Just Stop: The new solution to self harm

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

(Trigger warning for self harm and abuse)

A Mental Health Act tribunal is where people who are detained in hospital against their wishes get the chance to appeal their detention.  They get legal representation and while staff argue why they need to remain detained, the solicitor picks apart their statements to show that the detention is unjust.  Watching this are a panel of 3 people – a psychiatrist, a judge and a lay person and at the end of the merry process they get to decide whether the detention is required.  In the UK, this is how we make sure people aren’t deprived of their liberty without good reason.  This bit was a bit dull, but it gets more interesting from now on…

I was at a mental health tribunal once where I was asked the question “If self harm is what keeps them in hospital and they really want to get out, why don’t they just stop doing it?”  I relished answering this but my heart sank a bit as well.  This was the medical expert on the panel and it is so frustrating that people in such a position of power hold the view that self harm can simply be turned off.  

I’m not a fan of diagnosis, but using a medical model, self harm is one of the symptoms of borderline personality disorder. In what other area would we suggest people just stop the symptoms of their illness?  “Why don’t they just stop hearing voices?”  Or even “Why don’t the manic people just calm down?”  Obviously any action that someone takes has an element of choice involved but in mental health we work with many things that people do that cause them harm.  I’m going to suggest that if the attitude we take into our work is that people should just stop doing what they are doing, it is going to be absolutely impossible for us to help them.  It also conveys the idea that people who could just stop are unworthy of help. 

If you feel that alcoholics should just stop drinking, agoraphobics should just go out more or anorexics should just have a McDonalds, this probably isn’t the article for you.  If you’re interested I’m going to try and explain how to make sense of why people do things that aren’t obviously in their best interests.  I’ll probably focus on self harm but you can use this process for understanding most things.  I’ll give it to you in a couple of steps but the order doesn’t really matter.

1- The things people do make sense

Nobody self harms for the sake of it.  Nobody self harms because of their diagnosis.  The only reason someone self harms is because in that moment, it’s better than not doing it. 

2 – You’re not that important

There’s a good chance that the reason someone self harms is nothing to do with you.  Yes its painful to see someone you’re supposed to care for hurting themselves.  Yes it’s frightening to think you’ll be blamed for what they do and yes, it can feel personal.  Despite your initial reaction you will be much more useful if you can start in a non-judgemental and curious manner.  If you have to make an assumption, work hard to make sure it is the most empathic one you can think of.

3 – Be curious

The best source of information about why someone does something is the person themselves.  I once read “She spent time in her bedroom and self harmed due to her diagnosis” which I thought was one of the worst things ever written in somebody’s notes and the winner of my “Utter Lack of Interest” award.   We need to ask questions:  Can you help me understand why you do that?  I want to understand how it’s useful to you.  How does it help?  – These are all things we can say to help people talk about why they do things and as a bonus, it gives them a sense that we are interested in them.

4 – It does something for them

Everyone’s reason for self harming will be different but its likely that they get something positive out of it.  It might allow them to feel something (because feeling nothing is terrifying), it might ground them and help them focus, it might validate their sense that they need to be punished it might…..well, anything really.  Whether it affects their physiology, thoughts or feelings there is likely to be some result that is worthwhile. 

5 – It does something to other people. 

It’s very easy for us to start thinking of ‘attention seeking’ at this point.  Lets throw that term out of the window and just think about what happens in the environment once someone has hurt themselves.  It might mean that people spend time with you.  It might mean that people don’t abandon you.  It might mean that people keep you away from something that terrifies you.  It might mean that people care for you in ways that they wouldn’t otherwise.  I remember one person who had always been neglected by his parents.  They only showed they cared when he was physically unwell.  Later in life the only time he could accept people being nice to him without a crushing sense that he didn’t deserve it was after he had poisoned himself.  If we ask, we can find out why it makes sense. 

6 – But they could just ask us!!!

But you won’t ask for things you don’t think you deserve.  Many people have lived lives where they were never given what they asked for.  Even if they did ask, let’s have a think about who is given the clearest message that people care about them – Is it the person who asks politely for support or is it the person in their room turning blue with a team ensuring they stay alive in that moment then watching them for the night?  In mental health services we are very good at conveying the message that the amount of care you receive is related to how dangerous you are.  It’s weird that we then get annoyed when people respond to that. 

