An Open Letter to the Ballarat Base Hospital (Emergency Department)

Subject: An Open Letter to the Ballarat Base Hospital (Emergency Department)
From: Michelle
Date: 23 Feb 2017

Some things I want you to know about my Mental Illness Presentations.

Its 4am in the morning. I have found myself once again limping in agony and shame into the Ballarat Emergency Department waiting room. Intense feelings hold my body prisoner in a strangling death grip. Thoughts pelt my bruised mind one after another relentlessly like bullets. You see me presenting yet again. You see me in distress. You see I have hurt myself badly. Blood is dripping from several large open gashes. Both of my arms, and my leg, look like I have been through a meat grinder. You bring me through to Triage. I sit in the chair. Sometimes the nurse in Triage knows me. Sometimes they do not. Wrapping my battered limbs you ask me a barrage of questions. What is my name? When did I cut? What did I use? How did I get here? Why have I done this? Sometimes if it’s a nurse I have had dealings with before I get belittling comments, frustrated sighs or a look of contempt. “You won’t make it one day.” “You need to stop this.” “It’s a bloodbath.” These comments rip into me like daggers, shattering my already broken heart.

I try to separate the thoughts in my mind and answer the questions you’re asking. Depending on how I am, I either will or will not answer them. Sometimes I’m so tired and sore that I cannot speak. Sometimes I feel too frightened to speak. Sometimes I seem very okay, even happy. Sometimes, it seems like I am a completely different person. And other times, I am completely out of touch, out of control and disconnected.

You see me presenting.

You have never, ever seen the hours leading up to me limping through those doors.

Let’s go back to earlier that night. It is now 11pm. I have had an intense day. On top of my distressing day I have been away visiting friends and relatives for the past 2 weeks. When I am not at home, I can’t help but bottle up my thoughts and emotions. Imagine if you will, a box. The box is full. The box is always full. The box has been full as long as I can remember. Inside the box are memories, feelings, emotions… Secrets and things that nobody knows about. When I go away from my home, my safety zone, I continue to place things in this already full box. I keep jamming the lid on, but as time goes on and I can’t find release it becomes harder to jam the lid down. When I return home, I find I can no longer stash things inside the box. The box breaks apart, things come crashing out and I breakdown. The box doesn’t empty though, it just goes back to being full.

At 11pm that night, I was on my computer. I was thinking about my intense day. The decisions I was making about my life, my future, and the consequences of those choices. Then suddenly I begin to feel sick. The anxiety of decision making sets in rapidly. It triggers a catastrophic emotional breakdown. Anxieties about other things in my life then pile on, Insecurity sets in, doubt, frustration, uncertainty. Finally it compiles down into a deep, dark, heavy sadness. Sometimes I feel like my sadness isn’t normal. I see people around me who deal with sadness by crying and being outwardly emotional. I don’t do that. I sit rocking back and forth on my bed. I feel cold. I feel alone. Tears try to force themselves up, I shut them down. I fear crying. It’s like a deep vacuum. Instead of letting things out I seem to implode and drown inside myself. I experience all this but never show it on the outside. I just stare blankly.

Things begin to escalate and I try to shut it all down. I try to do my helpful strategies. I do deep breathing, put on my favourite YouTuber, listen to some music and cuddle my cow toy tightly. I Say things out loud trying to help myself. Name 5 things I can see. 4 things I can feel. 3 things I can hear. 2 things I can smell or taste. I look at my cow toy and talk about him. Trying desperately to calm and ground myself. “His name is Alistair.” I tell myself. “He’s black and white. He feels soft. He has black shiny eyes. His nostrils are pink. He has 2 ears, 4 feet, and a tail. He is my friend. He exists in 2017. I know I’m in 2017 because Alistair is with me. He didn’t exist when I was little. He is different”

