BORDERLINE PERSONALITY DISORDER: INTRODUCING A TRILOGY

connor-kinsella-jck-training Sian5 

I’ve known Siân Lacey Taylder for many years. A shared masochistic love of a) writing and b) a non-league football team sort of brought us together a long time ago, but it was much later on I discovered her history of Borderline Personality Disorder (BPD). It never was and still isn’t a big deal to me, and I can’t actually remember how I came to know, probably because it doesn’t matter. I love her writing, she’s thoroughly individual and supports Weymouth Football Club, so that’s quite enough for me.

But there is one area where perhaps we’re not quite on the same team. I spent many years as a mental health nurse, particularly in forensic secure units. Siân has spent many years living with BPD. I’ve helped physically restrain people like Siân, usually in an attempt to stop patients gouging their eyes out or rip their arm to shreds with pieces of glass. If some parts of the blogosphere and Twitter are to be believed, I’ve more than played my part in a rather nasty, controlling, self-serving, stigmatising and hugely anti-therapeutic mental health ‘system’. And Siân has been one of our victims. We shouldn’t get on. But we do.

We first posted these articles in the summer of 2012 following a conversation where I moaned about my fellow mental health professionals being at least under-appreciated and at worst, branded as some sort of fascist movement dedicated to making the lives of the mentally ill as impossible as possible. So taking her own experiences of BPD and often less than positive contact with ‘the system’ as a starting point, we thought we’d put this series together.

A recent Twitter discussion on the @mhchat community featured BPD and while I didn’t catch it ‘live’ it certainly caught my attention later, not least because of a number of comments from service users highlighting some of the issues which had precipitated the original series, and the fact that as a trainer I’m currently rewriting and updating a shortish book on personality disorder aimed at mental health professionals and community mental health workers. I could have just posted a link but soon discovered that WordPress had somehow mangled the formatting of the original work so here I am rewriting and reformatting my contributions while leaving my collaborator’s  contributions in their original and, in my opinion, highly readable state.

Part 1 is a very personal account of BPD from Siân herself. She describes the ‘good Siân’, the ‘gregarious, outgoing, quirky, generous’ person who is very good company and makes people like me like her very much. And she describes the ‘bad Sian’. The one whom ‘mental health professionals would like to eradicate from the face of the earth.’

In Part 2 she looks at some of the pitfalls of the mental health system and how labels such as ‘Borderline’ have proved so spectacularly unsuccessful at describing or helping someone as atypical as she is. But (and it’s a big ‘but’) do professionals and service users really have to be so many poles apart, and might we work together more effectively?

Finally in Part 3, I put a mental health professionals viewpoint on Siân’s observations. And while certainly not agreeing 100% with all she has to say, I ask if it’s possible for both the online and real-world camps of professionals and survivors to ‘put down the weapons’ and work more collaboratively, more imaginatively with a disorder which is so often castigated and misunderstood by so many.

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BORDERLINE PERSONALITY DISORDER: PART 1 OF A GUEST SERIES FROM SIAN LACEY TAYLDER

 Sian5

When Connor very kindly asked me to contribute to his excellent blog from the perspective of someone living with BPD (Borderline Personality Disorder) I think he was preparing himself for a metaphorical kicking. ‘I’m getting a bit hot under the collar over the survivor movement’s constant haranguing of the mental health professions’ he told me, as if he could almost feel me winding myself to vent my spleen.

I want to say ‘it ain’t so’ but that would be telling an untruth. The two sides of the equation – let’s call them ‘the professional’ and ‘the patient’ – ought to be travelling in the same direction, should, really, be striving for the same goal but I would suggest that isn’t always the case.

Why? Surely ‘the professional’ works with ‘the patient’ and in her/his interest? To answer that question I would like to describe, in sometimes quite graphic detail, the ‘realities’ of living with BPD and its various relatives (amongst others Narcissistic Personality Disorder, Paranoid Personality Disorder). Forget, for a few minutes, any textbook or clinical definitions, put any preconceptions to on side and try to see how from my perspective.

Let me begin by stating the bleeding obvious. There is no typical BPD ‘sufferer’ and maybe the condition lends itself to a greater variety of manifestations than other, similar, maladies. There is no one-size-fits-all and therein, I think, lies the first of the problems I would argue that the mental health profession – not necessarily the practitioners but the managers and commissioners, still believe in a universal panacea.

That stipulation – not necessarily the practitioners but the managers and commissioners – will become a recurring theme.

Some of the clichés are true enough. The underlying theme is one of instability and insecurity, in every aspect of life: emotional, professional, financial. But ‘instability’ is a pejorative term; in the mindset of the mental health professional it’s symptom of BPD that really must be cured and I think that’s something we need to address.

More of that anon. I haven’t yet mentioned the almost fanatical devotion to extremes. Everything is black or white; there can be nothing inbetween. Grey represents tedium and orthodoxy, the mediocre and the banal; characteristics that should not just be avoided but sought out and destroyed at all costs. I once had a psychotherapist who tried to persuade me that the grey was, in fact, in silver. I was lost in a haze of antidepressants at the time and she very nearly fooled me.

Very nearly, but not quite because deep down inside, you see, I don’t want to be ‘cured’. I’ve become so viscerally hostile to anything that might be construed as conformity or compromise that it might appear, to the neutral and/or relatively rational observer, that I seek out adversity even in places where it doesn’t really exist. For example, writing this essay – some would call it a rant – I soon realised that I wanted the reader to either love me or hate me; the last thing I desire is pity because pity is the preserve of the weak and the wretched. I don’t so self-pity, I don’t do misery; I only do self-destruct.

And that’s the Narcissistic aspect of BPD. I’m so often overcome with loathing for my fellow human beings that I could easily be mistaken for a misanthrope. Yet when I love someone I love them with a passion that soon veers into self-destruct. I rarely vent my anger on others; hatred – and violence – always turns in on itself.

