Care And Respect Is Sometimes Difficult To Maintain

I’m fully accepting of the need for some people to make suicide attempts and I’ll treat them with the same respect that I treat all my patients.  However, I’m only human and sometimes those people really annoy me.

We were called to a 25 year old woman living in a shared flat in a nice part of town – she had taken an overdose three hours earlier, it was now 2am in the morning so we were at the location very quickly.

We were met by a housemate who told us that she had taken some Ibuprofen tablets earlier – she had then sent text messages to her friends telling them that she had overdosed.  Then she refused to answer the phone when her concerned friends had tried to contact her.

As we walked in the door the patient told us, “I’m not going to hospital, I’ve taken 20 Ibuprofen before, so I know I’m safe”.  The patient had taken around eight of the tablets which, while an overdose, isn’t life-threatening.  This meant that the patient knew what she was doing, and I considered her actions to be manipulative rather than a serious attempt on her life or even a parasuicidal action.

Still, it didn’t matter, we still treated her with professional care – we advised she should come to hospital so that we could be sure that what she was saying was the truth, and so she could receive a psychiatric assessment.

But she was adamant that she wasn’t going to go to hospital – we tried to convince her, her friends (some of whom had driven for three hours to reach her) tried to convince her, but she wasn’t going to come with us.

The way she was talking and acting – laughing and joking, not in a “parasuicide has been cathartic” manner, but instead a more, “I’m the centre of attention” fashion – coupled with her history led me to believe that she wouldn’t be in serious danger if she were left in the care of her friends.  While I knew that the overdose probably wouldn’t harm her, our protocol and a wise protocol at that because I can always be wrong (IANAD*), dictated that we talk to our Control, and that they contact the poisons unit for the all clear.

While waiting for Control to get back to us, another of her housemates arrived at the scene – he was obviously a very sensible chap, a drug counsellor he told us some more about her history and agreed that while hospital would be the best place for her, we very well couldn’t kidnap her.  He told us that he was more than happy to take responsibility for her and would keep an eye out for her.

Just as we got the response from our Control one of the patient’s other friends came running out and told us that she had started to cut herself.

So…we went back inside and found her with some very minor cuts to her arm.

That was the final straw – she had undertaken self harm while her friends were present and while she knew an ambulance was sitting outside the house.  There was no way that we were going to leave her at home.

But still she refused.

I’m still not allowed to kidnap her.

I went back outside and told Control what had happened and that they should get the police to come to this address as in cases like this the sight of some ‘boys in blue’ often changes the patient’s mind.

Returning to the house I tried a little trick that has come in useful in situations like this – I offered her a choice.

Choice (a) was to come to the hospital with us under her own power.

Choice (b) was to wait for the police to arrive, we would then arrange for a social worker and two doctors to attend in order to have her ‘sectioned’ under Section 2 of the Mental Health Act 1983.  She could then be handcuffed and dragged from the flat kicking and screaming, ending up in the padded room at the local hospital.

With some help from her friends she chose Choice (a)

This is good, because Choice (b) is a royal pain in the rear to arrange, especially at 2am.

So the patient ended up at the hospital where her wounds were dressed and was left waiting for a psychiatrist to see her.

But, as I may have mentioned before, referral to psychiatric services never go smoothly – so when, after three hours, no psychiatrist had arrived (it is after all a long 200 yards to walk from the psychiatric unit to the A&E) she took her own discharge.

Another job well done…

 

A round of applause though for her friends who were absolute diamonds throughout this whole saga – supportive, sensible and caring – everyone should have friends like them.

*IANAD – I am not a doctor (nor do I want to be one)

46 thoughts on “Care And Respect Is Sometimes Difficult To Maintain”

  1. My point is that I prefer to assume “needs help” rather than risk dismissing as “need a good slap” someone who really nees help. Sure, it's frustrating. I'm lucky that on the board I mod for, I can choose to leave dealing with person x who makes steam come out of my ears to someone else. If it's just you then you have to swallow your frustration and vent elsewhere because of the demands of professionalism. But even when I vent, I try to phrase it as “this person's behaviour is frustrating me” rather than making judgements on their character and motivation and labelling them with terms such as “selfish”.I'm not denying that there are people who are time-waster and who think it's a lark to get the blue lights. I just don't want to risk misjudging someone as being like that when they're not.