7 – We can’t see the choice they’re making

If we don’t ask, we are in danger of thinking people self harm for the sake of it.  It’s very hard to sympathise with that.  If we can see a choice between cutting and another night of staying awake replaying the most traumatic experiences in 3D IMAX in their brain – it makes a lot more sense.  If we can see a choice between overdosing and feeling that your head is going to explode it makes a lot more sense.  If we can see a choice between head banging and listening to the voice of the person who hurt you telling you how awful you are and that you deserved it and that no one likes you and it will never get any better, ever – again, it makes perfect sense.   

We won’t know what is going on for someone until we ask them.  We need to make sure we do that.  

So all of the above are just some ideas.  Others are available so feel free to dismiss it.  I’m going to suggest that if you can do the above you’ll be much more effective at helping people.  It might even mean that you work on the problems that lead to people hurting themselves, rather than just trying to stop the self harm itself.  Don’t be the person with a deciding vote in someone’s liberty thinking that they should just pack it in.  Be curious, be empathic and honestly, if stopping was easy people would do it.  

It is the height of arrogance for me to be writing about this.  People who actually experience these difficulties do it much better.  I highly recommend this by @hoppypelican.  

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

It’s #TimeToTalk about #HarryPotterBookNight – The reality of 11 years in a cupboard

Keir provides consultation, therapy and training to help people with experiences like Harry’s, via www.beamconsultancy.co.uk

It is February 6th and this auspicious day brings together 2 great celebrations.  Firstly it is #TimeToTalk day and secondly it is Harry Potter Book Night.  At first glance there is no obvious connection but….lets take a close look. 

Time to talk day “is all about bringing together the right ingredients, to have a conversation about mental health”.  Last year I wrote a piece about the value of talking – not so much going to services and asking for help, but sharing some of the burden that we carry with those around us.  I took a bit of flack for writing it, partly because I think I lost sight of the privileged position I inhabit – I’ve led a life that has given me the conviction that I’m worth something, and I know that there are people around me who are interested in me and want to help.  It is a lot harder for people who haven’t had these gifts and I know full well that getting help isn’t as simple as asking for it.  What I wanted to get across last year is the relief that can come from sharing your worries with people. 

I work in a therapeutic community and for all the times I’ve seen people struggle with something that ‘cant be said’, not once have I seen people experience anything like the rejection they expected.  Equally in my own life, the things that I thought were too hideous to be unveiled seemed to lose a few warts when brought into the light.  Too many people will kill themselves without ever sharing any of their despair and I’d urge everyone to try to make an effort to make mental health (or ill health) something that can be talked about.  That might mean taking a risk and sharing something with people you trust, more importantly it might mean letting the people you care about know that that conversation would be ok.  

So this is all very worthy, but what does this have to do with Harry Potter?  I loved the Harry Potter books and my children are now picking up my old books to follow the adventures of the hero of the wizarding world.  Harry has a range of people who care for him and he inspires them to be a force of good in their lives.  

My experience of the world tells me that Harry is in a relatively unique position.  His parents died in his infancy and he was placed in the care of the pantomime villain-like Dursley family.  He spends the first 11 years of his life living in a cupboard under the stairs.  He is treated like a servant by the adults and bullied by his stronger, bigger cousin.  For 11 years he is constantly criticised, belittled and told that everything is his fault.  He is punished for trivial misdemeanours by being locked in the cupboard.  His birthday is never marked and his clothes are the massive hand me downs of his larger cousin.  We might imagine this leads to further bullying in school.  These tend not to be the ingredients for a charismatic leader.  

I work with a number of people who have had similar childhoods to Harry.  They didn’t go to school and make friends, instead they went to school feeling utterly worthless and fully deserving of any mistreatment doled out to them.  Their relationships with their peers and teachers were shaped by their core belief that they were insignificant, that no one would be interested in them, and that any interest that was shown was only to humiliate them more later.  The self hatred they experienced led to them acting as if they were deserving of hate.  They would hurt themselves or let others hurt or use them.  Their experience of others led them to believe that they shouldn’t be in the world.  Sometimes they sought death but even in the best of times (which were few) death wasn’t something to run away from.  Sometimes they would connect with another person but their conviction that they were unlovable led them to acting as if that was true.  It could also lead to them spending time with people who treated them like they thought they should be treated, because care and kindness felt too wrong.  They often end up with a diagnosis that labels them as being flawed in some way when all they have done is learn what the world has taught them.  