BPD has led in more directions than there are points on the compass. On the negative side it fuelled a latent gender dysphoria which ended up in gender reassignment surgery (in tabloid talk that’s a sex-change). It’s brought me to the verge of alcoholism and anorexia and encourage – yes, encouraged – me not only to self-harm but to revel in it; for several years gin and a sharp blade were my constant and sometimes exclusive bedfellows and I would literally spend hours gazing lovingly at the rows of knives on display in my local supermarkets. I tread a thin line between wealth and destitution; I’m perennially in debt because I don’t understand money in the same way as many of you do. If it’s there, I spend it; if it’s not, I borrow or blag and something always comes up in the end.

You can see how it can lead to a precarious existence. One more than one occasion BPD compelled me to quit my job, my home and my family to seek refuge on the other side of the world but guess what? Those bastard little demons saw it coming; they packed their bags and followed me; they turned up in El Salvador 48 hours later on my hotel doorstep.

You don’t believe me? Ask the duty manager; he’s the one who talked me down. And he didn’t laugh when I told him that although I hated those bastard little demons I couldn’t live without them. If there’s one phrase that defines the nature of my BPD it’s my relationship with those bastard little demons; I’m drawn to that which ought to repel me. Like a moth to a flame.

Finally it drove me to two overdoses, the latter of which was, I concede, pretty damned stupid and could well have proved fatal. But I survived. And you know what I’m going to say next, don’t you?
I don’t regret any of it.

Because, ridiculous as it might seem, there are positives and even if they appear to you to be vastly outweighed by the negatives, and if you were to offer me a pill or a course of therapy that put everything on an even keel I’d tell you where to stick it. What you call normality I call subservience; what you call instability I call a voyage of self-exploration. You’ll note how everything revolves around the self; the ego is the sun around which the rest of humanity must revolve. There are those who know me who would speak of my gregarious, outgoing personality – and that’s the key word, isn’t it? Personality. They would describe me as generous of spirit, intelligent, quirky and good company but they would be describing the ‘good’ Siân; some of them have known me long enough to come across the ‘bad’ Siân but she keeps herself to herself; locked away in her own little world.

The ‘bad’ Siân, of course, is the Siân the mental health professionals want to treat. They’d like to eradicate her from the face of the earth. Trouble is, more often than not I prefer the ‘bad’ to the ‘good’ and I don’t want to be rid of either.

Still with me? Well done! Now, with Connor’s permission I shall, in the second and concluding part of this polemic I shall endeavour to find some common ground on which mental health professional and service users might meet and smoke the pipe of peace.
It’s not going to be easy!

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. You can find out more about her here.

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BORDERLINE PERSONALITY DISORDER: PART 2 OF A GUEST SERIES FROM SIÂN LACEY TAYLDER

Sian5 

You should know that some of my best friends are mental health professionals. Indeed, my best friend is a clinical psychologist and I’ve nothing against the profession per se. True, there have been occasions when the system has let me down – sometimes quite badly. Like the time when, in the immediate aftermath of a serious trauma, a trainee RMN pitched up with the suggestion that I be referred to an alcohol dependency unit without being aware of my specific circumstances (I had, as it happens, just been raped).

Or the time my GP sent me to the local A&E because I’d carved ‘Siân is a bitch’ into my forearms (yes, I even did the circumflex); the duty psychiatric nurse asked me a few cursory questions then told me to ask my doctor for a course of Prozac.

Or the time when, sensing an imminent descent into the emotional abyss, I contacted my local community mental health team to ask for help. The reply I received was courteous but patronising, more or less implying that unless I staggered into the surgery with my wrists already slashed there was nothing they could do.

The upshot of all this? The worst in short-term planning. Instead of trying to avert the crisis why not wait until it comes crashing through your front door in all its bloody glory? Those few pennies you might save by limiting preventative care will be peanuts when you’re presented with the bill for my incapacity to engage with society – and pay my taxes.

Please don’t misunderstand me. I’m not suggesting the entire NHS should rearrange its priorities to account for my every change in mood swing, and I’m sure some of you – from the Julie Burchill School of Empathy, perhaps – will be shouting at your computer telling me to get a grip. I don’t want your pity, I really, really don’t; all I’m asking for is a little more consistency and some ‘joined up thinking’.

For example: I have been, more than once, referred to a therapist of some kind but the referral always comes with some sort of proviso. Normally it’s a limited number of sessions; last time it was six which was just about time for us to get to know each other. I had the option to continue on a private basis but a recent outbreak of BPD had left me with a paltry, part-time income.

Then there was the time I struck up a productive relationship with a Freudian psychotherapist. What should have been – and did, indeed, start out as – a fractious, adversarial relationship ended up like a marriage made in heaven.

Does it sound like a physical relationship? In some ways it was – only without the intimate contact, of course – because it has to be intense. Sadly, after a summer of psychotherapy, she suddenly disappeared. I never did find out what happened to her; I managed, eventually, to get an appointment with someone else but when I told him I was feeling better he declared me fully restored to health and no longer in need of therapeutic support.

Three months later I was up to my old tricks again and never really let up for the best part of eight years. I should add that in all that time various GPs, medical professionals and even the police were nothing less than understanding; what constrained them, what we were all fighting against, was – still is – an inflexible, unimaginative system. A system that insists that mental illness is no longer taboo but hasn’t yet worked out how to deal with it. Whether through ignorance, lack of funding or wilful desire, it just doesn’t take us seriously.

But I’ll say it again. I don’t want your pity and I certainly don’t want to stretch the resources of an increasingly-underfunded public service which, in any case, can’t offer much more than a metaphorical plaster and a patronising pat-on-the-head. On the basis that prevention is usually better than cure what I would really like to see is a radical rethink on the nature of BPD; of what it means to be sane or insane. It’s an argument that is more sociological than medical because BPD is as much a political condition as a psychological malady.

In Madness Explained, an excellent exposé of the myths surrounding mental health, Richard P Bentall argues that mental illness is not a product of brain dysfunction than can be cured – usually with medication – but a series of symptoms only a minority of which cause significant problems for the ‘sufferer’. In the words of one Amazon reviewer ‘I go to the doctors and they want to drug me to get rid of everything ‘wrong’ with me and flatten my personality … when only 10% of these symptoms are actually causing me any distress!’

