Through the Glass Doors is an autobiographical illustrated book, co-created by 16 previous patients of Huntercombe CAMHS hospitals. It details the horrors vulnerable children face every day at the hands of Huntercombe (now Active Care Group) in placements which supposedly provide specialist mental health care and treatment. The book, alongside a letter of recommendation which provides lived-experience based solutions to Huntercombe’s failings, has been sent to a number of key medical and political figures in the hopes it will stir a response, in turn drastically improving the quality of care provided by Huntercombe and wider CAMHS and adult mental health services.
When you are living in survival mode, making decisions can become particularly difficult & you can find yourself struggling with indecision, avoiding decisions or handing them over to others, or making suboptimal decisions.
Suboptimal decisions can range from those that are ok-but-you-could-have-chosen-better (especially for the longer-term) to those that are outright bad or dangerous (for you).
The aim here is not to criticise the decisions made but to try & understand why they were made i.e. why do we make (and keep making) decisions that are not in our best interest?
We’ll think about the more general case of decision making in survival mode & emphasise some of the particular impacts of trauma, mental illness & disability.
A few points about decision making first:
-decision making is cognitively effortful and takes time.
-it requires cognitive and emotional reserve
-it requires consideration of the timescale of the execution & consequences of the decision.
-it requires taking into account, your interests and goals, the various options to decide between and their relative merits, downsides and costs, often over different timescales. One of the major costs to be taken into account is the cost to yourself.
-it depends on the capital (financial, self esteem, social network) you have available at the point of the decision.
-it depends on the options you really have available to you as opposed to options that could theoretically be available.
A lot the time when it comes to more critical decisions (as defined by you), we make the best/least worst/only decision we can/feel able to at the time in the given circumstances (includes our state of mind & body at the time). This is by no means unique to survival mode.
What’s different in survival mode are the following:
There is less/little spare cognitive and emotional capacity to make decisions
This also shortens the decision timescales (you are only able to think so far into the future).
This can mean that you end up making decisions that are ok for the short-term but not for the medium or longer term ‘I just need to get through to the end of the week’, ‘this is the most pressing thing right now’.
However a more dangerous aspect of the shortened time perspective is that you can end up not really thinking about decisions that will impact you in the future (beyond the farthest you can see now). ‘It’s only going to happen 2 months later, I’ll think about it then’
This puts you at risk of making decisions that are unwise/bad for future you. Thinking about future you requires doing the difficult task of future projection. It’s difficult because we don’t know what our future state of being or the future version of us will be like.
We usually hack this by just projecting our current self into the future and think what we would do in the future circumstances we imagine.
This is effortful but in survival mode it can be v. overwhelming because it involves an awful and often realistic possibility.
Namely, ‘I may still be feeling this awful in X months time, nothing will have changed’. This a very common experience in depression and other mental illnesses and in survivors of trauma and it is understandably easier and self-protective to not project into the future.
Capital: depending on how long you have been in survival mode and your wider circumstances, you will have access to varying amounts of capital. Financial capital is a straightforward one, if you have enough, it can take care of a huge part of the business of surviving.
Financial capital provides a great deal of stability and other resources. It provides a buffer against some adversity as well as against the consequences of sub-optimal decisions, which makes the decision making less stressful, & gives you more options (see below).
Social support capital is fairly straightforward as well, who do you have available to support you? The more people you have, the more help you have to take decisions and buffer their cost and consequences. Let’s move the next one, which is particularly important.
Self esteem capital (how much you value and care for yourself) is an especially important factor and one that is often eroded (or never built up) by prolonged periods in survival mode, serious mental illness and experiences of trauma (esp recurrent trauma).
Self esteem capital is vital for considering one’s own interests and the costs to oneself. If you are short on this, you may not particularly care about your interests or what happens to you or what the costs and consequences are to you.
This is something to particularly consider when you see someone making decisions that put them in harm’s way or at risk of harm or making decisions that are more about looking after (or serving the interests of) other people and actually disadvantageous to themselves.
One of the very sad consequences of trauma and abuse is that it can make one rather enured or numbed to the costs and harms to oneself ‘I’m used to not being cared about’, ‘I’ve known much worse’, ‘At least this way I’ll be helping someone else.’
Which brings us to the last point which is about options. The decisions you have to make are about/between the options you have available to you. The more options you have to choose between, the more difficult the decision making task.
So when you’re depressed, the huge numbers of choices on a menu can be absolutely paralysing. But in such states, so can deciding which of 2 outfits to wear.
On the other hand having too few options can often means that the decision is often a more critical one.
To understand the above, consider this, one of the most valuable options to have is that of not having to make the decision and being able to bear the cost and consequences of that. If you do not have this option, then the decision is more likely a critical one.
Having financial capital means that you are more likely to have more options including the above particularly valuable one. The more critical the decisions, the more each of the (few) options has to be weighed up, the greater the consequences and costs.
So putting all this together, what happens to decision making in survival mode?
