Validation – Working with People who Think the Wrong Things

After another day of training people around how to work with people who hurt themselves and find it hard to trust others (often diagnosed with Borderline Personality Disorder) I was left thinking about how eager staff are for ways to be helpful. The generic ward and community staff often have a sense that they can offer nothing and that all the skills for working with this client group lie either with psychologists or mystic practitioners of 3 letter therapies. One of the exercises we do on the day looks at how to take the heat out of situations so that people can talk to each other. We normally identify it as ‘validation’ and in all my years of working with people labelled with personality disorder, I think its the most useful thing I’ve picked up.

In the spirit of trying to be helpful to the Keir Harding who struggled to work with traumatised people 15 years ago, I’m going to go through the 6 levels of validation as outlined in DBT. While DBT is a therapy specifically aimed at those with a diagnosis of borderline personality disorder, this way of relating to people is useful for everyone. I even used this to get £300 worth of free mechanical work so this is literally a valuable tool to have in your arsenal.

Level 1 – Being present
I think in the old days we would call this active listening. Eye contact, nodding, smiling in the right places. Budding Elvis impersonators might like to throw in an ‘uh huh’. While this seems like the most obvious thing in the world to do I think back to my early career when I was doing assessments with people. The session tended to move away from a place where we could learn something and instead turned into an exercise in getting a form filled in. I’m pretty sure I’d ask closed questions so as to fill a particular box and then stop listening once said box had been ticked or crossed.
So without being too creepy, look at people with rapt attention, as if in this moment what they are saying (or not saying) is the most important thing.

Level 2 – Accurate reflection
This is where you move on from showing people you are listening to showing them that you have heard them. This can be a simple “So you’ve told me you’re upset” a more hypothetical “It sounds like you’re really sad” or “When you came in you said you wanted x”. All we are doing here is repeating back what people have said in different (but not always) words. Again, when I think of myself doing this badly, I’d get to the end of the form and say “Right then, I’ll write this up and send you a copy. See you next week” which would pretty much give the impression I hadn’t heard anything they said.  It was as if the priority was getting the form filled in, rather than tryin to understand something about the person in front of me.

Level 3 Reading
This is where validation gets more interesting as we get to use our brains a bit more. Here we are taking what someone is telling us and offering something new. “When they walked out and the house was silent, I wonder if you felt utterly alone?” or “When your friend said she didn’t like her present, I wonder if that hurt?”. Again this lets people know that you’re not only listening but thinking about them. Try to avoid telling them what they should have felt.
I think my best (worst?) examples of doing this wrong is similar to the above, where I’ve written down responses verbatim or, where I’ve told people what they should feel.
“So he ran away with my bag”
“You must have been angry”
“I was too frightened”
“You weren’t angry that he took your bag?”
Telling people they should see and feel things your way never tends to work out too well…

Level 4 – Normalising based on past experience
This is one I use a lot and probably the one I’ve done most badly in the past. This is where we show that we are not only listening and thinking about someone, but we know them too. With this we try to show people that what they have felt/thought/done is entirely understandable given their background. It’s something I like to use when people say “I was so BPD”. For example…
“I get so worried about saying the wrong thing I just don’t say anything …it’s just my BPD”
“Well you could think of it as BPD, but you said that when you were younger you used to be severely punished for saying something that your parents disagreed with. I wonder if you learned that saying the wrong thing can be dangerous so it makes sense that you’re frightened.”

Here we are trying to show that their feelings are perfectly understandable, based on what has happened to them in the past. If we don’t know their past we can be curious – “So you say that you feel worried about speaking. Worry makes me think of fear and that makes me think of something threatening or dangerous. I wonder if something has happened that has taught you speaking can be dangerous to you?”. You might get a few “don’t knows” but I’m betting you will build a better relationship with one “I expect there’s a really good reason you feel this way” than you will from a hundred “There’s nothing to be afraid of”s.