Perhaps we should dissect the nomenclature. According to Bentall, the term Borderline Personality Disorder was coined to ‘describe a type of personality characterised by extreme emotional instability, severe problems of self-esteem, self-destructive behaviours and intense and unstable relationships with others’. All well and good; that’s an accurate-enough description of my own condition but phrased in a manner which would seem to render me pretty much incapable of living anything resembling a ‘normal’ life.

Not that I’ve any desire to live a ‘normal’ life; sounds like complete and utter madness to me. The fortunate truth is that I’m perfectly capable of being a fully-functioning, productive member of society – for most of the time. There are certain environments in which I couldn’t survive: the office, the nine-to-five; the corporate world or the micro-managing boss. But within the relative freedom of self-employment I thrive.

But society loves labels; whether it’s class, race, gender or sexuality it insists on packaging the relevant behaviour and prescribing it as the norm. Then capitalism comes in and sells it back to us; we no longer live lifestyles, we consume them.

Society will tolerate a certain amount of variation from the norm – the English love an eccentric, after all – but it also has its boundaries and when we transgress them we are considered deviant.

Deviant, disordered and, sometimes, dangerous.

Because that’s what it all boils down to, isn’t it? My personality is on the borderline; the borderline of what? Of what society perceives as functional and dysfunctional? Normal and abnormal? If, during a period of intense emotional distress, I feel compelled to cut myself I am doing so for a reason. I don’t expect to be condemned for my behaviour and even on the warmest summer day I’ll cover up the scars to spare your distress.

The problem is that the cutting comes with the territory; it’s a coping strategy to deal with a society I consider to be alien and hostile (there’s the paranoia talking) and any attempt to treat it, to remove it from my emotional repertoire, would be tantamount to a full-frontal lobotomy. It would kill my creativity, imagination and character stone dead.

Your sanity is my insanity; your chaos my order. Madness is as much environmental as it is neurological, if not more so. I’m a bit like a snake in the grass: leave me to my own desires and I’ll cause you no harm; trap me and try to change me and I’ll do my best to bite back.

If you missed Part 1 of our BPD trilogy, it’s here.

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. You can find out more about her here.

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BORDERLINE PERSONALITY DISORDER: PART 3 OF A TRILOGY FROM SIAN LACEY TAYLDER AND CONNOR KINSELLA

connor-kinsella-jck-training 

As an author and trainer I’ve written enough about mental health to wallpaper a small room. I’ve travelled the length and breadth of the country running courses on personality disorder, and can list the DSM-IV diagnostic criteria while hopping on one leg and loading the dishwasher. I’ve also spent many years working with personality disordered people in secure units, in acute admission wards, in the community. I’ve spent literally hours at a time trying to prevent patients gouging out their eyes, setting fire to themselves or trying to hang themselves with a bath towel, all the while trying to avoid the saliva aimed at my face and blotting out the screaming and shouting with ‘nice thoughts’ about home, family and the post-shift kebab. 

So I know a lot about BPD, then? Er, actually no.
Before reading Siân’s posts I assumed, with the eyes of one who has for many years seen BPD from the ‘professional’ side of the ward or treatment room, that BPD rendered a more or less constant diet of chaos, misery, institutionalisation and sometimes death. Through training and writing I try hard to dispel the idea that all individuals with BPD are manipulative, wildly emotional and self-destructive, but if you’re paid to treat or support people with this diagnosis, it’s always seen as bloody hard work and universally unpopular.
I was keen to hear Siân’s account of her encounters with ‘the system’. I’m certainly no apologist for the many, many faults of a mental health structure which has not so much failed over the years but never really got it’s act together in the first place.
As Siân puts it, we have: “A system that insists that mental illness is no longer taboo but hasn’t yet worked out how to deal with it. Whether through ignorance, lack of funding or wilful desire, it just doesn’t take us seriously.”
And it’s just this sort of voice I wanted readers to hear as opposed to some of the increasingly ‘shouty’ anti-psychiatry stuff spouted on just about any online forum having the words ‘mental’ and ‘health’ in the title. I asked Siân for a service user perspective that might inform and stimulate without stereotyping all mental health workers as a battalion of burnt-out, syringe brandishing stormtroopers whipping out section papers at the mere suggestion of deviation from the cultural norm.
To quote Siân again: “The two sides of the equation – let’s call them ‘the professional’ and ‘the patient’ – ought to be travelling in the same direction, should, really, be striving for the same goal but I would suggest that isn’t always the case.”
No it most certainly isn’t, for reasons that are far more widespread and complex than can be tested on the attention span of our readership. But I’d like to think that my guest blogger has eschewed anti-psychiatry polemic for a considered argument as to where at least some of the problems emerge. Siân highlights a rigid mental health care bureaucracy focussed on crisis management and firefighting, often where an inferno might have been averted with the pre-emptive application of a damp tea towel. And please let’s not have any ‘lack of resources’ argument here. Early intervention can save lives AND money.
At the more individual end of the scale, Siân offers us a glimpse of the ‘piss poor professional’. This is a phenomenon I know only too well as being far too common in the caring professions and about which I’ve guest posted in the Not So Big Society blog.

I probably don’t agree wholeheartedly with everything Siân argues. As a self-confessed science nerd I’m actually quite excited by much of the recent research evidence pouring out of the world’s ever growing collection of CAT and MRI scanners. I would argue argue that neither BPD nor any other mental disorder cannot be explained purely by environmental circumstances or social construction. But like Siân I do believe very strongly that ‘patient’ and ‘professional’ should be travelling in the same direction. So how can we do this?

Only by both sides dropping their weapons and beginning to realise that there is nature AND nurture, that there is medication AND talking treatments, that not anyone wearing an NHS badge is the spawn of Satan and that not everyone labelled as BPD is a spitting, screaming attention-seeking nightmare. A little understanding could go a long way on both sides of the void.
I could go on but let’s save that for another time. To paraphrase Star Trek’s Mr Spock, sometimes the needs of the reader outweigh those of the blogger, so let’s just leave it there and say a very big Thank You to Sian Lacey Taylder.

If you missed Part 1 of our BPD trilogy, it’s here, and Part 2 is here.