1. It becomes very anxiety provoking and can lead to decisions being taken to abort/avoid anxiety.
2. Your decisions become more short-term ‘I need to get through this week’.
3. They become more suboptimal & you consider fewer costs and consequences, especially future ones.
4. You find it harder to step out of the overwhelmed moment & think about possible decisions & futures more broadly.
5. You keep avoiding & postponing decisions. One way of avoiding/minimising decisions is to make life more regimented. This minimises daily decisions (what to eat & wear, where to go), and the chances of new decisions coming up ‘Do you want to go for coffee?’
6. You try and hand over decisions to other people where possible ‘You order for me’, ‘what should I wear?’.
7. You stop thinking about the wider and longer-term consequences of your decisions and increasingly prioritise what is easiest (least effortful) now.
8. You make decisions quickly, either before being overwhelmed by the process, or on the basis of a limited set of considerations, or repeating previous decisions (what I have done in situations like this before). Such decisions can be impulsive or reflexive/habitual.
9. The problem is that these decisions are either:
-not well thought out in the moment
-previous optimal decisions but in different circumstances (e.g. decisions that helped you survive previous abuse or trauma)
-are previous suboptimal decisions that were made in comparable states of mind and/or body.
The intersection with low self esteem capital is particularly dangerous here ‘I’ve never thought I deserved better, even from myself, so I never cared what happened to me’.
One of the most important consequences of our decisions is the set of future decisions they set up and the options that we have for those decisions. The longer you’re in survival mode, you have less capital, fewer options and harder decisions.
This is perhaps the best perspective to take on the impacts of mental illness, disability and trauma and how they accumulate over time.
All of these greatly increase the cost of functioning and reduce the reserve available for decision making.
All of them limit options, either through structural reasons or because options and opportunities were never available or had to be given up.
All of them impact the available capital, often because there was never the chance to build up capital.
What might help? It can be helpful to examine one’s decisions and decision making processes with a close friend/relative or therapist who can help you step out of yourself to look at the decision without the intense emotions being so closely involved.
The short cut version of the above is to consider advising a friend on how to make the same decision. It is crucial however to skip what is often the last part of this process which ‘but it’s different it’s for me/about me’.
However one particular area to focus your efforts and use your support systems for help with is to create time for decisions i.e. stop the anxiety taking over and driving the process. Creating the time gives you the chance to consider options, consequences and costs.
Finally, try and be kind to yourself.
It is easier to learn from the decisions of your past self if you can feel compassion for those past versions of you and how they took the best/least worst/only decisions they could in the circumstances they were in.
Hisham Ziauddeen @HZiauddeen Consultant Psychiatrist CPFT, Clinical SRA Univeristy of Cambridge
The suffering is horrific. NHS dentistry, community physio, podiatry, are effectively gone now. What’s left is hard to access and limited in what they offer. NHS dentistry has become an emergency antibiotic and extraction service (after weeks or longer). Patients are often pushed into paying privately.
There’s a link between oral health and cardiac health, right up to sepsis. The cost of not having access to routine dental care (fillings, crowns, root canal) is high. Patients are in serious debt for emergency treatment, root canal & crowns. NHS dentists don’t always refer patients on for gum disease treatment and let it progress to extraction and dentures.
In the US it’s said you can tell poverty by looking at people’s mouths, the same will be true here. I will never forget a film I watched a few years ago of Americans queuing up all night (including wheelchair users) outside a warehouse for free medical treatment and dentistry.
No privacy, exam chairs, beds all set out. People shaking violently having entire mouth tooth extractions under local anaesthetic.
There’s also no appreciation of the impact of antidepressant and antipsychotic medications on dental health which can cause dry mouth increasing the risk of decay, but mental health services nor NHS dentists inform patients of products to help with this. Acute patients might have periods of sugar laden liquid meds.
Dentistry should not be a luxury.
For me critical psychology was a revelation. It explicitly verbalised what I had been thinking. I still remember my first steps in challenging the certainties of, shall I say, positivist psychology and coming across writings of psychologists who were thinking in similar terms was a revelation. It’s all changing now.
I suppose my relationship with psychology has always been tenuous. As a linguist, understanding and teaching about the role of context, positivist psychology has always been a problem. I remember taking part in a discussion on a PhD proposal in which the student sketched a project on perseverance. I made a point that, surely, perseverance is always contextual, depending not only on, for example, our personality, but also the stakes involved or social importance of the task. And so, your perseverance in getting a new T-shirt is extremely unlikely to be similar to that of trying to resuscitate your child.
In response, I heard that my point was well made, but psychology was interested in ‘pure perseverance’, only that was perseverance proper. And so, the student invented a fatuous procedure that, apparently, enabled them to measure this purity of perseverance and correlate it with all sorts of psychological stuff. Psychologists nodded, I shook my head.
And here come the critical psychologists. Their writings challenge the certainties of mainstream psychology, much as discursive psychology did. All of a sudden, statistics does not provide us with much comfort, while questionnaires are not magic tools harvesting psychological experiences. As I was reading more and more, I was smitten.
Time for a reservation, as I move to offer critique. I do realise that critical psychology is not a homogenous group of people and there are disagreements within such a varied group. I also understand that Twitter psychology might not be representative of its entirety, although it’s worth saying that very prominent psychologists have accounts on Twitter and they are vocal representatives of their subdiscipline, both in proclaiming themselves part of it and in sometimes loudly dismissing those who disagree. I also accept that for rhetorical effect what follows is likely to be somewhat exaggerated.