  2. I can completely see why this ladies actions were annoying. But, from what you post it sounds like she has Borderline Personality Disorder, and so it really is part of her illness..Plus, when bouncing around MH services, you quite quickly learn that the more you “act out” the more attention you get – ie, the more treatment you get.

    I will, again, voice my cry for more Crisis Housing. Chances are, this lady didn't need to be sectioned, or even in hospital, but needed someone to take her pain seriously.. crisis housing is perfect for that. But they just so rarely receive funding. There is one opening in Barnet soon, which has the makings of a great service.

  3. i though the cops had powers to detain under the mental health act? or does excercising them, make it a right pain in the rear for them?

  4. lame? I think lame might be the wrong word.I think “This is obviously a case of self harm rather than true suicidal behaviour” are the words you were looking for *s*

  5. yay for positive reinforcement.”say you've taken a couple of extra ibuprofen, and we'll all dance around you, drive three hours to get to you, even at stupid-o'clock in the morning”

    This girl needs mental health services, yes. And hopefully they will help her address her issues so that she can look beyond herself and realise how selfish and mainpulative she is being!

    I hope for her sake, it's before she loses the loyal friends.

  6. Well… I'm not convinced that borderline personality disorder is an illness. Some people are 'bad, not mad' it is, I think a desire to medicalise normal human variations.I'm shy, does that mean I have borderline social anxiety personality disorder?

    My opinion is that the patient is manipulative rather than mentally ill – her acting out is a way to obtain attention that is outside some of societial norms.

    Thanks for the comment – and I agree that there needs to be some serious improvement in mental heatlh provision.

  7. Yes – that's a Section 136, but it can only be applied if the person is in a public place. They are loathe to do this, but if needed they will do this. It just allows removal to a place of safety, which in reality means the A&E department.

  8. but we'll never be able to offer crisis housing to everyone who is experiencing MH difficulties and is, as one might say, in a crisis.Should it go to the selfish noisy manipulators like this woman, who tells lots of friends she's taken some pills, honest, to get them to all flutter around her again? Or should it go to a quiet old widow, alone in the world, making genuine suicide attempts because they wish to end their hopeless and lonely life? Or should it go to a mixed up teenager with drug issues, because the Children Are Our Future?

    Too many priorities, not enough resources 🙁

  9. Well, I can't agree with your comment on it not existing.. I work in a fantastic PD Service, work heavily with people with BPD, work for a BPD charity, and advocate for people with BPD.. Oh, and have BPD myself!Borderline Personality Disorder doesn't mean you're borderline as to whether you have a PD or not. When it was originally name, it was thought you were “borderline psychotic” if you had BPD.

    I woudl also re-word that the patient was being manipulative (which people with BPD can be, VERY manipulative) because she was mentally ill (though, technically, someone with a PD isn't mentally ill.. so confusing).

    The MH system in this country though rewards manipulation. I'm not an “acting out” BPD type, so when I was hospitalised, I sat in my room quietly smoking and self harming. No one one the ward knew I was self harming as I chose not to tell anyone, and was discharged 3 days later (in a worse state than when I arrived!). yet, the woman in the room next door to me, who was loud, shouting she would self harm, loudly breaking mirrors in order to self harm etc got all the attention. Is this right? No, not at all, but shout loudly, and you will get attention from the doctors / nurses.

    I'm lucky that I now work for a very forward thinking service, who has learned these things, and thus doesn't reward such behaviour. It doesn't “punish” it as such, but you will receive more help if you don't act out.

    You're lucky you don't have to live with this disorder. Very lucky. When your “wise mind” is saying “huh I shouldn't be doing these things to these people”, but the “BPD mind” is saying “sod it, do it anyway, it won't bother them”.

  10. The actual wording is “a place to which the public have access”, which I, along with many other pragmatic types, interpret as “the front door is open”. If we don't use this ploy then invariably the 'patient' is arrested to prevent a Breach of the Peace, taken outside, de-arrested and then section 136'ed. I've never bothered waiting for the crisis team to come out, and I've never heard of anyone else doing it that way either.Neither of these two options are, on reflection, probably not exactly what Parliament / common law intended, but they are reasonable and proportionate and get the job done.

