The Skeleton Cupboard by Tanya Byron – Extract

The Skeleton Cupboard

At the Bottom of the Deep Blue Sea

When a child is hanging by the neck, grabbing their legs to hold them up isn’t easy. They wriggle and they kick. Imogen struggled in silence. Then she kneed me in the face, hard, and I tasted blood. The stillness of the room belied the horribleness of the task.

‘Hold her up, up, up!’

Grunts of effort in unison as the little girl’s legs were hoisted higher to relieve the pressure on her neck. The dressing-gown cord was looped over a slim copper pipe in the ceiling. Victorian plumbing was not designed with the health and safety of suicidal children in mind.

I couldn’t believe how heavy a small-framed anorexic child feels when you have to support her as a dead weight.

‘C’mon, guys – push up and hold . . . and hold . . .’

A snap of steel through fabric, followed by a bizarre pause in motion – everything still for a beat before the child dropped into our arms. My frustration melted into relief. I just wanted to hold this little vulnerable person and rock her gently, make her feel safe. Imogen, though, was having none of it. She lashed out, biting, kicking and snarling.

‘Imogen, be still – let’s work together here. Ow!’

Negotiations over, she was quickly flipped onto her stomach, arms held behind her back. Lying prostrate over bucking legs, I had a sudden urge to bite back, to sink my teeth into this angry, ungrateful kid and shock her into submission.

And then it was finished. Child sedated, taken off to the ‘chill-down’ room – chic and bijou, nicely padded, sparsely furnished – while staff dispersed to other duties. Voices in the corridor: ‘What did the librarian say to the kid who wanted to borrow a book on suicide? Fuck off – you won’t bring it back.’

Third week into placement number two and already I wanted to give up and go home.

I can’t remember what I’d imagined it would be like. I’d reluctantly agreed with Chris to do my second six-month training placement in a medium-secure inpatient psychiatric unit for twelve-to-sixteen-year-olds. I was spending my days with kids who wanted to do all manner of harm to themselves or to other people – to cut, to starve, to stab, to kill.

Once I’d had my few days off to recover from having Ray threaten to cut my eyes out of their sockets, the rest of my first placement had gone more smoothly. I hadn’t yet worked out Chris, but she was proving to be a great clinical supervisor and I enjoyed our sessions. She was calm and brilliant, and I loved her ability to pull the strands of the complex stories told to me by my patients into a coherent narrative: what we in clinical psychology call the ‘formulation’.

University had found a rhythm, and I’d made some friends among my fellow trainees. The lectures were interesting, even when I struggled with their content. I had already worked out that, despite saving me in my moment of need at the beginning of my training, I was not a big fan of Sigmund and psychoanalysis. Interpretations, the unconscious, projection, transference and counter-transference – it all felt so abstract and judgemental. And where was the evidence base?

I’d worked with some wonderful people since Ray. Occasionally George and I would have a brew with Edith, whom I’d grown to love. She’d been discharged and readmitted during my placement, just as George had predicted. My transgender heroes, ‘Josephine’ and ‘Daphne’, would regularly knock on my cupboard door and check in with me – they made me feel safe.

Leaving that placement had been difficult, and in the final week Chris had met me to discuss placement number two.

‘So, kids. Do you like them?’

I wasn’t sure. I didn’t know many.

‘Yeah, I love kids.’

‘Good.’

She bit into a biscuit. I had begun to notice that Chris did a lot of simultaneous eating and talking during our sessions, which I found gross.

‘And,’ she continued, ‘adolescents – you know, teenagers. You like them?’

Thanks for the translation – I know what an adolescent is.

I wasn’t sure how to respond to this either. ‘Yeah?’

Chris dunked her biscuit into her tea and then extended a long tongue to lick in the sloppy, mushy end. ‘Were you a nice teenager?’

‘I think I was OK.’

That was a massive lie – just ask my mother.

Chris smiled. ‘Shame. I had you pegged as a pain-in-the-arse teenager.’

I smiled, then wondered if I was allowed to. ‘I had my moments.’

‘Thought so. Anyway, here’s the thing. We’ve got a regional shortage of child placements and so I volunteered for you to do yours in an inpatient unit for young teenagers.’

I had no idea what that was. ‘Right . . .’

‘You’ll be dealing with kids who are presenting in a high level of crisis and so are too vulnerable to be treated in the community.’

‘OK.’

Chris offered me the packet of Rich Tea. I shook my head.

‘So,’ she said, chomping into a fresh one, ‘you’ll spend the next six months in a unit just outside of London working with a specialist multidisciplinary team assessing and treating kids and their families who are often in crisis.’ Chris smiled brightly and raised her eyebrows at me.

I swallowed hard. ‘OK. If you think I can . . .’ ‘Why wouldn’t I?’

I blushed. I hated blushing. My heart started racing as I thought of Ray.

‘Well, you know, it’s just that I was kind of attacked by I guess what you would call a patient in crisis in my last placement, and that was in an outpatient department . . .’

Chris stared at me, unblinking. ‘And?’

My face felt red hot. I didn’t want to tell her I was scared.

‘Well, based on my inability to manage Ray, perhaps I’m not ready to do this placement. You know, with kids and their families in crisis.’

Chris folded over the torn flap of the biscuit wrapper and shoved the packet into her large, overstuffed bag.

‘I disagree. I think you can and should do this placement. You’ll be protected by a strong staff team, and you’ve got me with you every step of the way.’

And so, reluctantly, I agreed. And it had started well. The staff team were strong. I liked the young people. I was really enjoying it until Imogen decided, that morning, to attempt to hang herself. Now I just wanted out.