And so, to continue, misfortune befell me – I joined Twitter. Daily I started witnessing quarrels, skirmishes and veritable battles between critical psychology and the regular one. Arguments I knew and continue to know very well have been rehearsed right, left and centre…Except something else happened. At some point I realised that more often than not I was joining with the ‘bad guys’, with ‘regular’ psychologists (and psychiatrists, to be fair). I started crossing the floor more often than I would have thought possible. When I noticed it, reflected on it, I realised a paradox. I continued to agree with the criticals (at least for the most part), but I actually didn’t want to be seen to agree with them.
What I found extraordinary was that it was the ‘enemy’ who seemed more open and prepared to listen. It was the enemy who was falling back on evidence. It was the enemy who was prepared to question and reflect on their assumptions. Indeed, over the last months, I have written more blogs criticising ‘critical psychology’ than anything else. From PTM framework, through irrational insistence that changing a few words will introduce world peace (under the guise of ‘language matters’), all the way to the recent report called “Understanding depression”. What all those documents have in common is the assumption that they are the revealed truth and those who (dare) criticise them are fatally wrong. There is an intellectual dishonesty underpinning even the major documents which, you would hope, would carry the nuance and sensitivity to other perspectives.
I continue to be disappointed with critical psychology (mostly its British version, at least) which uses a sledgehammer in dealing with its ‘enemies’. There are no arguments, no attempts to understand an Other. No, if you disagree you are in fatal and ultimate error, possibly just stupid. Recently, I was shocked to see those who disagree with the #UnderstandingDepression report being dismissed in highly disparaging terms and with no counterarguments.
That’s not critical psychology I used to read. It doesn’t have even the shadow of its former intellectual depth and clout. Today, it doesn’t argue anymore. It shouts.
This post has been long coming, I am sure I will get a lot of stick for it. I also know that this will be one of those posts that will result in tens of blocks and as many unfollows. What spurred to me to writing it was a recent Twitter exchange I took part in. Extraordinarily again, the only argument those progressive critical psychologists were able to offer was that those who disagreed just misunderstood ‘the real message’. And all from the position of delivering the truth to the minions.
But what really irritated me was this exchange:
I mean, really?! Like really?! If someone does not follow in your footsteps, there is no possibility of meaning or understanding? This is megalomania, this is psychological Trumpism, for pity’s sake. This is no critical psychology – this is bombastic, grandiose psychology so full of itself that the solar system seems too small for it. This is psychology walking on water.
And so, to repeat my reservations. Of course, I understand that I look at a snapshot of psychology in a particular context. And yet “Understanding Depression” has the imprimatur (those familiar with Vatican’s censorship will appreciate the word) of the BPS. I am really not talking about a few rogue psychologists from a galaxy far far away.
As I walk away from critical psychology as it is (not that it cares about it at all, not only am I a nobody, I am also fatally wrong), I am still up for a fight with positivist psychology, with all those smitten by the alphas, r’s and whatever other letters psychology throws at you. But I would like to be seen as someone who can be persuaded with an argument. There are wonderful quantitative studies, there are zillions of people for whom their nosological diagnoses were a godsend, there are also so many bad qualitative/critical studies that they could blight global agriculture.
And, finally, for pity’s sake, let’s assume, once in a blue moon at least, that we can be bloody wrong!
In June 2017 my life fell apart. I was raped and endured a year long police investigation into the matter. I had always had a good life up to this point but suddenly it was flipped upside down; I was out of work and struggling with thoughts of suicide and self-harm. My way of coping was to overdose and I was constantly in and out of general and psychiatric hospitals.
As some of the overdoses were away from home and, on occasion, I would abscond from hospital when in severe distress, the police decided to issue me with a Community Protection Notice Warning (CPNW). It read:
“This letter should be considered as formal notification of your need to put these problems right to avoid further consequence. Please ensure you take the following action/s within the timescales detailed.”
The actions were as follows:
- not to have any unprescribed medications on me
- not to act or ‘behave’ in a way as to cause another person to believe I’m in danger of harming myself.
- not to contact anyone by any means to make threats or allude to any thoughts of self harm or suicide. This includes my close friends and family.
In a time where “just talk” and “reach out for help if suicidal” narratives are everywhere, being under a police-ordered notice NOT to talk is incredibly isolating. It goes against all the research that talking about suicidal thoughts is crucial in managing them. It gives the police powers over my health, where they have no place. It is a violation of human rights.
Unsurprisingly, the letter didn’t help my feelings of hopelessness and my struggles to engage with mental health services. Instead of being instantly cured from my mental health problems and suddenly stopping the self-destructive ‘behaviours’ like the police had hoped, I continued to be admitted. My admissions became a lot more severe each time, and I usually ended up in intensive care units. Health professionals would mention the CPNW whenever I asked about signing forms to leave, and they would constantly threaten to contact the police and tell them I’d breached the notice. Health professionals became an extension of the police force and I found it impossible to trust them.