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. You can find out more about her here.

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SOCIAL WORKERS: A VIEW FROM OUTSIDE

As good as Twitter is for brief bursts of creativity, argument and taking the piss out of Joey Barton, there are times when 140 characters (including spaces) just aren’t enough.  So tonight I try to answer a very thought provoking question from Social Work MA student Natasha Andrews @SocialWorkKent “What glues #SocialWork together to give us a shared identity and if there is one what is it?”

Well it’s not every day I come up with ‘value-congruent’ and ‘stereotyping’ in the same sentence let alone a Tweet, but as I’m currently working on a little side project on personality and care professionals this seemed a really interesting question and deserves a decent stab at an answer.

I’m an ex-mental health nurse with many grey hairs worth of experience in all sorts of environments from forensic secure units to generic community mental health teams.  So I can only really form views about Social Workers based on working alongside many specialist Mental Health Social Workers (MHSWs) down the years, but putting that caveat aside, let’s try answering Natasha’s question.

In my experience at least, most MHSWs have been very much members of a multi-disciplinary team.  I’ve read comments online about the need to preserve the identity of social work within CMHTs, but to my mind the most effective MHSWs have been excellent team players and fellow mental health professionals first and foremost. The least effective have set themselves apart from the team, occasionally to the extent of virtually tattooing ‘I AM A SOCIAL WORKER’ across their foreheads.

But in my response to Natasha, I suggested that Social Workers ‘are the most value-congruent discipline by a long way.’ And added, running out of character by this time ‘Unwanted effect > Stereotyping.’

But what the hell does that mean? The mental health professions are as full of stereotype as anywhere else. Knuckle-dragging, depot-injection wielding nurses. Occupational Therapists called Emma with obsessive basket-weaving tendencies. Aloof and arrogant Consultant Psychiatrists. And Psychologists. Mm, better not go there even in a satirical way.

But Social Workers have a public profile and identity that goes way beyond the small enclave of the mental health universe.  They are , to the upstanding, hard-working, reasonably minded Daily Mail reading populace the very nemesis of what is right and decent. They are the friend of the feckless. The champion of the chav. The dangly-earring wearing, folk-festival going, real-ale drinking, sandal wearing, Guardian reading, vegetarian falafel eating do-gooder too busy carrying climate change placards to be bothered whipping children away from drug-addled Chantelle from the council house crack den. Oh, but sometimes they do whip children away from nice, middle-class parents because they don’t get European Unity and all that.

I’ve known many an MHSW reluctantly having to transfer a client to a colleague simply because the client “ain’t talking to no fucking Social Worker.” That’s a stereotype.

Well the nearest I’ve come to working with any of the above ‘Typical Social Workers’ is a female colleague who once succeeded in getting The Sun banned from a secure unit on account of Page 3 causing offence to women. And that’s about it really.

But one value shared by almost all of my past Social Work colleagues is this. They actually have Values. The foam at the mouth brigade will always castigate social work as a politicised profession. Left-wing liberals positioning themselves on the side of the oppressed. Whether the ‘oppressed’ means the disabled, the chaotic, the poor, the abused or the mentally ill, Social Workers are firmly on their side. This was often the cause of much sighing and harrumphing among GPs and Section 12 Psychiatrists stood on a wintry doorstep in the early hours while (the now defunct) Approved Social Worker would ‘insist’ on looking at all the alternatives to a young suicidal woman being detained in hospital against their will.

It is usually the team Social Worker who actually remembers things like ‘Nearest Relative’ and ‘families’ and ‘environment’ and ‘the big picture’ while the rest of us in the team chew on our pencils in team meetings trying to remember that very obscure diagnosis from DSM-IV and debating the relative merits of Cognitive Behaviour Therapy versus that anti-depressant that begins with ‘M’ and whose sales rep brought us those swanky new Post-It notes and a Marks and Sparks sandwich.

At the risk of waking a hundred Trolls from under their virtual psychiatric bridge, I would even go as far as to say that the MHSWs I’ve worked with have more often than not formed the ‘conscience’ of the team in a profession that is so often concerned with coercing people into things they would really rather not do, thanks very much.

This isnt to say that other mental health professionals don’t have ‘values’. Of course they do. But whether it’s through training or because Social Workers come to the role because ‘that’s the sort of people they are’ or perhaps a combination of both, it’s never very difficult to play ‘Spot the Social Worker’ in any multi-disciplinary team. And it’s not because they wear sandals.

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SOME NOTES ON SUICIDE

As I sit down to write this the headline news on BBC 5 Live is the death of a nurse called Jacintha Saldanha. Her death is being widely reported as suicide. Why is it headline news? That’s a good question. I very much wish it wasn’t. Not because her death doesn’t deserve recognition, but because nobody but her family and those that knew and worked with her would give a toss if it weren’t for a connection to ‘THAT’ news story. And of course because she just happened to take a phone call which resulted in ‘THAT OTHER’ news story. A story which took up the media and internet baton once everyone had run out of ways to report that a certain royal was pregnant and had morning sickness.

Lots of people kill themselves. Probably more than you think. Whenever I discuss suicide in training, people often struggle to believe that around 15 suicides are recorded in the UK every day. Of course these are official figures recorded by a Coroner as the deliberate taking of one’s own life.  With moral and religious taboos, financial implications and family feelings to take into account, Coroners set the burden of proof understandably high to record a death as self-inflicted. The actual suicide figures are quite possibly much higher.

There will of course be a brief outpouring of grief, indignation, speculation and utter cobblers written and spoken about the death of Mrs Saldanha. The armchair psychologists will be bashing away at their keyboards, speculating about people and circumstances of which they know little or nothing. Or if they’ve read about the story in the Royal-obsessed tabloids, they’ll be tweeting, blogging and writing column inches about her death based on some hack’s terror of getting a bollocking from the Editor if they haven’t come up with a thousand words on the ‘KATE NURSE SUICIDE SHOCK!’ story by teatime tomorrow.

