dialectical Behaviour Therapy (DBT) and Mentalization-based Therapy (MBT): https://www.nhs.uk/mental-health/conditions/borderline-personality-disorder/treatment/
Papyrus (under 35): https://www.papyrus-uk.org/
Crisis Services (Mind): https://www.mind.org.uk/information-support/guides-to-support-and-services/crisis-services/
Side by Side (Mind): https://sidebyside.mind.org.uk/
The editors would like to stress that you can and should contact the NSHCS (via firstname.lastname@example.org) if you are struggling. All emails are triaged to the appropriate people who are able to help, all contact is treated fully confidentially and a properly trained member of staff will respond to you.