Eventually in May of 2019 the police decided to issue me with the full Community Protection Notice (CPN). This is valid for 2 years and includes all the same actions contained in the warning letter that I must abide by. Once when I was struggling I text a friend to say I was thinking of harming myself. She ended up calling for help and the police showed up, who told me I had broken my notice.
I have never felt more isolated than I am now knowing that if I do need help I can’t so much as tell a friend or even a family member. I’m not even allowed to tell my mum I’m struggling. What sort of life is that? If my family call for help, it’s me who will get arrested. The only people I’m allowed to talk to about suicidal distress are specified mental health professionals, yet they are the ones who’ve put me in this situation. My trust in them is at an all time low. Talking about my distress and asking for help is now a criminal offence.
Increasingly more people, often those given a BPD diagnosis label, are being arrested and sent to prison because of suicide attempts or their communication of extreme distress, despite the fact suicide has been decriminalised since 1961. More and more of us are ending up in the criminal justice system because of our mental illness. It seems we are seeing a resurgence of the criminalisation of the mentally ill by the back door, in the name of ‘public protection’.
If you genuinely want to help people like me, please start by just listening. Provide me with appropriate support, talk to me, offer me therapy – just don’t call the police.
Elaine tried desperately to get help for her son during the final days of his life. She felt he was too unwell to ask for help himself. His mental health had deteriorated and he was hearing voices. He was having suicidal thoughts and she was worried that he was going to end his life. He was under a community psychiatric service for people who experience psychosis.
When she asked the mental health crisis team to contact him over that final weekend, they told her that her son needed to phone them. They had often said that they wanted him to take more responsibility. Their usual approach was to tell Elaine: “He is welcome to call us”. He never did, and tragically he took his own life on the Monday morning, while Elaine was downstairs on the phone trying once again to get help for him.
At the inquest into his death, the coroner commented that he had “mental capacity”. In her summing up, she said that he had the mental capacity to make decisions. The coroner made that statement based on psychiatrists’ evidence at inquest. They emphasised during and after the inquest that James “frequently” had capacity.
In fact, none of us know whether he had the capacity to make decisions or not, in the period leading up to his death. No one from the mental health teams had spoken to him for several days. A person’s mental capacity to make decisions can change from hour to hour. High levels of distress or mental illness are just two of the factors that can affect it. And James had a history of psychosis.
So why is it so important for psychiatric professionals to emphasise that someone has mental capacity? Too often, it seems to be about “responsibility”. If the person is assessed as having “mental capacity”, then the mental health team can argue that they have no responsibility to do anything. The mental health crisis team didn’t contact James, despite his mum’s pleas. But he had mental capacity, so they didn’t have to – that seems to be the sub-text.
But James’ mum had described James’ deteriorating mental health to the crisis team. He had completely isolated himself, was hearing voices and had a history of psychosis and she explicitly said that she was frightened that he was going to kill himself. Armed with that kind of information, professionals surely have a duty to take active steps to contact, assess and support the person.
When professionals refer to “mental capacity” as a reason to stand back and place responsibility on the person who is in crisis, I would remind them of article 2 of the Human Rights Act: the Right To Life. It takes precedence.
It is as if the “right to life” is being usurped by the “right to take your own life” when someone is in mental health crisis. Surely the balance is all wrong. If you are in mental health crisis, it is a time when you are least likely to be able to think clearly and rationally, or to be able to “weigh information”. Despite this, the system appears to respect your right to take your own life.
Surely there is a duty to do everything we can to help the person to survive. We should protect life, whether or not someone is assessed as having “mental capacity” – and whether or not they are detainable under the Mental Health Act, which is a different piece of legislation.
We cannot even be fully confident that all professionals are assessing mental capacity accurately. I have described in a previous article how a paramedic and a policeman made entirely different assessments of my mental capacity, on a night when I intended to end my life. I believed I had received messages to end my life on that date. Astonishingly, one of the professionals concluded that I had mental capacity. He said that I could understand and retain information. Fortunately the other professional quickly intervened and detained me. My ability to weigh information was clearly being impacted by the “messages” I had received. (Reference: Why do mental health professionals tell patients “It’s your decision to end your life”? https://www.savinglives.blog/uncategorized/suicide-why-do-mental-health-professionals-tell-patients-its-your-decision/ )
It is this ability to “weigh up information” which I think professionals may be getting wrong quite frequently. Depression often affects our ability to weigh information. We see life through its distorted lens. If depression makes you feel that things will never improve, that there is no hope and that you have no worth, then this is affecting your ability to weigh information and make decisions. And yet frequently, someone will explain all that and be assessed as being capacitous and able to make the decision to end their life. We know this from what we witness with clients at our Suicide Crisis Centre. I frequently express concerns to our local mental health services about individual clients, when depression appears to be impacting on their thought processes.
We have to redress the balance to place more of the responsibility on us, as professionals. It is our job to protect life. I run an independent Suicide Crisis Centre where we focus on doing everything we can to help our clients to survive. We actively intervene, whether or not we think someone has mental capacity. We know that the person is probably about to make a decision that they would not make if they were not highly distressed, or mentally unwell. Therefore, protect life – always.