Walking back to my office, I wondered why I let Chris talk me into this. What was I trying to prove? I suppose there had been some fantasy about sailing in on a cloud of compassion and being the one – the only one – who really understood these kids and could save them.

Pretty arrogant. I was training to do a job where I had licence to ask anyone anything and get an answer, where I would be part of a decision-making process that could fundamentally alter someone else’s life – it was important to remember that that didn’t make me all-powerful. I smiled at this last thought: I wasn’t the first person to imagine that they were the Almighty in this place.

Time to grab a coffee and go into the critical incident debriefing. How did the suicidal kid have a dressing-gown cord? Wasn’t she on highest-level obs? Who did the property search when she was admitted? A head was going to roll – thankfully, though, not mine.

*****

The following afternoon, sitting opposite Imogen in our next session, I started getting angry again.

I thought about transference and counter-transference, tried hard to work out whose rage I was experiencing. The look on Imogen’s face left me in no doubt that she was pissed off at being thwarted in her attempt to hang herself. She wanted to die, and we had stopped her. I got that.

But there was a lot of my rage sitting there as well. I’d been seeing this twelve-year-old since she was admitted three weeks ago. As a clinical psychologist in my first year of training, I had asked to be her individual therapist and her case manager. At first I was refused on the grounds of lack of experience – she was a tricky one, a complicated case. The social workers wanted her, the family therapist wanted her and the analyst wanted her.

But in the end I got her. No one else was receiving training in cognitive behavioural therapy. She came from a loving family, so no social work needed at the moment, thanks. The soft-spoken, leather-moccasined, vegan family therapist had too many other cases, and anyway, the focus needed to be on the child this time round, not the family. And the analyst? I wouldn’t let him near any child, especially not one like Imogen.

Yes, I did, even then, instinctively lean towards the here-and-now type of therapeutic intervention, as opposed to the one that lies you down, takes you back to your relationship with your mother and spends most of the session out of your line of sight, in silence.

At the time I didn’t get analysis. I suspect I would have been much more open to the ideas if the analysts themselves weren’t so bloody full of it. They were up their own rectums with self-importance, a belief that actually only they had read and understood the Holy Scripture of mental health.

For me, analysis had always been a bit too much like religion – purporting to possess the key to understanding the fundamental questions of life, but unable to provide any evidence to back up its case.

‘I am so sorry that you don’t feel any better about life after two years of thrice-weekly sessions. It pains me that you are still unable to form a meaningful relationship, and that on some days even washing your hair feels like an unattainable goal, but to question whether lying here on this couch while I silently write notes and say little is the right approach is – forgive me for pointing it out – a symptom of the difficulty you have in really connecting with this therapy, indicative of your difficulty in connecting with other people more broadly. It is clear that this rebellion is you acting out and sabotaging our relationship – as you so readily sabotage other relationships in your life. It suggests to me that you now need to see me five days a week instead of three, for an indeterminately long time – apart from every August, when I will be away on holiday.’

As I understood it, Sigmund Freud was a coke addict who fabricated the father-rape-wish-fulfilment scenario of his abused female patients in order not to upset the conventions of the time. Fathers and uncles were busy raping their daughters and nieces, but this wasn’t the moment to out them. So Sigmund snorted another line and created the most damningly misogynist theory of all time.

That analyst was not going to treat Imogen. I didn’t like him. I wasn’t a fan of his way of working. He knew it.

Back in my session with Imogen, the words were still not coming. I had to move past my own frustration and relax. But it is very hard to relax when you are looking into the eyes of a mute little girl who wants to be dead. You don’t want to relax; you want to run at her and pull her into your arms, hold her and then shake her until she tells you why. You long to say, ‘Why do you want to die? You’re twelve years old.’

My other problem was that I couldn’t shift my focus from the angry red welt round Imogen’s neck – that welt rendered us both mute. And while I knew silence could be a therapeutic tool, it was clear to me that this time round it reflected the powerlessness that both Imogen and I felt. I wasn’t good enough for her. She wasn’t good enough for life. I could feel my anxiety rising – my frontal cortex was shutting down. Soon I would only be limbic, running on raw emotion, and this was not a good place to be. I had to think, be rational, reconnect with the practitioner in me.

I ought to have felt more prepared for Imogen. I had tried to plan my psychological therapy session with her earlier in the day, but my meetings with Chris had become increasingly shambolic. That morning I’d rushed into Central London, but she had arrived at her office in the university late, stinking of cigarettes and cursing the people who’d been at the meeting she just left. Throwing her bag onto a chair, she began to make a Pot Noodle.

‘OK, speak. I’m listening.’

‘Well, to be honest, I’m not sure where to begin. I had prepared an agenda, but I’m not sure we can fit it all in. I mean, I was expecting an hour.’

‘How’s it going with the silent, self-starving one?’

I wasn’t sure what grossed me out more – the smell of synthetic chicken, the accompanying sounds of slurping, the neglected dribble down her chin or the lack of an apology for being so bloody late.

‘I’m not sure there’s time.’

Chris continued to eat, pausing only to wipe her mouth with the back of her hand. I drew a deep breath.

‘Imogen Trent-Evans, twelve-year-old daughter of Mary Trent and Jim Evans. Mary, magazine editor, lives in London; James is now in Los Angeles with his partner, Angus. Mary has remarried – Jake Robins, a male fashion model – and they have – sorry, had Maisie, who was five when she drowned in the family pool last August. Imogen, an obsessive skipper and self-harmer, has—’

An abrupt slurp. ‘Stop! For Christ’s sake, you’re not presenting at a sodding ward round.’

‘Sorry, not sure what you mean.’