Harry made friends in his first year of senior school.  He also found adults who cared for him and one in particular who became something of a father figure.  At the end of the first school year this father figure sent him back to the people who kept him in a cupboard.  The argument was that it stopped him from being killed.  The reality would probably be that he would end up wanting to die.  

We cant expect little Harrys to tell us about their misery and neglect.  It’s more than likely that they  won’t know any different.  We need to keep our eyes out for the children who are continuously sad, the children who are never made to feel special and who are dressed in ways that could only bring humiliation.  When we see such things, it time to talk.  When little Harry’s are talked of as being disordered, its time to talk.  When there is no help for people like Harry, or the help only makes things worse, it might be time to shout. 

Thanks to @hoppypelican for helping me shape the ideas for this blog.  

Keir provides consultation, therapy and training to help people with experiences like Harry’s, via www.beamconsultancy.co.uk

 

Learning to Be Me: Treatment in A Democratic Therapeutic Community

Keir provides training, consultancy and therapy via beamconsultancy.co.uk

One of my favourite ways of helping people is the day therapeutic community.  I got a chance to work in one around 2010, a time when I held (pretty tightly) some of the more stigmatising views people express when talking about ‘personality disorder’.  I joined for a year and left most unwillingly after 2 and a half.  I spent 5 hours on a Monday in a group being genuine with people.  I worked with experts by experience and saw those who I’d thought of as being manipulative and attention seeking being brutally honest and utterly self sacrificing.  Aside from the change the group made in me, I saw people who had been on the verge of death from self injury move into lives where they could care for themselves and allow others to love them.  It was a powerful transformational learning experience for me and it is with much pain and despondency that I see this way of working move into the shadows, eclipsed by DBT and other 3 letter therapies.  In a world where services for those who hurt themselves tend to be easily forgotten or overlooked, 2 of the day therapeutic communities I was part of either won or were the only mental health team shortlisted for the NHS Wales awards.  Both these services have now closed and it feels palpably ironic that services can be both celebrated and praised for their excellence while also marginalised and unsupported.  Perhaps one of the reasons people find therapeutic communities hard to support is that they are difficult to understand.  The lack of direction can be uncomfortable.  The idea of patients having full control of their group can be terrifying – especially to organisations that try to eliminate risk.  In many ways the only way to understand how a TC works is to see it.  In the world of social media I’ve always hoped for someone to write an account of their time in a TC to give people an indication of what it feels like.  When I voiced this on twitter one day the marvellously articulate @shadesofsky offered to write that very piece.  A few months later here it is, a powerful account of what a TC can feel like.  I hope people read this and think of TCs as an option.  I hope commissioners and clinicians read this and remember that recovery isn’t only spelled DBT.  I hope people can remember that the NICE guidelines say we need to give people a choice.  Finally, I hope you enjoy reading this as much as I did.

Keir

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It’s 4pm on a rainy Tuesday afternoon. I’m a member of a Democratic Therapeutic Community for people diagnosed with Personality Disorders. I’m sitting, curled tight on a sofa that’s nearly collapsed in on itself, trying not to do the same. My knees held fast against my chest, my hands are tearing at my hair. 

I want out.  I thought that this was one place I was understood, but I was wrong, wrong, wrong. I am always wrong. I myself, am wrong. I want out.

 I am crying, hard. I’ve left the community meeting in despair again. Run away, because someone said something that I couldn’t handle. I don’t like it here. My anger is too intense. I can’t stand conflict. I am too full of anger. The whole community hates me. I am too messed up to be put right. I need to leave. 

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It’s 4pm on a rainy Tuesday afternoon, 15 months and 500 miles away from that Tuesday afternoon. I am remembering what I used to be like, when I was starting out treatment. Even after spending 12 months in the preparatory group, I was still a crumbling wreck. Brittle, the psychiatrist said. I would snap at the slightest thing. Cry. Self-harm. Stop eating. Nothing – not courses of CBT, years of counselling, exercise, book prescriptions – nor medication had worked to change my mental health. I was volatile and lonely, with a self-esteem on the floor. Not that you’d know that from the outside. When I started in the TC, I worked multiple jobs, more than full-time hours, teaching; researching. Striving. Pretending to the world that all was OK. Trying to run faster than the emotional maelstrom baying at me, without success.  For the past few years, life outside work had been getting messier. And I was terrified that I wouldn’t be accepted in the TC. I had never belonged anywhere. 