For information about the Suicide Crisis Centre, which provides face to face support: http://www.suicidecrisis.co.uk
Elaine kindly gave her permission for me to write about James, who was known to his family as Jay. Elaine added: “Jay didn’t want to die. He wanted help. He was crying out for help.” Elaine found out about our charity after Jay died. We attended his inquest in 2019, to support his family. This article draws on evidence from the inquest. Our thoughts are with Jay’s family as they continue to fight for justice for Jay.
Other sources of help include The Samaritans on 116123 and the NHS 111 service (just call 111).
Joy Hibbins is the author of the book “Suicide Prevention Techniques: How A Suicide Crisis Service Saves Lives”: https://www.jkp.com/uk/suicide-prevention-techniques-2.html
Reproduced with kind permission of Joy Hibbins Saving Lives ©.
The Covid-19 outbreak has changed all health services. The changes have been far reaching and stretch beyond the pandemic. The pandemic has also highlighted pre-existing inequalities in the NHS – this blog is based on one person’s experience of accessing care and treatment for self-harm. From what other people have told us, they are not the only ones dealing with the same problems.
While emergency treatment has remained available, going to Accident and Emergency (A&E) is a changed experience. Now you have your temperature taken on arrival and are placed in a different waiting area depending on ‘Covid status.’ Staff who greet and treat you are wearing personal protective equipment. At present there are plans, drawn up by the Royal College of Emergency Medicine, to try to limit attendances to those who are referred by 111, their GP or are brought in by ambulance. This change, if introduced, could have a profound impact on people with mental distress, who already feel they are actively discouraged from attending A&E even when they feel at risk of completing suicide.
I self-injure by cutting at times of extreme distress. My self-harm is acutely painful, cyclical and compulsive in response to a number of events which become a personal crisis. The pandemic has made me avoid hospital services through fear of disapproval, shaming, concern about unknowingly infecting others or being infected, and taking up scarce resources.
I know that NHS services may see any temporary cessation of self-harm as a success. In reality, it is still a daily battle to stave off self-harm when I am alone and in difficult circumstances. Because of the lock-down, I have had no video or face to face contact with my two family members for four months. I am forced to work from home in a housing association flat that has no garden or balcony. I have lost the pastimes that served as a distraction and reason to live. I have needed to switch to Skype with my private psychologist, though I am getting used to this. I feel incredibly lonely and have suicidal thoughts at times given the way we now must live for a long time yet.
In truth I felt abandoned by NHS services long before the outbreak changed the services available. Mental health services view my self-harm as ‘impulsive’, ‘longstanding’ and due to Borderline Personality Disorder (BPD). These ‘specialist’ services, provided by a single mental health trust, avoid getting involved at all costs. It feels as though I have been blacklisted and that this status, along with the wretched diagnosis, will never be reviewed.
My experience has been primarily one of signposting and aborted referrals. I’ve had one off assessments that lead to nothing more than more signposting and ‘action plans’ that act as service back-covering tick-lists. All this leaves me feeling worse than ever.
There are misconceptions about those who self-harm feeling some high or adrenaline rush. My experience is that there is no high, pay off, or euphoria. There is only torture which is heightened by the response from NHS mental health services. I do feel the re-emergence of my self-harm in ‘later life’ can be partly attributed to iatrogenic damage.
There is no NHS service help for people who self-harm. It is a service gap which no-one talks about, including the NICE guidelines, NHS providers or Clinical Commissioning Groups. The only way of accessing a chat is to injure, get wound closure by A&E and then see a Psychiatric Liaison practitioner as a one off. Liaison and CMHTs will always assess and discharge someone back to the GP, no matter how serious the recent injury or risk of either accidental death or disability. I was seen by the CMHT in February and told: “you have capacity to make bad decisions and that is the law.”
There is a slightly different approach to suicidal intentions expressed, but still the response to those is that it is our ‘choice’ if we want to kill ourselves as we have ‘capacity’ to do so. This is especially true for people who have been given the diagnosis of BPD where suicidality is seen as a trait rather than a concern.
Self-harm deserves the same level of concern as physical ill health, attempted suicide, eating disorders or addictions. I appreciate there are shortcomings in all mental health services due to historic underinvestment, but eating disorders and addiction services do still exist in principle. Instead self-harm is seen as ‘longstanding’ and not an ‘acute mental health need’, for which someone needs therapies designed for those with ‘dysfunctional behaviours’ which come under PD. There is no crisis care as Crisis and Home Treatment Teams tend to say that they can’t make any difference to ‘chronic difficulties.’ People who self-harm may indeed feel in crisis, as I often do, but they are treated as though doing what they always do, as if it was a hobby rather than a sign of immense inner distress. I sometimes feel I could suffer amputation and still the non-response would be unchanged.
The lack of secondary care help for self-harm, apart from basic medical care, could be understood if there were primary care mental health services. I do believe that GPs and practice nurses are often dedicated and excellent, as my GP surgery has been. But still I now have the third named GP in one year due to GPs leaving the practice. During the Coronavirus pandemic, it has been more difficult to see a GP or practice nurse, phone 111 or access care for injuries. People with mental health issues have mostly all been left to fend for themselves unless they become very ill with the virus.