In a recent and well judged piece by political commentator Owen Jones, a ‘jumper’ chooses to end their their life by throwing themselves in front of the train Jones was travelling on. As a well known scourge of the right-wing Jones is better known for being the poster boy of my (mainly left-leaning/liberal) Twitter timeline, and the piece was not without highlight of the appalling dismantling of mental health services. But most telling for me was his account of people taking to the internet to moan about their journey’s being delayed by the selfishness of the suicide victim. Why, said the keyboards warriors, could the person not have committed a nice, quiet suicide without causing inconvenience to passengers and traumatising the train driver?

Even the most compassionate among us may look at that last example and think “You know what. Maybe, just maybe they have a point.” Suicide is often described as the ultimate act of selfishness. As well as the many professional and personal encounters I’ve had with those now dead by their own hand, I’ve also worked with those bereaved by suicide. The bewildered ones left behind by a family member or lover who has, like Gary Speed just over a year ago, hung themselves in a garage. And I’ve worked with PTSD sufferers traumatised by witnessing the very last moments of a person’s life which, in the case of a train driver, may be an image he or she will never be able to erase despite years of therapy, anti-depressants or, as is often the case, self-medication with a tanker-full of vodka.

But one thing we can never, ever ask of a suicide victim is ‘Why?’ Even the suicide note is no real explanation. The principal witness is dead.

One thing we do know is that suicide is not necessarily the end game of mental illnesses such as Depression or Schizophrenia. An extraordinarily large number of victims have never been anywhere near mental health services, or (like Speed), given an inkling of their desperation to those around them. A significant proportion of suicides happen in the aftermath of life events.

Failing businesses, failing relationships, redundancy, bullying, bereavement. The stuff of life that craps on all of us from time to time but is usually coped with through time and resilience and doesn’t force us to jump from a multi-storey car park. It’s a quick-fix solution to situations or mental states that few of us can begin to contemplate. Selfish? That’s a very big call when we can never, ever know those final thoughts of the person who has decided to bring an end to their own life.

There are many other myths around suicide. Many assume that Christmas and New Year is a sort of suicide ‘rush hour’. A fatal hell for those whose loneliness (whether actual or perceived) is compounded by the tsunami of happy families and festive warmth thrown at them every time they switch on the telly. That and the long nights are often cited as high risk factors, but if there is any seasonal pattern to suicide we are (in this country at least) more likely to see suicides peak in early Spring than in the depth of winter.

Statisticians, mental health professionals and social researchers have been fascinated by suicide since Emile Durkheim’s famous work from the late Nineteenth Century. We could go on and on with stats and explode many more myths, but pending the Coroners report, Mrs Saldanha is (allegedly) yet another statistic to add to the other five or six thousand people who will kill themselves every year.

She isn’t alive to tell us her story, but the Tweeters, Facebookers, broadsheet columnists and tabloid muck rakers probably won’t worry too much about that. The Daily Mail, which true to form managed a whopping twelve pages of preggers-related drivel almost as soon as the royal  foetus was announced will, at this moment, have their hacks chasing anything and everything to do with Mrs Saldanha’s precious but otherwise unremarkable life. But neither they, nor we, nor even those closest to her will ever really know why she chose to end her life, or what thoughts were going through her mind in the hours and minutes beforehand.

Well this isn’t the most cheerful thing I’ve ever written, but if you’ve stuck it out this far, please have a think about three final thoughts:

1) Please don’t assume that everyone about to kill themselves is writing wills and suicide notes, or checking themselves in for an appointment with the GP, or announcing to all and sundry that life isn’t worth living and that their families would be better off without them. Yes, sometimes it works like that. And very often, it doesn’t.

2) Whether it’s Gary Speed, Jacintha Saldanha or the person who jumps in front of a train, please don’t jump onto your keyboard with a handful of assumptions and a degree in cod psychology. Think about those who are left to pick up the pieces. They read the internet too.

3) And finally, please keep these good peoples details to hand. Someday you or someone close to you may need it. It could be a lifesaver.

The Samaritans

Tel: 08457 90 90 90

Email: jo@samaritans.org

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Homicide, Suicide and Mental Health: Time for a Rethink?

In the wake of yesterday’s ONS crime statistics revealing a major drop in homicide rates in England and Wales, has the ‘inquiry culture’ made any significant impact on mental health-related tragedies, and is it time for a rethink? 

If you’ve worked in front-line mental health at any time in the last two decades, there’s a small but not insignificant chance an independent inquiry has shone it’s torch at you, your colleagues and your collective role in a homicide.

Yesterday’s announcement suggests a downward trend in homicide rates, but before 2011-2012 there were between five and six hundred and fifty homicides recorded in England each year (National Confidential Inquiry, 2012). On average around ten per cent of these deaths will have been committed by a ‘psychiatric patient’, or to be more precise, by a perpetrator who has been in contact with mental health services within a year prior to the offence.

This relatively small contribution may come as a surprise to the more indignant ends of the media. And it is hardly a damming indictment of community care, especially as only a proportion of ‘psychiatric’ killings will have been committed as a direct result of psychiatric pathology such as command hallucinations or paranoid beliefs.  A mentally ill killer doesn’t necessarily kill for reasons that are different from anyone else.

Nonetheless, this is still fifty or sixty people a year dying at the hands of someone whose name is on the books of a mental health professional, and the question of preventability is one that must be asked.  And it does. Dozens of times a year.

Independent inquiries into mental illness related homicides were made mandatory in the wake of the Ritchie Report of 1994. In the light of criticism about their continued usefulness, not to mention the weighty invoices for an army of psychiatrists , barristers and other senior personnel who make up the panels, the ‘mandatoriness’ was slightly relaxed in 2005, but still we are seeing dozens of publications a year of inquiry reports which were once headline news but are now so common as to be barely noticed.
Homicide is not the only adverse event to trigger independent inquiries. Suicides, sudden unexpected deaths and safeguarding events can all be subject to scrutiny where circumstances dictate, generating what is now a vast library of reports, findings and recommendations. We are all aware of the benefit of hindsight, and there’s certainly no shortage of it here.
 