    (These views, of course, do not represent official Met policy…)

  11. Nobody's commented on the ethics of THREATENING a person with the Mental Health Act. It's just that kind of behaviour that reinforces the public view that psychiatry is nothing but a paternalistic, power-hungry, and abusive organisation which serves to use its powers of legal detention as some form of punishment or torture to the defenceless mentally ill in society.Of course, that's bollocks, but if you go round using the MHA as a bullying tactic that's the message you're sending out. From the sounds of it, your threat was pretty empty anyway, as I would very much doubt that a MHA assessment would find her detainable. Which means you've also threatened something which could probably not have even legally been carried out.

    I appreciate that you are not in a position yourself, despite your experience of situations like this, to carry out a psychiatric assessment to determine whether or not arranging a Mental Health Act assessment was necessary, but I do not believe that threatening somebody with the MHA is ever acceptable, particularly when there are little grounds for doing so, ie, she was almost certainly not detainable*. It is, I fully accept, very difficult to know what to do in this situation, and there are no easy answers. I don't know what the policy is of the LAS, and whether you would be “allowed” to leave a person like this without calling in the shrinks and coppers. But I will say again, the MHA is not a weapon; sectioning is not a punishment. Please don't think of it as such.

    *Not having seen her, I cannot, of course, know this for certain. I am assuming, based on what you have written.

  12. It's an awkward point.I think it's much like ADHD – I have seen and interacted with children who have ADHD who definitely have it. There is definitely something very different about the way these children's minds work. However, I have also seen and interacted with children who have a diagnosis of ADHD (often just unconfirmed by their GP, or even their parents insisting “he's ADHD, honest”) who are frankly just little brats in need of some consistent parenting and being told “no” once in a while.

    Similarly, I wouldn't presume to say that BPD “doesn't exist”… but someone demonstrating a few symptoms could very well just be playing for a bit of attention, and giving the people who are really suffering with it a bad name.

  13. I had a friend a few years ago who did a similar thing, only she declared shed taken an overdose in the middle of Safeway and then ran off. A couple of hours we found her and took her to A&E. We waited the best part of 5 hours for her to be seen and treated. Her ex went in with her, who was also a nurse in the department, and once we were on our way out dropped HUGE hints that she couldnt have taken more than 4 pills. There is no doubt that this was attention seeking she did it frequently, as well as cutting herself, but never seriously. It never seemed to enter her head that we had been very worried about her, nor did it occur to her to thank us for sticking around A&E for hours on end and leaving at god knows what time.

  14. when someone is posing a danger to themselves or others they can be sectioned. This woman was overdosing and cutting herself, albeit not severely. My impression is that the difficulties in getting her sectioned would have been the logistics of getting the appropriate MH professionals out, rather than having the grounds for it.As for it being a threat… what would you call it? A promise of a yummy treat?

    How would YOU suggest ambulance staff get people like this into hospital?

  15. Sorry – I should have been clear “Some people are bad, not mad”, perhaps the introductory sentence could have been clearer – I apologise, I'm coming off some night shifts.My point stands though, that some patients/professionals will claim BPD to excuse the fact that they/their patient is just not a nice person.

    It's that seeming desire to make 'conditions' where none exist that seems prevalent in the drug/therapy community.

  16. Thanks – I'll bear that in mind.An yes, I've only seen such powers used when it is indeed reasonable and proportionate.

  17. Less a threat and more coercion.(and I know that coercion is bad but you do what you have to do in the best interests of your patient)

    This is without the idea that maybe she needed a 'way out', to agree to come to hospital without seeming to lose face, and a 'threat' might be a good way to offer her that escape…

    Let me play the same 'choice' game with you…

    (a) You use all means reasonable to get your overdosing/self harming patient to a place of safety where they can be treated for their injuries and assessed by a psychiatrist.

    or

    (b) You leave the patient at home, where she further overdoses/self harms until she (mayb accidentally) kills herself. Even if she doesn't die, she doesn't get any form of assessment or treatment apart being asked to go and see her GP, something she is unlikely to do – so she gets worse and worse and never gains access to the care she needs because she keeps 'refusing'.

