Saying farewell

Hello people. I’d like to thank everyone who has subscribed to this blog over the years. When I first started out on social media it was the feedback from this blog that gave me the confidence to become louder and more involved in the areas I was passionate about. Just over a year ago two things happened – 1) I upgraded this blog site so that it could run some discreet adverts and 2) Facebook suddenly decided that the blog was spam. It’s been blocked from Facebook ever since and as you’ll appreciate, its pointless to update a site that no one can read.

If you’re interested in anything else that I might have to say you can find many of these blogs and some newer ones at

you can also find me spouting nonsense on twitter @keirwales, Facebook Keir Harding OT, and to a lesser extent on Instagram @keirhardingot and Linked in.

Hope to see you all online somewhere. Thanks for the support over the years,


Leaving the NHS, the conference that never was and the impact of C19

Well this week is going to be nothing like it was supposed to be.  Instead of heading to the British and Irish Group for the Study of Personality Disorder annual conference, I’m going to be isolating at home with a vague sense of unease, guilt about not doing more, and a growing sense that this is the worst time possible to be leaving the NHS.

Keir provides therapy, consultation, training and supervision via

Going to the BIGSPD conference is a highlight of the working year for me.  I was totally self funding so I’d booked my days of work, got myself an air B&B and was looking forward to hearing about some of the really big developments happening at the moment.  I was most keen to hear how much we are spending on Out of Area treatment for people diagnosed with ‘personality disorder’, or people who self harm, or people who feel recurrently suicidal.  Someone had contacted every CCG to try and get this information which has so far eluded me.  On top of that, we were going to hear about the future of training around working with those who get this diagnosis.  I was really looking forward to an update on the CALMED trial – this is a controversial study to look at the efficacy of Clozapine for people diagnosed with BPD.  I’ve got mixed feelings about this.  I went to a low secure unit the other week and everyone there was on it.  We can argue this makes sense because it’s for the people with the most severe problems but I have serious concerns that this is one of the dangerous things that happens when people are out of sight and out of mind.  The biggest thing I’ll miss out on is having a debate with the staff of St Andrews around the ethics of private mental health placements.  I’ve been looking forward to this for months and while I’m sure it will happen, there’s a definite sense of anticlimax.  Lastly, I wanted to talk about organisation centred care with @hoppypelican.  Thi is our wry take on person centred care where we argue you can only deliver person centred care if you target the anxiety of the clinicians/organisations working with people.

What would have been novel this year is that the Mental elf would have been taking the conference beyond the room for the first time ever, helping us to reach people who have never thought about this area before.  I’m often surprised by the amount of people who are really interested in this area but have no idea that BIGSPD exists.  The more people who think alike, working together the better I reckon.  Alas this opportunity is going to pass…

So instead of doing all the above, I’ll be trying to see if therapeutic communities can happen online.  Instead of leaving the NHS a week on Monday, I’ll be seeing if theres a way to stay on and help out while the crisis passes.  Instead of a brave new dawn I’m looking at the kind of evening sky that would terrify shepherds and wondering whether I’m doing enough.

I’ve read a lot of dystopian/post apocalyptic fiction in my time and theres a big part of me that wants to go and panic buy.  To get a gun and head for the mountains.  To break into warehouses and put aside stores for the future.  The heroes of these stories tend to be pretty well prepared and there’s an itch in my brain that sees people wandering through town with 200 rolls of bog paper that tells me I’m missing out.  I’m noticing the urge to hoard and instead, I’m trying to practice some of what I spend a lot of my time preaching.  Calmness, trust in others, a belief that this too shall pass and mostly a deliberate turning of my mind to hope.  I really enjoyed and was inspired by Hope in the Darkness by Rebecca Solent recently.  I’m going to leave you with a few quotes from it, and my own hope that we find ways to be together while being apart, that we show how much we are connected by keeping away from each other and that we can hold each other without being present.  Take care of each other, (but stay at home).

“To hope is to give yourself to the future – and that commitment to the future is what makes the present inhabitable.”

“People have always been good at imagining the end of the world, which is much easier to picture than the strange sidelong paths of change in a world without end.”

“Hope just means another world might be possible, not promise, not guaranteed. Hope calls for action; action is impossible without hope.”

“Inside the word “emergency” is “emerge”; from an emergency new things come forth. The old certainties are crumbling fast, but danger and possibility are sisters.”

“To hope is to gamble. It’s to bet on your futures, on your desires, on the possibility that an open heart and uncertainty is better than gloom and safety. To hope is dangerous, and yet it is the opposite of fear, for to live is to risk.”

Keir provides therapy, consultation, training and supervision via

Its a decent book if you get the chance to read it, take care of yourselves.

DBT: The therapy with the most user involvement ever….

TW – Self Harm

Yesterday I did something I haven’t done for a long time.  I sat down and read a book cover to cover.  The book in question was Marsha Linehan’s, Building a Life Worth Living and while I’m going to suggest that it’s audience is going to be limited to people interested in this area, I found it captivating. 

Keir provides supervision, therapy, training and consultancy around what gets described as “personality disorder” via

What will probably be a surprise to most people is the level of lived experience of self harm, suicide and institutional care Linehan experienced.  She describes being an intelligent, popular girl with no obvious problems until the age of 18 when she started having recurring headaches with no obvious physical cause.  After a period of her doctor scratching his head she was sent to the local psychiatric hospital for 2 weeks evaluation and so began her descent into hell.  Marsha feels she didn’t meet any of the diagnostic criteria for Borderline Personality Disorder before going into the hospital but like many people I’ve worked with, something about her reaction to the restrictive environment and the staff reaction to her reaction meant that pretty soon she ticked a few boxes.  She began cutting, burning, overdosing, and smashing her head on the floor.  She blames her severe memory loss on this and the ECT she was compelled to receive.  Her 2 week stay lasted 2 years and 1 month including a hospital record of 3 months in seclusion.  It was here that she made a solemn and holy vow that she was going to get out of the suicidal hell she was trapped in and make sure she could get others out of hell too.  

It’s not plain sailing from here and we read about further suicide attempts, the threat of prosecution for attempting suicide and a Kafkaesque moment where the crisis line couldn’t talk to her on the phone to help her stop self harming, so sent the police around to take her to a psychiatric hospital.  The more she protested that she was now ok, the more they wanted to detain her.  

For all the criticisms DBT receives – many of them justified but many of the ones I read being about it being poorly implemented – there is little denying that this therapy originates from someone who has lived it.  Does that justify ways of interacting with people that have been described as rude, cruel and childlike?  Perhaps not but we are often encouraged to listen to the voices of those with lived experience and this voice has been given more volume than most.  

The rest of the book tells an interesting tale of her drive (and she does sound driven) to help people who were recurrently suicidal that the rest of the psychiatric world wasn’t interested in.  She describes a battle to help those who were marginalised in institutions that were frequently disinterested and misogynistic.  She recognises some interpersonal problems and being viewed as a difficult woman, a description attached to many articulate, intelligent passionate people I know.   She describes putting a therapy together that initially didn’t work.  She had up to 8 people watching her at a time, constantly making changes to develop a way of working that helped people to accept themselves while pushing them to change.  