‘Tell me Imogen’s story. About the child. I want to see her and hear her.’

Blushing had always pissed me off – a sign of weakness, unintended vulnerability. That day I could do nothing except glow and, to my horror, feel tearful. Chris wasn’t sympathetic.

‘OK, you feel uncomfortable here. Get over it. You have talent, but you are way too self-consciously righteous for my taste. If I am late, I am late. If I want you to present to me in a different way, then present to me in a different way. If this all feels too much, there’s the door.’

Chris lit a cigarette. ‘So, how does this child make you feel?’

‘She makes me feel protective. She makes me want to look after her.’

‘And behind these obvious rescue fantasies?’

Would you mind not smoking?’

Chris walked to the window, opened it and, with her backside pushed towards me, leaned out and blew smoke at Tottenham Court Road.

She looked over her shoulder. ‘I think this girl frightens you.’

‘I am not frightened of her. I just feel so sad for her. She’s only just twelve. She lost her sister eight months ago. Bloody hell, the poor kid found her baby sister floating face down. She never sees her mum, never, because the woman runs her magazine with more care than she gives her kid. And her gay dad is . . . well, he’s off mardi gras-ing round the other side of the world. To add to the bleakness, there’s the housekeeper, Miriam, who speaks very little English but was her constant other until she was fired after Maisie drowned. And finally, to complete this happy home, there is a grief-stricken model of a stepfather, Maisie’s dad, who spends his entire time sobbing whenever he comes into the unit.’

‘A model of grief, or an attractive grieving man?’ That was funny and we exchanged a smile. ‘Both.’

The cigarette had burned down to its filter and Chris extinguished it in the dregs of the Pot Noodle. She sat back down, facing me.

‘She is so small and pale and just a tiny, tiny victim,’ I continued. ‘She is powerful, but she is also just a little girl cuddling her rag doll.’

‘A doll?’

‘Yes, a rag doll. Apparently her dead sister’s doll.’

‘Transitional object?’

‘Well, she never puts it down, and we can’t touch it. It really smells, but she won’t let us wash it. At night she sucks– well, sort of suckles in its face. In the daytime it’s tucked under her arm, constantly.’

Chris went still. Then she carefully lit another cigarette. ‘And people would think to want to wash this doll, why?’

‘Because it smells.’

A long smoke exhalation. ‘Listen. I wanted you to be my trainee because I thought you were bright and we could skip the obvious stuff. So, doll equals transitional object, as in link to dead sister. No one touches it. The doll is her sister. Smell and all. I thought Winnicott was first year, first week of training, basic lecture shtick?’

Christ, this woman made me feel like an idiot. ‘OK. No sulking. Carry on with the story.’

Aren’t you supposed to start by hating those you eventually credit with being your mentor? With Chris it was too early to call. I took a deep abdominal breath and continued. ‘When she was first admitted as an inpatient to the unit, she would skip obsessively whenever she was given monitored access to her skipping rope. Every moment she could, she’d skip and count constantly – and even now that we’ve taken her rope away after her hanging attempt, we can see her legs twitch up and down and her wrists circling. It was exhausting to watch. She was totally impenetrable – no one could engage with her. She’d stop skipping when any of us tried to talk and then the second we left, giving up on the non-conversation, the total lack of engagement, she would start again.’

‘How does this affect the team?’

‘She totally splits us. Completely.’

‘How?’

‘Pretty much the way you’d expect, because you know all the differences and interdisciplinary rivalries – the doctors get biological and diagnostic, and ram the sodding drug charts down our throats, while we sit with the social workers and disappear up ourselves with compassion, understanding and behaviour-management programmes. And of course, the analysts hover above us all with interpretations that make the team argue and end up disliking them.’

‘What, “she unconsciously wanted her sister to drown” – that sort of thing?’ Chris grinned.

‘Yep, the very one.’

‘But what’s wrong with that thought?’

‘What?’

‘Maybe she did want her sister not to be around anymore? Maybe she is very anxious and needs to control it all with obsessive and ritualized behaviour. Maybe she has got some neurobiological problems that need pharmacological management. Maybe she has a sad little life underpinned by a family in crisis. Perhaps every discipline is on the button. But that’s all maybe, and for now what I suggest is that here you have one powerful little girl on your hands who can split the team and stir you up while saying nothing, eating nothing and trying to die.’

In that moment I didn’t know what frightened me most– my supervisor, my patient or the way I seemed to keep getting this stuff wrong.

Later that day, looking at Imogen in our session, I saw hollow and empty. This tiny girl, one pale arm decorated with neat parallel red cuts, stared at me with large blank eyes and counted under her breath. Thinking over what Chris had said, I struggled to make sense of the word ‘powerful’ in relation to this kid. Yes, small could be powerful, fragile also, but how can bereaved, emaciated, mutilated, anxious and suicidal be powerful?

Chris had asked me for the story, and maybe that was where I would find clues – the clues to the hidden code that led to the unlocking of the child, of Imogen.

So I began to tell Imogen her story – as much as I understood it.

‘Once upon a time there was a girl who lived in a big house in a big city. She lived with her mother and father and a nice lady called Miriam who couldn’t really speak English. One day, when the little girl was three years old, her father decided he wanted to live in America in an even bigger house and in another city far away, with his friend Angus. The little girl was sad but stayed at home with her mother, who soon brought home a man with a lovely face who became the little girl’s stepfather . . .’

Imogen had stopped counting, and her eyes were now completely focused on me. I felt my heart leap, my throat tighten. Her brown eyes were huge, framed by her tiny white face.