Level 5 – Normalising based on it being normal
It’s this one where we help the person who feels freakish and different to see that they’re like everyone else in the world. We take the bizarre, baffling and unfathomable and turn it into pure reason. I often find this is what many staff struggle with and when they can’t understand, they make their own interpretations as to why people do what they do.  To use a real life example …
“I want to go on leave”
“We’ve sent you on leave a few times but you just sabotage it” – might possibly be better framed as:
“when you’re home by yourself you get frightened and desperate, so you cope by doing what you normally do when you’re scared. Everyone does what they can to cope when they are desperate.”
“I get scared that I’ll be on my own forever”
“I think everyone would find the idea of being alone forever fairly scary”

It is in this area that I excelled in invalidating people. I’d learned some CBT on my travels through mental health and I had an obsession with challenging ‘thinking errors’ and ‘negative thoughts’. I would have seized the above statement and tried to convince them that they were wrong to feel what they felt. I’d ask what there was to be afraid of, I’d ask what was so bad about being on their own. I think I would tend to keep going until they felt stupid and ashamed for thinking what they did. I’m not proud…but (sadly) I am certainly not alone in making this mistake. One of the interactions I regularly see in services is someone saying “My life is so shit” and the other person leaps in to tell them they’re wrong.
“I want to die, I’ve got no money, everybody hates me and I’m never going to go out on my own”
“But Rachel, yesterday you were laughing at Simons joke, and this morning you made a cake and said you’d enjoyed it”.
This rarely makes people suddenly believe that their life is worth living and it certainly convinces them you don’t understand.
“I want to die, I’ve got no money everybody hates me and I’m never going to go out on my own”
“I can hear how much you want things to be different. Most people would despair at the idea of being hated and dependent on people”
The other common one I used to do a lot was “I’m never going to get better” at which point I’d leap in with gusto (because remember, my patient not getting better is an explicit criticism of me) ranting “But you’re doing so well!!!” To make me feel better the college lecturer would nod and agree when I told him he’d caught a bus by himself and stayed in the busy shop for a whole hour. In reality I had totally dismissed what he was feeling and instead put some work in to make myself feel better.
It is useful to challenge people but for most, and certainly the group I work with, people hear you louder if you can validate what they’re saying first.

Level 6 – Radical Genuineness
This is the master level of validation that only the true mental health ninjas can achieve, although in essence it’s not that hard. Once we have shown people that we are listening, hearing them, thinking about them, shown it makes sense given their experience, shown it makes sense given the rest of the world would feel like that too, – then we can take the final step, “I would probably feel like that!” or even “I have felt like that”. This can be as simple as:
“When they said I couldn’t get any leave I was fuming and just trashed my room”
“If I’d been planning something all week and someone told me it couldn’t happen I’d be pretty angry too”
Or it can be a bit more personal…
“Its so unfair, I just want to go home and they said they’ll section me if I try to leave”
“My daughter was in hospital once and the consultant said we could take her home. He went off shift and the physio said we couldn’t take her until the Dr said it was OK. Knowing it had been agreed I wanted to discharge her ‘against medical advice’ and the ward staff told me they’d call social services if I tried to take her. I know it’s not the same but I understand some of that feeling of being trapped, threatened and it being unfair.”
It’s possibly my own reading of radical genuineness, but i think there is a value in being, well, genuine with people. I think back to the times when someone has told me of some weekend that Stephen King and HP Lovecraft couldn’t have imagined if they’d had a month together. I’ve nodded along as if tales like this are all in a days work for a consummate professional like me when inside I felt like a cartoon of a shocked man. It might well have been more useful to convey the horror of what they had told me. When it seems helpful I now tend to drop in the odd “If that happened to me I think I’d be terrified”, “I can feel myself filling up as you’re describing that” “I’m trying to listen to you but I’m so worried about what you’ve told me I think I’m going to be useless to you until you get medical attention and my anxiety comes down”.  Non verbally I might wince when someone describes something painful.
The other obvious element of GR is that if you can do something to make the situation better then you do it or at least be really explicit about why you’re not. I’ve known people who were desperate to be admitted to hospital be told that they won’t be admitted because it’s not in their best interest. End of explanation. Either acting, or giving a detailed pros and cons of why you are not acting is a lot more validating than giving the message that they are wrong to want the things they want.