You see when I become distressed, I become incredibly childlike in my voice and behaviour. My brain instantly goes back to that time. It feels like I am a small child. I cannot help it, it is as instinctive to me as breathing. It feels very real, and very scary. Bad things happened to me as a child. That’s why it is important for me to grip onto things that did not exist back then. I have a large collection of stuffed toys that I use to prove the current time-frame is different. Carl the Rhino. Teemo the Dog. Mr. Alex the lion. Alistair the cow. Tom the crocodile. Bob the shark. With the exception of Bob the shark, none of them existed in my life as a child. I do these strategies for well over an hour. Telling myself what has changed, watching things on my laptop, listening to my favourite music. Drawing. Writing. Playing games on my phone. Eventually though, it becomes too much.

It is now 12:30am. I feel something inside me change. I go from having extreme, overwhelming and all consuming feelings to complete numbness. I fade away from reality. I become a puppet. I become so overwhelmed I flee from my prison. I decide to run from everything. I silently get dressed, and leave the house, careful not to wake my housemate.

Outside it is cool, dark and quiet. I find myself walking the streets of Ballarat, but I cannot control where I go. “You need to run” my brain says. “It’s not safe. Don’t be seen.” At every road I wait in the shadows for the perfect time. When I feel it is safe and no cars are around, I cross the roads with haste to avoid detection. With every noise I jump. Every time a tree brushes against me I flinch, with every car that passes I hide in the darkness. I go down the dark streets. I even duck down pitch black alleys. I cut through parks. I do anything to not be seen. I embrace the darkness, I adopt it and wear it like an invisibility shield. Then, all memory fades.

3am. Where am I? What happened? Where did the time go? I look down and see a lot of blood. Deep gashes still actively bleeding. A pool of blood massing beneath me. The tsunami of feelings and thoughts crash over me. “How could I let this happen? What has happened tonight? How will I explain this to people? What will people think of me? I am a failure. I am a freak. Will this make people abandon me? People will be mad. How will I be treated at the Emergency Department this time?” I use my phone to find out where I am, and make my way to the hospital. Sometimes I am far away, having to walk a couple of kilometres to the Emergency Department. While I walk I am still very careful to avoid detection. I do my very best not to involve the public, Police or Emergency services. I feel bad when they need to intervene. It creates more work for them. I hate that. I hate the feeling that I am wasting time and resources, like I’ve been told I am before. Sometimes when I come back to reality I will find myself surrounded by Police. A deep feeling of guilt bubbles away inside me. I get anxious around the police sometimes. I’ve been let down by them at a critical time in the past, yet the Ballarat Police have almost always been great to me. I’ve only ever had 3 bad experiences with them, despite seeing them several times a month for years. I am torn in a battle of memories, pain, confusion and mistrust after what happened to me as a child, and a desire to trust the Police and accept their help. This adds to my overwhelming emotions, and sometimes I shut down again. This time, however, I am pleased to see that there are no police surrounding me.

At 4am I limp in. I’m sore. I’m tired. Emotionally, I’ve shut down the feelings to deal with later, I don’t like involving other people in my emotional rampages so I lock it all away. I’ve done my best to bandage the wounds with an old bandage. I’m feeling very confused and very distressed. I am paranoid about people in the waiting room staring at me. I am scared I will upset them or frighten them. I don’t mean to upset people. I never intend to hurt another soul. I have never actively tried to harm another person. I admit I have tried to flee from people before and run away, but never have I once sought to hurt others. Again I get asked the same questions by the nurses. It’s hard for me to think. A large number of voices consume my head, and answers seem hard to find amongst the chaos. Some questions I can answer. For the ones I can’t, I remain silent. Sometimes I know this is seen as me being deliberately uncooperative. This is not my intention I promise you. Being uncooperative slows the process of treatment down, and makes things harder. It’s frustrating for everyone, but there’s nothing I can do magically make my distress go away so I can answer immediately. Instead my face hides my feelings from the nurses. I exhibit as I do so often, the unrevealing blank childhood stare I was forced to adopt as a child so I wouldn’t get into trouble.

