Why I Can Never “Recover” Under NHS Mental Health Services.
[Content Warning: Mention of self-harm, abusive relationships, assault, psychiatric abuse]
I’ve been seeing a private therapist now for 6 months, and it’s been an absolute revelation. After 9 years under NHS mental health services, this is the first time I actually feel as if I am being heard. This is the first time I feel as if I can speak freely and openly, without negative consequences. This is the first time I feel I am making any progress with my mental health. I realised that of course I can’t make progress while under mental health services, because the entire system which currently exists is the antithesis of mental wellness and “recovery”. Recovery is not possible for me in a system which demands I be "responsible" and "independent" while simultaneously refusing to allow me to make decisions, or accept I am the authority on my life.
I attend my private appointments now once a week and talk openly about anything and everything I am feeling; about links I have made between my past and my present; about specific experiences which seem central to the understanding I’m slowly building of myself and my life. I feel liberated in these appointments. I do not worry as I do in every excruciating moment of my NHS appointments that I am building a case against myself which I will later be hung with, or providing my therapist with the ammunition to gun me down with a devastating formulation or diagnosis. I know with certainty that when my appointments end, my therapist doesn’t gather up my words and share them with her colleagues, firing out my secrets in emails and letters to “professionals” and “team members” I’ve never even met. I feel safe. For the first time in almost a decade of mental health care, I feel safe.
I am now experiencing a new phenomenon; I’m attending appointments without a clear idea of what I want to say. This might seem like a really small, or even insignificant point to some, but for me this is huge. For years I have meticulously planned and detailed everything I want to say in my mental health appointments beforehand, and obsessively analysed and gone over what was said in the previous appointment afterwards. There is one purpose for this exhausting behaviour – the need to ensure my survival. Patients unfortunate enough to have been victim of such labels as “personality disorder”, “complex emotional needs”, those who have been given “difficult patient” status etc. will likely know that it’s not an exaggeration to say that these labels can be death sentences. I am acutely aware of the devastation a few little letters can cause once they worm their way into a person’s notes. I have been deeply traumatised by service responses to the BPD label. Accordingly, I have spent years under mental health services, knowing that my presentation as a young, autistic woman with a history of trauma, and ongoing struggles with suicidality and self-harm, could at any moment attract a PD label (no matter how many times it gets removed) and have done everything possible to ameliorate this. I realised not too long ago that what I was experiencing, and what I was doing, was not new to me. My brain appears to have said to itself at some point: “Hey, I recognise this dynamic! It’s just like being abused. I am very experienced at this, I can play this game, I can make this work, I can keep myself safe.” And so, I have been doing just that:
Emphasising “symptoms” not necessarily associated with the PD label, such as flashbacks and nightmares, while downplaying “symptoms” heavily associated with such, such as stopping seeking help for self-harm, and no longer revealing suicidal feelings.
Never contacting services outside of appointments or seeking emergency care. The scars may be bigger because they have been glued instead of sutured, and the days and nights of crisis longer and more frightening without anyone to talk to… but at least I am not committing the biggest mental health service sin of all by “attention-seeking”.
Avoiding all forms of confrontation with staff, even when my rights are clearly being violated, or I am experiencing mistreatment from staff. I deliberately avoid making complaints, or even speaking about staff in a negative way to other staff. I don’t want to be seen as “splitting” the team, or, as my notes said once after I made a complaint, indicate to staff that my “personality traits” affect my relationships with professionals.
I was once told by a mental health OT (after I was referred to DBT instead of trauma therapy) that my “demeanour” and “presentation” didn’t make her “feel” as though I had BPD, and so she said the referral was not appropriate. I learned from this that staff wanted me to make them feel comfortable in appointments. This was the road to getting the help I needed; do everything in my power to make staff feel comfortable, at ease, to feel good emotions, to see me as non-threatening, but not so far the other way that I become obsequious to the point of “dependency”. It started to get complicated, there is such a fine line to tread.