I have tried to raise with clinicians and commissioners how lacking the response is to self-harm but am just told that “services are not set up in the way that they used to be.” It is as though the reduction in mental health services over the years (due to demand, underfunding, imposed boundaries for BPD, staff shortage and raised thresholds) justifies the worsening of attitudes. The message seems to be that we just have to get used to this basic level of endless signposting service, with any actual intervention aimed at younger people or florid psychoses. It is signposting with no existing service for most of us, just an endless frustrating hunt with advertised crisis text lines along the way. Charity helplines will never replace consistent low- level support that would help people with long-term distress to survive and avoid crises.
I don’t think the lack of resources can be used as an excuse for the current treatment of self-harm in the mental health sector. Using more compassionate and sensitive language doesn’t cost any money. Health professionals should stop using insulting language immediately, and this should be part of any training programme. I could come up with a long list of clinical insults to exclude for starters; Impulsive, PD, chronic, behaviour, neurotic, enabling, and emotional regulation. Liaison teams are making matters worse when they advise medical staff on self-harm by saying not to show emotion or give attention. The doctors and nurses I have met in A&E have often been far more professional, thorough and caring than any of their mental health colleagues.
The NHS front line has deservedly been praised for the heroism and dedication shown during the pandemic. I share that admiration and gratitude to medics who have put their lives at risk because they care as a vocation. But care still needs to be extended to people who self-harm. If the aim is to keep mental health patients out of A&E to help with infection control, then we need alternatives including physical wound care, crisis support and access to a service rather than another plan that isn’t really a plan. All mental health professionals should try to grasp that those who self-harm are not one homogenous PD group. Individuals are not harming to present a problem to the service, but because inner pain has become too much to deal with in any other way. It is an opportunity to listen and avoid further harm.
Nila K and C&P
Some things UK white people can do:
1. Get educated.
2. Learn about bystander intervention, practice and use it. If that’s not accessible/safe for you, then tell people about it who can do this work.
3. Donate to UK black led grassroots/radical groups. Or groups that do street medic/arrestee support. They might be about to get VERY busy.
1. Get educated
For starters – read or listen to Reni Eddo-Lodge’s fantastic book Why I’m No longer Talking To White People About Race. Google Books
Reni Eddo-Lodge has asked that people borrow/share her book if possible, and send the money you’d have spent black grassroots groups
“This book financially transformed my life and I really don’t like the idea of personally profiting every time a video of a black person’s death goes viral.”
2. Learn about bystander intervention
If they’re happening/its accessible, consider doing stewarding/action medic/arrestee support training. Even if you can’t get to demos, i promise you it’ll make you feel more confident about daily street intervention work – which is bloody important too.
Fantastaic ‘riot medic’ manual here: https://riotmedicine.net/
De-arrests are Holy. They save lives.
Persuade other ppl to donate/boost too.
3. Donate to black-led grassroots/radical groups.
Examples include BLM UK, Green and Black Cross, UK Mutual Aid, or INQUEST, an incredible organisation who work on Deaths in Custody and holding UK state to account. They work on ALL deaths in custody whether police, psychiatric, prison, immigration detention. And they do all this on no fucking money. Like, they’d have to save up for a shoestring. If you have spare cash, send them some. I guarantee you they’re already busier than usual and gonna get more so.
Boris Johnson’s argument for an acceptable number of deaths for herd immunity to work is a useful analogue to look back at how propaganda about benefits was to push through austerity.
A lot of arguments about benefits hinged on an idea of mythical distinction between deserving and underserving benefit claimant, the ‘you’re alright mate it’s that other lot’ attitude (an argument also known to people who put up with racism at work), like some petty gangster protection racket we were supposed to accept that argument about ourselves, whilst selling out other claimants in the hope we wouldn’t be picked on ourselves. Obviously on accepting this protection, we are no longer allowed to criticize government policy as were we to we would subsequently lose the protection offered by the prejudiced person taking us under their wing. The protection is flimsy though as of course whilst this person is ‘acknowledging we are different from those ‘others’’, obviously so in order not to have to challenge his own prejudices given he knows more details of your case, he has to separate you as exceptional to ‘those others’ he is talking in ignorance about (so in fact the ‘protection’ is also for his own ignorance from his conscience) and you arguing your defence based on a more universal principle challenges that. However, there are others offering the same ‘protection’ to others that they in turn know who are ignorant of you. If you get shit from them, your ‘protector’ has to challenge his ideological affinities with the other bigot, and you are just expected to get used to it. So, you can be ‘killed’ at any time, where being ‘killed’ is a metaphor for putting up with prejudice, just so long as you don’t rock the boat, so the ‘protection’ is in fact just from each individual bigot.
Given this, let’s return to herd immunity. A certain number of people have to take a fall, die basically (not a metaphor this time), so the others can be protected (herd immunity – but based on poor science), an ideological argument that is in fact cover for protecting the economy. If we turn back to the early days of austerity, the attack on benefit rights came early. The first Household Survey after the coalition came to power showed a large drop in attitudes of respect for benefits, an acknowledgment of rights that had previously been stable for some time amongst the broader population.