Nurses attempt to take my vitals and talk to me. I barely answer. I am afraid. I jump at fast movements. I flinch at being touched. If the nurse is male, my reflexes are worse. I become defensive, afraid. Again people see this is uncooperative and unhelpful. I don’t mean to make things harder for people, but past experiences have caused me to be especially wary of males. Loud voices frighten me and loud noises distress me. Sometimes I might start to act or behave oddly. These are ways I’ve learned to cope with my distressing thoughts and feelings over the years. I often don’t know how to express my pain and hurt. I withdraw and become either childlike or animal like. I get asked if I have taken any illegal drugs despite not being a drug user, and never testing positive for drugs at all. These are behaviours I cannot control. No matter how much you tell me to stop, I cannot just stop it, it’s impossible, like telling someone not to breathe.

I get very mixed reactions from doctors in the Emergency Department. Sometimes the doctors are caring and compassionate, understanding that I don’t enjoy this process and wish I could just stop. Other doctors seem to think I relish in it. I get comments that range from “I’m sorry to see you again, Michelle” to “What is it this time, Michelle?” “You should stop cutting yourself” “You need to think of us before you cut, we could be treating someone else”

“You have wasted several hours of a doctor’s time. You have wasted time and resources”

Yes those are actual quotes, said to me by various staff members, both nurses and doctors, within the Emergency Department. In fact, all those quotes have been said to me within the past 3 months. Imagine how I feel when you say that. Put yourself in my shoes for a moment. How would you like it? What if it was your child, relative or friend coming in seeking help with serious mental illnesses, only to be told they are a waste of time. Would you be angry? Upset? Do you think it achieves anything? In my head I already know and feel that I am not really worth it, and that I am just a waste. What you have just done is reaffirm that belief. You have hit the nail in deeper. It is then left to my treating team to pull out these nails. I can promise you, it takes a lot more time, and is significantly harder to pull the nails out, than it was to knock them in.

Sometimes, I feel like I’m being punished. “Don’t stitch her she does this all the time. Just Steri-Strip it” “…Surely this doesn’t hurt when I clean it. It would’ve hurt more to do it.” “You know the process Michelle, stop this.” I don’t feel pain when I cut because I am not present when I self-harm. I am in a dissociated state. Once I become grounded again, that’s when the pain sets in. Sometimes it sets in on the side of the road. Sometimes it is not until another person touches my injuries. I am very sensitive to other people touching me. I feel like a lot of people take for granted just how scary human contact is for me. Most of the people in my life cannot actually initiate physical content with me without a reaction. Only a select few can attempt to touch me first. I cannot even have my local doctor take my blood pressure without me becoming anxious. Out of the many people in my life, only 8 can initiate physical contact. 8. Otherwise I become very distressed and agitated. My trust is not easily earned, and is very fragile.

Yet some of the staff in the emergency-department have earned my trust. Even some of the police officers I regularly see have fought very hard to earn my trust. This is no easy feat. Some nurses even go out of their way to greet me and say hi even if I’m not their patient. This is very powerful to me. It suggests that I am not a waste of time. That I am not hated and despised as I so often believe. That I am, perhaps, worth the effort of saving after all. I thank those people with all my heart, they make the process so much easier and tolerable, and leave me feeling better, rather than worse. I wish sometimes people could understand just how their attitudes can affect how a patient feels and ultimately behaves. Sometimes I feel like I am being helped, and that I am being treated as I should be, with dignity and respect. Other times, I feel quite the opposite.

