Behaviourism, BPD, and the High Intensity Network
[Content Warning: Self-harm, suicide, SIM, ABA, child abuse references]
So, I’m guessing if you have opened this blog, you are already aware of the High Intensity Network and their “serenity integrated mentoring” (SIM) model of “care”. For those of you who aren’t, SIM is a joint intervention between the police and mental health services/GPs, which places police officers into the mental health teams of patients at high risk of self-harm/suicide, who are also considered “high intensity users” (HIUs) of emergency services. For more information check out www.stopsim.co.uk and the twitter hashtags: #HighIntensityNetwork #StopSIM
I have previously spent a lot of time looking into the role of behaviourism in NHS services which utilise positive risk-taking approaches, so when I started reading about SIM, this is how I framed their intervention – it really helped me understand it better. I thought I would write a twitter thread, sharing some of my thoughts and discussing some of SIM's apparent underlying beliefs... but then it got a bit long, so, being kind, I decided to spare you another mega-thread and make it into a blog post. Please note, I do not subscribe to the use of behaviourism for understanding and/or providing intervention for self-harm/suicide attempts, as I believe behaviourism to be reductive and (very often) unethical. I am also in fierce opposition to the label “borderline personality disorder” and do not consider it to be a legitimate or valid clinical diagnosis – rather, I see it as a means for health and social care services to label women, LGBT+ people, gender non-conforming people, autistic people, victims of trauma, and “complex” patients with a stigmatising pseudodiagnosis, which reframes our issues as arising from a lack of personal responsibility, and locates the source of our distress in our “disordered personalities”.
This is a very basic explanation of some of the psychological elements within SIM, as I didn’t want to go off on a tangent for hours. SIM is loosely based on the school of psychology known as behaviourism, which considers behaviour to be produced largely by interaction with the environment. There are a few different types of behaviourism, of which SIM prefer radical behaviourism, and it’s applied technique, known as applied behaviour analysis (ABA). ABA characterises behaviour as being driven by 4 basic “functions”:
seeking a tangible reward
ABA believes the function of a particular behaviour can be determined through “functional analysis”: a formulation process where the behaviour is observed and considered in relation to what happened before it (antecedent) and what happened after it (consequence). A similar technique is used in DBT, called chain analysis. The response to, or consequence of, a behaviour can “reinforce” the behaviour, making it more likely to re-occur, or “punish” the behaviour, making it less likely to re-occur. A third response, known as “extinction”, involves removing the behavioural reinforcement, in order to decrease/end the behaviour.
For example, if a child cries in a shop because they want a toy, and they are rewarded with a toy, the crying behaviour is reinforced (and more likely to reoccur). If they are told off and not given the toy, the behaviour is punished (and less likely to reoccur). If the child has repeatedly been rewarded for the behaviour, and now the parent has decided they wish to change this, they could ignore the child when they cry, and not give them a toy. Eventually the crying would cease, as it no longer provides a reward.
Observing what happens before and after a particular behaviour can help in gaining an understanding of what the function of the behaviour is and how it is reinforced. Once this is known, the “antecedent” and/or the “consequences” can be manipulated to change the behaviour.
The SIM model appears to be extremely selective in its understanding of behaviourism, and I believe this is largely based on the people designing and teaching SIM having internalised a vast number of negative clinical stereotypes and misinformation about “personality disorders” (particularly BPD). Stigma and discrimination against people labelled with borderline personality disorder is extremely well documented in literature and includes the recognition that much of this stigma actually arises from within mental health services. The (often entirely inaccurate) “understanding” of personality disorder held by the High Intensity Network, includes such beliefs as:
Pretty much everyone who repeatedly attempts suicide or presents with other “high risk behaviour” has BPD, to the extent that the SIM model is based on NICE guidelines for BPD
BPD is a “behavioural disorder”
People with BPD aren’t genuinely suicidal, they are seeking attention
Personality disorders originate from forensic psychology (the field of psychology focused on criminal behaviour)
A history of trauma/abuse strongly supports a diagnosis of BPD
One of the most concerning aspects regarding this view of people labelled with BPD (apart from how it influences potentially lethal risk management decisions) is that non-clinical individuals within SIM feel so confident in their understanding, they are actually TEACHING it to others, such as professional standards (to ensure complaints are dismissed), senior police managers and control room staff.