In the book I recognised some refutations of some of the common criticisms I hear of DBT and Linehan herself.  Firstly that she only ‘came out’ as having lived experience after she had made her money with the therapy.  As well as her taking a vow of poverty early in her life and spending much of her income housing the homeless, she was advised by two leading international researchers that telling the world about her experiences would cripple her chances of getting funding to prove DBT worked.  

Another criticism is that DBT wasn’t developed for people ‘with BPD’.  She is clear from the offset that she wanted to help people like her stuck in a cycle of suicidality.  It was late in her career that she learned about the existence of a diagnosis called BPD and she stated her therapy was for the people who got that label because that was the label given to those she wanted to work with.

“I don’t think of myself as treating a disorder.  I treat a set of behaviours that gets turned into a disorder by others”

I was captivated by this book although I think I’m more interested in this area than most.  For those who have an interest in what gets described as personality disorder it is very interesting.  For therapists and service users who want a story of how someone can get out of hell, it’s useful for that too.  There is a lot of God and spirituality in this book which some might find off putting.  Given that it has played such a dominant role in her life, I was surprised how relatively little it is a part of DBT.

A cynic might see the book as an advert for DBT but I think it’s better explained by someone who is fanatical about their life’s work.  I don’t think it is a particularly literary work, but I did find myself moved by a number of passages, literally to tears on occasion.  I certainly see DBT in a new light having read the biography and if you’re interested in personality disorder, DBT, user involvement or mental health in general, this is a good read for you.  

Keir provides supervision, therapy, training and consultancy around what gets described as “personality disorder” via


BPD – When your text book tells you you’re a manipulative, deceitful attention seeker

A few weeks ago I was trying to poke my eyes back in and pick my jaw up off the floor after reading the personality disorder chapter in Occupational Therapy in Psychiatry and Mental Health (2014).  This is a chapter that described people with the diagnosis as, among other things, manipulative, deceitful and dangerous to students.  At the time I wondered what it would be like for OT students to read this chapter and have their views shaped by it.  I also wondered what it would be like for someone with this diagnosis to read the chapter and find out that not only one person thought this about them, but that the view was so uncontroversial it could be peer reviewed and put in a textbook.  It just so happened that an OT student who has this diagnosis did read that chapter.  This is what @hattieporter_ (follow her on twitter) had to say….

Keir provides training, consultation, therapy and supervision around what gets described as personality disorder via

Hi, my name is Hattie and my personality is “inflexible, maladaptive, rigidly pervasive and deviate[s] from cultural standards”. At least that’s what my medical records and a quick read of Ann Nott’s ‘ Understanding Persons with Personality Disorders: Intervention in Occupational Therapy’ may lead you to think. I don’t tend to write this in my tinder bio and it rarely makes it onto my CV.

The chapter, in Occupational Therapy in Psychiatry and Mental Health (2014) Edited by Crouch and Alers, was incredibly painful to read with some parts which feeling too raw to comment on. The content not only makes sweeping, unsubstantiated (and at times weird) generalisations, but shows total indifference towards people’s pain, suffering, trauma and even death. What hurt the most was how every line felt like an echo of the abrasive language I have heard over and over again; there wasn’t much in the chapter I haven’t had someone say to my face.

This chapter purports to “give a broad outline of personality disorders and to clarify issues surrounding them” in the same breath as discussing the “clinical handling of behaviours such as manipulation, lying and deceit”. For me, the only thing this chapter clarifies is that the professional and institutional stigmatisation of personality disorder diagnosis I have experienced is firmly supported and legitimised though academic literature.

I was diagnosed with borderline personality disorder at the age of eighteen and was left desperately trying to figure out if this was an illness or an insult. I soon learnt that, essentially, it would serve as both; and I would have to navigate not only my symptoms but the secondary trauma of carrying such a stigmatising label. A label which was, at times, used as a justification for what I can only bring myself to describe as abuse.

But, of course, this chapter is not about the challenges of living with a diagnosis of a personality disorder, or indeed the symptoms (which are traumatic in separate ways) but about the challenges faced by professionals. It notes “people with personality disorders are associated with poor treatment outcomes as these disorders as so time-consuming”. I can assure you, no matter how difficult it feels for a professional to manage, it will never be as time-consuming as it is for the person living with it. And really, I cannot think of many conditions which operate with part-time contracts.

What this chapter misses, besides even basic compassion, is question marks. In fact, it explicitly tells us to “focus on behaviour and not an explanation of behaviour”. We don’t need to make excuses and we don’t necessarily always need explanations of behaviour, but we need to remember that there are explanations. That as humans we are shaped by the things we live through and some experiences are more corrosive than others. We can never begin to change behaviour without considering the purpose it serves and ensuring those needs are met in another way.

We hear that people with a diagnosis of a personality disorder are “deeply ingrained in maladaptive behavioural patterns”. I have certainly felt incredibly stuck, but my “maladaptive behavioural patterns” are my survival and, whilst it may look like malfunction to someone else, it is the reason I am alive today. Some people’s survival is not as pretty as others.

The chapter nearly considers the telling points of gender disparity across personality disorder diagnosis and the over-representation of LGBTQ+ people. However, dismissively choosing to use the term “sexual identity disturbances”. My ‘unstable sense of self’ certainly wasn’t helped by growing up in a world which taught me a core and integral part of my identity is yet another way I am “disturbed”. Personality disorder diagnoses are political and deeply embedded with wider societal inequalities; our experiences cannot be understood without recognising the impacts of that.

But this is not about one chapter in one slightly-dated textbook. This was not written in a vacuum, but is emblematic of the firmly laid foundations of stigma and prejudice around personality disorder diagnoses which is pervasive across all healthcare professions and settings. As the chapter notes, “the person [diagnosed with a personality disorder] is much more likely to refuse or ignore psychiatric help [and] point out the therapist’s problems”. What the chapter doesn’t say is how often people with a diagnosis of a personality disorder are themselves ignored. How often we are refused psychiatric help on the basis that we are ‘too complex’ or ‘treatment resistant’ or that everything we do is a ‘just attention-seeking’ anyway. The chapter doesn’t tell us how often this refusal of treatment ends in tragedy.

With the risk of sounding salty, I can’t help but point out how this chapter is an excellent example of ‘black and white thinking’ with its grand generalisations and, in its own words, “extreme [thinking] on either end”. What I have learnt through extensive dialectical behaviour therapy is the importance of holding two seemingly conflicting ideas as both true and important. Perhaps some people with a diagnosis of a personality disorder can be a challenge to work with, but at the same time we are individuals and we are humans. Treat us as such.

In my time using mental health services I have been fortunate to meet some of the most incredibly kind and compassionate people who believed in me during the times I didn’t have an ounce of hope myself. What made a difference was a simple as being viewed and treated as a human being; not being categorised based on the endless diagnoses I had accumulated; and being listened to and most importantly believed. Conversely to what this chapter suggests, working with people with a diagnosis of a personality disorder is really not vastly different to working with any other client group.