The TC, (group therapy for 15 hours a week) had offered yet another treatment option. Therapists from different health backgrounds, work with service users, as equal members of the community. Each member joins via a case conference which identifies the things that they would like to change in therapy, for a period of 18 months. I was voted in unanimously. I wanted to work on trusting others; on kindling a sense of self-worth, on handling conflict without falling apart. And on not needing to work so hard. But a few months in, I was crying more, breaking down more often. I had returned to the self-harm, that I’d been obliged to stop for a period of four weeks, as a condition of entry to the community. I felt intensely disliked. I was utterly unlovable: rotten to the core, my inner voice whispered. I’d given up working many of the hours I was doing. But I felt more depleted than ever. And I still felt rubbish. 

The community held me to account for my walk-out. I had to explain what had led me to leave; how I felt; what could stop that happening again. I had to face the reality of how getting overwhelmingly distressed and leaving the group had left others feeling. It was not comfortable. It left me feeling like I wanted to leave for good. But I didn’t. I kept going back because people would notice if you weren’t there. I went to group after group after group, day after day. 

TCs are set up to work like a microcosm of life outside. So, the idea is that with a small number of therapists and service users, each person will end up re-enacting the patterns of interaction that they use outside. And, within the boundaries of the TC, those patterns are examined and reflected upon, and changed.  There are endless boundaries in a TC. Twelve months into treatment, I was still discovering them. But I like structure and routine. After breaking the rule around no self-harm, I was put on a contract “to not cut”: and haven’t broken it since. The strict timings of opening and closing community meetings, the definite rules around contact with community members, the accountability for my actions, were keeping me contained. I struggled against flexibility; around times when the boundaries were deliberately broken – even by therapists – times that left me feeling like a small, lost child again.

Held by the boundaries, a few months into treatment, I was beginning to open up. Each week, the TC divided in half for “small group” – a time to test thoughts with a smaller number of people, look at events that had happened that week in more detail, or to share something new with the group. The feedback here was also painful. I was prickly, clipped, even condescending at times. I worked hard with the group to explore reasons for that. I was encouraged to take responsibility for the way I was acting – but not to blame myself for it, either. There was a reason – perhaps a wound that I was protecting – that was beyond my conscious experience – and that was driving my behaviour. The more I understood my knee-jerk reactions, the better position I was in not to resort to them. 

TCs don’t just consider interactions in the present. They consider their history, too. One way of doing that, in the TC I was a part of was psychodrama. Acting out the past. One time, I was nine years old, on the playground again. S — was standing in front of me, with J— and B— beside her. J—‘s family don’t want to buy a copy of the school class photo’. That was my fault, because it’s not a class photo’ because I’m in it, and I was not supposed to be in that class. I was in the wrong class. In the days before PhotoShop, S— and J— wished that they could scratch me out of it. So do I. I wished I could erase myself completely from everybody’s lives. Everyone hated me. Even my teacher standing less than a foot away didn’t respond as the slap S–struck across my face echoed over the playground. The whole world hated me. In the psychodrama, I fight tears, fight for control, as this scene is laid before me. I must stay in control. I must not cry. I am not nine years old. S— is not about to hit me for calling her a name, in despair because nothing else has made her stop. I’m OK. Really. I’m OK. The echoes of my present thought patterns are there. Surely, I’ve processed stuff that happened over 20 years ago. It wasn’t not your fault, S —. You were nine. The adults let you down.  So the therapist says.  The TC offer a different perspective on the past.  I have to work hard to believe that what happened when I was a child was not my fault. 

We spend time each week going through the Structured Clinical Interview for Diagnosis II. Each and every trait of personality disorder. And conduct disorder. We work as a group, reflecting whether we think we have the trait, and get feedback from the rest of the TC. As expected, I meet the criteria for EUPD. But I also meet the traits for Avoidant Personality Disorder, too. I intensely fear rejection. I am scared to let people in, unless I can be certain that I will be liked. So I distance myself instead, most of the time. It’s safer that way. I have some fairly rigid thinking, too. I like boundaries: I find flexible interpretations of the rules harder to bear.  Knowing the traits is useful. 

In Objectives (PsychEducation by another name) we go through model after model to try to explain our distress. I consciously try to apply my experiences to each one, to make some kind of sense of the mess. Radical acceptance, concepts from DBT, help me most. Seeing each emotion as a guest at your house. Trying not to slam the door on it, but to invite it in, instead, to get to know it better.  Mentalising, too. Thinking of all the other reasons why that person didn’t reply to my message, that aren’t about them not really wanting to be my friend. The world brightens after a realization like that. 