Reading the material published by the High Intensity Network and the programme director, Paul Jennings, it seems that the SIM model (based on this stigmatising understanding of BPD) believes behaviours in all SIM “clients”, such as self-harm and suicide attempts, are not “genuine” but driven solely by attention-seeking or the seeking of a reward (forgetting self-stimulation and the escape or avoidance of something – and all the other complex internal, emotional, genetic, and biological processes ignored by radical behaviourism). Unsurprisingly, this aligns with the mental health service perception of people labelled with BPD as being “manipulative” and “attention-seeking”.
Accordingly, SIM believe if mental health staff or emergency services respond to self-harm/suicide attempts by providing the person with attention or some kind of reward (medication/hospitalisation etc) the behaviour is “reinforced”, making it more likely to reoccur.
The SIM model believes that such a response creates a situation in which the person will be taught to repeatedly put themselves at a high risk of “accidental death”, while pretending to be suicidal, because they have learned it will succeed in getting them attention/reward. I have found it really quite disturbing how many times SIM resources refer to suicide as “accidental death” or “accidental suicide”. There appears to be little to no suggestion that suicide attempts in BPD labelled people could ever possibly be “genuine”. (This also appears to be a widespread belief in mental health services, hence the high numbers of people labelled with BPD who have “risk of death by misadventure” in their clinical notes instead of risk of death by suicide.)
This “understanding” of self-harm/suicide is, however, very far from reality. While some people do harm themselves or say they are going to harm themselves because they are seeking something from another person (attention, love, validation, compassion etc) research shows that the most common self-reported reason for self-harm/attempted suicide is actually to modify or terminate a negative emotional state. In terms of how it is “reinforced”, this process happens automatically (e.g a person feels immense emotional distress and self-harms, the self-harm reduces or ends their emotional distress, the person learns self-harm is effective at reducing emotional distress. Every time they self-harm and it reduces their distress; the act of self-harming is reinforced).
In the same way that not all self-harm serves the same “function” in all people (e.g. some people self-harm to reduce negative feelings, some self-harm to give a sense of control, some self-harm to punish themselves etc), not all self-harm will necessarily serve the same “function” for each individual on every occasion. (E.g. a person could call emergency services in the morning, while in a risky situation, because they are seeking human connection and compassion. Later that day they could present at A&E requiring treatment after self-harming, which they did to end a negative emotion – same person, same day, two entirely different reasons.) Due to this, NICE recommends that every single incident of self-harm should be separately assessed – it should never be assumed that a person’s self-harm is always the same (motive or means).
So how are SIM attempting to modify these behaviours?
As already discussed, the response to, or consequence of, a behaviour can “reinforce” the behaviour, making it more likely to re-occur. Responses can also “punish” the behaviour, making it less likely to re-occur, and remove the behavioural reinforcement, in order to decrease/end the behaviour (extinction). SIM appear to use a mixture of punishment and extinction in an attempt to modify the behaviour of people they “manage”.