So those are the 6 levels of validation. I find myself using them most when meeting people for the first time and when the situation is becoming heated. Very often I’ve seen someone go up to a member of staff and shout at them. The staff member shouts back. They shout louder and a few minutes later there’s a wrestling match going on for which the staff have a numerical advantage. I’ve seen people shout at staff and the immediate response is that “You can’t talk to me like that”, which is a valid point, although a debate on the niceties of social etiquette is not something anyone whose emotions are dialled up to 11 is ready for.
“Youre a F***ing C*** you are!!!”
“You seem REALLY angry, can you help me understand what’s going on for you”
“You seem really angry at the moment but when you shout at me my anxiety goes through the roof and I can’t think. Can we both take a breath and think together about what’s going on ?”
And you can wrap up with “If that happened to me I think the other person was a bit C***y too”.
In other blogs I’ve talked about wanting to ‘win’ interactions with people. Validation is not about ‘winning’, but giving the people we are talking to the clearest picture possible that we are there for them. When I’m doing training, at some point someone says that we can’t just validate everything. There are limits. Lines have to be drawn. And this is true, there are behaviours that can get people in trouble with the police, hurt people and destroy relationships. We do not validate the behaviour we find unacceptable, but we do validate the motivation. We don’t validate the assault but the anger. We don’t validate the overdose but the hopelessness.
The other question that comes up is whether or not we can challenge people. Of course we can. Most of the people I work with have been repeatedly abandoned so theyre always on the lookout for signs its about to happen again even when the staff are really invested. While being told how much I hate the person I work with, I’ve found a Monty Python style “Oh no I don’t” usually isn’t going to cut it.
“To be honest, I do get a bit frustrated when you interrupt me, but I wonder if I can be slightly irritated sometimes and enjoy working with you as well”
“I can hear you think I hate you. I wonder what I’ve done to make you think that?”
“You seem upset and angry with me. I expect I’ve done something that’s led you to feel that way. Can you help me understand what it might be”
The consistent thing with all those examples is to validate first. Once they know we’re listening we can offer something else. That might be a direct contradiction or it could be a synthesis of ideas:
“I’ve got nowhere”
“I know you feel stuck and that nothings good enough, but I wonder if two things are true, that your standards of success are really high and you haven’t changed as quickly as you wanted”.

So there is validation in a nutshell. It is not rocket science. It is barely paper aeroplane science but it is something that can easily slip when we’re tired and the work is hard. I forget a lot but I tend to be at my most effective when I’m using this a lot. I think this would have been useful to me when i was first starting out in the NHS. I hope it’s useful to you.

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

Growing Smaller: My Part in the Great Expansion of Mental Health

On the Today program at 8.34 on May 31st, Jeremy Hunt the health minister announced that the conservative party had presided over the greatest expansion of mental health services in Europe.  The statement went unchallenged on the program but it was so different to my experience that it’s bounced around my head for the past 2 days, asking other people if they heard it and finally going on iPlayer to make sure that he actually said what I thought he did.  And he did.  Said it loud and proud as a fact that couldn’t be disputed.  I’m going to dispute it.

I’ve worked solidly in mental health in England, Scotland, Wales and a brief stint in New Zealand since 1999.  That is a fair few years of experience and I was trying to think of a time when it felt like things were expanding.  I started my first community mental health job around 2002.  This was a time of major change as the 1999 National Service Framework for Mental Health had directed trusts to put together a number specialist teams.  A Home Treatment Team to keep people out of hospital, an Assertive Outreach Team for those with severe mental illness who were in danger of dropping out of services, and an Early Intervention Team to work with those who had had their first psychotic episode.  While some staff from the community mental health team (CMHT) went off to staff these new services, I remember it as a time of expansion, as a time when we were doing more with more, a time when there was time to spend with people and options when things got tough.  This period might have lasted about 5 years.  After that talk became less about how we expand, but how we could contract.  It was probably around this time that that the “doing more with less” paradox began to float around the NHS.

Since the heady days of the early millennium I’ve heard a lot more talk of trust deficits, balancing books and saving money.  This has played out in a number of ways.  The obvious ones that I’ve seen are not replacing staff who leave.  In a team of 10, this means cutting the staffing by 10% and watching the rest of the team get on with it while the savings are counted up.  Where that is unsustainable, experienced staff who move on are replaced by less experienced staff.  A band 7 nurse becomes a band 6, who becomes a band 5.  For me, this left teams short staffed, staffed by those with less experience or with vacancies that were only available for new graduates in teams that were already struggling.

So why are teams struggling?  As well as the staffing issues above, it certainly feels like demand has increased.  When I first joined a CMHT there was time.  There was time to build a relationship, time to do things that felt useful and time to think about the quality of what you were doing.  CMHTs now feel like they’re under siege.  There is a mound of referrals flying in each week, the caseloads are so large you can barely spend any time with people and instead of building relationships and making plans, you spend your time putting out fires.  And there are many fires.  There is someone sat on a duty desk and daily they’re receiving calls from those who are acutely psychotic, desperately suicidal, wildly elated or all of the above.  Their choice is often not how to put out the fires but which fires to put out.  Overwhelmed, the CMHT referral meeting is less about who to accept but how to refuse.  With no disrespect to those who work in CMHTs now, it feels like the standard of care people get has fallen.  Weekly visits were common when I was working in CMHTs.  Now they seem like a luxury reserved only for the most acutely ill.