It terrifies me to think of fellow occupational therapy students reading this chapter, and carrying these abhorrent attitudes into practice with them. Students are the future of occupational therapy and we need to be part of creating change and reform to mental health services. Where this kind of content, which breaches professional and ethical guidelines lacks any level of compassion is being provided to students, I fear we are risking the same abusive practices we have today being replicated in the future.

As I have said before and will never stop saying, there is nothing you can learn from a textbook which is more valuable than what you can learn from the voices of people. If you want to know how to work with people with a diagnosis of a personality disorder, a good place to start is to ask us.

My other piece of advice is to avoid reading this chapter at all costs.



(Keir again) Just as a follow up to the above I’ve emailed the editor of the book and the commissioning editor. I’ve had no reply from my email and while the commissioning editor has offered to put me in touch with the editor, he hasn’t responded to my request to place a warning against this chapter in the Ebook.  I’ll chase him up again soon but – Would people be interested in a joint letter to Wiley asking them to provide a warning in the E-copy of the book?  Comment below, to @keirwales on twitter or Keir Harding OT on Facebook.

Keir provides training, consultation, therapy and supervision around what gets described as personality disorder via

“Understanding Persons with Personality Disorders: Intervention in Occupational Therapy” A (very) critical review

It’s not often that you read something and find that you immediately need to go and share your thoughts about it with the world.  The most recent one for me was Hope in the Dark by Rebecca Solent (Highly recommended!) until Friday afternoon when I found myself on a long train journey with some time to kill.  I’d just finished a week of Dialectical Behaviour Therapy training for those diagnosed with Borderline Personality Disorder and while I knew I should have been reading more about that, my mind skipped onto thinking about what was written in the world of Occupational Therapy and “Personality Disorder”.  I know that the answer is ‘very little’ so I decided to throw myself into “Understanding Persons with Personality Disorders: Intervention in Occupational Therapy” by Ann Nott.  You’ll find it in Occupational Therapy in Psychiatry and Mental Health (2014) Edited by Rosemary Crouch and Vivyan Alers.


Keir is an Lead Therapist in an NHS Specialist Service and provides training, sconsultation and therapy around complex mental health problems through

The chapter got off to a bad start for me by giving one of the Key Learning Points as “Clinical handling of behaviours such as manipulation, lying and deceit”.  Lets take a deep breath and see what else we’ve got…

It opens by sensibly defining personality and what might then describe a personality disorder.  Given that ‘personality disorder’ covers such a spectrum of presentations it then makes some incredible generalisations such as “No feelings of anxiety about his/her behaviour…blame is put upon others…they believe their behaviour is right, ignore or refuse psychiatric help”.  Now I have not conducted a randomised control trial, but I have met many people with this diagnosis who are crippled with anxiety about their actions and choices, they believe they are always, always wrong, they blame themselves to the extent that they have to punish themselves and they cannot get psychiatric help regardless of their levels of distress.  

We are told that long term progress can be poor which is not the case for what gets described as Borderline Personality Disorder.  We are also told that some can have a “good prognosis with excellent work histories, supportive networks and willingness for therapy”.  While I suspect that’s true it reads as “people who have difficulties that don’t particularly affect their lives tend to do ok in life”.  

The chapter goes on to describe the ICD -10 and DSM-5 ways of categorising personality disorder.  Sadly these are presented in a fairly factual way with no critique as to their value.  While personality disorder is one of the most contested psychiatric diagnoses, you would not know this from reading this chapter.  There is equally no comment on the stigma that the diagnosis can bring or the flaws inherent in diagnostic system.  Now this isn’t unique to this chapter and as OTs we need to be more critical about this and challenge our medical colleagues a bit. 

We are invited to consider 4 different theoretical frameworks for the development of personality disorder but the chapter skims over these, leaning most on biological explanations.  There is the interesting statement that for cluster B & C clients (including people diagnosed with borderline personality disorder) “psychoeducation is contraindicated as there is already a distortion of thinking present which would be counter effective in any therapy”.  Ummm, so no therapy then?  Obviously you then have to wonder if this is the one client group in psychiatry with disordered think and whether psycho-education and therapy needs to be withdrawn as an intervention for all.  You can balance this with the widely held view that psychological therapy is the primary intervention for this client group.  

Common Defences

The chapter gets a bit Freudian at this point and while it spouts about ego and unconscious processes, it points out the “defence mechanisms used by the person with personality disorder”.  What it neglects to say is that assuming all the splitting and projection stuff is accurate – these are things that are identified as being used by everyone in the world.  Dividing the world into good and bad is by no means unique to people given the label of personality disorder and if you’re being mean, you might point out that saying this is the case is an example of projection.  Also, it states that “Parasuicide is often seen in persons with borderline personality disorder, and although it is attention seeking behaviour, it should always be seen as a cry for help”.  It doesn’t link these attention seeking cries for help with the fact that one in 10 people with this diagnosis will die by suicide, risking people in distress being dismissed.  

Models of Treatment

We begin with “treatment normally takes place in a psychiatric unit” which I’m not sure is the case at all.  “The person with a personality disorder settles quicker within the contained environment of the hospital” doesn’t fit with my experience whatsoever and while I’m very supportive of admission where it’s helpful, too often I associate it with people who have lived through abuse being restrained for things that would pass unnoticed in the community.  Anyway….

I heartily agree that the team should have a unified approach and shared frame of reference but the absence of a focus on a collaborative approach is striking.  We are told “family involvement….(is) essential for success” but we are not advised to seek permission or consent to do this or consider the extent to which events and behaviours within the family have impacted on the difficulties these individuals experience.    

Some different approaches are outlined.  We hear about behavioural approaches and how OT interventions such as relaxation and assertiveness training fit.  We may have trouble telling the rest of the mental health world these interventions belong to OT. 

DBT is outlined where there “may be positive validation” rather that it being the most important aspect of DBT.  There’s no mention of how OT can fit within this which I think is odd as my version of Occupational Therapy mirrors much of DBT. 

CBT comes next and there’s little for OTs to do other than know that assertiveness skills are useful for those with avoidant personalities.  

The therapeutic community model is described and while I normally love this approach, unusually there isn’t an emphasis on collaboration, consensus and shared power described here.  This could reflect that therapeutic communities are different things in different places but might also reflect a common attitude that people should be ‘done to’ rather than ‘done with’.   

Pharmacological Interventions

We learn that people with personality disorders “take poly-pharmaceutical medicines in a desperate attempt to cope” with no mention that you can only get prescribed these by a doctor (who may well be prescribing them in a desperate attempt to cope).  Despite there being no recommended medication for ‘personality disorder’ the chapter then describes how different medications can be used.  We might be starting to see how these poly-pharmacy issues come about…

Occupational Therapy

Into the meat of the chapter!  What can OTs do for this client group? Initially it is quite sensible but in my opinion it starts to meander a bit.  We are given some principles to work on such as…

“Focus on behaviour and not an explanation of behaviour” – I believe if you cannot think about why people do what they do you are likely to be directive, judgemental and often wrong.  Always work out why behaviour makes sense.  If you don’t know what drives it, you will never stop it. 