The first steps taken appear to be “extinction”; the removal of service responses which have previously been thought to “reinforce” the behaviour. For example, if a person is repeatedly detained on s.136 because they are displaying “high risk public behaviours”, such as contemplating jumping from a bridge, the service response could be for the police not to use s.136 anymore, but just escort the person home and leave them. This response basically ignores the patient’s behaviour – neither punishing nor reinforcing it. The massive problem here which jumps out to me immediately, is SIM staff have decided that the function of the person displaying “high risk public behaviours” is attention-seeking, hence the removal of attention. If the person is actually suicidal and meaning to end their life, removing attention will not have any effect on the behaviour. In fact, taking a suicidal person home and leaving them there alone could be fatal. This is the issue with assuming what the “function” of behaviour is - even if you have carried out a full functional assessment, including functional analysis, you cannot know for sure that this will remain the same for all future behaviour. (Even if the SIM team are correct about the function, and the person is "attention-seeking", such an intervention is still not without significant danger. This relates to a phenomenon known as an “extinction burst”, which involves an initial, sometimes extreme, escalation or surge in the target behaviour, as the person makes increased attempts to have their needs met. If, for example, the person is repeatedly standing on the edge of a bridge as a means of seeking human connection/compassion, and emergency services decide to stop responding, the person could increase the frequency of this behaviour, and/or attempt more dangerous/risky behaviour, such as jumping from the bridge, in order to elicit a response.)
The creation and circulation of crisis plans to numerous organisations and services, detailing what responses they should take/not take in emergency situations (based on whatever formulation the team have come up with for each individual) appear central to this tactic of extinction. The screenshots below below are perfect (horrifying) examples of this.
Given that many healthcare staff are already looking for an excuse to dismiss this marginalised, stigmatised patient group, having a police and mental health services endorsed care plan which states “this person pretends to attempt suicide for attention, taking them seriously will only encourage their behaviour” runs the risk of people being actively denied medical attention when they are in serious danger. There are so many situations in which this could cost the patient their life. Say, for example, a person frequently overdoses on medications which are “safe” in small quantities. Their care plan could indicate to A&E staff not to undertake blood tests and not to keep them in A&E for observation if they come in following an overdose, as such a response “reinforces” the behaviour (i.e. the overdoses). Not only does this ignore the possibility of the person becoming suicidal and taking an intentionally lethal overdose on a particular occasion, but it also forgets that even if this individual has never intended to end their life by overdose, nor ever intends to do so, there is no such thing as a safe overdose. Most patients will not be qualified pharmacologists: there is always the very real risk that an overdose could be fatal.
I find it extremely concerning that SIM appear to be encouraging healthcare and police staff to essentially provide negligent care/services and I believe any staff who don’t share this concern should take a good long moment to consider their career choice – and their humanity. (Perhaps consider how it would feel to be in a coroner’s court feebly explaining to the court and the grieving family that after you refused to take a vulnerable person seriously, after you refused to do bloods, after you refused to keep them in for obs, they died in the carpark of a treatable overdose. Imagine explaining that the care plan you were following, instead of doing your job, was written based on a model of care invented by a frigging police officer… Better yet, consider how it would feel to die alone and frightened because you asked for help after taking an overdose, but were faced with “no, I won’t help you because, firstly, I don’t believe you need help, and secondly, I don’t want to encourage your bad behaviour”.)
The next technique used by SIM is punishment. Punishment differs from extinction, as it involves presenting the person with something unpleasant and/or removing something pleasant from them in response to the “undesirable” behaviour. For example, if a person is repeatedly detained on S136 because they are displaying “high risk public behaviours”, such as contemplating jumping from a bridge, the service response could be for the SIM police officer to issue the person a community protection notice (CPN), banning them from public displays of suicidality. Breaching a CPN is a criminal offence and can lead to fines of up to £2500. Once again, the massive problem here is SIM staff deciding that the person displaying “high risk public behaviours” is not genuinely suicidal. As can be seen in countries where suicide is illegal; threatening legal action does not work to discourage people from attempting suicide. Rather, it causes people to hide suicidal feelings, not seek help, and increases societal stigma.
For most people, the presence of a police officer in their mental health or GP appointments would most likely be unpleasant, frightening, or uncomfortable enough to be considered punishment in its own right. Personally, I struggle so much with the power dynamics in mental health services already, if a police officer appeared in my appointments, I would immediately discharge myself and most likely never ever seek help again. It appears this is partly the point.