The TC has a creative hour each week, too. I relished these. This was something I could do. I was allowed to write about how I felt, and that I could do. I wrote letters. Letters to my ex-partner in prison. Letters to my four year-old self. To myself. But writing is easy for me. I am challenged to use a different medium. I recoil. I’m less certain of myself in the break times as well, at first. I prefer to go where others aren’t. Hide on my ‘phone. Others might not want me to be hanging out with them, anyway. 

Around ten months into treatment, things start to change, measurably. I have drawn a rose in the creative session. And the rose is in bud, and delicate, but it is growing, and I am beginning to believe that it will bloom. I have started dating. I think I can trust someone else that  much. I am more accepting of the bad bits of me. Some things still get me. Using ableist language is one very quick way to get me riled.  But maybe that’s useful, too, if I can use that anger in a helpful way. 

A few months before I leave, I start applying for jobs again. And I get one, to dovetail with my leaving date from the community. Apart from, as much as I wanted to leave, three months into treatment, I don’t want to leave now. I have made firm, secure attachments to members. They have seen me scream and cry, and they still come back to me. They know the authentic me, and they still seem to want me around. But they encourage positivity in me, too. They are excited that I have a new job, in a new country. A new place to live. They wish me well. And I leave. I am now not allowed to contact them until they are discharged. I miss them, even a couple of months later. And things have been stressful with the job and the move, and I crave the structure of the TC to hold me safely again. I am frightened that I’m going to be no good at being an adult. But I am acknowledging that, rather than hiding at work. TC was tough. Leaving it was heart-rending. I am scared of life beyond its boundaries. But TC has given me the determination to make the most of what I have; to look forward to the future. I believe that the best is yet to come. And I can’t wait to live it. 

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@shadesofsky is certainly worth a follow on twitter.

Keir provides training, consultancy and therapy via beamconsultancy.co.uk

Throw Away the Key: An Alternative to Women in Prison?

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

This is a very lazy blog, but on a day when there are calls for women’s prisons to close, I thought I’d dig out an old essay I did for my MSc. This was my least academically successful essay and earned me the feedback that I had portrayed women as victims. Should you ever be tempted to write a similar essay, you’ll find it is very difficult to do otherwise given the amount that the system victimises women.
We had to describe a service that would better respond to the needs of women and my attempt is below.  It will help if you know that the Corston Report was “a review of vulnerable women in the criminal justice system”.  Enjoy

Welsh – “Fenyw” (noun)
“Woman” (verb )English

A Service for Women in or at Risk of Entering the Criminal Justice System
My experience is in working in the community, most often with people who have not be arrested and convicted of crimes. There is a tendency to think of the forensic population as ‘other’ however many of the behaviours exhibited by my clients, if done outside the context of a mental health services, would certainly be of great concern to the general public and thus the agents of criminal justice. I will outline a service that would help the clients that I work with as well as those who have been arrested for crimes, those who have the capacity to hurt themselves and others, who struggle to maintain relationships with families and partners, and who experience strong feelings of rage, fear, helplessness and despair from those who work with them. In one sense, my service could be thought of as an organisational intervention that will target aspects that professionals find difficult to think about. In another way, my service would be for the clients as it will focus on and hold in mind the aspects of people that services are often keen to push away.

Before designing the service it’s worth looking at why change is required. The Corston report itself puts forward a number of reasons why the status quo is unfair. It can be argued that the system discriminates against women. (All of the following figures and statistics are taken from Corston 2008). Women are twice as likely as men to be jailed for a first offence. This is despite women committing less violent crime. In court women are more likely to be remanded to custody than men yet over half of the women remanded do not receive custodial sentences. If over half of the decisions to incarcerate are deemed unnecessary when the accused is tried, it seems that something untoward is occurring when women first enter the criminal justice system.
Women commit different crimes to men being involved in more acquisitive crime and substantially less involved in serious violence. Not only are their crimes different, the reasons behind their offending are different, with relationships, accommodation issues and substance misuse being greater factors than for men.