Now, I don’t mean to say that I expect everyone to be ok with my behaviour. I don’t, and I know that is completely unreasonable. In fact, I myself am not happy about how things have progressed to this point, and that my self-harm has become so serious. As I have said earlier, I do not enjoy this process. However it still to this day bothers me that some people cannot keep personal opinions to themselves and can at times be very unprofessional. “Mental illness is not a disability” “Just get a job” “You’re in here so much” “Back in here again?” “What a mess.” “An absolute bloodbath” “You need to stop seeking attention” “She’s done this to herself just Steri (Strip) it, it doesn’t matter really” “She will just do it again, what’s the point?” I face judgement and prejudice every single day in my life. People stare at my scars, and me. People whisper as they walk past me down the street as though I cannot hear them. Parents snatch their children away, as though I may harm them or be contagious. I get filthy, judgmental looks and negative comments. I would think the one place I should be free of that judgement would be a hospital. Unfortunately, however, this is not the case. There is a dark suffocating blanket of stigma surrounding Mental Illness, especially my mental Illnesses.

I am diagnosed with Post-Traumatic Stress Disorder – Chronic (PTSD). This means I have experienced trauma throughout my life. Being chronic means it has been with me for a significant period of time. The PTSD causes flashbacks and nightmares. This in itself isn’t too much of a problem to other people, but it still very difficult for me to manage. Aside from being asked what the trauma was, it doesn’t really get mentioned, as people seem more understanding of PTSD. I feel like this might be because there is a bit more education around PTSD. The real kicker is the Borderline Personality Disorder (BPD) diagnosis. I would give almost anything to not have BPD. It is not well understood, and I don’t imagine there is a lot of education around it like PTSD. So please let me tell you a bit about Borderline.

Borderline Personality Disorder (BPD) is also known as Emotionally-Unstable Personality Disorder. It was first recognised by the American Psychiatric Association (APA) in 1980, making it a fairly new mental illness diagnosis. To be diagnosed with BPD you need to meet 5 of the 9 Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. They are;
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). This does not include suicidal or self-harming behaviour.
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
6. Affective instability due to a marked reactivity of mood - intense feelings that can last from a few hours to a few days.
7. Chronic feelings of emptiness.
8. Inappropriate intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideas or severe dissociative symptoms

BPD has been estimated to affect 1-2% of Australians and most of these are women and youths. People with BPD have a severe difficulty being able to regulate emotions appropriately. People with BPD can change emotions suddenly and without any warning. This leads to difficulties maintaining relationships, and is amplified by low self-esteem and self-harming behaviours. Borderline sufferer’s have a habit of black-and-white thinking. This means that we view things as either all good or all bad, with nothing in-between. This is also true for relationships, where people with BPD will alternate between extreme idealisation and adoration, to devaluation and hate. BPD also carries a significant risk of suicide, with an estimated 10% of people diagnosed with BPD completing suicide. Frequent hospital visits, suicide attempts and self-harm are common for people with BPD. Although the causes of BPD are not well known, there is a significant portion of sufferers who have experienced some form of abuse. There are people who develop BPD after no abuse history however. People with Borderline Personality Disorder are often thought to be difficult, manipulative and attention-seeking. This stigma is also very real in the mental health field among treating clinicians. Some clinicians throughout the country even refuse to treat people with BPD because of these misconceptions. People tend to throw us all in the one basket. We are instantly labelled as attention-seeking, manipulative, dramatic, unstable, difficult, impossible to treat, bad and awful people to have any relationship with. Admittedly, some Borderlines will be like that, for within any population group you will have your bad eggs. Not all of us are like that however, yet we still get treated the same. Regardless, all BPD sufferers deserve to be treated and have a chance at a better life.