Looking through SIM resources, SIM police officers are often described as being introduced into mental health teams “to reinforce boundaries”. What these “boundaries” are is never fully explained (nor are “legal consequences”, what “behavioural compliance”, “authoritarian”, “behavioural grip” and “coercive” mean, or what “strict sanctions” are). However, thoroughly reading through multiple reports and case studies gives us a good idea. The SIM police officer exists not only to liaise with the police and other emergency services, helping to ensure all services respond in a consistent manner, but they also exist to place pressure on the patient to change their behaviour. This pressure can come “merely” from the presence of a police officer in clinical appointments, can escalate up to the person being threatened with legal action, such as criminal behaviour orders, and finally, can end up with the SIM team supporting conviction and imprisonment.
Basically, to boil SIM down, crisis behaviours which are expensive or annoying to the NHS/police (e.g. public suicide attempts, repeated A&E attendance, repeated missing person reports, repeated 999 calls) are targeted by this intervention, and alongside future service responses being denied/reduced, people are intimidated by police in their healthcare appointments, and/or threatened with legal sanctions to force them to stop being so annoying/expensive.
Other behaviourist techniques
As previously stated, I do not subscribe to the use of behaviourism for understanding self-harm/suicide attempts. However, theoretically, if one were to use ABA techniques for understanding and/or providing intervention for self-harm/suicide attempts, functions other than “attention-seeking” and responses other than punishment and extinction-through-ignoring do exist and should be considered.
Even if, for example, SIM staff are correct that one of their “clients” calls emergency services and expresses suicidality because they are looking for a human response, such as compassion, firstly, as already discussed, there is nothing to suggest that this “function” does and will exist permanently for that person (i.e. at any point in the future the call to emergency services could be because the person has taken active steps to end their life) placing them in danger of being summarily dismissed despite a change in circumstances. Secondly, other behaviourist approaches to supporting someone in this position exist. There is absolutely NO EXCUSE for ignoring someone in such a situation. SIM is modelled on an area of psychology which reduces the extraordinarily complex human experience down to an extremely simplistic model – and yet SIM still managed to get it wrong somehow.
Rather than withdrawing reinforcement (i.e. ignoring people to death) or punishing their behaviour (threatening them with arrest and prosecution), a sensible, legal, trauma-informed approach could attempt to work with the person to understand what actually drives their behaviour. (When I say “work with”, I can’t emphasise how much I mean that – why on earth would someone want to engage in a process which is entirely about them, if it doesn’t even consider them relevant to the conversation?) Once this has been established, different forms of support could then be considered.
There are a number of different options that spring to mind - “differential reinforcement” is a common intervention for self-harm, and involves the person swapping self-harm for something else which serves the same function (e.g. If a person self-harms because the physical pain helps ease emotional pain, they could replace self-harm with a less risky activity which causes pain, such as holding ice cubes, plucking hairs, snapping rubber bands on the wrist etc). The most sensible behaviourist approach in my opinion is “antecedent modification”. Whether what drives the self-harm/suicide attempts is emotional distress, a desperate need for compassion, the need to avoid unpleasant thoughts, the need to take or lose control… it doesn’t matter. If you can identify and provide adequate, trauma-informed support for the underlying need, the behaviour will stop.
It seems extremely obvious, but surely, if someone is repeatedly harming themselves or calling out for help because they are struggling with a past history of trauma (which appears to be everyone under SIM), addressing the trauma (and/or whatever else is driving the distress) seems the most logical option.