“Confront and not interpret defence mechanisms” –  I’m going to suggest this language is really unhelpful.  Be curious and wonder rather than confrontative.

“Allow for participation in groups and helping others” – this makes sense but I’m not sure which clients in other areas should be banned from groups or helping others.

But OTs should NOT:

“Listen to repetitious complaints” – Turn your back on people?  Fingers in ears?  See the above about seeking to understand why people do what they do.

“Insist on a contract” – Now I’m not too aware of insisting on a contract being a huge issue but this chapter also contains the advice “the client is…encouraged to take responsibility for behaviour by signing contracts”, “It is imperative in all therapeutic processes that there is contracting”, “The occupational therapist needs to contract in therapy” and “It is useful to get group members…to sign a group contract”.  It isn’t massively consistent.  

“Save face if fooled and resort to blame and punitive acts” – I’m 100% behind avoiding blame and punishment, but I wonder how helpful the idea that people are out to trick you is?

“Lie or present conflicting non verbal messages” – Again, I wonder about the wording of this.  Who is the client group it is useful to lie to?

Different Clusters

For the next part we go through the different clusters of personality disorders and how to be helpful.

For cluster A the author points out that group work isn’t recommended but can be beneficial.  If we need to exclude people it should be because of their specific difficulties rather than their diagnosis. 

For B it’s suggested we manage conflict with confrontation (best way I know to get the ward alarms ringing).  We are warned (and hold your breath here) “students due to inexperience may not cope with the highly demanding, manipulative and undermining characteristics that may emerge in therapeutic intervention”.  This client group is not safe for students?  Wow. “The ‘gentle, do good approach’ is not beneficial and the occupational therapist will need to delineate his/her own boundaries…so the process of therapy…(is) not sabotaged.”  

For working with people diagnosed with borderline personality disorder “take care that there are no physically harmful tools lying around” rather than collaboratively managing risk. 

“The pharmacological approach has been to include both mood stabilisers and antipsychotics” – 3 paragraphs back you were blaming them for their poly-pharmacy!!!

After some discussion on cluster C we then get to look at intervention methods

I’ve got no problem at all with this section.  I have a minor quibble about group therapy being optimal rather than a mix of group and individual, but most of the rest of it makes sense.  The chapter is explicit that OTs could be delivering aspects of DBT which I heartily agree with.  We get given two case studies that have fairly unbelievable changes in functioning and I question the outcome measure of angry drawings becoming happy drawings indicating success.  Aside from that I’m content with this section.

So as a whole I seriously disliked this chapter.  It makes no mention of the stigma clients with this diagnosis face, which is an incredible omission for me given the focus OTs have on the social environment.  The likely explanation for not talking about stigma could be that the attention seeking, sabotaging, manipulative, lying, deceitful, blaming, help refusing, unable to hear information about their diagnosis, think in ways that would counter any therapy, inappropriately medication seeking, demanding, sabotaging and undermining people who are not safe for students deserve everything they get.  I would say that OTs should try and get all the above language out of their practice and out of the environments they work in.  The words we use shape our environment and we should be making it a place where people understand rather than judge.  

Take all of the ways of describing people listed above.  If you walk into work thinking that about people it is going to be impossible for you to develop an empathic relationship.  If the people we work with read this chapter and believe this is not only what practitioners think but that it has enough validity to be published in a textbook – how can they possibly trust us to help them? 

I shudder at the idea that this is the first thing that OT students might read about this diagnosis.  I wouldn’t want it pulled from the shelves but I think as a profession we need to distance ourselves from this total acceptance of the diagnostic system and the judgemental language described.  In the UK the RCOT professional standards state:

11.1 Your language and communication style demonstrate respect to those with whom you are working

Now this is opinion rather than fact, but if you are using the language above I don’t think its possible for you to be working within your professional standards.  

Now having read though all the above I have a mix of feelings.  I know that I’ve taken somebody’s work and eviscerated it.  I’d hate it if it happened to me.  Further, I reckon 15 years ago if I’d been asked to write this chapter I’d have written similar things.  We learn the things we do from our experiences which are shaped by people who know more than us.  I’ve been lucky to be exposed to people who would not let me continue to think like this and not everyone gets that opportunity.  Equally in the UK we have had a few publications that have sought to identify and reduce the stigma around this diagnosis.  They may not be known in other countries however, in a book with international reach (and a publisher based in the UK) I’d expect those publications to  be evident in the narrative.  I know that another OT textbook is currently seeking the views of service users to comment on chapters.  I think this chapter would look a lot different if views had been sought, discussed and understood rather than confronted.  I did ask Facebook and Twitter how influential this book was and unfortunately someone told me it had really influenced them, the personality disorder chapter in particular.  It was then that putting a different view into the world became more important than upsetting someone.  

If you work in education please, please let your students know there are other views on this subject.  I say nothing of the quality of –

Harding K (2016) Working with people with personality disorder. In: J Clewes & R Kirkwood (eds) Diverse Roles for Occupational Therapists. Cumbria: M&K Publishing (p237-250).

– but it is certainly different. 

  • I was lucky enough to be able to bounce these ideas off a respected lecturer in Occupational Therapy.  Given that there are many unbalanced aspects to this review and the author they didn’t want to be identified.  Regardless their approval and guidance was much appreciated and needs to be acknowledged.  I’m going to contact Wiley to ask them to update this chapter asap and regardless of what you think of my criticism, feel free to make your views known to them.
  • Keir is an Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through


Prediction 1 – 2020 “The year we talk about BPD?”

It is the first week of the new year!  A time when resolutions with no chance of success are made as we stare into the future with an optimism that things might be better.  In the spirit of gazing into crystal balls to peek into what lies ahead, I thought I’d share my mental health/“personality disorder” predictions of the year to come.  Let me know what you think on twitter, Facebook or comment below and I’m interested in any predictions of your own.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through

1- 2020 – The Year Borderline Personality Disorder becomes more mainstream.

In general I’d say the public knows very little about personality disorder.  Part of what makes me say this is that too many mental health staff know nothing about it either.  What do I think is going to make this change?  Well the year begins with the Royal College of Psychiatrists launching their Position Statement on Personality Disorder.  This will get the diagnosis talked about, not least because I think theres likely to be some controversy around how the ideas are presented.  The profession of Psychology has already put out their de facto position statement in the form of the Power Threat meaning framework, and I wonder if the other professions will now feel obliged to say something about those with this diagnosis.  It is becoming increasingly unacceptable for professionals to say they don’t work with this client group and my hope is professional bodies increasingly make this explicit.  