For me personally, I don’t believe I am attention-seeking or manipulative. I don’t actively try to manipulate people. I struggle to do my best to remain emotionally stable, have committed myself to both of my therapists and our work. I don’t break any laws, or commit any crimes. I try to avoid hurting people. I have put a great deal of effort into maintaining the small number of friendships I have. Despite living though such horrible events, despite all my negative feelings, I somehow have the good sense to know that hurting other people is something I never want to do. Out of the criteria for a BPD Diagnosis, I believe I show 8 of the 9 symptoms. This means for me personally, my BPD is like a living hell. I internalise everything and conceal most of my feelings. Only a trained eye can see through my front and see the pain and torment going on inside of me. The only symptom I do not show is number 4, impulsivity in at least 2 areas that are damaging not including self-harm and suicidal behaviours. My BPD makes life a constant and unpredictable ride. People often compare mental illness to a roller coaster, with ups and downs. If my mind was a roller coaster, id say the roller coaster was in a dark, suffocating cave. It doesn’t go just up and down, but all different directions. It does loops, corkscrews and sickening inversions. Plus, you have to ride it blindfolded. And when you think the ride is finally over, you just descend deeper into the abyss and keep going. That is how I would describe my mental illness coaster.

Let’s go back to the current night. I finally get seen by a doctor a couple of hours later, I don’t mind waiting patiently for my turn to be seen. I understand that once we cease the bleeding my situation is no longer as urgent. The doctor walks in and tries to patch me up. However I am in so much pain that I scream, whimper, and beg for the Entenox. Previously, doctors and I have discovered that Entenox is extremely helpful for me to have when the wounds are significant. While I can push though the pain for less serious injuries, I cannot tolerate people touching and handling the more serious wounds. The Entenox is very helpful. It wears off fast and it is more effective than Panadol and Neurophen. I don’t like talking pain medications, as they seem to make me feel ill throughout the day. As usual with unknown staff, I get told to stop. ‘Stop screaming. It would’ve hurt more to cut. Just deep breathe. You don’t need the Entenox, you have done this to yourself.” If anyone thinks for one second that someone sticking hospital grade antiseptic into a 10cm long, 2-3cm deep laceration and scrubbing it doesn’t hurt they are kidding themselves. Despite self-harming, and my extensive tattoo work on my body, I have a low pain threshold, especially when other people are touching wounds. I beg and beg, and keep getting told to deep breathe. This is where I also get confused. I don’t understand why some doctors seem to fight against me rather than work with me. Deep breathing does not help the pain go away magically. “Trust me. Just breathe.” The doctor says. Trust. TRUST. I have never met you before, you are a male, and you refuse to listen to me, or talk me through anything. Yet you expect me to sit down and trust you. Do you have any idea how ridiculous it sounds to someone with severe trust issues?

I think sometimes that doctors need to realise that just because you are a doctor, doesn’t mean you get instantly trusted by everyone. In my eyes trust is earned through hard work, dedication and respect. You say to me “You trust the nurse so trust me.” I’m sorry, but it doesn’t work like that. The nurse you say I trust, yes I do trust her. She has seen me countless times over the past few years. She has got to know me. She advocates for me, shows me respect, has helped me when I needed help most. That nurse has got to know me and my story and has earned my trust. Saying “Trust me” does not make me trust you. Especially when you are seemingly making my night so much harder and traumatizing because you refuse to work with me. I understand that I do this to myself. I am working very hard on my mental health issues with my two psychologists. My self-harm is not going to be fixed overnight by a doctor in an Emergency Department. It will be solved by hard work in therapy over years and years.

Do you know what bothers me the most out of everything? It’s the judgement and shame that I experience for cutting that I know other people who self harm in other ways wouldn’t get. I have seen people go into the Emergency Department from car accidents where they have been heavily intoxicated or drug-affected, and get treated with absolute respect and dignity. Everyone seems to treat them nicely. They don’t get told that their pain is “ridiculous” and that they are a waste of time and resources. Yet like me, one could argue they have in fact done this to themselves. It is a form of self-harm. There are people who come in yelling, kicking, screaming abuse and threatening everyone around them. Guess what I have heard people say about them. “They’re just hurting.” “It’s just the drugs talking.” “We just want to help. It’s going to be ok.” I have even witnessed one nurse treat a 14yo girl with a tiny cut on her wrist with kindness and compassion, then walked in next door to me and say “Well. One day you’ll learn and stop I guess” and walk out. I can appreciate that my actions can be confusing to some people. How can anyone deal with pain by creating more pain? It doesn’t make sense to other people. I get that. It just doesn’t seem fair that my self-harm is judged so harshly, when other peoples are not. People who have decided to take drugs and yell and abuse staff often still get more respect than me, who will 90% of the time sit patiently and wait for hours.