Ethically, the punishment aspect of the judicial system seems harsh for a population already suffering. They are frequently victims of crime, ill or already punishing themselves. 80% of women in prison have diagnosable mental health problems with twice as many women as men seeking help in the year prior to their sentence. Despite making up only 5.5% of the prison population, women account for 51% of the incidents of self harm. In prison, women are more likely than men to kill themselves. Two thirds of women coming into prison require detoxing from drug addiction. It might be unsurprising that women in prison hurt themselves given their backgrounds. Half of them have been victims of violence while one in three (compared to one in ten men) have experienced sexual abuse.
It seems sadistic to be harsh to this population yet the experience of prison is felt more harshly by women than by men. There are the invasive searches which cannot be well received by the third that have been sexually abused. There is the fact that a third of the women are lone parents who suffer knowing their children are not with a parent. 12% of women prisoner’s children will be looked after by strangers in the care system. When in prison, 30% of women lose their accommodation often including their possessions. To compound the punishment, women are separated from their families. Living in Wales, if my wife was to be unnecessarily remanded she would serve her time in a different country.
Discriminating and sadistic…it makes sense that Corston would want change. Others might take issue with Corston’s report and seek to emphasise the similarities between men and women. Adshead (2004), looking at forensic mental health patients, highlights the similarities in the in the backgrounds of males and females in secure settings with high levels of childhood abuse and neglect coupled with high levels of lifetime and childhood victimisation in both sexes. While this is a risk factor for violence in men Adshead points out that the gender stereotyping of females means that the masculine trait of violence is likely to be interpreted as madness in women but understandable in men. Women then go to hospital while men go to prison for the same actions. What we could take from Adshead is that a focus on the outcomes of abuse and neglect might be less important than an understanding of how the past affects us. Rather than treatments for men and for women, an intervention for victims/perpetrators of violence might serve better.

To adequately design a service that meets the needs of women, we need to understand the population we serve. I’ve already outlined the deprivation in backgrounds of many female offenders. When we add that “71% of female offenders have no qualifications whatsoever” (Civitas 2010) we can picture a background of poverty, stress and deprivation. “60% of women in prison are single. 34% of women in prison are lone parents. Around two-thirds of women were mothers living with their children before they came into prison” (Corston 2008). Nearly two thirds of boys who have a parent in prison will go on to commit some kind of crime themselves (Prison Reform Trust 2012).
We can picture some of the difficulties at home (if the children can stay at home). There is not only the statistical impact on offending but from a psychological perspective there are many examples of people who have a history of early neglect and/or abuse who go on to unconsciously recreate their pasts with the next generation (Motz 2008, De Zulueta 2008)
Some of the needs of this population are obvious: drug abuse, being unemployable due to literacy and numeracy deficits, lack of housing, difficulty parenting, self harm and mental health problems. Fenyw will address these needs and more. In describing Fenyw I am not going to confine my thoughts to a specific service and building, instead I’ll attempt to describe elements on a pathway that I feel are essential while leaving the practicalities of how this might be achieved to better minds than mine.

Keeping Women Out of Institutions

There are many arguments above as to why prison is not a good option for women. In my work I see people routinely hurting themselves in the community and uncontrollably maiming themselves in institutions. Studies show how restrictive environments can increase the frequency and severity of self harm (Harrison, 1998) while Pearson suggests that “suicide attempts and assaults are increased when women are detained in secure settings where the means of self harming and the access to substances that might dampen feelings” are reduced (Pearson 2010). Part of Fenyw would be to provide an advisory service to courts to divert women from custody wherever possible. Fenyw would hold in mind the idea that “Custodial sentences for women must be reserved for serious and violent offenders who pose a threat to the public.” (Corston, 2008).
To be able to thoughtfully divert women from prison Fenyw would need to hold a balanced view untainted by discrimination and mindful of what does and doesn’t work. Fenyw would remember “it is very unusual for women to act violently at all” (Adshead 2004) and that female violence is often directed at themselves (Motz 2008). We would embrace Welldon’s (1998) notions of the child being an extension of the mother’s body when recognising that 40-45% of female homicide offenders kill their children (Yakeley, 2010). We would also hold in mind that a third of female homicide offender’s victims are their partners while 80% are close family members (Yakeley, 2010). Fenyw would hold the idea that the vast majority of female offenders pose little to no danger to the public at large, therefore they do not need to be imprisoned. I think of my experience of Women’s wards and while I haven’t worked on one I have always been aware of their reputation as being the most violent and chaotic wards in the institution. Staff seemed to be regularly assaulted, residents were always fighting. Given the statistics on women assaulting non family members it seems that there must be something toxic on female units that allows women’s usual patterns of violence to be subverted to such an extent. Fenyw would avoid these environments as much as possible.
Diversion from prison would be done on the basis of a psychological formulation consistent with the Personality disorder pathway. Some would have to go to prison. Some would self harm to such an extent that they would need protection from themselves. Fenyw would stay involved to ensure periods of restriction were as short as possible. Much as I resent the notion of hierarchy in the NHS and other institutions (not least coming from the lowly status of OT) Fenyw would need consultant psychiatrists to be part of the team to take on an RMO role from staff who see the only solution to risk to be greater restrictions and heavier nurses.