    I like my job, and I tend towards liking the whole idea of keeping people alive as an ethical standard to live by.

    In my mind a 'threat' is a reasonable use of 'force' in order to preserve the safety of the patient.

    Otherwise we'd end up in the position where a suicide attampt refuses to go to hospital – then kills themselves minutes after the ambulance leaves.

    I'll tell you now – the crew would lose their jobs.

    At no point did I intend Sectioning as a punishment – it's always with the patients best interest at heart – trust me, I can do without the aggro of dealing with a social worker and two Doctors…

  18. “when someone is posing a danger to themselves or others they can be sectioned.”It's not as simple as that, actually. You can only section someone who you believe to be suffering from some form of mental illness. Someone making a few superficial self-harm gestures with no evidence of mental illness (if this was indeed the case) is not sectionable. A section is not the same as a bloody ASBO.

    “My impression is that the difficulties in getting her sectioned would have been the logistics of getting the appropriate MH professionals out, rather than having the grounds for it.”

    Yes, it would be difficult to get the relevant professionals out, but it can be done. Just because you get the relevant professionals out does not mean they're going to say “jolly good, chaps, let's section her”.

    “As for it being a threat… what would you call it? A promise of a yummy treat?”

    This sentence makes very little sense to me, so please forgive me if I misconstrue it. No, of course I wouldn't call it a yummy treat. What an odd thing to say. I just said that this was a threat. Sectioning should not be used as a threat, because it is not a punishment. I agree sectioning is not a nice thing at all. Something to be taken very seriously and not used lightly. Ie, not to be used as something to threaten somebody who happens not to be doing what you want them to. If I need to let someone know I might have to consider placing them under the MHA, I will try my utmost to explain to them my reasons for this, and actually, that I'm really sorry for them that it might have to come to this, but it is in what I believe to be their best interests and I don't want them to think that it's a punishment or because of something they did wrong. I would not say “if you don't do what I say then I'm going to call the coppers, so ner-ner to you” (NB. Tom – I'm not suggesting this was your turn of phrase, merely emphasising a point).

    “How would YOU suggest ambulance staff get people like this into hospital?”

    Well, therein lies the problem. As I said, I don't know the LAS protocol. If I was assessing her, and my feelings were that she was not genuinely suicidal and did not pose a significant risk to herself, and she didn't want to come into hospital, I'd send her on her merry way, which is probably what the psychiatrist would have done. But I am a psychiatrist, so I am in a position to make that decision. It is harder for someone who is not a mental health professional, and you obviously need to cover your back in a situation like this. I understand why Tom didn't want to have to just leave her there. I presume he is supposed to bring all patients like this into gospital for assessment – it is certainly the policy in hospitals that all patients presenting with self-harm see the mental health bod. I totally appreciate that Tom would have been in a bloody difficult position. What I did not like was the implication that she was responding to a threat – the way he described it as a “trick” – offering someone an impossible choice. Perhaps I am too PC for my own good. When it boild down to it, perhaps we are all just threatening patients with the MHA when we explain to them they might have to be sectioned. But there are gentle ways of doing it, and way which do not lead patients to feel they are being punished.

  19. I would like to say that the patient was aware at all times that I wanted her in hospital for her own benefit. So I was using the 'sftly, softly' approach – or at least I think I was.As I said in the posting IANAD – so if I did go down the route of trying to get her sectioned then I'm have people who _are_ doctors on that section of the register (section 12? I forget) come down and assess her.

    Then if those people who are especially trained to deal with such situations (I would hope…) say that it is safe for her to stay at home, then I'd be happy to leave her. I'd like to think that I know the limits of my knowledge.

    I'd suggest that we use verbal/semantic 'tricks' whenever we interact with other people. But in this case 'trick' was meant in the 'tricks of the trade' sense, rather than the 'I'll trick her into doing something'.

    I also understand the nightmare of getting a Section 2, having spent 11 hours of a 12 hour nightshift trying to get one done on what I can only describe as a “completely violent nutter”. It was only after I suggested that should the patient leave the A&E, not only was I not in any position to stop him, but that I'd hold the Social worker who was being obstructive personally responsible for the first person he killed.

    Now that's bullying.