Lack of communication, inter-agency squabbling, non-adherence to the Care Programme Approach and poor or non-existent discharge procedures are all among the usual suspects to appear within the panel’s cross-hairs. We will also read frequent accounts of agencies such as the police, mental health professionals and social services treating each other as if they had a communicable disease. 

But other themes are also present in abundance. Professional disinterest. A ‘more than my jobs worth, guv’ attitude. Rigid bureaucracy and referral criteria trumping good clinical judgement. Oh, and we nearly forgot a lack of common sense and sheer incompetence.

We should all by now have learnt our lessons. We should have developed evidence-based, multi-agency training in prevention of violence and suicide. We should have developed collaborative approaches to working with crisis and risk involving everyone within a community who works with mental health: Community Mental Health Teams, the Police, Parmamedics and Support Workers. Everyone.

We should have developed collaborative, reflective approaches to analysis of adverse events and ‘near misses’ which involve service users and those so often excluded from deliberations, the families and carers. And we should have developed robust policies and procedures which mean risk work becomes a key clinical skill and not the ticking of a few boxes on a side of A4.
 
But while there is certainly evidence that care providers have followed recommendations at an organisational level, have eighteen years of automatic inquiries really made an impact at the sharp end of care and support? Are inquiry recommendations actually being followed and learnt from in day-to-day practice, or are the reports offering little more than a handsome hourly fee for their very expensive authors?

There is no evidence of any decline in the rate and frequency of homicides, suicides or other adverse events. Suicides are becoming less frequent among in-patients, but is this due to improved care on the wards or to the fact that trusts have followed previous advice from the NCI in removing ligature points such as curtain rails? And why has there been a rise in suicides among patients in ‘home care’? 


The faults highlighted by countless inquiries and repeated here are still happening day in and day out. I don’t need a literature review to know this – I’m a trainer. I see and hear the horror stories from staff all over the UK and from a wide variety of settings. So if these are the problems, where are the solutions?

I have two very simple, affordable suggestions for mental health care which may (if you’ll forgive the drama) save lives.

Firstly I would very strongly support the suggestion that we now abandon the independent inquiry system and hand responsibility for the scrutiny of adverse events to the National Confidential Inquiry. One centrally organised body using standardised methodologies to examine homicides, suicides and sudden unexpected deaths, feeding their work directly into a programme of training and research that directly links evidence with day-to-day reality.

Secondly, I think it’s time for a change in how front-line mental health services work with risk. We’ve seen painful evidence over many years of how the collective will, for a variety of reasons, make mistakes and allow tragedies to occur.

Perhaps it’s time for an individual response. A Risk Practitioner.  Or even, if you prefer the dramatic, a Troubleshooter.

An experienced individual who knows what can happen, has an intimate awareness of the inquiries and evidence base, can coach, micro-teach and work alongside front-line colleagues, and has the ability to link agencies, teams and individuals together  in a way that we seem patently unable to do when left to our own devices.

If this sounds rather fanciful, it’s been done. Unfortunately the very partisan forces that so often plague inter-agency working brought my particular project to a premature close, but as a Forensic CPN I once worked closely with an Assertive Outreach Team fulfilling pretty much the job description outlined above. There was of course a little more to it than that which might have benefitted from formal audit or research, but as proof of concept it worked extremely well.

The tragedy of psychiatric disaster is far more real and important than any number of statistics or findings or recommendations. If even only a few of these events is preventable, then surely we should be sitting up and taking notice of how to do the precenting. Maybe it really is time to try something new. 


This post was written as part of a Risk and Mental Health project currently in preparation by the author
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The Occasional Tragedy of Mental Health


A Problem of Understanding
I used to work with people who had committed the most serious and often disturbing of crimes. All in all I spent twelve years in very close proximity to patients in secure psychiatric units. I played cards with killers, badminton with rapists and darts with men you had last seen played by an actor on Crimewatch.

I’ve been shopping with people who hadn’t seen a town centre for twenty years. I’ve handed out tissues to those still haunted by what they had done, and locked up patients in small secure rooms as the voices commanded them to kill anyone within range of a pool cue.

I’ve had the sort of conversations you could and should never forget with fellow human beings who have done unimaginable things. But one thing I have never done is to understand.

Not for want of trying or because I wasn’t clever enough. I ‘got’ the psychopathology of the psychopath. I ‘got’ the biochemistry of psychosis. I ‘got’ the medical model and the social model. But faced with someone who had tortured a child, blown off a neighbours head with a shotgun, or knocked nails into someone’s skull, I simply failed to truly understand.

Thirteen-year old Casey Kearney was walking through a park on her way to a friend’s. She was stabbed by a woman walking in the opposite direction. It wasn’t a frenzied attack, just one brief blow with a one of two kitchen knives purchased earlier that day by a woman called Hannah Bonser, who simply continued on her way before turning up at a local mental health resource to confess to what she called “a silly thing” and hand over her knives.

This was an appallingly random act of extreme violence. Bonser would have expended more time and energy stopping to ask her victim for the time. For any parent to imagine the deliberate killing of a child is not only incomprehensible, but entirely unimaginable for any more than the most fleeting of dark moments. But Casey Kearney’s family have had to deal with this reality since February 14 this year, and have no doubt tried and failed to make sense of the senseless.

Making Sense of the Senseless
Hannah Bonser was yesterday convicted of murder and sentenced to life imprisonment. She will serve an absolute minimum of twenty-two years before being able to seek parole. Those not involved with the case might have been surprised that Bonser did not receive a Mental Health Act hospital order and a conviction for Manslaughter rather than Murder.

After all, this was a bizarre and random killing committed by someone well-known to mental health services for some time before the event. Her legal defence argued she was suffering from Paranoid Schizophrenia at the time of the offence, and that her responsibility for the crime was therefore ‘diminished.’ The jury did not accept this argument.

But as with all homicides involving mental health service users, an independent inquiry will now take place in the aftermath of the trial. Like the dozens that have preceded it since the mid-1990s (when such inquiries became mandatory) the report will provide a public and detailed account of Bonser’s relationship with mental health services in the months and years prior to February 14th 2012.