Within the NHS and criminal justice system, self harm is often a fast route to responsibility being taken from you and restrictions being placed. Fenyw would make the understanding of self harm a priority for the service. This is an important distinction as while the service will help people who wish to stop self harming, the focus will be on making sense of the purpose of the act. You wouldn’t need to work in my organisation for long meet someone who regularly cuts themselves at home, but  in a ward environment gouges their arms wit broken CDs or torn Coke cans after their blades have been taken away to “keep them safe”. Based on a psychological formulation of their behaviour, Fenyw would understand self harm as a communication (Motz 2009), a way of solving a problem (Linehan 1993), a re-enactment of past abuse or as something else that made sense to the client. Fenyw would then thoughtfully only remove responsibility from someone in the most extreme circumstances and then in the least restrictive way possible for as short a period as possible.
A Different Community Service

I envision women being diverted from court to the women’s centres Corston described. I would take her recommendations further and rather than the centres be places to refer and signpost, I would have them co-run with the NHS to provide ongoing intervention and support. Residential accommodation would be on site as well as units to cater for families and units to detox those who required it. The women might attend local centres to be able to work on their difficulties while living in their usual environment. Sometimes it might be more beneficial for the women to have a new start away from old toxic relationships where the process of starting new relationships can be examined and thought about. People might be compelled to attend these centres when they are sentenced but for me this is where the compulsion should end. My probation colleagues speak of the lack of reward inherent in providing interventions people attend under duress.

My background is in working in Day Therapeutic Communities where the only expectation of people is that they come – everything else can be talked about. Within the women’s centres I would work to the principles of the therapeutic community – attachment, containment, communication involvement and agency. (Haigh, 1999) In essence the centres would be a place where women felt they belonged and were accepted, a place where unspeakable thoughts can be put into words and acted on, a place that the women own and sustain. It’s not easy to engender these concepts but for those who cannot make use of the formal therapy on offer, this very different and more subtle intervention has more of a chance of success. The enabling environment of the TC can build the sense of belonging and personal efficacy the clients are unlikely to have developed in their backgrounds of deprivation (Pearce& Pickard 2012). Key to maintaining the ethos of the centres will be the roles of Experts by Experience in the centres. Thus much of the modelling, sharing, advice and direction will be imparted by people without a theoretic knowledge of offending and mental health, but with a lived experience of surviving trauma, illness and the criminal justice system. Those with lived experience have been shown to provide better outcomes than traditional services when “engaging people into care, reducing the use of emergency rooms and hospitals, and reducing substance use among persons with co-occurring substance use disorders. …peer staff have also been found to increase participants’ sense of hope, control, and ability to effect changes in their lives; increase their self-care, sense of community belonging, and satisfaction with various life domains; and decrease participants’ level of depression and psychosis.” (Simpson 2002).

The client group Fenyw targets comes from a background of abuse and neglect, where the template for healthy relationships has not been taught, and where communication has been more through actions than words. One of the main goals of Fenyw is to help our clients to use help and much of the work will be exploring the relationships that develop in the centre. Motz (2014) highlights the impact of experiencing and witnessing intimate partner violence and the frequency with which these toxic relationships are replayed later life. Fenyw will attempt to help its clients understand their relationship patterns in a community setting where mistakes can be made and thought about.

While Fenyw’s TC elements would qualify it as an enabling environment (Haigh et al 2012) there would be a number of other therapies on offer. What people attended would be based on their preference and formulation with a focus on managing acute problems first. I would struggle to make use of anything if I was withdrawing, psychotic, penniless, separated from my children and/or homeless. Staff including social workers and experts by experience would prioritise these needs. Once clients are able to think about more than survival, psychologically focused individual and group work would be on offer including DBT, metallization and psychoanalysis. In addition there would be roles in the centres which clients could take on the gain work experience and qualifications, there would be links to voluntary work and education and a program for increasing literacy and numeracy. Ideally our initial clients would be our future experts by experience.
What I have outlined in the two points above is an organisational intervention to keep women from going into environments of high security and a clinical intervention to subtly provide a healthy attachment for the women to go on to make use of more structured therapies. My rational for doing this is that people who readily identify their difficulties and believe change is possible tend to do well in therapy. Alas from the profile outlined earlier, these people are not reflected in the female prison population.