  20. ok, I think there is a bit of a semantics issue, perhaps.Personally, you could *threaten* me with a section, and the restricted freedom and so on that entails which, let's face it, is a scary prospect. I would wish to avoid it. But if it were to happen, if I was unable to make the decisions that were best for my welfare, then even once I was on a secure ward I wouldn't think I was being *punished* for anything. It would be more an unpleasant necessity.

  21. and I should add that most of the reason it would be unpleasant, is because in the mental health trust for this particular area, the Admissions Ward and the Acute Ward are one and the same. To quote a service user I knew a few years back, who went in with severe depression and had to spend a week in Admissions before they could use the Rehab flats: “and if you didn't have mental health problems when you went in, you'd damn well have some when you came out.”

  22. batsgirl:”But if it were to happen, if I was unable to make the decisions that were best for my welfare, then even once I was on a secure ward I wouldn't think I was being *punished* for anything.”

    Well, you'd be amongst the fortunate few who have that degree of insight.

    Tom:

    “But in this case 'trick' was meant in the 'tricks of the trade' sense, rather than the 'I'll trick her into doing something'. “

    Oh, I know – I did realise that. I guess I'm uncomfortable with this being thought of as a trick of the trade, even. As I said before, I do totally understand your position. I think maybe it was just the way your post was phrased – could reinforce the antipathy that a lot of people feel towards the mental health system. I also think it would be important to point out, in this situation, that what you would be doing would be to have some people ASSESS her for a section, rather than you're going to “get people to come and have her sectioned”. Telling her she might be handcuffed and dragged kicking and screaming also sounds like a threat to me. Maybe you didn't actually say that to the patient, but the fact that you wrote it may indicate, to some, that you consider the MHA something of a weapon for disobedient patients.

    I guess I'm probably oversensitive because I spend my life defending psychiatry and the MHA to people who think we're a bunch of paternalistic, control-freak bastards, and I don't want anyone to inadvertently reinforce that view.

    Tom, no offence meant. I like your blog a lot.

  23. Don't worry, no offence has been taken. It's interesting to see this sort of thing from the other side of the road. I'm afraid I'm a rather simple person who just wants to'get the job done' and so don't worry too much how people see me or my profession just so long as I'm able to do my work.I don't think that people have antipathy towards the mental health system – I think they would just prefer an 'out of sight, out of mind' system (no pun intended).

    I don't have any systemic problem with mental health services except that in my experience they seem…well…crap honestly.

    But like GPs – I don't see the good ones, I just see the ones who refuse to see a patient if the sun has gone down,, or they have to walk more than 50 yards. (I'm sure you know at least a few people like that). It's _them_ that are the cause for the antipathy.

    But now I digress…

    The MHA is, in my mind at least, sometimes the only way to get help for a patient who needs it. Not a punishment – I've been to more than enough Sections where the patient is really happy to travel with us to the unit.

    And I don't think you are paternalistic as a profession. Wishy-washy hippies maybe, but not paternalistic. 😉

  24. I can't wait for the next thrilling installment where she says “I've taken three paracetamol! and it says on the packet only to take two!”. I bet her friends don't put up with it for much longer.

  25. I don't know about antipathy to the mental health system, but I do know many people with mental health difficulties who are absolutely terrified of getting caught in it. Not necessarily even because they've heard anything bad about it, but because of what they perceive it to mean, and what they think might happen. For example, they might feel that coming into contact with MH professionals will mean that they really are mad/sick/broken/defective, whereas as long as they don't they can keep pretending they're okay. Alternatively, they might be afraid that everybody would find out, or that they will be “locked up”. Thirdly, there's the whole issue of what it would entail: would you have to deal with people asking you questions, would you have to talk about things you don't want to, would they drug you, will it affect your job if it goes in your medical records, what will people think of you, will you be labelled for life.I recently plucked up courage to go to my GP about long-standing depression, and got as far as getting myself some medication. Much as I know I also need non-pharmaceutical help, just the thought of it makes me want to curl up in a ball in the corner. I can just about cope with my GP because she's treated me the way i want to be treated, but I'm very much afraid of how anybody else would treat me.