Outside of mental health world, the term personality disorder is increasingly coming into public consciousness.  In 2019 we’ve had the UK actors Nicola Thorpe and Joe Tracini talk about their experience of being diagnosed with BPD, alongside the American comedian Pete Davidson.  There’s lots of campaigns that try to get us to talk about about mental health more, but I think the modelling that high profile people have this diagnosis will make it easier for us to discuss issues around it more.  In addition the campaigner Sue Sibbald has made it onto the New Years honour list (to my knowledge the first person associated with Personality Disorder to receive such an honour) which I think will again help to stimulate debate.  

In the media we have Hattie Gladwell of the Independent regularly talking about her diagnosis and people like Paul Kelso at Sky looking at inappropriate detentions.  The stigma, exclusion and harm caused to people who get this diagnosis is being talked about more and more.

Now many people will think that wider recognition of a mysogenistic and harmful construct is nothing to celebrate whatsoever.  I might well be wrong but I think its very difficult to critique a concept that no-one has any idea about.  People don’t respond to issues they are ignorant of, and I think they’re more likely to be concerned about people who have lived though neglect, abandonment and abuse if their plight is talked about more, particularly when the wrongs that have been done are labelled as a disorder in the person themselves.  

One disadvantage to this is that the UK parliament has lost the one person with an MP badge who I’ve ever heard mention the term personality disorder, let alone put his name to something critiquing the label.  Norman Lamb leaves a hole in parliament far larger than the space he took up.  I hope someone else sees the continued exclusion and discrimination of this client group as a cause worth fighting for.  If nothing else I hope someone considers we could save money by not locking people in locked rehab facilities miles from home.  

2020, the year “Personality Disorder” enters the public consciousness??  Let me know what you think. 

Unspeakable Thoughts: When staff think “If you were going to kill yourself you’d have done it by now”

Trigger warning – Suicide, Dismissive ‘care’

This phrase has popped into my head a few times over the years.  Mostly, when I was first starting out in the community mental health team and I had my first taste of doing ‘duty’. ‘Duty’ (I have no idea where this name comes from) involved being in the office and fending off phone calls; seeing someone who pitched up at the building; or leaping into a car to go on an emergency visit. It was here that I first came across people who were recurrently suicidal.   

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through

The first time I listened to a detailed description of how someone had prepared their method of suicide and was now phoning me because it was in their care plan to ask for help, I was terrified. I felt it was my duty to keep them safe. I suggested solutions, I reassured, I tried to instil hope. I probably suggested hot baths and milky drinks. All to no avail. I remember the first conversation ending with no reassurance that they could stay safe, so I sent an ambulance round and crossed my fingers. They were suicidal. I was the last person to speak to them. Could I live with myself if they died? Would I be blamed for not doing better or not doing enough? I spent the weekend worried I’d find out they were dead on Monday and when all seemed well on the Monday morning I breathed a sigh of relief.   

Fast forward 3 years and I’d probably had the same conversation with the same person 50 times. When I heard their voice on the phone I started to feel less compassion and more annoyance. Rather than my first novel experience of trying to save someone, I think I was frustrated, bored and eager to get the conversation finished. My colleagues supported me by reassuring me this person would never kill themselves and while we would occasionally still send ambulances if ‘the right words’ came out in the conversation, it was always out of a sense of ticking boxes rather than doing anything that might be useful.   

During this period that I was fully immersed in stigmatising attitudes around ‘personality disorder’.  I remember my amusement when someone told me they were putting on a course for people with Borderline Personality Disorder to teach them how to kill themselves properly. The ‘joke’ here being that despite repeated attempts, by some chance people always live. The implication is that the statement “I’m going to kill myself” has no value when uttered by someone with that diagnosis despite the 1 in 10 suicide rate. 

As I’ve developed within mental health services I’ve found myself working more and more with people who are recurrently suicidal. They have the misfortune to be supported by people who have attitudes similar to those I had in the past. Those staff still harbour the idea that “If you were going to kill yourself you’d have done it by now”. It either stays in the head of the practitioner (and gets acted out in more subtle ways of dismissal) or said openly to insult or attack. Neither of these are helpful and over time I’ve learned that being able to articulate a more empathic version of that view is essential to be able to work with those who feel life isn’t worth living.   

I think we need to see suicidality (a word that I use a lot but which every spell check hates) as being on a spectrum. People are rarely 100% suicidal or 100% loving every moment life sends. People exist somewhere in between. For me, someone saying they feel suicidal is the beginning of a conversation.   

Because this conversation is happening, we can assume that someone isn’t at the 100% stage. I’ve listened to people tell me with absolute clarity, the method they will use to end their life once I have left them.  10 years ago I’d have been furious at them for ‘putting me in this position’ and ‘knowing I would have to react’. I can now be curious about why someone would say these exact words to me. This can lead us to a discussion about my anticipated reaction and the pros and cons of this for them.   

This might sound invalidating but its important to keep in mind here is that telling someone you are suicidal might be a way of keeping yourself safe.  This is to be celebrated.  All people working in mental health want those in their care to live.  We could consider being grateful when someone says they are suicidal because in some way, it’s an invitation to help.  It might not be the most effective invitation, but it is an invitation none the less.  We can explore what’s going on in more detail, rather than ignoring everything in pursuit of someone saying they can keep themselves safe until the next person comes along.   

This might sound invalidating too, but even attempting suicide might be a way of inviting help.

For me attempting suicide and not dying is something to celebrate.  Often something will have got in the way which was, to an extent, predictable.  Not always, but where these occasions occur, they are again an opportunity to be curious and something to be joyful for. Some force, conscious or unconscious has intervened to keep them safe. I suppose some examples of these are people who take “small” overdoses (if such a thing exists), people who begin their act after saying goodbye in a way that will alert people, or do something that is likely to attract attention (e.g. standing at the bridge, walking down the tracks).  In here, somewhere, is a communication about distress that gets in the way of dying.   

The trap (which I have often fallen into myself) is seeing all this as some ploy to ensnare an unwary clinician. Just because someone has taken 40 overdoses with the stated intention of dying doesn’t mean they’re only saying it to torture you. It’s a chance to wonder about what is happening in that pattern. Whatever it is, is useful in some way.  Equally, it’s ok to ask what has kept someone alive.  I’ll often preface this with “This might sound like I’m trying to catch you out or trick you, but I’m really interested”.   

This might be massive invalidation number 3, but it’s important is to hold onto the idea that what we say isn’t always what we mean.  If you disagree, consider how often you’ve told people you’re ‘alright’ when really your world has collapsed.  I’ve worked with many people who have learned that merely asking for help brings nothing.  I’ve worked with people whose life has taught them that if you don’t use volume 11 then you won’t get heard.  I’ve worked with people whose life has taught them that only actions make people respond.  

My argument is that we should always take people seriously.  This does not mean that we take them literally. I’ve seen people who have wanted to be dead in the community for the past 5 years be kept on a hospital ward because they wanted to be dead.  It made the staff feel better.  It meant the person lived in hell.  Sadly, a conviction that death is better than life is very common for people who have lived through shit.  We generally compound this if we respond to their words with dismissal or restriction.   

