Hello, How (Risky) Are You Today?
[Content Warning: Suicide theme]
It is commonly suggested that mental health services are too risk averse, that too often they act to reduce risk too readily and too heavy-handedly. But I have always found that hard to believe for the majority of us. In my experience, and in the experience of many people I know, far from trying to avoid risk, services are extremely comfortable taking risks with our safety, our welfare, and our lives, often without our knowledge or consent. How can they be risk-averse and yet leave so many of us to die, I think every time I read about this apparent all consuming risk-aversiveness. Where does the systemic neglect we have lost friends to, fit into this narrative? But I realise I have simply been looking at it the wrong way, assuming the risk services wanted to avoid was our risk. That was where I was going wrong. It was never about us.
I recently experienced quite a serious mental health crisis. Over a short period, I made three attempts to end my life and was “dealt with” by doctors, nurses, mental health nurses, psychiatrists, paramedics, street triage, and police. Over those weeks, not one member of this merry gang asked me if I wanted to talk; what would help ease my distress; how my life could be made easier; or what they could do to soften the pain I was in. All they seemed interested in was my “risk”. I was asked about my suicide method; why I had chosen it; what equipment I had used; what chance I thought I had of succeeding; whether I had planned to be found. I was asked about future plans; was I going to do it again; was I going to do it better next time; did I have a time and date for that; could I show them I’d booked it into my calendar. The questions were harsh, impersonal, perfunctory. I asked what it was they wanted, why they wouldn’t leave me alone. We want to keep you safe, they kept answering. But why? It’s my choice if I want to die. That’s what you have always said to me. Consistently, for years and years. You haven’t cared before, when I have begged for help. You have always been happy for me to choose to die. Happy to “tolerate” the risk. Happy to decide I have the capacity to choose suicide. Why is that different now? They didn’t have an answer.
But really the answer was that if they didn’t make a show of at least trying to help after receiving concerned referrals from external services, it would look bad at inquest. So they pushed me into a corner which had only two exits. Either I could be honest with them that I had plans to attempt again, in which case I was informed I would likely be sectioned, or I could lie and tell them I had no intention of attempting again, in which case I would be left alone. It’s not much of a choice for a suicidal person, is it? I don’t like lying. It is not comfortable. I will lie to protect myself and others, but it takes energy and leaves me anxious. The one thing I consistently lie about in my life is the abuse I experienced as a child. I have lied about that since it began, by keeping it a secret, telling everyone I was fine, denying anything was wrong. I lied under threat of something worse, and this is what it felt like to lie to mental health services and the police recently. “Just tell us that you don’t have a plan”, one clinician said. “If you can assure me of your safety, we’ll go” said another. Lie to us, or we will do something deeply frightening and traumatic. They were eager for me to lie to them. They encouraged the lie. They believed it without question despite it being so obviously untrue. They didn’t want to keep me safe, that much was obvious, they wanted to keep themselves safe. They didn’t want to face the blame for not acting if I died. But they didn’t actually care if I did die, as long as they could say it wasn’t their fault.
When we talk of risk-aversiveness in services, what no-one mentions is the risk truly being assessed and avoided is the risk to the clinician. Far from the prevailing narrative, this does not translate into mass sectioning and all patients being victim to restrictive practices, keeping us wrapped in cotton wool safety bubbles forever. Avoiding the risk of disciplinary action, legal measures, scrutiny from regulatory bodies, etc, does not necessarily line up with avoiding clinical risk or practising in an overly cautious manner. What it means in practice is that clinicians ensure they tick all the right boxes; they create nonsense clinical and legal veneers for action and inaction which are acceptable to disinterested coroners (“you have the capacity to kill yourself”, “we are taking a positive risk-taking approach by discharging”, “crisis team to end call with patient after 5 minutes to empower and promote autonomy”); they cultivate narratives which explain why someone desperately reaching out for help is best served by being ignored, silenced, or criminalised (“responding in a caring or protective way reinforces harmful behaviour and increases long-term risk”, “ongoing care only increases the risk of dependency”); they design their risk assessments to support staff in encouraging the obvious lie that a patient is fine (“patient denied feeling suicidal”, “found to be low risk”, "were able to guarantee their own safety"); they pre-empt being found at fault in serious incident reviews and inquests by reducing the perception of duty of care and increasing blame on patients in medical notes (“high risk of death by misadventure”, “patient fully aware of the risk of their actions”); and write policies which provide explicit instruction on how staff can make decisions appear defensible (“any decision that is well documented, including the reasons for the decision, will be defensible if a serious incident occurs”).
