TW: Suicidal ideation

Completing a PhD is often a time of academic and personal discovery. In spending so much time thinking about your subject, it seems only natural that people think about who they are as a person and if this has changed over time. 

What did this look like for me? 

Well, there’s things like my accent changing, and feeling a loss of ‘who am I?’. This was a natural occurrence during my PhD due to living in a different region, but in my earlier university education, I’d deliberately softened my accent due to being made to feel like an outsider. There’s also new cultures, hobbies, foods, and music that I’ve had the privilege of exploring and enjoying. But the biggest thing I look back on is that, whilst completing my PhD, I was also going through the process of having been diagnosed with – and subsequently managing – a serious mental illness. 

I was diagnosed with borderline personality disorder halfway through my PhD. It’s an illness that has a wide range of symptoms and presentations. For me, it presents as extremely intense emotions and frequent suicidal thoughts and ideation, which is quite a lot to deal with alongside doing a PhD! With the huge benefit of hindsight, in this blog I’ll reflect on how the stages of me being diagnosed with, and managing, a serious mental illness interacted with completing a PhD. 

The denial phase

There was some contradiction in the first 6 months of how I dealt with my mental health and the PhD. Having lived with depression (and symptoms of anxiety and OCD) since I was an early teenager, and knowing it had influenced my past studies, I thought it best to be open with my primary supervisor from the outset that I often have periods of low mood. 

This proved to be a false dawn, because after this I decided to tell those around me that my work and mental health were completely mutually exclusive, and therefore my mental health problems wouldn’t affect my work at all. I was in complete denial that my health could impact on my ability to work in any way. 

Why did I do this? 

Honestly, I don’t fully understand – I didn’t then, and I don’t understand now. I suspect it was, at least partly, due to the fatigue of having to battle my poorly addressed mental health and it was easier to repress and deny its impact than to face up to it. It won’t be a surprise to you that this wasn’t a successful strategy.

The bit when it ‘all hit the fan’

Funnily enough, trying to suppress and hide the impact my mental health was having on my work wasn’t a good decision. My brain and body became a ‘pressure cooker’, not letting any stress be managed or released. Being closed off from my emotions was no longer working, and, just short of a year into my PhD, it all became too much and the ‘pressure cooker’ burst. 

I won’t go into too much detail about how this looked, but it was quite a destructive period where, for a period of time, I struggled to get from one day to the next and needed a lot of support from those around me. The constant nature of my suicidal ideation was too much to bare and, in response, I acted in ways that showed to people that it was the case. I sought to destroy my friendships by suggesting they be broken off and weren’t working, and that I wasn’t a good person for them to be around. I took steps to quit my PhD, making out that I wasn’t the right person to do it and I couldn’t see myself being able to finish it. There were moments where I couldn’t keep the suicidal thoughts internal any longer, but I couldn’t find the right words to seek help and it resulted in some emergency medical attention. It was the trigger for an 18-month process to receive a formal diagnosis that the mental health professionals I spoke with could recognise instantly, and another 12 months after that to finally start specific treatment. 

Picking up the pieces – the road to a diagnosis and treatment

18 months can feel like a long time. A lot can change in a year and a half. When you’re living with a condition that involves (at least in my case) intense dark thoughts coming into your head dozens of times a day, it is a very, very long time. 

The journey to receiving a diagnosis felt long and arduous. I felt, and still feel, very privileged in that my education means I can make some tangible sense of the healthcare system and how to navigate it, but it is not at all set up in a way where people who are struggling with their health – mental or physical – can easily navigate it. In England, mental health service provision is different depending on where you live. This means that in Cambridge, where I studied for my PhD, the service was set up in a completely different way to how it was in the places where I grew up and previously studied. All this means there are a lot of cracks one can fall through when navigating the mental healthcare system but, depending on where you live, these cracks are different. As you can imagine, piecing all this together after I experienced a serious mental health episode was almost impossible. The system requires a lot of cognitive energy to navigate and proactive management from the patient to ensure that referrals are followed up. When one is exhausted from just the everyday battle of a serious untreated mental health condition, it often requires the support of those around them to ensure these appointments are kept to. 

Going through the various appointments, and jumping through all the necessary hoops, was extremely time-consuming. Luckily, I had an incredible academic supervisor and colleagues around me which meant I had a lot of flexibility to manage my workload around the appointments. But it still wasn’t easy, as it was very emotionally draining seeing doctors or other mental health practitioners (I was meeting with a mental health nurse once a week alongside regular medication reviews and counselling appointments). Initially, I met with community mental health professionals, alongside regular contact with my General Practitioner. This was helpful in that I could complete certain therapy courses, such as Compassion Focussed Therapy, that could ease the pain of some of my symptoms. The GP would manage my antidepressant medication, but even though it was apparent an alternative was needed, they couldn’t do much else with my medication. Gradually, though, the picture became clearer, and I moved closer to the diagnosis and the hope that treatment was not too far off. It did seem, at times, that with every appointment or conversation the crucial stage that I wanted to reach – an appointment with a psychiatrist and on to trying other medications and psychological therapies – was getting further away. Almost perversely, an acute episode would sometimes speed up the process, but often this would occur at points where I didn’t have the mental capacity to fully engage with the mental health services to move along the road towards diagnosis and treatment. 

Then, after 18 months, I received the dates of two appointments with a psychiatrist. At these appointments, I finally had the space to properly discuss my mental health with someone who had the ability to prescribe medications and recommend talking therapies that offered me a glimmer of hope that I could, one day, not be at the mercy of my mental health. 

Finishing my PhD post-diagnosis

Once I received my borderline personality disorder diagnosis in late 2021, I was then left with a bit less than two years to finish my PhD. At this point, I felt a lot of relief at having received a label that could explain to people how I was feeling and why, under times of emotional distress, I may act in certain ways due to how I feel some emotions more intensely (e.g., telling my supervisor I was quitting my PhD, or telling friends I wasn’t a good person for them to be around).  

I naively thought that it would be the end of my journey, but the reality was that a diagnosis meant I would now need to wait to access treatment. There were more hoops to jump through, but I completed group dialectical behavioural therapy whilst finishing my PhD. It definitely helped give me some control over the intensity of my emotions and how I respond to them, but the post-diagnosis mental health trajectory was far from linear. My mental health hasn’t recovered to how it was prior to starting my PhD, and I don’t think it ever will. There are mental and physical scars that won’t ever leave me, which often sadly come with having a serious mental illness. That being said, I do love the person I’ve become over the last four years. 

Conclusion

Much how PhD theses are never quite ‘complete’ (rather they reach a point of ‘good enough’ and ready for submission), I’ve learnt to take a similar approach about treatment of my borderline personality disorder. Many mental health conditions – including borderline personality disorder – are rarely ‘cured’. Therapy is intense and tiring. For me (and this is different for everyone!), it isn’t healthy for me to always be having therapy or treatment. After a therapy course, or a few weeks of counselling, I sometimes reach the point where I have the toolkit again to manage my mental health in a healthy way. In these moments my mental health isn’t ‘perfect’ – but good enough to be healthy and happy. Much like the day when my PhD was finally ready to be submitted.

Jack Birch is a Research Fellow in the Coventry Health Determinants Research Collaboration and at the University of Warwick. He completed his PhD in Public Health in 2023 at the University of Cambridge. His research focuses on reducing inequalities in health outcomes. Outside of research, Jack can be found refereeing football or playing korfball. He can be reached via X/Twitter (@jackmbirch), where he regularly posts about public health and his life with borderline personality disorder.

This blog is sponsored by Joshua Reilly (crowdfunder).