Curiosity about why suicidal people are still alive is an essential part of work within mental health.  It allows us to expose strengths that are difficult to articulate.  It can let us know what is going on in the minds of those we care for.  It can prevent us doing things that are deeply unhelpful.   

A colleague now passed away once described the work of the CMHT to me.  “We will get a barn full of notifications that people are suicidal every year. Within that barn is a desk. That desk has a drawer. In that drawer is an envelope and in that envelope is a piece of paper with a few names on.  The work is trying to sift through the barn to find the people who are going to kill themselves”.  I identify a lot with this analogy, but I’d add some research to it as well.  We can predict those who are at high risk of suicide, but we are useless at predicting which high risk people will go on to die.  We risk a brutal system of ‘care’ for hundreds of people to save one life.  This might be a price worth paying, but it might not be the view of those who lose their liberty.   

We work in a system that demands accurate risk assessment – a task that no one has been able to manage so far.  Until our organisational and political systems recognise this, our workers will be filled with anxiety. Anxious workers dismiss people or restrict lives.  The work isn’t easy, but we will serve people better if we can thoughtfully voice the thoughts in our heads rather than having to act them out.  We will always be more helpful if we’re honest with people that we want to trust us.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through

* There was someone I only ever met on twitter.  She was very kind to me and very supportive of a blog I wrote called Why Are People With Personality Disorder So Manipulative?  We talked of a follow up around Why Are People With Personality Disorder So Attention Seeking?  This isn’t that, but I think it touches on some of the issues that mean that accusation gets thrown around.  I hope she would have approved of this.

* This was originally part of a co-produced workshop delivered at the BIGSPD conference in 2019.  It was originally Published in Asylum Magazine Vol 26 Issue 3.

Occupational Therapy: The Greatest Career in the World? #OTweek2019

When I was sat in school at the age of 16 I didn’t really know what I wanted to do with my life.  I had a vague notion that I wanted to be of help to others but no real notion of what that might entail.  I pictured flying fighter planes, being a barrister, teaching and being a physiotherapist. A lackadaisical approach to education ruled out a few options but after much pondering, I eventually applied to university to do either physiotherapy or education.  In their wisdom the admission tutors took one look at my lack of academia and attendance and decided that higher education was not for me.  It was with much trepidation that I collected my A Level results knowing that I had no offers and while my peers were off to pack for uni, I was off home to go through clearing. 

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through

Clearing is an interesting experience that I hope you never have to go through.  You find a list of all the institutions that have vacancies on different courses and get in touch to see if they will take you on.  You phone asking after one course e.g. Spanish and they offer you a different one like woodwork.  I was on the phone making or waiting for calls for the next 2 days and eventually I spoke to a guy called Chris Bailey in London.  Once we had ruled out physiotherapy (“not with those grades mate”) he asked me about Occupational Therapy.  It had the word therapy in it so I said I was interested.  He made me an offer to go and study Occupational Therapy at Brunel in London and as soon as I had accepted I went down to the library to find out what on earth Occupational Therapy was.  

Occupational Therapy is great.  You help people to do the things they want and need to do.  Sometimes you teach people things so that they can do what they want and need to do better.  Sometimes you change the environment around them so that it becomes easier to do them.  When you’re working with people, more often than not you are doing things together – frequently things that either you or they love.  You find that rather than stopping people from dying, you’re helping them to live. 

What surprised me was the breadth of occupational therapy.  I wanted to be like a physio when I turned up at uni and there was full scope for me to specialise in areas like hand therapy, people with amputations, traumatic injuries, blindness, stroke…any physical health problem that impacted on their ability to live the lives they wanted and needed to.  One of my placements was in social services and I went around giving out equipment, fitting handrails and even designing houses so that people could live in their own homes and care for themselves independently.  If this area of work had piqued my interest I could have spent my career working with people with physical health problems and making a profound difference to their lives.  

Two things happened.  Firstly I discovered that I found learning anatomy rather dull and there’s loads of it.  Secondly I went on my first mental health placement and fell in love with it.  I became fascinated by what went on in people’s minds that meant they were unable to do what they wanted and needed to.  Equally I was shocked when what they wanted and needed to do in the moment, was totally outside of anything I’d ever thought of.  After university I threw my green trousers away and never worked in physical health again.  

Occupational therapy is a recognised profession within the NHS.  This means you will find a job pretty much anywhere in the UK.  I knew I wanted to work in forensic mental health so I took the first job that wanted me and moved to Edinburgh.  I loved my first year in Scotland and took away some really important things from my first job that set me up well for the rest of my career. 

After a year my wife got the chance to study in London and off we went without any doubt that I was going to get employment.  While there I worked on hospital psychiatric wards running sports groups and making sure people were safe to go home.  I went onto the psychiatric intensive care unit (PICU) and spent a while working with severely ill people, trying to help them get to a place where they could go back to a normal ward.  

Once the PICU had seen through my incompetence I went off to work in community mental health before going on to the really exciting area of assertive outreach.  This is where people who normal services struggle to be helpful for, get a more interested and determined approach.  I used to love building relationships with people who rarely trusted anyone and whose experiences of mental health services were often around being forced to go into hospital.  I also used to love using my knowledge of their likes and habits to find people who hadn’t been seen for a while, scoping out their regular haunts, waiting around in the hope of making contact with them, anything that would give a chance encounter and an opportunity to avoid the next relapse.  There was a lot of talk about how important medication was but now I know it was all about the relationships.  

One of my ambitions was to go and work abroad.  At one point we decided to go and work for a year, then we wanted to to work for six months and we got to a point where we didn’t want to work at all.  In 2003 I packed in my job and my wife and I bought round the world tickets which ended up including 3 months in a Community Mental Health Team in Masterton, New Zealand.  While there we went to hot springs, climbed mountains and spent too long touring vineyards and sampling wine in an incredibly disproportionate ratio to the amount of wine that we bought.  Those were happy days. 

When I got back to the UK I was able to try a few different areas of mental health.  I’ve found an area that I love and I’ve managed to build a specialism in a non-traditional role.  Occupational therapy has so many opportunities to be forward thinking, creative and innovative and I’m aware of loads of OTs getting themselves into places we’ve never been before, crafting out opportunities to help people live the lives they want in multiple areas.  Housing, homeless, asylum seekers, charities, schools…all over the place OTs are finding a way in and showing they can bring value.  

Within the NHS its traditionally been hard for OTs to get into senior leadership roles but this is changing.  I’ve loved seeing OT ward managers and Heads of Therapies come along.  There’s a definite career path for those who want to make systemic change but growing scope for specialised clinicians. In our hospitals and universities OTs are researching so that we are more aware of what will be most helpful in the years to come. 

In my area of work, its still hard for OTs to get into senior positions but this helped me to start my own business.  I’d never have envisioned this 20 years ago but the core clinical skills I’ve developed over the years are valued in the private sector.  Working for myself means that I can target the areas that I prioritise but the NHS finds difficult to work on.  It’s immensely rewarding.