    So, not necessarily antipathy, so much as fear. Hence it being so important that sectioning doesn't get used as a threat. Fear prevents people from getting help they need. If you're afraid that the ambulance man is going to come and force you into going to hospital or he'll get you locked up, then how likely is it that you're going to call for help next time you hurt yourself and you really need it?

    I'm not talking in reference to this specific post, here. I just want to mention how afraid people can be of the consequences of coming into contact with medical professionals when they suffer from mental health problems. It may well be that this woman was attention seeking, but for every one of her there will also be someone who isn't, and hearing that she was threatened with sectioning might make them think that that is what will happen to them if anybody ever finds out about their self-injury/overdosing.

    Just my 0.02.

    PS Over a year of reading religiously and this is my first comment. 🙂 Although I might not be happy with the whole “sectioning trick”, I do like reading your blog.

  26. These characters are a total nuisance.Maybe someone could setup webcams throughout her home so the whole world can pay attention to her 24/7. That's what she really wants.

    As long as society/friends/neighbours pander to these attention seekers they will just get worse, demanding more and more attention.

    When she started laughing shows her true motive – attention, attention, attention. I would have force fed her all the pills left and walked out.

  27. “Should it go to the selfish noisy manipulators like this woman, who tells lots of friends she's taken some pills, honest, to get them to all flutter around her again?”Manipulation is a horrible word – because it implies this behaviour is conscious & deliberate. I don't believe this is always the case. Sometimes people don't have the skills or know-how to deal with their distress any differently… Some people choose to label parasuicide as 'attention-seeking' Maybe so? But, I can't help but think that if that is the only way someone knows how to get help, that is very sad and indicative of deeper-routed problems.

    In my opinion, if someone reacts to life in those ways – they lack coping skills to manage life & that is as genuine a problem & warrants as much attention & treatment as the other scenarios you cite.

  28. Its really interesting that you both think this actually. Its not something I have come across before – but then, I do come from things from the service users side of things very much, and maybe no one has had the guts to say this to my face.What I normally hear is that its a “oh god, they're self harming and I don't really know what diagnoses to give them, but I really should, so I'll say BPD” kind of cover all diagnoses. Problem is, the MH system requires a diagnoses, so if someone self harms, its easy to just lump them into this category.

    And believe me, its not a nice diagnoses to have – you have to fight peoples stigma every single step. Trying to get through NHS Occupational Health with that diagnoses took me 6 months of fighting, even though these same people had been allowing me to work unpaid for them for a long time.

  29. To avoid any arguments about the whys and wherefores of the arrest, I usually try to “persuade” the patient to step outside and get some fresh air. Most of them have no clue about the powers we have under Sec 136. Our local hospital have been very reluctant to be used as a “place of safety” and strangely enough, so has the local psychiatric unit.They usually change their minds when we threaten to leave the patient with them, whether they like it or not. If they accept, we offer to stay and assist while the crisis team do their stuff. This usually has the desired effect.

  30. I recall a conversation with a paramedic in our local area, who was so fed up with one particular self-harmer messing about scratching her wrists that he told her how to slash her wrists properly. He advised her not to go across the wrist, but up the forearm, as this opens up the blood vessels and makes it more difficult to stem the flow of blood.A week or so later, he had to call us in to deal with the sudden death of this young lady who had taken his advice and did the job properly.

  31. A nuisance for paramedics? Yes. But don't you think there's something wrong with somebody who feels the need to do this to get attention? I know someone who swallowed a couple of pills then told all her friends and got taken to hospital. Was she attention-seeking? Knowing her, undoubtedly. But she was also a sick person who needed help.There probably are people who think it's all a joke or that there's no problem with worrying people like that, but I prefer to assume that they need help which will teach them to fulfil their emotional needs without scaring the hell out of their friends and calling out an ambulance.

  32. that's kind of my point – all those scenarios need the help.And while manipulation isn't *always* on purpose, it often is – just ask Reynolds how many obviously faked “faints” he's seen, for instance.

    I have limited sympathy for those who mess others about. Luckily, I'm not a healthcare professional of any kind so I'm allowed that luxury.

  33. you have nothing to fear from mental health services, except possibly long waits for psychiatrists who overrrun their sessions and a certain amount of paperwork.I got caught up by mental health services as a teenager, when I was suffering from post-traumatic stress disorder following violent rape. No one will force you to do anything you do not want to do, unless you get to such a point of panic and terror that you really are dangerous – and even then, that's a temporary thing and purely for safety's sake.

