"Presenting Well: The Mental Health Catch-22"
Lindsey Morrison Grant
It's to my detriment and chagrin... and perhaps will even to be written upon my tombstone, "She presents well."
My early childhood trauma from numerous hospitalizations happened before I had the understanding, let alone the words to process the pain and terror. Instead, it triggered combative tantrums in doctors' offices, in the hospital, at the smell of isopropyl alcohol or even the glimpse of white coats. That was my truth in the time of "Children should be seen and not heard." I wasn't heard, so I internalized the angst and created my own survivalist credo: You must not be sick. If you appear sick, you will be abandoned.
Over twenty years, I endured a fear-laced and abusive marriage. My credo magnified the need to "present well" (so I'd not be abandoned) and it caused me to abandon the truth repeatedly. I traded physical and emotional pain for what I saw as acceptance and security. My own lack of transparency caused social isolation which reinforced my own false narrative and its emphasis on presenting well.
Ignorance played a key role and coupled with the internalized and ingrained fear, I unwittingly managed to create neuro-pathways that made my self-preservation credo my default system for coping with stressors. In other words, I became adept at lying to myself and others... I learned to “Present well.” My divorce did not relieve the need to apply the credo, it only magnified it, for now I had no one to fault for my pain but myself.
In June 2018, at the urging of my therapist, friends and family members, I found myself in the emergency department. After five hours in the treatment area, I was told it could be another 16 to 36 hours before I could be admitted. I was weary and panicky. My default kicked in, and escape seemed the optimum choice. Although I presented quite authentically as suicidal and clearly had numerous high-risk factors (including means, plan, recent psychiatric hospitalization, living alone and having had a previous suicide attempt), my "subject-changing" ability allowed me to redirect conversations with an approach, both subtle and chameleon-like. And, when I asked to go home, I was handed the coveted Get-out-of-hospital-free card: a discharge summery which instructed me to follow up with my doctor and return to the hospital if symptoms returned/worsened.
The technique of redirection I inadvertently developed, was like a magician's employing slight-of-hand. When interviewed I'd introduce topics less challenging than the hard topic of self-harm. Whether it was puppies or children, seasonal changes or beverage of choice, the softer topics invite the inquisitor to linger on pleasantries while that awkward stiffness in the air from uncomfortable questions dissipated from the room. You know the ones: about plans and means which present like massive emotional boulders and block the escape route.
Such emotionally charged topics can stymie even those who often must traverse this inquisitors' or therapists' terrain and trip up the less experienced and less watchful. This "course-correction" allows aversion, for the moment, of the hard questions of self-injury and intent, triggers of both the psychological and munitions-kind, caustic conversations and substances, poison pens and products, falls from grace and from high places, dangling conversations and the nuances of a noose.
So, as I sat upright on a wilted gurney-foam mattress in my freshly laundered scrubs, whether by intentional subterfuge or rout, I cast my rather well-hooked line with ease and anticipation, awaiting the strike with each "care team" encounter. Whether it was puppies or babies, the green of the Northwest, or even the more political... (such as the urgency to more fully fund health systems without disparity), the emotional bait was set. Not one listener realized their clinical objectivity had been compromised, as they were readily hooked, with bated breath, by their own assumptive, "She presents well."
That night in the Emergency Department, there were no more discussions of triggers and means, stressors, and plans. The clinicians seemed to find rare solace in this patient who "presents well," as at that moment the shroud of normalcy allowed them a respite from the wearying responsibility of judging what was normal and what was not; who is an obvious danger to themselves and others.... and who, in the wisdom of Almighty scientific assumptive-ism, is a prize to safely "catch and release."
After returning home, later that evening, I recognized that half a century of practice, of reinforcing a facade of normalcy, created in me this innate urgency and ability to "subject-change." I was relieved, but disappointed at these professionals' apparent inability or unwillingness to peer through, what I thought was a very thin veil of falsehoods and ask the more appropriate screening questions or at least contact someone who knew me well enough to gauge my desperation.
Presenting well in and of itself is both systemically reinforced by the fearful ineptitude of social convention-based intervention and driven by the unconscious adaptation for survival in those who think just a little differently. Though challenging and burdensome, if not totally foreign, it's essential for the sake of true efficacy and safety to refuse this ruse of the sales-force of clients or would-be clients who " present well," and for clinicians to become truly insightful, patient and literally life-saving consumers of the truth by refusing to "buy-in" to superficial presentation and manipulative "subject changing," no matter how well presented, no matter how tempting the lure.
Just as there are Asian companies who flood Western markets with "knock-off" products with superficial "genuine" appearance and appeal to the consumers' desire to save time, money, or effort, a closer examination of the "knock-off" of normalcy in presentation is vital to avoid being defrauded. More than just looking foolish when the truth comes to light through circumstance, exposure of this “Normal”-knock-off is usually more tragic than embarrassing.
I realize that presenting well is my default. It's as ingrained in my behavior and thought-processes as any habit I've acquired, but nevertheless anchored in trauma and a survivalist's need to avoid vulnerability and possible victimization at any cost.
I know how dangerous, if not insidious, this deception can be. It is less likely that an interviewer not known to me would have the awareness to question the dubious nature of the “alternative facts” I present, especially when the buy-in allows for the expedience of processing numbers, and turnover is the goal.
Although at the end of the night, I found a safe sanctuary at home, there had been no guarantee of it. As I've reflected on my engagement with healthcare professionals and their choice to simply send me home with no specific contract for safety, I find that not only am I chagrined by the ease of this legitimatize "elopement," but with a system that takes the word of a self-admitted suicide-risk without any verification by someone who knows them and can vouch for their safety.
I hate to have my veracity challenged, but there are times when my perceptions are skewed to the point I will justify dangerous thoughts, choices, and behaviors. I depend on the expertise of others to fine-tune this thinking and quiet the white-noise that manages to drown out common sense. Just as a well-proportioned individual may not be screened for diabetes, because they can skirt the assumptive connection with obesity, that assumption puts the height-weight proportionate individual at greater risk, if only because they, "present well."
The night I was sent home, other markers in my symptomatic cluster were not addressed, examined, or tested (predominantly, cognitive impairment). Although I was still struggling with physical balance/stability, cognition, impulse control, thought-processing, memory, and speech/thought latencies. In the presence of these other impairments... the risk of a resurgence of suicidal ideation was (at least for me) still quite profound.
There are REALLY some good screeners, both quantitative and qualitative, for these things. The Suicide Prevention Resource Center complied and published its “Caring for adult patients with suicide risk: A consensus guide for emergency departments” guide, which is readily available. Therein lays the grave disparity. A patient presenting with ANY other life-threatening symptom would have their functionality tested, stabilized, and documented prior to discharge.
However, a good presentation or story, apparently, covers a multitude of sins and symptoms. And so, for this storyteller, the observation of “She presented well,” is not the worst that might be said, it just very well could have been the last.
Self-identifying as a neurodiverse, two-spirit, elder storyteller with deep roots in the Pacific Northwest, Lindsey Morrison Grant's mindful efforts for recovery and to maintain wellness are attributed to an invaluable support network, personal accountability, meditation, and practicing creative expression in Words, Sounds, and Images.