I have an understanding now of how the hospital works and appreciate that everyone is busy. It is for this reason I will sit quietly most of the time only asking if I desperately need something, trying to make the nurses and doctors job just that much easier. I help take the bandages off when they ask. I hold bandages down so they can tape them. I add suggestions and information when I can. I’ve even agreed to one doctor having her students practice stitching on me if needed. It doesn’t bother me as long as she is present, they need to learn somehow.

So why can’t I have that respect back?

Have I done something to not deserve it? Is it because I seem so laid back? Or do nurses and doctors actually legitimately think I do this out of sheer enjoyment? I can quite honestly promise you, this is not fun. It is not enjoyable. Respect goes both ways and unless I am very out of control, I have nothing but respect for emergency services and hospital staff.

Do you perhaps think I am not committed to treatment? I have never been more committed to anything in my life. In a standard week for me I see my Treating Clinician, my Doctor and my Psychologist. I also used to have weekly sessions with a community mental health worker as well (This ceased in December 2016). I see a psychiatrist monthly. I do all my homework tasks my clinicians assign to me. I follow suggestions made by my team. With all this hard work, I have actually made some small progress. Unknown to a lot of people, I have been self harming since my family moved to Kilmore. That would have been end of 2002. It started as punching walls, pulling out my hair and burning. In 2004 I was threatened with a knife at school. I was in year 8 and the attacker was in year 11. He threatened my life and safety by cutting himself repeatedly up his forearms, and then cutting my pencil case to pieces. I was terrified but fascinated. I started experimenting with cutting, starting with only small scratches. This went undetected for a long time. My grades slipped, I became very unhappy and by the end of 2004 I had failed every single class. I moved schools to a private catholic school. My self-harm continued to go undetected until year 10 (2007). When my best friend noticed and told a teacher. I denied it, and nothing further ever happened. I again moved school in 2008 to do year 11 and 12 at a large private catholic school. I continued self-harming. Until eventually in year 11 I attempted suicide the first time by swallowing Methylated Spirits. I was rushed to a hospital from school and my parents were called. The nurse in that hospital asked me if anything was happening at home, I denied everything. I denied the torment I was enduring, the hurt I was feeling, the sheer emptiness and anger inside. They seemingly fell for it. In the bitterness from wanting someone to help me to knowing that I couldn’t be helped, the cutting got worse. I started wearing the wrong uniform to school. Only my Physical Education uniform covered the scars and open wounds. I was constantly in trouble for wearing the wrong thing. I went to every single detention I got for incorrect uniform. I went to every detention for not doing homework because things were bad at home. I tried for years to do this all alone until I got to Ballarat. I started drinking heavily and continued self-harming. I got into a lot of trouble with the University’s residential services for my alcohol-fuelled meltdowns; I ruined important friendships with my neediness and instability. I couldn’t understand what I was doing wrong to push people away. Then everything collapsed in 2011 when one of my close friends died. She was 19. After this I began serious therapy.

I have been dealing with this all alone until 2012.

You might see the events from one night of cutting, but I have so much swirling around inside me that cutting is currently my only way out. This is also why I attempt suicide a lot. You could break all of the bones in my body and it will never hurt as much as the emotional pain that I feel daily. I feel like some Emergency Department staff expect me to just get better overnight. That won’t happen, and to be honest it is unfair of you to ask me to ‘be fixed’ overnight. I cannot function like a normal person. I am unpredictable, I feel damaged and broken. I feel detached from the world.