Before I get shouted down for not recognising that this isn’t possible for everyone – I am well aware that not everyone is in the position to undertake difficult therapeutic work (or even wants to). It seems to me though, the often rolled out “you’re too high risk to have therapy” is usually an excuse to refuse care. I’ve been denied appropriate trauma therapy for years by the NHS, being told “once you’re better you can get help”. However, despite what mental health services say, stabilisation work does actually exist, as do peer support groups and more gentle, holistic approaches to therapy, such as art/creative therapies, therapeutic communities etc. In fact, even just working on building a trusting relationship with a therapist without any mention of trauma can be healing in itself, as can support to build stronger social networks, escaping abusive living situations, and improving housing conditions. Why bypass this and go straight for STOP TRYING TO KILL YOURSELF OR YOU’LL GO TO JAIL..?? The only answer I have is money. Why invest in trauma support when frightening people into keeping their distress contained is SO. MUCH. CHEAPER. Pretending this neoliberal intervention is anything but a money saving exercise is delusional. And that’s where it becomes so, so sad, because if the state actually invested money into protecting children, protecting women, protecting vulnerable groups, so many of these people wouldn’t even be in this situation. Is this what we are now? A country more enthusiastic about prosecuting abuse survivors for attempting suicide than prosecuting the people who abused them?
Ultimately this is political. There is no political will to end abuse/violence/misogyny/poverty/ discrimination, so it continues. There is no political will to properly fund, expand and improve mental health services (far from it – it’s actually being defunded). When the people who have been abandoned by the state then “clog up” mental health services with their distress and “inconvenience” police with behavioural manifestations of the trauma they have experienced, what better way is there to shut them up than to label them disordered and criminalise their existence?
Despite this, I honestly think for some SIM staff members, there is a feeling that such interventions are in the person’s best interests – that the people they “manage” aren’t actually suicidal but are putting themselves at such high risk, unless SIM take these actions, they will likely kill themselves by accident. A clinician in the SIM pilot said: “They may never thank you for it but inside they know it is exactly what they needed.” The paternalism present in such a statement is staggering.
There are so many issues I have with this take, I could probably fill a book, so I will limit my final thoughts to just a few bullet points:
Threatening people with legal action in an attempt to stop them publicly displaying signs of crisis may work on the surface for some, but it does nothing to address the distress which underlies the crisis: distress cannot be controlled via threats of prison. Silencing someone who is screaming in pain does not help their pain, it just makes it nicer for everyone around them.
There is absolutely no evidence to suggest that forcing people to contain their distress through threats and legal sanctions is clinically beneficial.
No one is “unhelpable”, to have reached this point these people are likely to have been very badly failed by services, and yet this intervention removes all blame and responsibility from services and places it squarely on the person who was failed.
People labelled as “high intensity users” who are not suicidal, but seeking human connection or help, are still people. They still deserve the same high standards of care as everyone else. They still deserve to have help and support and to be treated with compassion and respect. I would have thought that was obvious, but here we are…
Attempting to move away from coercive practices in mental health, such as detention and treatment under the MHA, seems utterly pointless if this is only achieved through different coercive practices. It also implies that this intervention is actually financially driven, not about health and welfare.
Interventions which criminalise suicidality do not only affect the individuals “managed” by such schemes. As the current social media storm surrounding SIM can confirm, that such an intervention exists creates enormous amounts of fear and mistrust in all people who can imagine themselves or someone they know being managed by such a scheme.
Interventions which criminalise suicidality and make certain clinical diagnoses synonymous with criminality set society back years in terms of mental health stigma.
People may believe that this intervention is only for a very small minority of people and won’t affect ordinary services. They would be wrong. Practices like this (particularly ones which appear to be saving the state a huge amount of money) begin by targeting unpopular, stigmatised minorities, but that isn’t where they end. The language and concepts which form the foundation of SIM are insidious and will continue to creep into services until police officers in clinical appointments, police officers with NHS cards, police officers with access to wards and medical records are no longer unusual, but part of everyday practice. This must be resisted.
Check out www.stopsim.co.uk and sign the petition for an independent review: (https://www.change.org/p/nhs-england-stopsim-halt-the-rollout-and-delivery-of-sim-and-conduct-an-independent-review)
Love and rage,