This is the first in a series of blogs we are publishing about ‘positive risk taking’ in mental health. The Department of Health published its guidance, Best Practice in Managing Risk, in 2007 as part of the National Mental Health Risk Management Programme. It describes positive risk management as a collaborative process with the service user and their carers, which emphasises the importance of building on the service user’s strengths, while recognising the responsibility of individual clinicians and organisations as a whole. Positive risk taking is meant to be about collaboratively weighing up potential benefits and harms, with the aim of taking a risk for a positive outcome. As you will read in the blog below, this couldn’t be further from how it is being used in practice.
At a time of continued austerity, and neoliberal and neorecovery agendas, I see a worrying trend. NHS mental health services are covertly enforcing positive risk taking as a way to justify neglect, lack of care and exclusion. As long as services can defend their actions it seems they can avoid blame. I can’t help thinking that it’s something else; decisions are made due to diagnostic discrimination, financial reasons and lack of resources – not of clinical need. But there is no honesty or transparency when it comes to discussing risk with me.
“Positive risk taking needs a person-centred approach, where staff take a positive, recovery- oriented view of the service user and investigate what is important to keep them and others safe as they move towards better health and more independence. Positive risk taking is based on finding creative solutions rather than simply ruling out options for recovery based on fears and worries of what might go wrong”
from ‘Therapeutic Positive Risk Taking’ by Greater Manchester West Mental Health NHS Foundation Trust
I was forced to wear the Bullshit label of Borderline Personality Disorder and remain unrecovered for many reasons, despite being under the so called care of secondary mental health services for almost three decades. I have already written about this here.
Having the BPD label is not conducive to a therapeutic and trauma informed relationship with professionals. Clinical judgement is biased and I have mainly been treated like shit on a shoe. Written throughout my clinical notes and said verbally so many times is; attention seeking, manipulative, complex, demanding and difficult. This has never changed. I’m sure I’m seen as someone who is taking up valuable resources. My severe distress seems to provoke negative reactions and less empathy from most professionals although it is not fake!
I have often found the mental health system to be coercive and controlling. In the past there have been times when I don’t think I needed to be detained under the Mental Health Act. Yet other times, I have no doubt that being locked up saved my life. I have recently tried to take back some control regarding risk, and whilst there aren’t as many threats of Mental Health Act Assessments and police involvement, there seems to be no action taken when I take responsibility and ask for help in an emergency situation.
Whilst I know that risk assessments are not that helpful in predicting suicide, I see the push towards positive risk taking from mental health services also comes alongside aims of zero suicide and suicide prevention, ‘ask for help if suicidal’ narratives, and Time to Talk. There seems to be an increased focus on those with milder mental health difficulties, yet those with long term need and severe and enduring difficulties are not having their needs met. I’m acutely aware that many people don’t have a Crisis Plan or a Care Coordinator despite being under the care of secondary mental health services. Some can’t access secondary mental health services at all, despite their need.
Over the years I have seen support for people like myself decimated. Crisis services are failing. I used to have some hope that services could keep me safe if I asked for help. I remember in years gone by there was more care in the community and effective and collaborative crisis planning. I could access the day hospital and extra appointments with my CPN or visits from the Home Crisis Resolution Team. I was offered short voluntary respite breaks in hospital as detailed in my Care Plan. Stays (even detained ones) in hospital were more therapeutic than they are now; nurses had more time to chat, there was not as much rush to be discharged and there was better follow up upon release.
Then came austerity, neoliberalism, minimisation of the State, the selling off of the NHS, social inequality and insecurity, and the move to a neorecovery based approach. This accelerated the emergence of individual responsibility and self-management, dependency and loss of productivity, all whilst ignoring the social detriments of health. Mental health services are now in crisis themselves and often struggle to provide even basic care. There is a lack of inpatient beds and more out of area beds. Emergency departments are under increased pressure. Community mental health teams are underfunded, under staffed and under pressure to discharge people who fail to recover. Staff seem to have become demotivated and detached and many of the better ones have left the NHS. Dual diagnosis services have been scrapped. There are long waits for therapy, which are often short term. Day centres closed and turned into recovery colleges, social care and welfare benefits cuts, peer workers are now often called recovery workers and bear no resemblance to grassroots peers. Police are taking up the slack for those in a crisis and some patients are even being prosecuted for trying to take their lives.
It’s difficult to get taken seriously when I’m desperate for help. Fears about my safety from my family aren’t taken into account and they no longer accept the responsibility forced on them by services to keep me safe when psychotic. There seems little point in having a crisis plan (now called a crisis recovery plan). Although I have had some input into my plan, it is very much led by professionals, with much less support on offer in a crisis situation than years ago. In any case the plan is no longer followed in acute crisis situations, despite it stating in capital letters at the top that if I do contact someone it will be an emergency. Professionals tell me that I have capacity to suicide but rarely provide any support. I feel like they just hope I don’t, and that if I do then I was actually telling the truth!
When I am detained under the Mental Health Act it’s often because of police involvement. Psychiatric wards are now hostile environments which I try to avoid at all costs. A recent CQC inspection of my Trust saw the safety of services had deteriorated and required improvement, and that acute inpatients wards were inadequate. Suddenly, it appears that only very short admissions to keep me safe are advised for people with my label and NICE guidelines for self harm are not being followed. Yet, the link between self harm and suicide is well known, with estimates of one out of 10 people with the BPD label taking their lives. Even coroners are issuing Prevention of Future Deaths notices after being alarmed at the lack of care that emerges during inquests.
For many years according to my clinical notes I was “at high risk of suicide.” This has now changed to “at high risk of accidental death.” In the last few years I have been left in high risk situations, because of the misuse of enforced positive risk taking. After a “near miss” serious incident a few years ago, whilst psychotic, three separate NHS mental health crisis services failed in their duty of care. Despite an internal investigation, which resulted in “lessons learned”, similar incidents have happened since (I will spare you the details). CPN stated that if I had died “the Trust wouldn’t have had a leg to stand on at a Coroner’s Court.” I am lucky to be alive! Others have sadly not been as lucky when asking for help and some simply gave up asking.
Neoliberal discourses attempt to position me as a responsible and active participant in my own care but also as blameworthy. I already feel like a failure, undeserving, worthless and ashamed. Am I not trying hard enough to be resilient, to be responsible and to recover? Am I too dependent? Have I not empowered myself enough? As a person with a severe and enduring mental health disability I realise I need to take some responsibility for reasonable risks in my daily life, but there are times that I simply can’t be responsible for my own safety. In these situations there is no joint decision making between myself and professionals. Being told it’s my choice to suicide when desperately asking for help in a life threatening situation as per my crisis plan is totally inappropriate and not one bit therapeutic. It seems to be shorthand for “We don’t give a fuck.”
Surely, services should not withhold support and care when I’m at serious risk of harm under the guise of it being in my best interests, to teach my badly behaved personality a lesson, as a way of tapering care to somehow facilitate resilience, or in a way to avoid blame. You’re actually gambling with my life. It’s scary! Positive risk taking – positive for who? It’s no good promoting recovery if I’m dead!
Written by G