I ask you, do you know what it is like to feel like the only way out is death? To go from feeling everything to nothing within seconds? To feel completely out of control and alone? To not know what the future holds, or whether you even have a future? To face the very real possibility that if things don’t get better and soon, that you will not make it to your 26th birthday. To feel so upset, frightened and miserable all the time that you are scared people will leave you? Always questioning everything people do and things that happen. Hating yourself more than you can imagine. Feeling like you can’t be too happy because the crash could literally end you. To not feel safe enough to sleep because you’re unsure if you will awaken back in a horrible situation? Do you have multiple nightmares every night that feel very very real? To feel guilty that you cannot function unless medicated. To feel the bitter of sting jealousy every time you look at a friend or family member, knowing that they can function and yet you cannot. The feeling of failure because you couldn’t go to the police and get help all those years ago. The guilt and torment that comes from that.

I experience this every minute, every day, 24 hours and day, 7 days a week, 365 days a year.

Imagine then, going to a hospital feeling all this, and then being told you are a waste of time. That you deserve all the pain and misery because it is self-inflicted. Imagine the shame and guilt you feel from this.

It’s hard to imagine I bet. But this is what I feel sometimes when I present for self-harm.

And frankly, it isn’t very fair.

So here are some things I want Hospital staff to know about me when I present:

1. You will not fix me overnight. My mental illness is going to take time to figure out. I have a bunch of very supportive people working for me and supporting me. All of them understand Borderline Personality Disorder and are working to treat it with me. They haven’t pushed me aside because I am “too difficult”. Whilst I don’t mind questions at the Emergency Department, and I might tell you some things, know that you do not have the whole story, only snippets and fragments. It is not your job to cure my mind. So please don’t try. Judging and criticising me is also not helpful, and is actually quite damaging. Telling me that “Mental Illness is not a disability” to “Just get a job and be happy” or that “You are a waste of time and resources, we could’ve spent an hour helping someone else” is counter-productive. It upsets me a lot, and upsets the people treating me, because it is enforcing my beliefs that I am useless and a waste of time. I do not cut for the sheer enjoyment of it. Just because I don’t tell you the reason, doesn’t mean there isn’t one. I spent a long time holding onto to this stuff alone. It’s hard enough for me to trust my workers and tell them things, let alone people I don’t see regularly. I do not cut because I enjoy it. I cut because it helps me. I am not doing it to upset you, or anyone else. It is to help me cope with things.

2. Follow the plan. I cannot reiterate this enough! Most staff should be aware that I have a Service Response Plan on my file through the Youth Mental Health Team. In it, it requires that staff from the Emergency Department contact Youth Mental Health Services, or Psych Services (after hours) to report my presentation so that a follow up call can be made within the community within 48 hours, unless a session occurs within that time frame. It makes it very hard for my clinician to follow her side of the plan when she isn’t being told that I present. It does not require Psych Services to come over and see me in the Emergency Department, It is just a simple phone call to say I have presented, which should then be passed on from the psych services duty-worker to my clinician. I have come to expect the follow up phone call from my clinician following a presentation, and not telling her negatively impacts our relationship because she cannot follow the plan.

3. Work with me, not against me. If I suggest something it is because I genuinely have ideas to help the process. I have been in so many times that I have a pretty good idea of what will work and what will not. I should be well within my rights to request or deny things about my treatment. Generally however, if you explain things to me clearly it makes the process easier because I know what is going on. Leaving me guessing only adds to my anxiety. It is also important for staff to be aware that I am not trying to say I know more than them medically, or that I’m trying to tell them what to do, or how to do their job. I am simply trying to help, and suggest things that are helpful to me. Also I have become quite skilled at masking my feelings and emotions. Although I may seem fine and may smile or joke, I am not ok. I can pretend to be happy and OK for quite some time before it becomes too exhausting and overwhelming, which is when I seem to ‘crash’. Pretending to be happy is how I have coped with bad things in the past. It is instinctive, and I cannot currently control it.
4. Not all Mental Illness is the same, even if 2 people share the same diagnosis. My Mental Illness is not the same as the next persons. So what works for them may not work for me. Telling me “You should keep a journal because it helped *this person* that I know” is fine, but it is not useful to become annoyed or defensive when I say it will not work for me because I’ve already tried it. Equally, treating me the same as “this girl I knew who was attention-seeking” isn’t helpful. Think of it as leaves on a tree. Whilst many leaves may share the same branch, we all have different patterns and sizes.