If CMHTs have become overwhelmed let us consider the wards.  The Telegraph tells us that 15,000 beds (in all areas) have been cut over the past 6 years.  This year 2037 people were given mental health beds ‘out of area’ in 4 months.  This says something about the demand on hospital beds.  It also says something about how acutely unwell you need to be to get onto an acute ward.  These wards are populated by the most disturbed, disinhibited and dangerous (to themselves and others) people in the mental health system.  People used to come to mental health wards for respite.  The restraints, alarms and noise of the ward mean that there is little respite to be had.  They feel chaotic.  They don’t feel safe.  And places that don’t feel safe cannot be therapeutic. 

The recent Panorama program on mental health gave me an account of mental health services that I was a lot more able to relate to than the health ministers.  Instead of a confident service expanding, the program focused on a trust that opted to save money by reducing inpatient mental health services.  “Very Sensible!” we might think.  “Care in the community!  Lets keep people in their own homes!”.  Laudable sentiments.  Alas the trust made the egalitarian decision to cut community service too. The results were a disaster.

For a few more personal examples (as if any of this isn’t just the thoughts at the top of my head) I walked past my friend who was sat in his police car the other night. He  told me people were sleeping in the corridor at the local mental health unit and the nearest bed was 150 miles away.  Even closer to home, my friend had 3 assessments in 3 days from a variety of mental health services.  Each agreed they required an admission.  There wasn’t a bed to be had.  Not in their area, not in the next.  “What do I have to do to get a bed?” they asked.  “Something potentially lethal to yourself or someone else” I thought.  To quote a very wise service user consultant I once worked with – “Don’t think this message doesn’t seep into the subconscious of those looking for help”.

Since returning to work in England I have noticed some significant changes.  Services being put out to tender means that companies can bid to replace the NHS services.  If you are in the NHS and your service is going out to tender in 2 years, why invest in it?  Why invest in your staff?  Do you focus on improving patient health or demonstrating change so that you win the next tender bid it takes months to prepare for.  If you are a private company you look at how you can undercut the NHS.  The easiest way to do this is to hire less experienced staff and spend nothing on developing them.  After all, you might not be running the service in 2 years time. 

It’s worth saying at this point that I work with people who would be classed as having significant mental health problems.  The Improving Access to Psychological Therapies program has certainly provided much to people with mild to moderate problems, even though I hear a lot of criticism about how time limited the interventions are.  That aspect of mental health services may well have expanded but I will argue that services for those I work with have not.  It feels like they have contracted and even the most charitable part of me could only say that services have robbed Peter to pay Paul, expanded one area at the cost of another.  But I may be wrong.  I hear the government is putting £1.4 billion into mental health.  I haven’t seen it.  I have heard of CCGs spending their extra money on other things.  I have heard much talk about how to do more with less.  If there are mental health professionals rubbing their hands together at a loss as to how to spend all the extra cash that is rolling in, I have yet to meet them.

If all of the above is the expansion, I would hate to be relying on the mental health system when it starts to shrink. 

After I wrote all the above I shared it with some fellow mental health professionals to check that my experience wasn’t unique to me.  The comments they made below suggest not.  To keep this apolitical, I first saw services contracting under a labour government.  I haven’t seen them expand in many, many years.

To be clear, all of this is a general impression rather than reflecting any particular team I’ve worked with or been a part of.

This is very accurate, working in a CMHT with caseloads of 50+ service users is not only reckless but it’s neglectful for those who use our service. Not to mention the detrimental impact it’s having on the physical and mental wellbeing of the NHS staff on the frontline trying to carry the load and the responsibility.