‘The family lived together in the big house, and soon the mother and stepfather got married, not long after the little girl had her fourth birthday. The little girl was a bridesmaid and wore a pink shimmery dress with . . .’

There was a croak from across the room, and while I couldn’t be sure, I thought that the croak was the word ‘blue’. ‘A blue shimmery dress . . . Is that right, Imogen? A blue bridesmaid dress?’

She started counting again. Shit – how could I have been so stupid? I continued.

‘After the wedding the family lived together, and while the mother was travelling and working, the little girl stayed at home with her stepfather and Miriam.’

Feeling my throat constrict, I suddenly realized that I had been mouth-breathing for too long; my throat was dry, and without a glass of water, I knew that I would start coughing uncontrollably and lose the moment, the connection – whatever was going on here.

How to get to the water, however, was beginning to panic me – I felt pinned into my seat by Imogen’s wide, staring eyes. And then I started coughing.

The fit came with such force that I was left doubled over.

The more I tried to control it, the worse it got.

I was bent over, with my eyes streaming, when I suddenly became aware of someone close by. Sitting up slowly, I found Imogen standing an arm’s length away from me and holding out a glass of water. The start shocked me into stopping. I took the water and gulped it gratefully.

Imogen sat back down, the stinky rag doll under one arm, wrists circling and counting under her breath. And then she stopped and said in the tiniest voice, ‘My dress was blue.’

The next few sessions were uneventful. This was because I pushed her too hard. Buoyed up by the ‘conversation’ about the blue dress, I pressed for more. But Imogen was giving me no more – and why should she? She sat silently with her dead sister’s rag doll. Her wrists rotated through half-turns and back, and she counted under her breath. I was going about this all wrong.

Chris and I met for a coffee between her meetings.

‘Try and understand Imogen’s communication. Stop trying to get her to communicate on your terms.’

‘What she’s communicating is that she has given up and she wants to hang herself – I understand that, and I think she knows it.’

Chris was shaking her head. ‘Hanging is not a communication strategy. Hanging is about coping. She feels alone, afraid and misunderstood, so she wants to leave the party. That’s all there is to that.’

I think I was shocked by this idea. I’d never thought of suicide as a coping strategy. I could see it as a way out for a desperate adult who has given life a shot but found it unliveable. For someone like that, suicide might be an active choice, something they could control and finally get right after a miserable life of perceived failure. But could a child think like that?

‘OK, look at this another way. Stop pathologizing Imogen’s behaviours. Stop trying to “stop” her when she behaves in ways that seem “abnormal”. Join her, get in alongside her, listen to what she is trying to tell you via her behaviour.’

‘Her behaviour is suicidal, pathological – how can I get alongside that? The risks would be—’

‘You are not listening to me. Suicide is merely an exit strategy. Look at what else she’s doing.’

I ran out of the supervision because I had to get to a lecture, but driving back to the unit the following day, I kept thinking about what Chris had said.

Pathology: a variation in normal or healthy functioning; abnormal, or not typical, behaviour or thinking that is caused by mental or physical disease.

A grim concept, and a bleak word to apply to a child. Where was Imogen being pathologized? She had been admitted in a crisis; she was on the highest-level obs; she wasn’t allowed to possess anything that she might use to kill herself – her skipping rope, even her trainer laces had been confiscated. All that stuff had to be pathologized if she was to be helped, right? So what else was there that I could apply Chris’s theory to?

What were we missing?

The unit was located in the grounds of a large, mostly derelict asylum, which was once a Victorian manor house. Apart from our modern centre, one other wing of the old complex still functioned – living there were long-stay institutionalized residents who were unlikely ever to leave. I drove in torrential rain through the vast hospital grounds, past the detached infirmary that had been built away from the villas to house those with infectious diseases, terminal illnesses and those considered so insane they were locked away until they gave up and died. This building was in the rear of the asylum, north of the other buildings. That was so that the prevailing winds, which blow southwest, would not carry its influence down into the city; in those days, they thought that pathology was catching.

The Victorians were deeply afraid that it was possible to ‘catch’ immorality and insanity. In Victorian London, the dominating wind was a westerly one, and so the slums, in the poor end of town, were in the east – spatial order dictated social order. The insane were housed even further outside the east of the city, so no one – not even the most poor – would be exposed to their influence.

Driving up the main central road of the asylum, I knew that on my left were those villas that once housed the women, on the right those for the men. Every building had been a micro-community of individuals considered unfit to live in civilized society.

Morally defective women – usually those who had been in service and been raped by the squire or his son and given birth out of wedlock – would be dumped here after their children had been taken away. They would cohabit with epileptics, who were considered ‘degenerates, lunatics and idiots’, and others with depression, anxiety, learning difficulties and psychosis.

The ‘defectives’ had to be gender-segregated. God forbid they fornicate and produce a new generation. The large bushes lining the long track, however, told the real stories: ones of furtive couplings, a need for contact and connection. There were awful stories about those villas: of the rape and sexual exploitation of residents by the people charged to care for them.

Considering the history of the place I was working in, I began to resent the word ‘pathology’. Taken from medicine, in the mental health setting it nailed a boundary between ‘normal’ and ‘abnormal’ as if such a division existed. It continued to segregate those with mental health difficulties from the rest of the ‘healthy’ world. But we’re enlightened nowadays, right? We don’t see them as contagions anymore. On the other hand, here we were trying to cope with these kids in the grounds of an early twentieth-century asylum. Perhaps not that much had changed after all.

Imogen’s skipping. Her skipping, her counting and those deep, parallel cuts into the soft skin of her left arm and both thighs – behaviours that had been labelled as pathological anxiety-management strategies, maladaptive coping techniques. The ‘wrong’ sort of coping.

