Helping Only Makes It Worse

I wrote this a while ago when the A Day In My Head project was collecting diary entries for a book on mental health. As our computers refused to speak to each other it didn’t make it into the book but I thought I’d share it just to describe some of the agonies that work can bring up.

To give a bit more context than the original word count would allow, we were doing Dialectical Behaviour Therapy. This is an intensive therapy that aims to get a life worth living for people who have difficulties managing strong emotions. As part of starting therapy a few things are agreed with the client and therapist before you can proceed. The one that is most relevant here is the agreement to make every effort possible to give up (or seriously reduce) things that might kill you. The main idea behind this is that therapy doesn’t work if you’re dead. DBT ‘demands’ that things that might kill you are what the session focuses on if they’ve happened in the past week. Due to my feeling (which she didn’t share) that she was repeatedly putting her life at risk, thats all we had talked about for some weeks. This might sound harsh. It certainly felt harsh. What I had to remember was that DBT is an evidence based therapy that we had both freely chosen to try…

I came home from work today feeling useless. I’d been working with someone whose partner has been repeatedly violent to her but she wants to maintain the relationship. She’s keen to get help with her suicidal thoughts, self harming, substance misuse, low self worth and anxiety. She doesn’t accept these issues might be exacerbated by the person you love kicking you around the house. It’s really hard to be in a job where you’re there to help someone, see them suffering, offer help but get told that you can only help with the symptoms rather than the cause. It’s as if she’s got her hand stuck in a mousetrap but only wants help with the pain rather than help to get the trap off. This puts me in something of a dilemma as I either need to pull out and invite her to come back when she thinks her relationship is a problem, or I stay involved and give the impression that you can get a life worth living while the person who lives with you tells you how shit you are and punishes you when you fall below his standards. Which is often. And the standards vary.I feel quite callous when I’m weighing the options up, mostly because I really care about her and hate to see her opting for a life with so much guaranteed unhappiness in it. I know that making changes is frightening. I know that people have always hurt her, so why should she believe things can be different? I also know that she takes massive comfort from SOMEONE choosing to be with her, regardless of how she’s treated. People have suggested that it’s unreasonable to ask her to choose between him and me, but in a sense that’s not what I’m asking. I want us to agree that wanting to live with someone who hurts you is a problem and I really want to help with that. That doesn’t mean that she has to leave tomorrow, but it does mean that a life without a resident abuser is a goal to aim for. As it is, she is really keen for therapy to continue, as long as it focuses on things other than her relationship. This leaves me with a dispiriting choice. On one hand I can stick with her, see the evidence of her assaults, hear her suffering and pretend I can help her feel better about it, which will leave me feeling like shit. On the other, I can tell her that I can’t help her to suffer less with the life she’s chosen, but I will be there to help if she ever wants a life without an abuser in it. She will feel abandoned, and I will feel like shit. It’s a difficult job sometimes. I tend to go to work to help people, so watching them suffer or leaving them when they’re suffering doesn’t feel at all good. In fact it makes me feel quite bad at my job. Rather than abandoning her, I’ve carried her around in my head all evening wondering about the ethics, the effectiveness and the outcomes of both courses of action. The logical part of me wants to respect the choice she’s made and let her get on with it. The emotional part of me wants to rescue her, to help her, to keep her safe. It goes against almost every part of my being to leave someone in that situation. I’m sure “you have to be cruel to be kind” has justified some brutal behaviour towards people in the mental health world. In this case I do feel that telling her why I can’t work with her now but would work with her in future if this issue changed is the thing that would give her the best chance of a better life in the long term. What will be painful for me (and her) is telling her and following through on it. It would be so much easier to just hang in and hope things change. There’s a bit of me wondering why this is what I chose to share. I think I want people to know the impact that the work has, that we don’t skip home at 5 o’clock, that we think and feel about what we have and haven’t done during the day. We talk a lot about compassion in the NHS, but being compassionate isn’t always doing what people ask for.

I shared an abridged version of this story while having a conversation about people experiencing domestic violence being intensely miserable on mental health wards. Staff acted as if they were ill rather than having a natural reaction to prolonged suffering. I got the feedback that I was a misogynist with a worrying attititude towards domestic violence. I’ve thought about that comment a lot and it’s probably done more than anything else to inspire me to write this down. In truth I’m not sure if this vindicates me or makes my hole a little deeper. Perhaps it’s worth adding that if I had done what I think would have been most useful (stopping working with her until she agreed that living with someone who might kill her was a problem) she would still have had support from the CMHT, she would ‘merely’ have lost a therapy that prioritised getting things that could kill you out of your life.

I wish there was a nice tidy ending to this story. In the end I changed jobs and she transferred to another therapist. I don’t know how life turned out for her but in my head when I think of her I tend to see her smiling before being beaten. I’d like to think that things turned around but thats purely based on hope. There’s nothing I can hold on to that suggests things would improve. She’s now one of the people I carry around in my head. I wonder what has happened to her and whether I could have been more helpful. Helping someone to stay in hell seems wrong while leaving them there to burn in the hope it gets too hot seems wrong too. Maybe sometimes  there just is no good option…

Let me know what you think,

Keir

@keirwales

You can get the full book of A Day in my Head packed with many better entries than this here-

A day in my head
by Aron Bennett
Link: http://amzn.eu/e4YRwJM

7 thoughts on “Helping Only Makes It Worse

  1. It’s an understand dilemma, but unless she lacks capacity then it is her choice and she chooses what she wants help with your role is simply to assist as much as you can with what she pays you to help with (or the state pays you on her behalf). Most help from state services deals with the symptoms not the causes. Take parenting programmes that focus on the mothers parenting skills when we all know far greater impact would be achieved through social and political change rather than individual psychological programmes.