Until recently I worked as an OT IN A CMHT we were overwhelmed, I would try to do 6 or more home visits in a day and would rarely have time to eat lunch. As we were short staffed I had a high caseload (56), this was not a caseload of individuals who had a particular OT need I just picked up whoever needed allocating. Sadly it didn’t feel like what we provided was good enough despite the staff being very dedicated. Just over half of the care coordinator were b5 and there are few opportunities for career progression, good staff left to work outside the nhs for this reason.
I now work in an early intervention team which is much better resourced.
There is a good IAPT service but they are very selective about who they will take and service users are referred to CMHT because they are too high risk where they are assessed and then referred back to IAPT because they don’t meet CMHT criterea – it must feel very unhelpful and for some people a repetition of the experience of rejection that have suffered in their lives.
I work in a CMHT. Everyone is overstretched. B5 colleagues have had very complex clients allocated to them inappropriately due to lack of capacity amongst B6 staff. There isn’t enough time to care for people in the way we should. Before I worked as a Care Co-ordinator I used to be annoyed when CCOs “didn’t bother” to visit their clients when they’re in hospital, but now I can see the other side. Those clients are in a place of safety, so you know they’re being looked after. They have to slide down the scale of priorities while you’re fire fighting elsewhere. I regularly get home from work, put the kids to bed and then work for another 3-4 hours writing up notes on my laptop because I have to spend all day visiting people to ensure they’re seen as often as needed. I don’t have time to do all of the extra stuff that would benefit people’s wellbeing, only the essentials. It’s heartbreaking.
I have only been qualified for just over a year and have worked on an acute MH ward since then. There used to be one OT per ward and now there is 0.5 OTs per 16 patient ward (so one OT covers 2 wards). We have to prioritise – there is no way we can get to see all the people who need OT. There is constant pressure to discharge as there is always a massive waiting list for acute beds. People will be discharged to the community before they are ready or before they have adequate community support in place (because the community teams are so stretched).There is a high rate of readmission. Ideally we would treat more people in the community but there is no resource or lack of suitable supported housing (social care is a major problem). Also many of the voluntary organisations that used to bridge the gap or help people in the community have had their budgets cut reducing potential support networks further. I see no evidence of expansion of MH services or budgets at all!
I work in housing support services and am a newly qualified OT – what I find is that we now receive referrals from CMHT for people who have a housing need but I am most definitely managing the mental health as a priority over the housing need – my OT skills come in very well but it’s not my remit to work as an OT within that role but when I refer back to CMHT I can hear the stress in the workers voice – like they become unable to cope with their case load – what is the answer – clearly investment – I’ve seen nothing from the Tories – nothing – they continue to cut benefits to PIP and ESA (by the way in two years I can apply to be an assessor for DWP and my salary world be 34k?) it’s all unbalanced and it’s because those who represent these people cannot empathise with them – get labour back in – at least we will see more compassion – isn’t compassion more important than budgets anyway ?????? It’s sad that as a newly qualified professional I would rather set up a social enterprise supporting people grass roots than be in the NHS or CMHT because all I hear is stress and disparity 😩
I’ve worked in MH for 20 years and have never known it as bad as it is now. Under funded, cut back after cut back after cut back. Staff morale is awful because people’s hands are tied and cannot give the care they want and the service users need due to lack of resources and increasing pressures to do more and more with less and less
I completely agree with this post
I hear you loud and clear…. unfortunately its not just in CMHT its community wide. I myself will be leaving and heading towards grass roots community development services. It can’t continue the way it is.

 Also, under resourced Crisis Services struggling to safely support people in the community because there are no hospital beds. People presenting to A&E due to deterioration in their mental state and having to spend hours (sometimes days) in medical bed

I agree wholeheartedly! 😔money seems to be directed towards assessment teams not treatment. So more people know they have a mental health issue but there is less clinicians to help them through it. Money allocated to iapt but for people with mild moderate anxiety and depression issues but who present with minimal risk. CMHT work with people at more severe and enduring end of MH spectrum with less care to co-ordinate then ever and fewer beds and the plethora of people in the middle fall through the ever expanding gap. They present in ever increasing numbers to ED. Certainly not a model of care to be proud of as the increasing numbers of people ending their lives would evidence. It’s only going to get worse with Tories in power. Selling of NHS assets for BOGOF!! 😡 Where will this end???
 It is sad to say but I have to agree with this post. 😞
sadly my experience in NI exactly mirrors yours. I have 22 years experience in MH and I have watched services being eroded to the extent that people are actually at risk of dying through lack of care. This used to be the exemption- now it appears to be the rule. I watch colleagues burn out and break down because of being blamed for losing someone to suicide because they simply couldn’t offer the level of security and safety the individual needed, often having been refused hospital admission or being discharged back to the community barely treated. But time after time the CMHT staff shoulder the blame rather than lack of service due to cuts being recognised. 
Neither service users nor staff win in the current climate and the voluntary sector can’t plug the gaps. 
I’m one of the lucky ones – I work in forensic mental health with a protected caseload- but who knows how long that will last. 
It’s hard to stay positive when the future looks so bleak. And as for Jeremy Hunt, I think he’s firmly embraced ‘post-truth politics’ and sadly his agenda seems to be to dismantle the NHS in favour of some sort of private health care
Thanks for sharing this Keir, it’s good to know that others are seeing this too!
A lot of what has been said here resonates with me. I am barely qualified; I worked in a cmhrs for a year and have been in inpatient​ forensics​ for 3 months. I would add to the revolving door those who are referred to the cmhrs but do not meet the threshold only to be referred repeatedly until they have deteriorated to the point of meeting it, too late for any preventative work. So people are now sicker and for longer than they perhaps have to be. How does this save money if that is the point? My caseload was thankfully protected where I worked, 15- 20, (still felt like a lot!) and there was always OT need, care coordination was minimal, and the team was cohesive. One of the main reasons was an excellent manager. I cannot say the same in my current position where it would be a stretch to say there was an OT service at all due to the ‘natural wastage’ described by another commenter and the politics that comes about when most people are inexperienced, underresourced and frustrated and different disciplines are fighting for the paltry resources that are available. 3 months in and I am considering leaving because there is no sign that it will improve. It can only get worse under the Tories.
Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through