The purpose of this change in attitude from the propaganda pushed by the government was to push through austerity, as there had been a crisis of capital it was necessary for the capitalists to consolidate their class position, this means, using Thomas Piketty’s formula for inequality, r>g (where r is the return on capital, and g is growth), increasing r again (after its drop) relative to g. Given g is growth, that includes both wages and profit from production (total revenue of all ‘firms’ – GDP (excluding dividends from shares and rents)), and that wages are paid based on the supply and demand in the marketplace for labour, but all labour-time contributes to total revenue, thus profit is the difference (after costs), then to increase r, wages had to be kept low. But this needed to be sold to wage earners. It’s quick to point to the demonisation of benefit claimants, but in an inverse of Cameron’s argument that ‘it wasn’t right that people earned less than those claiming’, it is in fact true that therefore benefit claims, especially the ‘humanitarian measure’ of how much was needed (based on relative poverty measures – in fact this form of measuring poverty was also attacked as part of the propaganda), were in fact a bottom level it is true below which it was not worth working (hence also the need for punitive sanctions for benefits), it’s just that the issue was that these wages were already too low, not that benefits were too high. The other bottom level was the minimum wage so it was here the demonization was required on top of the 1% freeze on benefits, minimum wage and public service wages (this would then have a weighting effect on supply and demand of wages in the private sphere through the competition for jobs), not just as a distraction from the attack on wages, but to give popular assent to the perceived minimum amount that wages themselves were worth in order to work.
But for a propaganda campaign like this to work that would give popular assent to austerity (with regards the other part of this campaign that involved lowering the average wage – the economics of it – it turns out, this aspect was tackled on misinformation about debt (it is worth noting that there was a ‘popular justification disjunct’ between the claim that austerity was necessary to pay off the debt, and that the debt was in fact rising)), given there were many reasons why people still understood the purpose of a social security system, it needed to meet a large enough audience.
We live in a world of targeted advertising, but it is still not an exact science, to get enough sales you still need to ‘reach’ far more people than will eventually buy. Similarly, the propaganda analogue therefore is that you need to negatively affect more people than the propaganda appeals to, to get sufficient support for the propaganda to push through its agenda. So, if demonization of benefit claimants was necessary, and part of that method was ‘deserving and undeserving’ distinctions. Then sufficient ‘genuine’ claimants had to be demonized in order to ‘get’ the perception of this mythical ‘cheat’ or ‘fraud’, at least in the popular imagination, to be a sufficiently large amount. It is here we get back to the protection racket mentioned above and its relation to herd immunity. In order for sufficient demonization to occur, a certain amount of harassment of ‘genuine’ claimants had to be tolerated. This included not allowing even the ‘genuine’ claimants to protest their treatment lest the Emperor’s New Clothes be exposed and people realise that more people were genuine than the ‘benefit bashers’ would otherwise allow, lest they realise their own behaviour might be more morally questionable than, ironically, the supposed ‘cheats’ they were demonizing. A certain amount of denial of equal rights of ‘genuine claimants’ had to be accepted, which included a silencing of them, even, by their ‘protection racket’ allies, often friends and family (who wanted a clear conscience demonizing other claimants), much as a certain amount of Covid-19 deaths had to be perceived as necessary to protect the economy, which given we are due a recession after this, and again r will have to be reconsolidated with regards g (again – before we had full recovered from the damage done by austerity) would again involve lowering the average working class wage further.
I find myself in a dilemma.
I have spent the past 15 years engaging in ‘recovery’. I have spent the last six years (or thereabouts) shouting about how utterly grateful I am to the services that ‘saved’ me. I have worked hard to come off benefits and pay my way. From being the most difficult patient, I have become the poster girl for the recovered individual. I have been an (unpaid) service user facilitator in a DBT group, I have a chapter in a book edited by a renowned clinical psychologist and I have delivered motivational talks to groups of professionals. The dilemma I find myself in is that I no longer believe what I have said. My dilemma is further exacerbated by the fact I work in mental health services.
I would not be writing this if my internal self was congruent with my apparent external state. I keep thinking, ‘well, I am in a much better position than I was 10, 7, 4 years ago’, and this is true to a point. I am not attending A&E every weekend; I am not getting myself so drunk, I wake up two days later; my financial situation is much more stable. I have been able to maintain a relationship to the point of marriage, and I am able to interact with others in a socially acceptable way. In all of that, however, I do not state I actually feel better.
I imagine I must feel better because I am not doing the things I used to do…although I am. Recently, my spouse went away for a few weeks and I was left to my own devices. I took a ton of codeine (not to harm myself, just to get off my head, to feel better), I drank a fair bit (a litre of whiskey in one sitting), and I self-harmed (pretty fucking badly in all fairness). Not having work to go to and actually still being as isolated as I was 10 years made brought home the stark reality of my existence. All I have done is supress how I feel, ignore my experiences and distract from reality. With work removed, I am scrabbling around, afraid of myself and wondering what the fuck is it all about?