This was so heavy, so complex, so ridiculous... I couldn’t keep it up forever. I had break downs and melt downs and self-harmed continuously, and with greater severity, and began to lean more heavily on my friends for support. Then the Samaritans. At one point I was contacting the Samaritans every single night. I looked for help everywhere else I could find it, because I was too afraid to show mental health services how I was really feeling. I cracked once and argued with my psychiatrist. A week later my new formulation, drawn up without me, indicated I had a personality disorder. I felt completely crushed, and so angry with myself that I had allowed this to happen. I spent the next year doubling down, being "good", working to have the label removed. It was one of the worst years of my life, and almost cost my life… but it worked, and the label was removed.
The powers often talked about in mental health services are the restrictive powers, such as sectioning/detaining, forced medication, sedation, seclusion, loss of liberty and autonomy etc. The powers less commonly discussed by professionals; the power to overwrite and redefine your own experiences; the power to use psychological and psychiatric theory to recreate a version of you they feel fits their own narrative; the power to share information about you without your knowledge or consent; the power to decide what parts of you are broken and in need of fixing; the power to decide that you are officially “dysfunctional” and not “normal”; the power to withhold care and ignore you; the power to use their feelings as proof of your dysfunction; the power to entirely discredit you in the eyes of society; the power to completely obliterate who you actually are… can be just as devastating. You don’t need to be detained, secluded, or sedated to feel trapped by mental health services. They don’t even need to touch you for you to know the whole of your being is under their control.
The element of services I find most challenging is the fact that every moment of every interaction is a chance for staff to judge, record, and diagnose you… over and over again. Every single thing you do and say in their presence contributes to your “paper-self”: making any and all interactions exhausting, because even one moment of annoyance or frustration or anger or despair, or just misspeaking, can tarnish your entire future under services. It is exactly like being in an abusive relationship – watching your every word, ensuring every action is calculated to keep the other person happy. Knowing if you slip up, you’ll be made to pay. You might get a flag on your notes/address stating you are aggressive, which you can’t remove for years, if ever; you might get a new formulation or diagnosis without your consent or knowledge; you might end up the subject of an MDT where your whole being is torn to shreds by an entire room of people who weren’t even present at the time of the “incident”; you might be discharged when you don’t want to be, or not discharged when you should have been; you might have your medication changed without discussion; you might have “privileges”, such as reasonable adjustments, removed... No matter what it was that happened, it’s never just passed by without consequences. I expressed some frustration to my psychiatrist in an appointment once, and in the letter to my GP he wrote that I was being “challenging” and “difficult”. In every single letter since then, my conduct is compared to that one appointment, with either a comment that I am “less challenging” or “similarly challenging” etc... That one single appointment, one of hundreds of appointments, in which I didn’t swear or leap around or threaten anyone, but merely told my psychiatrist over the phone that he was paternalistic, follows me everywhere. I had a course of psychotherapy years ago, and although I attended every single appointment without issue, I got a flag in my notes that I was uncooperative and at risk of “unplanned disengagement” because I missed my final appointment. Five years ago, I was assaulted in a pub, and responded by pushing the person. After recounting this extremely distressing story to a psychologist, my risk assessments have since included “risk of aggressive behaviour”. No context, nothing to explain to staff that the apparent “aggressive behaviour” was self-defense, nothing at all but that. I have subsequently experienced staff wanting to risk assess my appointments with them to ensure their own safety.
It’s hard to describe how it feels to be on the losing end of this power dynamic, to be in this situation continuously. It’s like being under surveillance. Nothing is ever forgotten, nothing is ever considered in context. You will be reminded of your failure to be "good" forever. It replicates an abusive dynamic, which so many people under mental health services will have a lot of experience with. I have found it more and more unbearable, the more I interact with services, the more I feel it. Feeling as if I am completely unsafe, needing to control everything about myself to make sure I don’t do anything wrong, so that I can’t be punished. It’s overwhelming. It has completely destroyed any chance I had of being able to make any form of progress. For all intents and purposes, while under services, I am back being abused, and my mind and body react accordingly; screaming "BE A GOOD GIRL" in every interaction I have with staff; screaming "RUN" whenever I see an opportunity to escape; screaming "SOMETHING IS WRONG" all the time...
I cannot “recover” in this environment. I can only continue to try and remain safe, while hoping to survive it.