And of course they were – excessive obsessional and ritualized behaviours do not make for an effective way of managing anxiety in the long term. Anxious thoughts may be managed in the short term by elaborate counting and other behavioural rituals, but long term that kind of compulsive behaviour would not enable Imogen to get to the root of her anxiety: her need to control.

This kid, unbelievably controlling in the external world, was, I began to realize, internally in complete turmoil. She felt out of control and afraid. Skipping was a way to keep it all together.

By pathologizing those behaviours, all we had done was see them as symptoms of an underlying condition. We’d responded with anxiolytic medications and behavioural boundaries – no skipping, no counting out loud and definitely no cutting while in the unit – and by doing that we had effectively removed Imogen’s only way to manage herself and left her with no way of coping with her painful and overwhelming inner world. We couldn’t bear what she was doing and what we were seeing, and so we had taken it on ourselves to put a stop to it. No wonder the poor kid wanted to kill herself.

Imogen is anxious – why? That was easy:

  1. Emotionally uncontained by an absent mother.
  2. No connection to an absent father.
  3. Nurtured by a woman, Miriam, who could be kind in a task-oriented way, but did not have the language skills to enable her charge to learn to verbalize feelings.
  4. The loss of Miriam when she was fired after Maisie’s drowning.
  5. Nurtured by a stepfather who was so able to emote that he was too consumed in his own grief to attend to that of his stepdaughter.
  6. Guilt at finding her little half-sister, Maisie, drowned, but not being able to save her.
  7. Perhaps even frightened by her own unconscious desire to get rid of Maisie, who had come into her life and so taken away everything that was once only Imogen’s.

Maybe I would have to talk to the analyst after all.

So, real anxieties, understandable and obviously overwhelming for one so young. No emotional constant to help her make sense of it all. No ability to verbalize what she felt tormented by. No one to help her understand that this wasn’t her fault; she wasn’t to blame; she didn’t cause or will her sister to die.

But that didn’t answer Chris’s suggestion about getting into Imogen’s painful world. I still didn’t know how to do that. She can’t do words yet. What can she do?

And then, just as I parked outside the unit and turned off the engine, I got it.

She can skip.

I scrambled to grab my bags and climb out of the car. I needed to find the analyst, get my head straight. Turning to open my door, I jumped out of my skin. The naked buttocks of one of the long-stay residents were pressed firmly against my window. I crawled across to the passenger door to get out.

*****

The meeting that followed with the analyst was full of clichés. Woody Allen meets Almodóvar.

I entered a small, dark room with requisite couch against one wall. Abstract prints alongside postcards from Anna Freud’s house in Hampstead, all dominated by a huge reproduction of a self-portrait by Frida Kahlo, with her complicated and untended eyebrows. Endless books stacked up (very few with the spine broken) on a faded kilim rug on the floor. It smelt dusty.

I told him that I needed to skip with Imogen. I asked him how I could persuade the team, especially the nurses who ran the health and safety of the unit, to give Imogen back her skipping rope.

‘Why would they? Won’t she hang herself?’

‘Not with the skipping rope. It means too much to her. It’s her voice.’

Then silence. Interminable silence. Just talk to me, tell me what you think.

‘Are you asking me for permission?’ he asked. Oh, so bloody, fucking frustrating.

‘No. I am asking you for your opinion.’

More silence. And then, finally: ‘My opinion is that you should begin to value yours.’

Sod him. I left and marched to the nurses’ office. To my amazement, they said yes and handed me Imogen’s skipping rope, although I did wonder whether it was done with an ‘OK, then – put your money where your mouth is, girl’ attitude. And so I did.

I found Imogen sitting on the window ledge in the rec room with half-closed eyes, silently counting and twirling her small wrists.

This was her regular place. She could look out of the window at the pond recently dug by the other inpatients and staff. It was a great activity, but one we couldn’t encourage her to join in on. Imogen plus water equalled way too dangerous for her, and us.

‘Imogen, it’s time for our session.’ No response.

‘Imogen, I’ve come for you. It’s our time together.’ Nothing.

‘Imogen, I believe this is yours.’

I placed the skipping rope on the window ledge next to her and after a beat she turned to look at it.

‘C’mon, Imogen, let’s go outside.’

*****

Jelly in the dish,
Jelly in the dish.
Wiggle, waggle, wiggle, waggle,
Jelly in the dish
.’

Imogen stared as I sang the next rhyme and continued skipping with her rope:

Lady, lady, touch the ground.
Lady, lady, turn around.
Turn to the east, and turn to the west,
And choose the one you like the best
.’

No response.

I’m a little Dutch girl dressed in blue.
Here are the things I like to do:
Salute to the captain,
Curtsy to the queen,
Turn my back on the submarine. I can do the tap dance;
I can do the splits;
I can do the holka polka just like this.

No response.

A sailor went to sea, sea, sea
To see what he could see, see, see,
And all that he could see, see, see
Was the bottom of the deep blue sea, sea, sea.

I had never skipped so hard in my life. In fact, I hadn’t skipped since final year juniors, over ten years ago. Sweat was pouring off me, and my calves and arms ached.

‘I’m sorry, Imogen. I have to stop.’

‘I was at the bottom of the sea, sea, sea.’

That was the longest sentence I’d ever heard from this most serious little person with a fading red welt round her neck and her dead sister’s stinky rag doll tightly clamped under her arm.

‘Were you at the bottom of the sea, sea, sea, Imogen?’

‘I was at the bottom of the sea, sea, sea. In my blue dress.’ We looked at each other. My heart was racing.

‘I didn’t want to.’