In OT you escape some of the worst parts of work that unfairly seem reserved for nurses.  You skip away from most of the tedious bureaucracy I see social workers drown under.  Occupational Therapy is the key to a great job and and the gateway to wherever you want to go.  

There are many different ways of being able to help people.  Occupational Therapy may not be the best one but because it’s OT week forgive me if I say it is.  You get to be a part of helping people do what they want to do most.  You get to help them by doing things that are fun, engaging and meaningful to you and those you help.  Work has got me going to the cinema, going out for dinner and, because it was a client’s life long ambition, running the London marathon.

This year I joined the board of a national body and I’m going to give a keynote speech at a national conference.  No one would have thought this possible from the socially anxious, awkward student that lazily turned up in Brunel 20 years ago.  No one would have thought that the bumbling, incompetent practitioner I was for a good part of my career would ever get to a point where he was seen as an authority on anything.  OT shaped me into someone who could avoid being judgemental and make sense out of why people did what they did.  It shaped me to confidently stand up for the rights of others.  It shaped me to push myself and others to do more, and I’ve loved the journey it has taken me on.  

The point of the above is that OT is a decent job.  You can spread out into multiple fields and change tack whenever you see fit.  It makes you highly employable, it gives you experiences you might never have otherwise, and it can help you travel the world.  It will let you help people without just talking to them, but by actively doing what’s important.  

The health service workforce is changing.  The influence of OTs is growing.  When you’re thinking about your career don’t just think about if you want to help people, think about how you want to help people.  I could very easily have missed my chance to be an OT as I knew so little about it when I was was younger.  Make better choices than I made.  Best career in the world. 

Huge thanks to Ruth Hawley, Elaine Rutherford, Dianne Lane and Hollie Berrigan for reading over this and offering their feedback (which I did not pay enough attention to)

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through

Lived Experience Practitioners: The Most Valuable Resource the the NHS Isn’t Using?

Users of mental health services shaping their organisation and delivery.  It’s a bit of a mad suggestion isn’t it?  It’s like asking the passengers to fly the plane.  Like asking the prisoners to run the prison or maybe like asking the kids to govern the school.  Health services are staffed by experts and what possible value could there be in letting a patient have a say in what goes on?  We didn’t spend all that time getting our training for some uppity service user to come along and act like they know better.  That we label ‘grandiosity’.  Problem is the people who have actually tasted what we are selling know a great deal.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through

One of the best sources of information is a randomised controlled trial.  Here we have something a tad less substantial – the bitter ramblings of a middle-aged welshman.  I’m going to take you through my history of working with lived experience practitioners and some thoughts about whether they should be a part of future mental health services.  

My first contact was with Lucy (@smile4wales).  A therapeutic community was being set up and when I joined the team Lucy was already there as the service user consultant.  I remember saying hello, dunking a biscuit in my tea and watching in horror as it dropped onto my shirt.  This set the tone for much of our working relationship…

I’d never worked with service users without offering them treatment before (not knowingly anyway, although having said that many of the NHS staff I come across would be diagnosable in another setting) and it was a bit weird to be in a team and in theory, equal.  It helped that Lucy and I were the least experienced members of the team and we were able to bond over “not knowing what the hell we were doing”.  One of the ideas around having a service user consultant in the Therapeutic Community was that it helped people engage in the group.  The Service User Consultant bridged the gap between the members and the staff.  What rarely got talked about was how it worked the other way too.  While something had obviously made people ask me to work in the TC, I was still very much in the Us/Them camp, with some fairly stigmatising ideas around people diagnosed with personality disorder that I’d picked up over the years.  Working in the TC with Lucy made it impossible to maintain that split and those views.  She became a colleague who supported me.  She validated me when I was frustrated and defended me when others were critical.  On the other side, she disagreed with me when she thought I was wrong, she voted against me when the group considered issues and she challenged me when I needed it.  Because she became a real person in my life and because I knew she shared a diagnosis with the people in the group the way I saw them changed.  The way I saw others in the whole service changed.  I would not be the practitioner I am today (for better or worse) without those years of working alongside Lucy.  We shared some painful experiences and we celebrated winning awards.  It was great that we became friends, and awful to see the organisation around her casually exploit her (who doesn’t want to wait 3 months to be paid your less than minimum wage income?).

Alongside her effect on me, thee was the magic that Lucy brought into the group.  Because she ‘had lived it’, she could challenge the members in ways the staff couldn’t.  Because she had lived it, she could validate in ways the staff couldn’t.  No member or visitor ever left without emphasising the impact that Lucy had on them and the group.  She had the skill and insight to use her experience in to help both staff and members respond in ways that were more helpful.  

Fast forward a few years and I found myself doing a masters degree in ‘personality disorder’.  The set up of the course meant that it was put together and taught in partnership with people with lived experience.  Again, this meant the course touched on areas that most wouldn’t, but also that the debates and teamwork came with heavy doses of a lived experience perspective.  These are easy to ignore when then they arrive in a complaining email.  They hit home a lot harder when delivered by your lecturers and peers.  

Around the same time as the MSc I started doing KUF awareness training.  This is a 3 day course that attempts to shift peoples views of ‘personality disorder’, moving away from a fixed diagnosis and looking more at how we see ‘the past in the present’, often how experiences of neglect and abuse have led to current difficulties.  One of the novelties of the KUF training is that it is always delivered by a lived experience trainer and professional trainer.  I’ve probably done over 100 days of this training but one day I wandered into a room in Cardiff where a Brummie woman was setting up a computer.  Hollie @hoppypelican delivered the training in a way that kept people amused and engaged.  She used her experience when it highlighted important issues and resonated with the material.  We did a few more sessions and I met her again at the British and Irish Group for the Study of Personality Disorder conference a year later.  I was on my own but Hollie and her clan looked after me during what could have been a fairly isolated experience.  We kept in touch and Hollie is my go to person for delivering training, thinking through issues and getting a second opinion.  I’ve worked with her to engage people that services had written off and to argue the case for reducing restriction.  The lived experience perspective when delivered in a way that can be heard moves people far more than my accounts of facts, figures and research.  Hollie does this exceptionally well and it’s great that I get to work with someone that I’ve become very close friends with.  

Problem is, not everyone has had my experience of working with LXPs.  (Brace yourselves everyone, this is the controversial bit).  I think what is often forgotten is that Lived Experience is not enough.  There is definitely a place for user involvement, there is definitely a place for getting a wide range of views but it is a fact that if you’re so angry you can only shout at people, no one will hear you and your views will be pathologised.  One of the clinicians I respect most in the world used to argue passionately against user involvement based on their experience of being in meeting with a service user rep with an axe to grind.  Yes we need to hear peoples anger.  Yes we need to give forums for anger to be expressed, but the role of the Lived Experience Practitioner goes beyond that.  It is not just telling your story, regardless of how people voyeuristically want to hear it. 

In my experience, a good LXP will have:

Experience of a range of mental health services

Experience of care delivered voluntarily and under compulsion

Thats like the core training but it isn’t enough.  To excel as an LXP:

In the same way that a clinician applies models, the LXP uses their experience to explain, inform and solve issues.