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    1. Thanks for taking the time to comment. I take your point that my role to to help with whatever I’m paid for but I think about the idea of “first do no harm”. I think that if I supported her with the idea that she could get a life with lots of enjoyment and high self esteem while she was regularly beaten by the person she loved, I fear that I’d be keeping her in he’ll for longer. Appreciate your thoughts and thanks for reading ☺

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  2. The personality disorder service chose to discharge me in June when I was sectioned and placed onto an acute ward. The reasoning was surrounding being acutely unwell/risk to self etc. and that it wasn’t the right time to engage in therapy (a therapeutic community)…and that the earliest a re-referral would be accepted is the end of Jan 2018 (I was taken out of the TC in November 2017 but they had been “holding onto me” rather than total discharge after CMHT rejected a referral to temporarily takeover my care during the “break” from therapy).

    What you’ve said about making hard choices, that sometimes you don’t want to do really hit me and reminded me of my experience. After months of them keeping me under their care, but only seeing me every 2-3 months, and me ending up on a section 2, they came to the decision to completely discharge me. It hit me really hard and probably increased my need to be on the ward with no leave for a short while. But what stands out from it, which is a real comfort to me, is knowing that it wasn’t just a difficult final meeting for me. I was with two nurses, and one left to arrange transport to return me to the acute ward…the one that remained, we had a short but really genuine talk about how we both felt, and she cried. It shocked me beyond measure because I felt like I was being rejected and not wanted, and it was difficult for me to get my head around the fact that they genuinely did care/want the best for me, did want to be able to help me themselves, but that for them at that point, discharge was the best option for me.

    I agreed it was best at that point. I actually said I wish that CMHT had taken me on when I was taken out of the TC, until I was ready to go back, because then maybe I would be able to go back sooner and wouldn’t have ended up being sectioned.

    On reflection I am mixed on my thoughts now. I was moved to a section 3, then discharged a week ago. I have on my own volition, started 1:1 low fee therapy at a local private counselling centre, because I am in such a determined position, that I want to grab that motivation and feed it now. I feel that waiting till end of Jan (or later) to return to the therapeutic community for therapy would result in me deteriorating between now and then…and then being deemed still too “unstable” in Jan…so in some ways I think that the best thing the PD service could have done is understood that actually time out was the thing making me worse, and that getting me back into therapy ASAP would give me the best chance of managing it….but I started the private therapy tonight, and if the PD service had agreed to take me back/not discharge me, then I wouldn’t be doing this, and maybe this is what I need. I’m trying to be more open to keeping my options open, rather than saying I am definitely doing this 1:1 therapy long-term, I am definitely not going back to the PD service etc.

    Any way, the point of this awfully long rant (sorry!) is that as someone who is diagnosed with BPD and has been on the receiving end of a decision that was really difficult, I think, for the professionals who made the decision…I think KNOWING that it was hard for them, them being really transparent about it, is what helped me. I mean to be honest it’s the thing that upset me most afterwards. I spent days on the ward crying because all I could think about was the nurse crying and how horrible a situation it was in when we both really want the same thing for me, but the situation makes it impossible right now. BUT, I needed to get upset about it and seeing the nurse cry made it feel less like rejection. I know some people may believe she shouldn’t have become so emotional in front of me.. but firstly, getting upset is not something one can always control, and secondly, seeing that human part of her, and seeing how hard it was for her as well as me, made me feel something…something positive. And it made me feel like I wasn’t alone in finding it hard…that I wasn’t the only one hurting from the situation and that somehow helped me.

    I think when making a decision that is difficult and in a lot of ways looks like you are “turning your back” on a patient when they are most in need…it is complex and varies so much from case to case…but I think if you are making that decision, if you are going to withdraw help (for now), letting the patient know it is difficult for you and not about not wanting to help etc. really is the key thing.

    I am sorry for ranting on. I have found your blog tonight and I am reading through the posts thinking woah your perspectives/opinions etc. sound a lot like my own and I am sat here nodding my head at everything so thank you, it’s not often I get this drawn into a blog 🙂

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    1. Thanks form your comments Natalie. Far from ranting I thought you shared some really interesting points about your experience that I think are really important. Often in services staff have a team meeting where they argue like hell then they allow the service user in and present them with a plan saying “the team view is…” as if it has unanimous full throated support. There’s a view that staff need to present a united front but as you say, some decisions are hard. Sometimes everyone is trying to pick the least worst option and then selling it like it’s a winning lottery ticket.

      I am very glad that you’re going in a direction that feels useful to you and sorry to hear it hurt so much to get there. TCs are my favourite way of working so I hope you’re able to enjoy it when you go back. Thanks again for the kind comments, they really do help me to keep writing. Keir ☺

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      1. Definitely keeo writing. And your comment about TCs being your favourite way is super helpful in me trying to decide whether that’s something I want to return to so thank you 😊

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  3. I think the united front thing is sometimes really unhelpful. Being transparent about the decision-making process can really help to avoid that “they just made a snap decision on my life with no significant thought” feeling that can pop up when “the team” unilaterally decides on your care. Although some services like to pay lip service to the idea of the patient being part of the team, when the rest of the team always acts as a bloc it doesn’t feel much like a team at all.

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