As both a practitioner and trainer who has read with depressing regularity how tragedy has resulted from the failure of various services involved in mental health care over the years, I very much hope we will not be hearing from the usual suspects. Failures of communication, lack of information sharing, poorly motivated professionals, bureaucracy. All these and more have become depressingly familiar to readers of such reports, but seldom appear to change the way we work with potentially dangerous people.

What’s in a Diagnosis?
For some months prior to the killing, a close friend of Hannah Bonser had noted how her behaviour had become increasingly unusual. She claimed that her flat was possessed by demons. Her self-care deteriorated and she travelled down to London, where she slept rough and searched for a character called ‘Simon of Lambeth’. She was detained under the Mental Health Act before being transferred back to a Doncaster hospital, but was discharged shortly afterwards. Life appears to have become increasingly disjointed and chaotic. Shortly before Casey’s death, her killer had presented to mental health staff stating she was hearing voices commanding her to harm others.

Her legal defence was that her actions were driven by severe mental illness. It’s well beyond the scope of a short blog post to attempt to describe what we mean by this, but on current evidence we could state the following. That at the time of the offence her brain was showing signs of abnormal structural and biochemical functioning and was interacting with an environment which to Hannah Bonser would be a very, very different place to how most of you reading this would experience that environment. It may have been quite a terrifying place. Perhaps terrifying enough to randomly stab a complete stranger.

The prosecution argued that Bonser was not psychotic but suffered from a Personality Disorder. We know even less about the inner workings of PD than Schizophrenia, and argue about it a great deal more. This diagnosis would imply that the person is fully aware of one’s actions and knows exactly what they are doing, even when what they are doing is indescribably unpleasant.

The Sadness of Madness v Badness
The difference between severe mental illness and personality disorder is characterised by some as the ‘mad versus bad’ dichotomy. This is a very false dichotomy. In fact, it’s not a dichotomy at all.  The opposite of ‘mad’ is ‘sane’ and the opposite of bad is of course ‘good’. It’s an old and rather stale argument often used by lazy mental health professionals to characterise the difference between behaviours which are driven by ‘genuine’ and ‘proper’ mental illness on the one hand, and behaviours which are apparently ‘manipulative’ or ‘attention seeking’ on the other.

Being ‘Mad’ is beyond both the conscious control of the sufferer, and the moral judgement of others. It warrants our intervention, diagnosis and treatment, particularly with pharmacological means which offer a quick and relatively simple solution to ‘Mad.’

But ‘Bad’ is just, well, bad. If it isn’t ‘Mad’, isn’t a psychiatric problem, we needn’t offer an intervention. Personality Disorder is ‘Bad’ and this is what Hannah Bonser is now judged to be. She’ll go to prison not hospital.

The jury at Doncaster Crown Court accepted medical evidence suggesting Bonser suffered from a Personality Disorder. Essentially, she knew what she was doing.

The conception from both the public and aggrieved families is often that a ‘proper’ sentence is infinitely more acceptable than the apparently soft option of a psychiatric bed. Part of the argument around this case was that the stabbing of Casey Kearney was a calculated and manipulative act designed to achieve Bonser’s demands for hospital admission. To have received a Mental Health Act section might have been seen as a triumph for Bonser’s manipulation, and one could understand how that might be seen as unacceptable by many.

To Inquire or Not Inquire?
Nonetheless, an inquiry will now take place and the report will tell us something of how a family have lost a 13-year old girl who just happened to be in the wrong place at the wrong time. The court has already delivered it’s verdict on Hannah Bonser, but the inquiry will hopefully reveal a highly complex interaction between a twenty-six year old woman, her troubled background, her environment, her mental state, the services she turned to for help and the killing of Casey Kearney.

There are some who now call for the end of mandatory inquiries into each and every mental health related homicide. I wouldn’t disagree. It’s a hugely expensive procedure which, as we’ve already seen, throws up very similar conclusions time after time without seemingly making much difference.

But perhaps we should continue to study events such as these which, incredibly rare as they are, remain sufficiently horrific to merit the deepest scrutiny and may help us to at least try to prevent the preventable in future.

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MPs on Mental Health: Almost Human After All?

BBC Parliament used to mean little more to me than the sight of several hundred MPs honking and snorting their way through Prime Ministers Questions like a herd of Wildebeest on a legal high-fest.

But yesterday’s Mental Health debate was a curious beast. In fact, as a ‘general’ debate it was neither adversarial nor even mildly confrontational. In fact, it was more or less a small bunch of MPs from all sides of the house talking a lot of sense and being nice to each other.

In fact, it went even further than that. It turns out Alastair Campbell isn’t the only case of mad pride in the Westminster Village. Kevan James opened the theatre by throwing down his pre-prepared notes, clearing his throat and revealing an experience with severe depression hitherto hidden from all but his closest family.

Charles Walker followed up with a superb stand-up based on his own long history of Obsessive Compulsive Disorder, describing himself as a ‘thirty year fruitcake’ with seemingly bizarre number-based rituals and even the odd voice in his head commanding him to delete a digital photo or face the certain
death of his son.

In fact, just as I was thinking the BBC had got it all wrong and planted their cameras in the Commons weekly self-help group, #mentalhealthdebate started to trend on Twitter. And a small group of MPs decided to forego the spectacle of Dave dodging the now telegraphed punches of Leveson in favour of a debate featuring, in no particular order, resilience, IAPT, self-referrals, care pathways, mentally ill prisoners, police involvement, stigma, advocacy, over-prescribing of psychotropic drugs, recovery models, recovery colleges and (more than once) the appallingly poor morbidity of the long-term mentally ill.

Andrea Leadsom and Sarah Wollaston talked about their own experiences of desperation, severe anxiety and suicidal thoughts following the birth of their children. Shocked? Amazed? Yes, me too.

And just in case you were beginning to think this was all getting a bit ‘bean bags and whale music’ for our Upper Chamber, along came the announcement of a Private Members Bill on Mental Health Discrimination. Croydon MP Gavin Barwell talked of the stigma and injustice of laws such as the Mental Health Act’s Section 141, which removes MPs from office after 6 months of detention. Yes,it’s obscure and has never been invoked. But as Mr Barwell pointed out it’s up there together with legislative barriers to jury service and company directorships for the mentally ill as a piece of archaic symbolism long past it’s sell-by date.