‘You didn’t want to do what, Imogen?’

‘I’m hungry.’

‘OK, Imogen. Let’s go and eat.’

I told myself I was getting somewhere. I was sweating, building a picture of what had happened to Imogen in my mind. I was feeling good about myself. I thought I was on my way to understanding.

I would turn out to be very wrong about this.

Sitting behind the one-way mirror in the family therapy suite and watching the family session was, frankly, exciting. I could see them, but they couldn’t see me.

It was also uncomfortable – who thought up this therapeutic strategy? The family knew they were being viewed but were expected to ‘act normal’. I felt guilty.

Imogen sat still and pale-faced between her mother, Mary, and stepfather, Jake. Jake cried; Mary didn’t. They were reliving the moment of discovering Maisie dead. My soft-moccasined colleague was with them in the room, steering the event.

‘Tell me about that day.’

It was a normal day, they said: the girls were playing outside. Mary was working in her office in the house, on a call to LA to a celebrity’s assistant. Jake was conferencing with his agent, publicist and manager about an upcoming photo shoot for a launch for designer swimwear. Yep, an ordinary day in an ordinary household.

‘Where were you, Imogen?’

She said that she was at the bottom of the sea, sea, sea. And then she asked for me to come into the room and pull her out.

I am ashamed when I think back. When I entered the therapy session from that room behind the one-way mirror, there was a moment with Jake. A look we exchanged. I had seen him on billboards around London, and in the pages of glossy magazines. And now I was in the room with him, for real, joining a family meeting as Imogen’s individual therapist, and the eyes were the same, the slight smile the same. He knew exactly how I was feeling; worse still, he knew that I knew that he knew. It was a split second, but Imogen saw it – saw that ‘moment’ between her stepfather and me. I had let her down by being pathetically and predictably human. I snapped back into the room just as Imogen jumped up, lifted her chair, threw it at the one-way mirror and, with her dead sister’s stinky rag doll under her arm, ran out of the room.

In the chaos, I leaped up and chased after Imogen. As I left the unit, I heard the alarms going off.

Outside, it was raining: the type of dense, light rain that drenches in seconds and leaves everything looking oily. I could feel myself slipping, so I kicked off my shoes, immediately regretting it as the loose shale bit the soles of my feet. No time to stop. I had to keep running – besides, the pain was my punishment for being rubbish.

I could hear colleagues behind me shouting and dispersing in tag teams to try and close down our little quarry. My name was being called, but I didn’t dare stop or slow down because I still had Imogen in my sights. I was responsible for her running, so I ought to be the one who caught up with her.

As I got to the end of the central road that divided the asylum and rounded the corner towards the exit, my heart skipped. I had forgotten that leaving this closed community, I would enter the real world and the large B-road that met the motorway. I looked frantically left and right, and spotted a tiny figure sprinting towards the flyover.

I was panting and feeling leaden-leg heavy. It occurred to me to wonder – not for the last time – why the fuck we were housing suicidal children so close to a major road. These were big roads, ribbed with flyovers – perfect platforms for the suicidal. Thinking this, still running, I started to cry.

We were heading towards the motorway, towards civilization and the big city. She was slowing down; I wasn’t.

I was wet and cold and, I assumed, running for Imogen’s life. I kept her in my sights as I watched her climb up onto the barrier of the flyover; I didn’t blink or look away. My magical thinking told me that if I didn’t take my eyes off her, she wouldn’t jump.

As I got nearer, I could hear the noise of car and truck horns. People had spotted this little girl and stopped to jump out and call up to her. I saw two men leap out of their van and begin running up the embankment, someone else on the hard shoulder talking frantically into a mobile phone.

As I approached her, I instinctively slowed down: run at a person ready to leap, then leap they will. My feet were sore, my muscles ached and my lungs felt near to explosion, so I stopped and stood still.

Imogen, on the barrier, turned to look at me; all noise was gone. She was calm; she smiled at me. I was soaking wet from rain and sweat, and panting harder than I ever had. I wanted to bend forward, put my hands on my knees and recover after my marathon, but I couldn’t look away.

Imogen broke our gaze. She and her dead sister’s stinky rag doll looked over the edge of the barrier and into the road below, gridlocked with vehicles. In the distance, a siren was wailing. I started to walk slowly towards her.

‘Imogen, shall I pull you out of the bottom of the deep blue sea, sea, sea?’

I felt calm; I was back in my grandmother’s front room staring at her bloodstained carpet.

She looked at me again, her mouth moving and her wrists circling. She was deciding what was about to happen. I willed her into my arms.

And she came.

I held Imogen, locking my arms around her and pulling her into my body as we both flopped onto the oily, wet flyover tarmac. I felt light, as if I was floating. And then there was a thud on top of me as we both ended up under male bodies, sweating and panting from their sprint up the motorway embankment, wrapping their arms around us.

Life continued. Young people came and went on the unit. Imogen and I carried on with therapy – I was the only person she would talk to. And talk she did.

Over time she joined the unit school and after using the ‘sliding-in technique’ – where a teacher would sit in a room while Imogen talked to me, getting closer and closer over days and weeks until our little charge felt comfortable enough to let them join our conversation – I was able to leave her with others, chatting confidently and engaging in lessons; she was a bright little button.

The skipping and counting stopped almost completely, only reappearing occasionally to remind us that we had missed something she was still struggling with. Self-harm became a thing of the past. Imogen put on weight. Eventually she was able to wear her trainers done up with their laces, and a dressing gown secured by its cord. It was time to plan her discharge from the unit.