5. Some of my behaviour is unusual, and may seem odd. I might seem childlike. Sometimes I can even behave in a wolf-like way. This is just what I have learned to survive. Saying “Stop acting like a child” is not helpful. Yes I do become childlike. However at the time I cannot control it, I don’t even realise it is happening. It happens all the time. It happens with my friends. It happens in therapy sessions, and it even happens at home when I am alone. It is like me telling you not to stand or walk a certain way. It is impossible, and quite frustrating. Please try not to be offended if I do not trust you. Trust is very hard for me. I do trust some staff, but not all. I have had a traumatic upbringing. So I have become naturally wary. Telling me to “Trust me because I am a doctor” is not going to make me trust you. Trust is earned. I flinch at every touch, it isn’t personal. Even my best friends, who I trust a lot, cause me to flinch when they touch me. I jump at sudden movements. I might not talk at all. I might begin shaking. It’s just what I have learnt to do. I don’t pick and choose who it happens for, it is uncontrollable. Sometimes I believe I am in legitimate danger. This causes me to try to run, dissociate, flee to a corner, or start hyperventilating. Again, this is a behaviour I cannot control. I cannot tell when or where it will happen. I am not trying to make things difficult for you; I am just trying to deal with the feeling that I am very much in danger, no matter how untrue it may be.

6. Talk to me, not around me. Some staff seem to think it is appropriate to talk about me (within earshot) with other staff. While I understand communication is important, and my treatment will need to be discussed between the treating staff, it is not fair to talk to your colleagues who are not even treating me about your personal opinions on my presentation. Yes if you have your little chit chat outside my bay (while staring directly at me), I can hear you, it does upset me, and it is in my opinion very unprofessional. I have overheard several conversations now about how “I present all the ****ing time” and “Do it for the fun of it, clearly”. It doesn’t end there. A staff member commented to another about how they “had to do a bloody clean out front of the ED because she has dripped blood everywhere yet again.” I have overheard staff complaining about how they are sick of me. Again, put yourself in my shoes. That is not fair. If you have a problem, fine, but keep it professional while working. It should be common sense. I will not bite, you can talk to me. As long as you do so in a gentle and calm manner, I should feel safe enough to respond.

7. Take me seriously, and don’t invalidate me. If I do tell you what is wrong, or some of what might be bothering me, please don’t belittle it. It might not seem like a big deal to you, but it is huge for me. Don’t laugh at me when I tell you that things are hard because I lost an online game and my ‘friends’ flamed me. What is trivial to you is a big deal to me. I am very reactive, and I ping between extremes rapidly. Telling me to get over it isn’t helpful. Why not help me process events rather than shutting me down.

8. Remember I am still a human being. Under all this pain and torment, I am still just a person trying to cope. When you are treating me, remember I am not immune suddenly from physical pain, I am actually quite sensitive. Remember than I didn’t choose to be like this. Nobody in their right mind would choose this.

I hope that this letter helps Emergency Department staff to become more informed about mental health presentations, particularly mine. My intention is that this will help raise some awareness about people with Borderline Personality Disorder who struggle with frequent presentations to hospitals after self-harming. I do not mean for it to offend anyone, but rather educate and shed some insight into my world.

I thank the Ballarat Base Hospital for your ongoing support into the future. For the most part your service is second-to-none. I thank all the nurses and doctors who see me and treat me with respect. I congratulate you and respect you for all you do. It is not an easy job, and yet most of the staff excel and exceed all expectations.