Those who feel that they’ve been part of the greatest expansion of mental health services are quoted below:



(You may wish to read those quotes twice)

Why Prince Harry has set the mental health world back 200 years.

It seems habitual for me to write about rugby in these blogs lately but why interfere with a winning (unless you read the stats) formula.  So 2 weeks ago Prince Harry poked his head above the trench and spoke about some of the mental health problems that he has experienced in his life.   What surprised me was some of the negativity that surrounded his sharing of his experiences.  The issues that I came across most were

1 Why the hell are we talking about this millionaire who has been a bit sad when there are people with real problems who can’t get help?

2  It’s all very well for you, a privately educated millionaire to tell people to seek help that doesn’t exist.  Go and live in a tower block and once you’ve queued on the phone for an hour to see your GP she can tell you about waiting lists, service gaps and a mindfulness leaflet

The issue with point 1 is that people regularly share their desperation, pain, and feelings of hopelessness on social media and the response they get is relatively muted.  Some of their friends are interested.  They might even get a like or retweet but in general, the world moves on.  Two weeks ago someone talked about having some mental health problems and it was on every news program, every newspaper and social media exploded with people sharing thoughts about Harry’s story.  Even those typing “But what about people with real problems” missed the irony that they were only typing that in that moment because of the choice that Harry had made.

Point 2 has a bit more substance to it.  One of the benefits of private healthcare is that people will take your money and do what you want very quickly.  Harry need only have thought “I think I need to talk to someone” and it probably happened the next day.  So we can all agree that Harry’s experience of accessing help was different to the majority of other people’s.  We might also agree that it’s as useful for Harry to extol the virtues of seeking help as it is for him to encourage people to drink more water during a drought.  If there’s nothing around then there is no point asking for it.

 Both of these miss the point of how helpful it was for Harry to speak out.  (Here comes the rugby part)

I’ve played rugby for about 25 years now.  During this time I’ve known men with piles who have poked them back in while we were showering, I’ve known men talk of the colour, volume and aroma of their ‘nether’ discharges, I have seen men compare and contrast the size of various ‘private’ rashes, bumps and blemishes.  Not once, not once have I ever heard anyone talk about their mental health problems.  That’s not to say that mental health isn’t discussed, but it belongs to another realm.  A realm of nutters, loonies and those who are very different to us.  We are ragingly, emphatically sane while those ‘others’ are broken, weak and flawed in some way. 

So I’m suggesting here that mental health carries a greater stigma than sexually transmitted diseases.  What Harry has done, and what I truly think everyone should be grateful for, is something that erodes some of the stigma surrounding mental health.  “But what good does this do?” we cry, knowing that services struggle to cope with the business they have, let alone another 50 customers walking through the door next week.  Well, let’s remember some statistics (and as I’m reading them I’m not terribly convinced, but here goes) in 2014 there were 4882 suicides in England.  Of those 751 were current mental health patients.  Even if those figures are way out we can see that the majority of people who come to the conclusion that death is the only way out do so without ever setting foot in a CMHT, my uncle included.  I’m going to suggest that the majority of people who kill themselves carry a huge sense of shame.  The weight of the burden they carry drags them down and due to society’s attitudes towards mental health problems it is better to die than it is to share that burden with someone else.  