I thought I wanted to be a clinical psychologist, but it turns many of them are narcissistic, egotistical, elitist sociopaths. Furthermore, the selection process for the clinical psychology training is based on many things, a key one having the ability to interpret statistical data. I’ve met too many clinical psychologists who are excellent with graphs yet not so skilled with people. As long as I adhere to their way of thinking, then I am doing just dandy. Any deviation from their thought processes, then we are being difficult, wilful, and defensive. Their toxicity is disguised, however, as they talk about trauma as opposed to personality disorders (which isn’t a bad thing, as at least experiences are being somewhat acknowledged). What further happens is that the good ones think, ‘fuck this shit’, and they leave. Whilst I’m definitely not a clinical psychologist, I’m at that point of wanting to leave. Everything I thought I wanted has fell around me, and I realise that recovery is but a concept coined by the professionals who have no peripheral vision.
As someone who grew up in the care system, what am I trying to recover? I was sexually, physically, and emotionally abused. I did not see my biological mother for over 20 years. My child was removed from my care. I have struggled, but been made to feel guilt and shame for my responses. I was instructed to hide old self-harm scars during DBT. We were not allowed to talk about self-harm within group, because of the risk of glorifying or romanticising it. I have been indoctrinated just as much as the people from my childhood indoctrinated me.
I work as a mental health care support worker. Some of the people I work with are genuinely nice people, but I see their limitations created by the system. Terms such as, ‘it’s personality’, ‘they’re med seeking’, and ‘they’re a nightmare’ are bandied around without thought or reflection. How offensive is it to term someone’s personality as disordered following a whole heap of childhood trauma? Why are we ok to dispense diazepam when ‘patients’ are not asking for it, but when they request it for the same problem, we no longer see it as a beneficial? What makes someone a nightmare?
What I am left with is a fear of someone finding out about me and my ‘stuff’. I work in an office with a whole bunch of mental health ‘professionals’, yet I am terrified they will find out my secret. This fear comes from the stigma I have witnessed and been subject to throughout both my non-working and working life. I was stigmatised as a service user with a diagnoses of BPD, and I am unwittingly stigmatised within my profession. There are mental health nurses who quite happily state that people with mental health difficulties CAN NOT work in mental health. When asked what recovered, ex-service users can do, they cannot answer, just that we shouldn’t be working in mental health.
Why can’t I find someone to talk to, without them trying to fix me? Why can’t I say, ‘you know, I feel shit, and there’s a good chance I will always feel shit given my start in life, but I accept that. I might self-harm from time to time, as safely as possible, I might engage in some other behaviours, but I am not asking anyone to patch me up. I’ll do that myself. I just want space to talk about it’? Why is this not acceptable? Why am I not accepted as I am, cuts and all? Why do professionals only care if you are ‘engaging’? Engaging in what? I have done everything asked and expected of me, and more. I’m lonelier than ever because I have been trained to put up and shut up.
The mental health sector does not believe in the recovery they try and push, but they do not recognise this. If difficult, PD, nightmare patients cannot recover or work in mental health, what are the mental health service doing with their service users? What are they working towards? There is such a blatant, screaming irony in the system, yet most are blind to it. I see people who have started out with good intentions, but they quickly get swallowed by the toxicity around them. At least two thirds of the employees talk about how they won’t come out of the NHS because of the bloody pension. Right now, I feel trapped by the money, and hate myself for it. I do not want to be that person. I have been that person, in the past, screaming at professionals that they are simply ‘doing it for the money’. That’s me, right now, in this moment in time, doing my job for the money. I care about the people I work with, but that care is overshadowed by the misery of what I am witnessing. I am at the bottom of the pile, sneered at for being a band 3 HCSW (I am asked ‘why don’t you go and do your nursing?’ at least twice a week). The hierarchy is real, and damaging, and people are made to feel shame.
I am in a quandary, a place of unease. I need to live, survive, so I need my wage. For a few years, I believed that people were not doing ‘this’ for the money, but we are. When our motivator is money, what have we become? Our priority is us, not the people accessing the service. It’s not a bad thing to want a wage, to have the right to earn a living. It’s certainly not a good thing, however, when the wellbeing of others is dependent on the wage being offered. Every day in work, I hear judgement and disdain, frustration and contempt for both users of the service and for the system as a whole, yet people continue to work in the same environment for many years. I am not the only one who hates their situation, but I see few, if any, doing something about it. Those in-office attitudes should remind us of how the system is run, and who is running it – a group of unhappy individuals, entrusted with the care and treatment of unwell individuals.
Mental health services need a complete reform, yet I do not see that happening any time soon. The good ones leave, the weak ones follow the crowd, and the leaders bully and intimidate. Stigma remains rife and continues to grow, and treatment is based on the egotistical needs of the practitioner. Where therapists have told me, ‘it’s not your fault’, they have instilled a deep shame within me regarding my reactions. My words are out there, on paper, as the model patient, and I cannot undo that. I was so desperately trying to please, that childlike need in me still searching for a mother, and professionals have either been blind or willing to take advantage of it. I’m trapped, and I am afraid of becoming ‘one of them’.
About the Author: I would like to be able to be transparent with who I am, but it is difficult to do so right now; Because of the institutional nature of current services – once in, you cannot have a voice, or as a service user, you don’t have a voice unless it is tokenistic. I hope to be able to come out of the NHS safely and be more open about my experiences.