    It can't affect your job simply by existing on your medical records as that's none of your employers business.

  34. Because I've been on the receiving end of being seen as a nuisance. Because to me, that assumption doesn't mean writing them off in the way that “a manipulative nuisance” does. Because I've been crazy and known I've been crazy and not known how not to be crazy. Because when you've given up on yourself, there's nothing worse than being given up on by other people. Because I find it more productive in my life to think in terms of liking/disliking a behaviour than in terms of characterising a whole person on the basis of the behaviour I see.I'm not going to claim that I don't find attention seeking and manipulation annoying and frustrating, nor that I think it's something to encourage. I do find it frustrating. I'm a moderator on a mental health forum and there are a lot of members who drive me nuts (in a different way ;)). But at the end of the day I know what it's like to be crazy, so I make the assumptions that lead to the most compassionate outcome. Sometimes. OR at least I try. Mostly I avoid dealing with people whose behaviour really frustrates me.

    But to say “a nuisance” is a pretty negative judgement on a person. It reduces them, dismisses them. I find that a pretty harsh thing to do to a person so I try not to do it. If I assume that somebody is behaving in this way because they have some need they don't know how to fulfil otherwise (e.g. they don't feel cared for unless they're the centre of attention) then (assuming I have the time or inclination) I can work with them towards recognising that they can matter to people whether or not they're the centre of attention, and thus get them to stop wanting/needing to act in such an annoying way.

    *shrug* For me it boils down to “do as you would be done by”. As someone with mental health problems I happen to know exactly how I would like to be done by in such a situation and what would be the most effective treatment for me.

    NB Again I'm no talking about what should or should not have been done in this particular situation but rather commenting on the general situation of how I respond to what appears to me to be manipulative behaviour. I recognise the constraints of the situation in the original post and I also recognise that dealing with this must be very frustrating.

  35. “I don't think that people have antipathy towards the mental health system”Oh, lord! Take a wee trip through my blog, including the comments, and see if you still think that!

  36. just because you've been there, and it was real, doesn't preclude the fact that there are plenty of people who will attention-seek for the fun, yes FUN of it, or because they're bored.Some people have genuine mental health problems. I've been one of them too. And some people are immature pains in the bum who have no mental health problem. Both are bloody difficult to deal with.

    As the title here indicates, while outwardly you should always maintain respect, and if you are a care professional you should provide appropriate care, information and referrals… it's difficult not to inwardly feel frustrated, annoyed and so on, and you have to let that not interfere with your professionalism. Especially when you've seen genuine cases, and you've seen people trying it on, and you have a guess that this person doesn't fall on the “genuine” side of the line.

  37. but if the behaviour is selfish…I, speaking for myself, think that when I was genuinely having all the panic attacks and mood swings and nerves and so on, with a reason for it all that no one in the world could or would argue with… I was still sometimes desperately in need of being told “you're being extraordinarily selfish – you've got problems but that doesn't preclude the fact that we have lives too!” by my friends and family. They really should have done it. Having a Genuine Mental Health Problem ™ doesn't give a person the right to mess others about as if their friends were their own personal puppet theatre.

  38. I agree r.e. the “self-harm means BPD” diagnosis; I fought tooth and nail with one junior consultant to have a diagnosis of BPD removed from my records because it was put on there for just that reason. As far as he was concerned, self-harm is not a characteristic of bipolar disorder, so he felt he had to find an additional diagnosis – so he could have me neatly pigeonholed.However all too many MH professionals use a BPD diagnosis as a form of shorthand code to tell other MH professionals, “Look out, this one's trouble” – whether that trouble be acting out, as with the original post, or just someone who isn't going to tamely sit back and take the patronising pat on the head and the handful of tablets but instead insists on fighting for the threatment she (and the vast majority of people diagnosed with BPD are female) needs and insists on playing an active part in her own treatment.

    It doesn't help that there are far too many people who think they can get away with behaving like utter brats by blaming it on BPD.

  39. Have found this post after a trawl thru the archives (I'm bored).I am aware that my comment will probably get lost in the ether here but I feel quite strongly on this one so I want to stick in my 2p worth.