The difficulties for staff working in Fenyw will be significant. “Without robust frameworks to make sense of the intense emotional content of interpersonal contact there is a high risk of…(staff) being drawn into toxic relationships with the women patients, other professional groups and each other (Aiyegbusi 2004). The relationship difficulties of the past will be played out in the centres. Not only do we ask the staff to help those who have little experience of carers being helpful (Hinshelwood 2002), we ask them to thoughtfully hold back from the urge to protect those who are communicating their pain and to let the clients learn from their peers rather solving problems ourselves. This is all while the staff are holding ideas about those who hurt others coming to an easy option rather than being punished. One solution is to employ the mythical ‘right staff’ but in their absence, the service user consultants will be key to ensuring that splits are reduced – its hard to think of ‘us and them’ when the staff have been in prison and the offenders are in the staff room. Also “the experience of co working with service users reconnects staff with them emotionally” (Farr, 2011) reducing the risk of dehumanising our clientele. This deconstruction of the powerful/powerless dynamic that has proved so unhelpful for this client group will be difficult for staff, used to being in positions of authority, as they adjust to a different role. Tuck & Aiyegbusi write of the damage staff can sustain when receiving the raw communication (projection) of their clients trauma. Staff “need supportive, containing structures where they can think about their relationships, test reality and reflect on their experiences thoughtfully. (Tuck, G & Aiyegbusi A 2008).  Fenyw would provide regular individual and group supervision to help staff process the experience of the work. While our staff would recognise our clients as victims, they must not “behave as if they had no idea why their clients had been imprisoned in the first place” (Barrett 2011) so supervision would help us to keep a balanced view of those we work with. Fenyw’s leadership must promote an environment where mistakes are opportunities to learn to reduce the chances of a blame culture developing. We would also emphasise shared decision making (particularly with our clients) so that no one person is held accountable.

The goals for Fenyw would be typical of a criminal justice/NHS service. We aim to reduce offending. In addition reduced self harm, mental health problems, substance misuse and more clients having stable accommodation would be key. These might be achievable via increased problem solving skills, parenting skills, literacy, numeracy, sense of belonging, self efficacy and people in work education or training. Also we’d like less children going into care and victimisation (avoiding typical relationship patterns). Because Fenyw will keep clients in the least restrictive environment, there is potentially a risk of increased completed suicide or accidental death when engaging in potentially lethal self harm. It would be important to measure the quality of life of clients currently in prison/secure settings to compare it with those in the women’s centres. Many would be fearful of a higher number of deaths, but there would be less people living in hell. This is likely to be a highly contentious issue for the public and the media but for Fenyw to be successful it cannot replicate the environments that seek to eliminate risk which currently fail women so badly.

Our women’s centres cannot be islands where men don’t exist or are seen only as abusers. There will be a mix of staff so that the experience of a relationships  can be scrutinised and thought about. After the women have gained some understanding of their patterns of relationships (either from individual therapy or the TC) they will be encouraged to explore relationships  in the community, ideally in environments outside of mental health or criminal justice. Women would move from residing at the centres, to attending regularly to attending as required as indicated by their formulation.

 

And that is my ‘Moon Under Water’ of the female criminal justice world. What you missed out on was another 1000 words about what it was like to study women in a largely female educational environment.  Interestingly I started wearing figure hugging tops and grew a beard.  No doubt if the course was a few weeks longer I’d have dragged the carcass of an animal I’d hunted and killed in with me.

The service I described is quite idealistic but certainly no worse than the prison environment where something so toxic happens that women kill themselves at a higher rate than men. As ever, let me know what you think. Keir @keirwales
Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

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246-257, (ed.) P Campling and R. Haigh, London and Philadelphia: Jessica
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Hinshelwood RD (2002) Abusive help– helping abuse: the psychodynamic
impact of severe personality disorder on caring institutions. Crim Behav Ment
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Care in the Community

This really is cheating but just to let those who follow the blog know, my blog on the importance of using forced residential care as a last resort is published by the Mental Elf today at

https://www.nationalelfservice.net/mental-health/personality-disorder/psychodynamic-programmes-for-personality-disorders-residential-versus-community-treatment/

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