They express their views in ways that can be heard

They validate the views of others before challenging them

They recognise the complexity of the work 

They are in tune with their feelings and can express them in ways that are helpful

They can put up with a lot of shit and articulate it so it can be addressed.  

If you have people like this working in your organisation they will engage people who are hard to reach, they will stop staff enacting myths and stigma, they will ensure that service users are thought about, they will notice when staff are burning out, they will focus on the patients best interest and challenge defensive practice, they will tell you things you hadn’t considered and they will rub away much of the Us/Them dynamic in the service.  Hollie and Lucy are the best exemplars of all the above and I know there are others like them out there.  I am a better practitioner because of my work with LXPs and I don’t think we can do anything that would reduce stigma quicker than employing more of them. 

In an NHS that seems determined to incarcerate people hundreds of miles away if there’s a chance they could be blamed if something risky happens, we need people who can hold the patients interests at heart and make organisations listen.  After years of tokenistic user involvement lets make sure that the voice of lived experience influences all the decisions in our organisations.  We’ve been deaf to it long enough. 

I could not have written the above without many and varied influences of Hollie, Lucy, Becky, Jake, Sal, Jane, Tamar, Tania, Zoe, Sue, Jen, Mel, Tori, Julia, Kath, Lou, Cameron & Andy.   Please don’t ever judge the value of your input by what the NHS is prepared to pay you.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through


Mad or Bad? – The Portrayal of Mental Illness in Joker

I am just back from watching Joker in the cinema and thought I’d share a few ideas I had while I was watching it.  This is one of the first films I’ve gone to see with a level of professional curiosity and twitter had whet my appetite by telling me it gave the message that people with mental illness  were dangerous.  

Before we start I’m going to warn you that after this paragraph, while I won’t go into detail of the plot, there are bound to be things that will spoil some elements of the film if you haven’t seen it.  I’ll add that I thought it was very good.  Gripping, well acted and with a powerful message.  Go see it to make up your own mind then have a look at how much you disagree with what I’ve written below.  

** Warnings for spoilers, violence and abuse

So we’re going to take the line that was in my head when I went to the cinema about people with mental illness being dangerous.  Throughout the film there’s a few references to mental illness.  The ones that spring to mind are Arthur (Jokers name before his name is Joker)  asking for more medication because he feels terrible all of the time.  There is another reference to having stopped taking medication and two episodes of Arthur slightly losing contact with reality.  In one he imagines being recognised, understood and hugged by someone he has admired for years.  In another he imagines someone he is attracted to liking and supporting him.  There’s a reference to him having been detained in hospital with no explanation as to why.  If you got the Diagnostic and Statistical Manual out you could probably pathologise these and I’m sure the film deliberately uses them to place Arthur in the ‘mentally ill’ bracket.  What was important for me was that none of these seemed to have any impact on the violent, antisocial and sadistic behaviour that happens later in the film.  

What does bring out the descent into violence is far better explained by the question “What happened to you?”.  We learn of Arthur being at least physically abused and neglected while a child.  This led to his mothers detention in a psychiatric hospital.  While there she says how he was always happy.  I got the impression that regardless of how Arthur had felt, his mother had pushed him to show happiness and joy.  Arthur has a neurological condition that means he laughs inappropriately, often when under stress.  I wasn’t sure if this had always been there or whether it was a result of brain damage from his physical abuse.  Either way, from a young age he was given the message that he was worthless and unworthy of protection – merely a thing to be tied up and beaten.  Arthur is told that others find him creepy and even without the psychological damage caused by his upbringing, we can picture how manic laughter under stress would be like painting a target on your back in school. 

Fast forward 30 years and we see Arthur working as a clown.  We see him humiliated and beaten again.  We see the people who are supposed to help him abandon him and we see a number of public humiliations as he reaches out to connect with others.  He doesn’t know how to fit in.  He is given a gun by someone who hears of his first beating.  When he finds himself being powerless and beaten again, it is shocking but not surprising when he turns to violence.  The next few scenes imply that Arthur is for once experiencing something like control.   While it’s mixed with fear it’s clear that someone who seems to have had a life being hurt by either others or himself, has found a way to feel powerful.  Over the next few scenes we find Arthur struggling to work out who he is, being betrayed by the only person he thought loved him and being set up for for his most public humiliation yet.  During this time Arthur learns what many people that I have worked with have learned – that power over others can temporarily rid the body of intolerable feelings of being vulnerable and humiliated.  It seems that this is a factor in Arthur choosing not to end his life as he planned, but to attack the person who had arranged his public disgrace.  As his violence increases Arthur finds an acceptance and approval that he never experienced during his times of trying to make people happy.  Every horrific act in the film can be understood by looking at not what was wrong with him, but what happened to him. 

One of the most powerful lines in the film is:


“What do you get when you cross a mentally ill loner with a society that abandons him and treats him like trash?

You get what you fucking deserve”

I’ve read criticism of this because it draws a parallel between mental illness and violence.  I’m arguing that mental illness has absolutely nothing to do with it.  None of his actions are based on any mental illness.  It would be better to swap ‘mentally ill loner’ with ‘person who has been hurt by people who should care”.  It doesn’t sound as good to the ear, but it conveys the overall message of the film better.  

Time to get the red flag out and get political.  The film makes an effort to portray society as corrupt.  Nobody helps anyone else.  There is rubbish everywhere.  Vermin roam unchallenged.  The poor are dismissed and unimportant.  Those who are interested in the poor are dismissed and unimportant.  There is only interest in those who are rich.  Obviously such a society could never exist today….or maybe it could.  This film is set in America which is the ultimate embodiment of a capitalist society, where even a self confessed sexual predator can get himself elected president seemingly on the back of being a billionaire celebrity.  The gap between rich and poor is accelerating in most western societies and in a system where people are expected to be poor, powerless and humiliated day by day, it shouldn’t surprise us that people seek power in ways we do not approve of.  As of October 1st 2019 there had been at least 21 mass shootings with at least 124 dead in the USA this year alone.  Somehow this has become an acceptable part of society which although disapproved of, seemingly cannot be addressed.

There has been a lot of disquiet about Joker.  I’ve heard that it might incite violence and I think that it could.  In the same way that Catcher in the Rye and the 120 Days of Sodom were associated with horrific acts, I don’t think it’s beyond the realms of possibility that someone who was on the brink anyway could see this film and decide to ignite a similar blaze of glory.  The film even parodies the voyeuristic news coverage that inspires the next intake of mass killers.  To watch this film and worry about the response of individuals is to totally miss the point.  We need to look outside the cinema to the world around us.  If we support a society with massive inequalities, if we condemn people to poverty based on the lottery of their birth, if we leave children to be neglected, if we tell people to seek help when there is none available and all the time we push the idea that the only thing of value is money – then we will get what we deserve.  The president of the United States has told us that people who commit mass killings are mentally ill.  This film suggests it has nothing to do with mental illness and  everything to do with the products of humiliation, poverty and injustice.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through