When I was a much younger man there was a period in life where I felt that I’d lost just about everything that was important, that the future was going to bring only more misery and that a potential solution to this dilemma was to go rock climbing (which I’d never done) up a massive cliff.  During this period I had a best friend who I could talk to anything about and after I shared my ideas with him he helped me think up a few solutions and even got into the car with me to drive off and put them into action.  Without having him in my life and without having the (courage? Foolishness? Vision?) to get what was in my head out of my mouth I could easily have become a statistic.  What I’m saying is that talking about mental health problems isn’t necessarily seeing a therapist.  It’s telling your friend, your partner, your boss that you’re struggling.  It’s about voicing the thing that you know people will hate and despise you for and finding that they accept you.  It’s about turning thoughts into words so that people can examine them with you, rather than having to carry them yourself with the certainty that every bleak thought and every hopeless prediction is 100% accurate.

But for people who need treatment there’s still no services!!!!  That’s true but for me the thing that makes things change in the NHS is demand.  Now that can be demand in the form of a queue of people out of the door or DEMAND as in people screaming that they are (literally ) as mad as hell and are not going to take it anymore.  To go back to the genital urinary analogy from earlier, if the wise people in my town’s NHS decided to radically cut the funding of the GUM clinic the response would be…..muted.  There would be no marching in the streets, there would be no celebrity endorsements of the campaign.  No one would make too much of a fuss because it’s just too noxious a brush to be tarred by.  The same is true to an extent of mental health.  Hugely underfunded in both services and research this is largely because people don’t campaign about it to the same extent that they do for heart disease or cancer.  Someone who dies of cancer ‘lost a battle’ someone who died by suicide ‘gave up or couldn’t take it any more’, as if mental health problems aren’t something that can affect anyone, just a thing that weak people choose.

Prince Harry is the highest profile ‘normal’ person to talk about his experience of loss and managing strong emotions that we call mental health problems.  If he can have them and he’s normal, maybe other normal people can admit they struggle too.  Maybe we can rethink our ideas about what normal might mean.   If more people share that they struggle, maybe they won’t have to kill themselves.  If more people go to their GP for help, if the queues for therapy get longer and if more normal people shout, write to their MPs, complain, and/or march in the streets then the government will have to listen.  By saying it’s ok to talk about mental health problems, Harry showed that it was OK to have mental health problems and for that alone we should celebrate and recognise the good that he has done. 

On the other hand I loathe the phrase ‘we all have mental health’…..



It’s Hard to Keep Going

exhaustedThis is a lot more light hearted than the past few blogs but I think being able to laugh occasionally is no bad thing.  This came about around 10 years ago when a service user I was working with spoke of his lifelong ambition to run the London Marathon.  Within a few weeks we had signed up to run it together for the charity Mind.  Within a month the service user had panicked and withdrawn and I found myself facing the prospect of running it alone (as alone as you can be in a crowd of 20,000) and needing to raise £1200.  Training was not entirely successful but the account of the day is below.  You can still donate to Mind ( ) and I’m they’d appreciate it.

I did it! I did it!

In 4 hours 39 minutes and 12 seconds, I ran 26.2 miles. I came 16736th beating around 20,000 people, although to be fair, that does include blind people, people on stilts and a giant robot. It was easy. Well some of it was easy. Quite a lot of it involved great pain and terrible suffering.

Despite the predictions of tropical storms and thunderous showers, I awoke to a pretty nice day on Sunday morning. I met my friend Ian at Charing Cross station and we packed ourselves like sardines into the train that would take us to Greenwich Park. Due to the blisters I had been getting each time I had gone running, I had taken to covering the balls of my feet with duct tape to reduce the friction. This had worked like a charm and I had been blister free for weeks. You can imagine how pleased I was when, sitting on the train hurtling towards the beginning of a 26 mile slog, I realised that I hadn’t taped my feet up that morning. Picturing blisters filled with blood erupting from my feet and running through Westminster making loud squelching sounds with thick footprints of gore trailing behind me, I grimly decided I would carry on regardless. Flicking through my kit bag I discovered that I had been saved. Paul and Sian, two of the kindest and most practical people in Wrexham, had appeared at the station in on Saturday to wave me off. As I was getting onto the train they presented me with a goody bag including sticky strips to treat blisters!!! Even better, my wife (who was born with more sense than I will ever have) had packed them into my kit bag. Delighted I taped these all over my grateful feet, happy in the knowledge that when I failed to finish the marathon now, it wouldn’t be because of my blistered feet.