    I am one of those people – the really annoying attention-seeking overdosers.

    I have a history of depression (not severe, and controlled – and imho you don't ever get “cured” of depression, it's sort of hard-wired into you, you just learn to cope with it). I had a particularly low point after an emotional argument with the other half. I wanted attention and I was not thinking straight, so I did pretty much what this patient did.. took about 20 paracetamols and some codeine, and a pint of last night's wine (more like drinking vinegar, yech). Then rang the offending other half, who rang 999. The ambulance crew were lovely if a bit bored (I now know why).

    I would like to clarify something for all the commenters who have said “oh these people are bad, not mad, and want attention”. Yeah, I speak for myself when I say I DID – but to go about it in that manner is irresponsible and stupid and brought on because I was not in my right mind – my coping mechanisms were all shot to sh!t that day and something came a wee bit loose upstairs. At the time, I thought “I don't want to do this anymore, I want to be dead”.

    Looking back – I wanted attention. It's a mark of how much I have recovered that I can a) admit to that and b) make this comment in public. Anyway, the nurses in A&E stuck me with nasty great needles (I hate needles so this was my punishment).

    Please do not judge us all too harshly. It was a wake up call I needed – I went on to have counselling (useless) and now I am quite OK, thanks for asking 😉 My point is this – people who do this might be after attention, but they go about it in this manner because they are unscrewed. So don't hate them.

    And no. I won't be doing it again.

  40. I read your book and came to visit your website to search specifically for self-harm, cos I was curious as to how you people viewed us “self-harmers” – must say I'm a bit disappointed. I understand how frustrating it must be – and I'd like to point out that I've never done what the woman did – I have self-harmed for over 14 years – and occasionally I need to go to A+E to get stitches (I only go to A+E when I know I can't patch it up myself with steri strips) I'm very apologetic when I get there (I make my own way there – never in an ambulance) and feel very guilty. And I often wonder what the staff think of me.What may be surprising is that I'm a 28 year old professional biomedical scientist. (ie I'm the one A+E ring when they say “we need 6 units – stat” – and I work quickly to make sure the blood is compatible for the patient. I work shifts like yourself, 12 hours long, alone on a night – have my own house, pay my taxes and try not to be a burden to society. but sometimes, when I'm struggling, I cut myself to make myself feel better – and sometimes I go deep enough to warrant a trip to A+E (on occasion needing internal stitches when I've hit a muscle)

    I just hope you don't tar us all with the same brush.

  41. The thing is, there is a difference between what this woman was doing and what you are doing.It's long and complicated but I hope you see that.

  42. I'm the same as you biomed – I take care of my injuries at home, and the only time I've been to the Hospital was when I mis-judged the shapness of my blade and the amount of pressure, and cut through to the subcutaneous fat on my arm. I woke up my flatmate and we called a taxi.At the hospital I was, like you, embarrassed and apologetic. Perhaps I should have screamed and made a fuss, because the nurses just patched me up with steri-strips which fell off within a few days, leaving me know with huge, ugly and suspicious-looking scars running from my wrist to elbow. Scars that force me to wear long-sleeved shirts in the hottest Auckland summers, and have indirectly led to me passing out from heat exhaustion at work on a film set on two occasions.

    Many self-harmers don't WANT attention. For me, at least, it is a deeply personal ritual that surfaces when I have so much emotional overload that I have to find something to distract myself from the constant cycle of thoughts that scream through my head when I'm alone. It's a habit I have almost managed to drop – especially since I gave up drinking a year ago – but I wouldn't like to say that I have given it up entirely. I think it will always linger in my subconscious as an alternative, even when my rational mind knows it will not help the situation.

    Of course, this is a world away from taking an 'overdose' (and I've taken more Neurofen than that on days when my back pain is playing up) and calling all my friends to fuss over me. But it's hard to say if those same urges – that irrational part of the mind that says 'yes, do that! It will take your mind off your problems!' – are operating on the 'attention-seekers' in a different way.

    On the other hand, I would be thankful to be bullied into getting medical attention when the dark part of my mind in to the fore. I only hope that when she's down from her hysteria, she will have a good chat with the psyche team and they will help her to understand better why she does these things.

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