Saturday, September 23, 2017

The Chronically Suicidal Patient and Stigma from Within the Mental Health System

There's an on-line psychiatrist discussion group where docs exchange information, ideas and resources.  As in all things on-line, it's sometime is invaluable, and it sometimes makes me shake my head.  Today, I was tagged in a post that discussed an article in Psychiatric Times called We Need to Talk About Stigma in the Mental Health System.  Louise Harvey writes about her hospitalizations in the UK.   Here is an excerpt so that you get the idea, and in the UK the term "sectioned" means involuntarily hospitalized.

Quickly it became clear that I was considered to be a histrionic, attention-seeking young woman whose problems amounted to an individual moral failing, and a refusal to take responsibility. I was not alone. There were other young women my age and we were all subject to the same invalidating experiences which served only to exacerbate our distress.
Our common presentation was self-destructive; we self-harmed and attempted to take our own lives, refusing to suffer silently once our despair had surfaced, the seasons of being able to keep our demons under lock and key well and truly over.

The common refrains we would hear from mental health nurses and doctors went like this: ‘just take responsibility;’ ‘there’s nothing wrong with you;’ ‘you are bed-blocking’ (even though they had sectioned many of us, including myself, and it wasn’t in our power to free up any bed); ‘stop playing games;’ and the worst of all, ‘no one believes you.’

Despite being considered a risk to myself, and lacking mental capacity, these judgements were accusations of mere misbehaviour and laden with mixed messages: ‘you are too ill to make your own decisions,’ and simultaneously, ‘you should stop being willfully disobedient.’ It must be noted that these comments were not levelled at the male patients on the ward, and were not reserved solely for younger patients.

This kind of treatment followed me for years until a desperate attempt to take my own life by jumping from a bridge startled others into taking me seriously. I wasn’t meant to survive. I felt that I was a lost cause and that my inability to just snap out of the madness was a personal failing.

I may not have died, but stigma within the system kills. It is far deadlier than any amount of stigma that one might face outside of the system because these are the professionals we are told to go to for help. Many of my friends who were treated as I was have since taken their own lives because their distress was not taken seriously.

This was my response to the group of psychiatrists, based on my experience as a clinical outpatient psychiatrist and upon the research I did for our book, Committed.  Just so you know, within minutes, another psychiatrist called me out as being wrong, so take it for what it's worth.   And remember, these issues of how to manage chronically suicidal people are very difficult for everyone: the patient, the family, and even the psychiatrist.
Thank you for tagging me. This is a wonderful article, it gives us an insight into the world of the patient. I think we've all been ingrained (as people, not psychiatrists--if those can be different) that if someone does something negative to get attention, then we should ignore it so as not to reinforce it, and people who get suicidal as a means of 'seeking attention' (a horrible thing...note sarcasm) are often dismissed, or punished-- and the inpatient unit here is often used for punishment. The label "borderline" turns into name calling/blaming, and not the acknowledgment of a personality gone awry and something that no one would ever want to have. Would you want to live a life where stress made you feel suicidal or where slicing your skin was the only thing you could find to alleviate psychic pain? Of course not, and yet we, too, often blame the patient. 

What the behavioral 'ignore it' doesn't include is the Skinnerian concept of an "extinction burst." If you ignore a behavior to get rid of it, the behavior escalates before it extinguishes and in these cases, you end up with a dead patient. I fully believe that if someone is asking for attention with suicidal threats/gestures, you give them attention, in a kind and caring way. And you point out to them what they are doing, how upsetting it is, and you suggest that if they need attention, they might try asking for it rather than upping the ante. I've been known to call family members and say "your family member needs some TLC, they are feeling suicidal and would really appreciate some of your time and attention." It's a much quicker phone call than looking for a bed, and so far this hasn't come back to bite me, fingers crossed, no one has ended up dead. And I have been known to talk suicidal borderline patients out of going to the hospital (although I do say, if you really think you are actually going to kill yourself, then do go to the ER!). 