This is risk-averse practice. The core structure of mental health services being built around a scaffold of self-protection, scrutiny-avoidance, and defensibility. And so what follows is an entirely risk-centric service, which places the creation of acceptable disguises for neglect and abuse over actual patient care; where everything comes down to minimising professional risk, at the expense of our very humanity.
As patients, we learn quickly that “high risk” equals greater levels of concern and interaction. High risk can bypass waiting lists. High risk can quickly sit us in front of a real person, pulling us from the labyrinth of answer machines, letters, online booking systems, and information leaflets. It can feel like emphasising or even maintaining our "risk" is the only way to be seen, but it becomes clear very fast that we are not what is being seen. We are simply the bearer of The-Risk-To-The-Clinician-And-The-Service, and it is this which is seen, assessed, and managed. We, the patient, do not even enter into the equation, and that can be exquisitely painful. I didn’t approach services all those years ago because I needed help to be less “risky”, I needed help to be in less pain. But pain isn’t important, because until my pain has some physical manifestation which could land a professional in a coroner’s court or bring the CQC to the Trust’s doors, it can be ignored.
On realising that this is how services work, I re-evaluated my care and suddenly it all made sense. For so long I felt ignored and unseen even when staff were looking right at me. I was told over and over that my perception was simply wrong, that I would never be satisfied, no matter what... But I was right. I wasn’t seen. They may not always have been physically ignoring me, but years of prioritisation given to reducing my “risk” without a thought to reducing my pain, what actually mattered to me was ignored, and I could feel it. It feels like bursting into flames in a room full of people and watching as everyone rushes around making sure you don't burn the building down, instead of stopping the flames from burning you. You wonder, can they actually see me burning? Can they hear my screams? Am I less valuable than the furniture?
I have been on the receiving end of many types of risk management, and so far, they have all left me injured in various ways. Asking for help because you are going to kill yourself, to be met with professionals who disbelieve you, ridicule you, dismiss you, and send you away with nothing, is like going to hospital with a broken arm to have all the staff come out and jump on it until it snaps off completely. Your injury and your pain are compounded. The worthlessness that arises from begging someone to save your life to have them calmly choose to do nothing, is gut-wrenching. They might as well have come close to your face, looked you in the eye, and whispered, "Do it. Kill yourself." The opposite is also true. Not asking for help, turning it away, begging services to leave you alone because of how traumatised you are by their previous actions, to have them repeatedly ignore you and disregard your boundaries without discussion, just says “we don't actually care what you want, we just don't want to be blamed if you die”.
I have had over a decade of interactions with mental health services and never once in all this time have I been at risk of harm or death and had a mental health professional say to me, how can we best support you? What would be helpful to you in this situation? By viewing patients not as people in need of help, but potential threats to their careers, mental health professionals fail us from the outset, because they have centred their own needs, and forgotten the most important person in the room.
This is normally the part in my blogs where I suggest how professionals can change their practice or give an example of something helpful, but I don’t have an answer to this. No amount of funding or training can fix cruel, self-serving indifference. All I can think right now is that staff should be reminded that mental health patients are human, but that is such a degrading request. No-one should have to beg for their humanity to be recognised. Perhaps instead staff should be reminded that being a healthcare professional is a privilege. We as the patients allow you into our lives, sharing our secrets and our pain and our fears with you. In that intense position of vulnerability, we trust that you will look after us, we trust that you will do your best to help us - not simply assess how much risk we pose to your career, and calculate what you can write in our notes to ensure if you leave us to die, you won't get in trouble.
If you are a mental health professional reading this, maybe next time you are deciding if ignoring someone is "defensible"; ticking a risk category on your paperwork; overriding a patient's wishes; choosing to take "positive" risks; withholding care because you have decided someone "has capacity"; writing "risk of death by misadventure" on someone's notes; or pushing a patient into "denying" their suicidality, maybe stop and reflect on whose risk you have assessed and whose needs you are meeting. Because if you are being honest, its probably not ours.