Coming into an inpatient psychiatric unit is hideous for anyone, but leaving it can be even worse. As a team, we would spend months talking to the kids about leaving, giving them weekend leave, introducing their outpatient team to them and beginning to integrate them back into mainstream school. We told them that this process needed to be lengthy because there was so much to organize, and we needed to give them the chance to disengage slowly, to say goodbye to us. The truth also was that we took so long because we were reluctant to let them go.

We expected all young people to act out a bit before they left us – they were anxious and wanted to find a way to remain because the outside world felt too scary. Institutionalized children are difficult to support because their anxiety can only trigger a sense of protectiveness in us and we had to work hard not to collude with their need to remain with us. We wanted to keep them with us – to keep them safe.

Let’s be honest here. If you know you’ve turned a kid’s life around and they want to live, how hard would you find it to send them back to the shitty world that made them want to die in the first place? Don’t judge my arrogant protectiveness before you have checked yours.

Imogen was dealing well with the discharge planning; in fact, she was managing it too well, and it spooked me. My colleagues, however, were careful to help me challenge my own reluctance to let her go, and so the frequency of our individual sessions decreased and soon I became just another member of the staff team preparing Imogen to leave us. But this pissed me off big time.

At this point Chris was off work for an ‘indeterminate’ time; the rumour was she was in rehab. This was really bad timing: I needed some guidance. I resented the fact that I didn’t have a way of getting in touch with her.

When I told my colleagues that I instinctively felt there was something that Imogen hadn’t told us, they were kindly patronizing in expressing the need for me to ‘distance’ myself from Imogen; I was being told that these were my issues, not hers.

Since the mirror incident, everything had felt too smooth. Meetings with Imogen and her family were calm: Imogen talked more, her mother listened, and her beautiful stepfather stopped sobbing. Everything, like the mirror, was getting fixed.

So why did I feel uneasy?

I decided to consult my girls, my three closest friends, in the pub. I could always rely on them for support. Since I started my training I needed them more than I ever had.

Ali, whom I’d known since university, and who was now an HR manager, asked, ‘Why, when you have a good outcome, with all family communication intact, would you doubt what you see before you? Discharge the girl – let her get on with her life.’

The brilliant Megan, my friend from school and now a research scientist, said, ‘This little girl has been in your unit, supported mostly by you, for months. Her symptomatic behaviour has decreased to virtually nothing and she understands the links between her thoughts, feelings and behaviours, and is choosing to engage with life. What’s not to celebrate? Move on to the next patient – you’ve done your job here.’

My oldest friend from primary school, the lovely, kind Rosie, who was doing her second degree while waiting tables, said, ‘If this doesn’t feel right, then get some bloody advice.’

But where the hell was I supposed to go? I felt abandoned and pissed off with Chris for suddenly disappearing. I had not seen anything coming – she was odd, but nothing had led me to believe that she needed rehab. God, just how shit was I at this job? Couldn’t even spot my supervisor having a breakdown.

The university were being very tight-lipped about where Chris was and, because it was coming to the end of this placement, felt that there wasn’t time to get another supervisor set up for me. It was suggested that I looked within the unit team for some one-to-one supervision.

And so I did.

The room still smelt dusty; the majority of book spines were still unbroken, but actually it felt good to stretch out on the couch by the wall underneath Frida Kahlo.

‘She’s not ready to go.’ Silence.

‘It’s too easy.’ More silence.

I picked at my nail varnish and then bit my cuticles. ‘Oh, come on. Please talk here. We both know that this sudden recovery is weirder than an angry kid leaving us and getting on with their lives to prove our rejection wrong.’ I tugged at my sleeves – I’d bitten my nails to the quick. ‘I need to find out why she has bounced back. She was so . . . broken that there has to be a bigger narrative.’

I realized, suddenly, that his silence had helped me understand that we didn’t know this silent girl’s backstory.

We’d examined and controlled her behaviour, but we still didn’t really know what caused that behaviour in the first place. Not the narrative – not the end of that story I’d tried to tell her on day one.

And then he spoke.

‘I think her story is bigger than the grief of losing her sister.’

No shit, Sigmund. That’s what I was saying.

‘What else have you experienced with this child?’ he asked.

I knew what I had to say, but I couldn’t – it felt too clichéd to say while lying on a couch with an analyst.

‘There was a “moment” with her stepfather in the meeting before she ran.’

I felt beyond foolish. He said nothing.

‘OK,’ I back-pedalled. ‘That was too much information. Irrelevant. Just tell me, what do I do?’

And then the pale, self-contained, silent, god-like analyst shocked me.

‘Just bloody find out what this is all about, before it’s too late.’

Imogen was leaving in a week’s time and I was under pressure. I hated psychoanalysts, but suddenly this one was my best friend at work. My head was a mess. I met him again, but he’d reverted to mostly silence; I felt stupid for revealing the frisson moment.

Imogen’s mother, Mary, and stepfather, Jake, were happy. Mary was pregnant again and life held hope for Imogen after the freak accident that took her half-sister; here’s a replacement puppy! Everyone was happy.

And why wouldn’t they be? I was being a selfish bitch: I couldn’t let go of a happy, healthy girl ready to move on.

I decided to stop the self-pity and we all prepared for the unit summer fete in the hospital grounds, which was when I found her staring into the pond.

‘Hey,’ I said. She didn’t reply.

‘Imogen, come get some candyfloss.’ She crouched down.

Imogen and water. Oh God, should I be scared? No, get a grip – evidence-base this girl’s progress. She knows how to handle herself. Be calm.

‘Hey, Imogen. What’s up? Come on, candyfloss is beckoning! Race you to the stall.’