Short term (few day) hospitalizations may help people to regroup and live through a rough moment alive and so it should be done if there is no alternative, but this is not the best setting for a person with a personality disorder, and if the wrong chemistry occurs on a unit, things may get worse. Also, people with borderline personality disorder generally have co-morbid mood disorders that should be treated aggressively. Many people who behave terribly stop doing so when their mood is better. More than you wanted, and you know, it's a hard group of people to work with, and I am not the best at it. No deaths, but often these patients leave my care, and sometimes to my relief.

Also, do see my article over on Clinical Psychiatry News called Suicide: A Surprisingly Ambivalent Topic


Anthony Peckham APRN, PMHNPBC said...

Suicidality comes in many personal contexts. The exfreme negativity of the borderline personality is difficult to get a feel for. Emergency stabilization is a supportive safe environment while the patient complains contnually and with the energy of genius that the misery of their lives is only extended by the miserable treatment offered in the unit. Well that's true to their experience, an attitude fixed and pervasive. To soften the defenses, to open the shuttered mind, to seed new life in the desolate geography of the eclipsed imagination is the fix. By comparison suicide watch is therapeutic but of limited value for the extent of the problem of chronic suicidality. Modelng compassion and sensitivity to unit staff to help maintain clinical objectivity is needed. Staff may not know how to interact with these very special, unusually dark and conflicted personalities.

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clairesmum said...

Good post. All behavior means something, even with patients with dementia. It's the job of professionals and paraprofessionals to listen and find out what the behavior means to that person. Borderlines are just people that we haven't figured out how to hear and hold safety so they can heal. Hospitals used to be places of safety and healing and holding so that a person could collect themselves, in a structured milieu that anchored the person to the real world.

Anonymous said...

Know two young women, diagnosed with EUPD/BPD from teeange years. Rediagnosed and treated for depression for one and schizophrenia for the other. |Suicidality and self harm disappeared! How much time and grief would be saved if psychiatrists did a thorough review of patients. Often seems to be you are young , female, self harming must be EUPD. And ny the way that menas you get no treatment and just have to somehow learn to manage it. Very recently read that depression in teenagers often presents as school refusal, irritability, etc. not as classic symptomns of depression in proper adults......

Fertig said...

"And you point out to them what they are doing, how upsetting it is, and you suggest that if they need attention, they might try asking for it rather than upping the ante"

Nice notion but makes it seem lie their state of mind is more upsetting for you than for them and that they have total control or outside supports to just go ask for attention in a healthy way. Hmm. The what they are doing part is interesting, because I do believe that more often than not, people become more actively suicidal as a result of what has been done to them as well of triggers (reminders of what has been done to them). Not to make it appear as none of the chronically suicidal have any social supports or other resources, but I do believe that we are looking more at trauma than not and you can talk about resilience ad nauseum, but many factors play into that and it is not really rocket science.
Borderline was rejigged by J Herman. Is it a personality disorder or more of an adaptation to a traumatizing environment. We have all lived through all sorts of traumas in life and I will not speak about big T vs little t, but I will say that chronic suicidality is probably a normal reaction to some pretty awful events when no one was around to give a hoot and no one since has respected the reality of the horror and the fact that no matter ho hard any therapist tries, they are never, not ever going to make up for what was absent in childhood with any of their techniques or meds and no matter how empathetic or hard nosed they may be. The chronically suicidal suffer a great deal and no one can help them. The damage done can never be undone.
I never went to med school but I know this. I do not seek attention and neither do I know what may or may not one day tip the scale to the point that chronic becomes right here and right now, but I do know that if it does, no one will have advance notice.
And sure, treat co-morbid disorders "aggressively" so that you can say you truly tried but there is so much overlap between chron s and co that you do not really know what it is that you are treating. Ah, I've never known or considered a brief H stay to be a break. They are holding pens at best and places which re-traumatize at worst. Sigh. TLC --what a funny idea. No wonder I barely come on this site anymore.