Now I don’t know much of how these parliamentary thingies work, but it would seem cheerleader in chief of this most surprising and groundbreaking of days in the Upper House was Loughborough MP Nicky Morgan. She had apparently fought not only for parliamentary time but for the venue to be the Chamber itself and not Committee Room 4b or some other dark and forgotten recess of the Palace of Westminster. And in both introducing and summing up the debate, she along with many of her political peers currently receiving all the public adulation of the childcatcher from Chitty Chitty Bang Bang spoke more intelligently, authoritatively and compassionately about mental health than I’ve heard from many a professional.

As Ms Morgan put it much better than I could myself: “All of us have mental health, it’s just some people’s is better than others.”

Remarkable.

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Mental Health, MDT’s and the A-Team

I’m not usually given to talking shop on a Friday night, but my ire is piqued and curiosity aroused by a spate of recent blog posts, all of which pile yet more misery on a mental health system which, if it were a human being, would have several coppers, a psychiatrist and an AMHP all trying to talk it out of throwing itself off the top of a multi-storey car park.

In a well written and understandably anonymous post, a Mental Health Social Worker (‘Being Here’) describes their redeployment from front-line mental health care within a Community Mental Health Team (CMHT) to, well, even the author doesn’t sound too sure. But it sounds a little like pushing bits of paper around a desk and pissing many years of valuable experience into the gale force winds of budget cuts and reorganisation.


Being an independent freelancer I’m lucky to be able to write stuff like this under my own name and not to have to adopt identities, but ‘Zarathustra’ works within a Child and Adolescent Mental Health Service (CAMHS) and has some further (again understandably anonymous) scorn to pour over similar losses of Social Workers from their CAMHS team. More redeployment, more cuts, and definitely less joined up working between health care and social services. With seriously distressed people already being left to fester in their own metaphorical shite by skeletal levels of mental health provision, this in itself is inexcusable. But there’s more to the story than that.


As both a Community Psychiatric Nurse and a Secure Unit Team leader I’ve been lucky enough to have spent many, many years working closely alongside Social Workers and all the other disciplines making up the typical Multi-Disciplinary Team (MDT). In the Being Here blog, the author makes a case for the inclusion of CMHT Social Workers on the basis of the oft-quoted position that the Social Work perspective adds a much needed holistic perspective to the often overly medical-model approach of the CMHT. 


Well I can see the argument there, but don’t really buy it. Not because the argument is intellectually flawed (it isnt) but because I’ve never really bought into the ‘I’m a Social Worker’, ‘I’m a Nurse’ thing. 


The most effective MDTs I’ve worked with have pretty much left the qualifications at the office door and got on with using their individual skills to simply do the stuff of helping the people we’re there to help. And the not so good teams I’ve worked with? They’re the ones with Doctors and Psychologists and Social Workers and Nurses and Occupational Therapists all sitting in their own offices with big red labels tattooed across their foreheads saying ‘DOCTOR’ ‘PSYCHOLOGIST’ ‘SOCIAL WORKER’ etc etc. You get the picture.


I’ve yet to meet a psychiatric nurse who can give a truly convincing account of the particularly special skills they bring to the MDT party, and at the risk of upsetting even more psychiatrists than I already have in these pages, there is a loudly whispered argument (even within the trade) that there isn’t much a psychiatrist does that couldn’t be done by a reasonably psych-friendly GP. 


But before making myself too troll-friendly to CMHT people currently creating voodoo dolls into which depot syringes can be sunk, let’s just say that I’ve worked with many mental health professionals who, were I given the option of hand-picking a Dirty Dozen style A-Team to staff a top quality CMHT, I would recruit in a heart-beat. Would they be Social Workers, Psychologists or Nurses? Doctors or Occupational Therapists? Would I give a toss? No. They’d be Garys and Debbies, Steves and Amandas. Just people who are really very good at doing mental health care.


Okay, I’m hearing a very loud flaw in this argument which is sounding suspiciously like the age-old ‘generic mental health worker’ mantra possibly dating from the pre-Cambrian period. Being Here refers to their skills and training as a Psychosocial Intervention specialist. I’ve worked with many individuals who have trained in this invaluable specialty. Or as Cognitive Behaviour Therapists. Or in Dialectical Behaviour Therapy. Me? I’m pretty good at depot injections, but we could train a chimp to do that. I’m also pretty good at helping people understand why they’re having a needle stuck in their bum. I’m also pretty good at crisis intervention. Can’t train a chimp to do that. 


Aha. Now we’re getting somewhere. We’re now talking specific treatment skills. So now I’m not only recruiting my A-Team based on good all round skills, ability to work as a team and a fondness for getting exceptionally silly at the CMHT Christmas Party. I’m also recruiting people who are trained in specific interventions and approaches. Skills that are not discipline-centric, but based on the ability to provide a really thorough, all round service for the pot-pourri of distressed people we’re typically going to see in the course of a working day. 


And just one more thing before I press the ‘Publish’ button and sink back into the Friday night wine bottle. Zarathustra’s well-argued and highly accurate observation is this. That health services on the one hand, and social services on the other, who are meant to be working together in a lovely, happy-clappy, seamless congruence of shared meetings, shared coffee and first-name terms, are in reality batting cases between each other like a hot potato across a very scary and rather large table-tennis table. I run lots of Dual Diagnosis courses and am more than familiar with the scenario.


So the final bit of my job description for the A-Team, once again based on experience working with the mythical ‘MDTs That Rock’, is this. 

To have the imagination, the ‘thinking-out-of-the-box-ness’ and the ability to remember just why we do this job. To consider the patient/service-user/client (you choose) as being just a little more important than the petty bureaucracy, disciplinary empire building, back-covering, petty squabbling and general anal retentiveness that seems to pervade today’s mental health care. And as a UK-wide consultant working with just about every discipline known to social care, I’d like to think I’m able to say that with some authority and a not a little sorrow.
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With Connor Kinsella: Lead Trainer, JCK Training