She pulled the rag doll from under her arm, then threw it into the pond. I reached in, lifted the smelly rag doll from the water and handed her back.

‘C’mon, sweetheart. Are you angry about leaving the unit? Tell me about it. Don’t take it out on Rag Doll!’

She threw the rag doll back into the pond at my feet. And then she said, quietly and clearly, ‘I am sorry, but I am not going to save you.’

She was staring intently at her dead sister’s doll, lying face down in the pond water. My heart thumped; her face was becoming a mask again, her wrists beginning to rhythmically circle and her mouth twitch with silent counting. Here comes the grief, I thought to myself.

I knelt next to my little charge and began to try and soothe her back to me.

‘Imogen, I can see that you are having big feelings at the moment. I think that these are about Maisie drowning and this makes you feel very sad and very anxious.’

Without taking her eyes off the drowning rag doll, Imogen shook her head.

‘Imogen, why don’t we pull the rag doll out of the pond and go inside somewhere quiet where we can have a talk?’

Imogen shook her head again.

‘Sweetheart, listen to me. I think it would be so sad for you if we leave Maisie’s doll to sink to the bottom of this pond. This is Maisie’s doll, isn’t it? And now that Maisie isn’t here to love her doll, you are doing that really important job for her.’

Finally Imogen turned to me. ‘I don’t want to save her.’

I began to feel very cold. ‘Why not, darling?’ I stooped down to pick up the doll. ‘Look, we can save her together.’

‘No!’ Imogen grabbed my arm. She was shaking and beginning to pant. ‘No. No. No. No. No. No. No. No. No. No.’

She threw herself down on top of me. As I held her, I could feel her heart racing, her entire body shaking. She was sweating.

‘OK, sweetheart. Shh, darling. It’s OK. I’m sorry, darling.

I’m sorry. We will leave Rag Doll there.’

I started to rock her as she sat into my body, her back against my chest, her legs inside mine. We sat like this for a while, both staring ahead at the rag doll slowly swelling with pond water and getting heavier, beginning to sink. Time went by slowly and I began to relax, listening to the sounds of happy children at the fete behind us.

But then I felt Imogen twitch and pull away from me. ‘What is it, Imogen?’

‘It’s not fast enough.’

‘It’s OK, darling – she’s beginning to sink.’

‘It’s not fast enough.’

Imogen jumped out of my arms and waded into the pond. I scrambled forward on hands and knees, trying to catch her and pull her back. I was panicking; was she going to try and drown herself? I crawled into the pond, but then I stopped.

Imogen pushed the doll below the water line, ever so gently. She was whispering. I struggled to hear what she was saying.

‘It’s OK now, Maisie. It will all be OK. I love you, Maisie, and you are now safe. Nothing more bad will happen. I promise, Maisie. Immy promises.’

Imogen was drowning her sister.

I felt sick. What was I seeing here? Was this a fantasy re-enactment? Was this a reality re-enactment? Or simply a way for Imogen to find some closure – to deliver the rag doll back to its rightful owner?

That was it, I told myself. Imogen was drowning the doll slowly and gently, so I had time to think this through.

Rag Doll for Imogen was Maisie, or at the very least a transitional object that connected her to her dead sister. When she came into the unit, she was mute and regressed – a distressed neonate without words, communicating extreme despair and acute distress in her behaviour. She suckled the doll at night and held her next to her body by day to comfort her, to keep her sister near.

Over time we helped Imogen heal, right? She had expressed her grief, and her family had come to a new place of understanding and acceptance. They all had a bright future, with a new little baby to come. Life would now move on.

That was it. That made sense. Now I felt back in control. All we needed to do was let Rag Doll sink to the bottom and then Imogen could be at peace.

The rag doll was by now fully submerged and Imogen placed her foot on it. It was time to move on.

‘Sweetheart? Is it done? Is Rag Doll with Maisie now?’

Imogen turned to look at me and spoke in a calm, clear voice. ‘Yes. And now he can’t touch her anymore.’

Imogen was sick into the pond. She wiped her mouth, and then she began to talk and the rest of the story followed, not clearly, not in the right order, but I understood every word of it.

Imogen had helped Maisie drown when she turned five, the age she herself had been when Jake, her stepfather, had started sexually abusing her.

She had watched her sister fall into the swimming pool at their home and then had gently placed her foot on top of Maisie’s head to keep her under the water.

In order to protect her sister from sexual abuse, Imogen had been making herself available to her stepfather; she thought that if she was always letting him enjoy their ‘special friendship’, he would never go near Maisie. But however hard she tried, she realized he didn’t want her anymore, and that’s when she knew she had to protect Maisie.

But it was getting harder. Imogen was growing up, becoming less attractive to her stepfather. He wanted only the very young. Imogen knew that she was now being passed over for her little sister.

‘I didn’t mean to let her die. I didn’t plan for it to happen, but when she fell into the pool and I couldn’t pull her out, I realized what I could do to help her.’

The air smelt of pond water and puke.

‘I killed my little sister, Maisie. Please will you tell the police and take me to prison?’

I scooped Imogen into my arms and walked her out of the pond as she lay her exhausted little head into my neck.

As we walked into the unit, the analyst met us at the door and wrapped us both in a large, warm blanket.


Excerpted from The Skeleton Cupboard by Tanya Byron. Copyright © 2014 by Tanya Byron.
First published 2014 by Macmillan, an imprint of Pan Macmillan, a division of Macmillan Publishers Limited, 20 New Wharf Road, London N1 9RR, Basingstoke and Oxford. Associated companies throughout the world http://www.panmacmillan.com.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Pan Macmillan Australia solely for the personal use of visitors to this web site.

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