We arrived at Blackheath Station and began the long walk to Greenwich Park. We were passed by men in Rhino suits, two men in a camel costume and a host of superheroes and people in charity vests all the colours of the rainbow. The information that had been sent out was quite explicit that there was to be no urinating in people’s gardens on the way to the park. Normally a walk to the park without urinating into someone’s garden is not a challenge for me, however, after a morning of gorging on water I had a bladder like a barrage balloon and seriously considering breaking my first rule. It occurred to us that there had been no mention of whether or not any other toilet functions were permitted in people’s gardens or whether we could urinate anywhere in public apart from gardens, perhaps in wheelie bins or in the streets. Distracted by these musings we entered the park and saw queues for the ’ample toilet facilities provided’ snaking up and down the park as if someone had just announced tickets were on sale for the Elvis comeback tour. We waited in the queue for a few minutes. Scratched our heads as to why people were popping into the portaloos and not emerging for ten minutes, convinced they were taking the morning paper in there with them, before dashing off behind a tree whilst being scrutinised by the local constabulary.

We walked to the top of the hill where the race was to begin. At this point Ian, who was wearing jeans, a tee shirt and slip on shoes, asked one of the officials at what point we would get separated. The official looked at me in my jogging top and shorts and informed me I would have to stay outside the gate while the runners went through into the pen behind. I clearly do not have the look of a distance runner yet.

I said my goodbyes to Ian and went through the gate. The atmosphere was that bit more electric. Ten minutes until the start and I had to find the right van to put my kit into and go to the toilet four more times. This done I got into the queue and with music pounding, joggers stretching and cameras snapping all around me, I began the slow amble towards the start line, determined not to jog until I had crossed the beginning point lest any energy be wasted.

The first ten miles were quite enjoyable. I felt a freshness and euphoria that shoved me along. Strangers were shouting “Come on Keir” (I had written my name on my top in duct tape the night before. Remembered to put duct tape on my shirt. Not on my feet though…) and I was trotting along at a brisk pace, overtaking more people than were overtaking me. Every time I saw someone else in a MIND vest I would jog over and patronisingly wish them good luck as I ran past. Despite all my overtaking, there was always someone in front of me who looked like they really shouldn’t be there. Some shuffling pensioner who may well have dodged out of a home and found their way onto the course. I pictured a residential home where nurses were franticly searching cupboards and looking up and down the street annoyed because “Mr Smith has got out again”.

After 5 miles I came to my first Lucozade station. Here, thousands of bottles of Lucozade are picked up, sipped, spilt and thrown to the floor. The road looked like two bin lorries had collided and spilt their contents into the street, while the surface itself had assumed the texture of fly paper, greedily sucking at the soles of my trainers as I slowly plodded along.

After 9 miles I was overtaken by my first Womble. This was not an event that inspired confidence in my running abilities. The miles went by. I was looking forward to mile 15 where my wife and child might be waiting for me. The fifteen mile marker arrived and it was in the middle of a tunnel with no spectators to be seen. Disappointed I trudged on, knowing I would have a chance to see them at the 18.5 mile mark. Then suddenly at the end of the tunnel I heard a familiar voice shout my name and looked up to see Ian’s 6ft 8 frame looming out of the crowd as he poked the family in my direction. After a quick dash over to see them I was inspired…to start walking. There was something about having hit the milestone of seeing them that took all the energy out of me. Granted I would see them again in 3.5 miles, but for goodness sake, that was 3.5 miles away!! I walked/ran for the next 3 miles, watching other MIND runners that I had sailed past earlier casually cantering past me. I picked up the pace at this point. I didn’t mind walking for a bit but there was no way I was going to walk past my family and friends who had stood in the rain for two hours to see me. Sure enough at the 18.5 mile mark I saw Ian’s giraffe like profile in the crowd and ran over to them. “You’re doing brilliantly” they said. “Little do you know” I thought. And started running again, waiting until I was around the corner before slowing to a walk.

I had began the day with my Ipod in my pocket, beating out inspiring tunes to keep me going. After mile three I had it at full blast and still couldn’t hear a damn thing due to the bands, supporters and PA systems along the side of the road. Both times I saw Ros I had meant to give her the bloody thing rather than keep it in my pocket. Unfortunately as soon as I laid eyes on them all thought of such mundane tasks leapt from my mind. It is because of this that my most impressive injuries are two raw, weeping sores at the top of my thigh where my Ipod rubbed against it for four and a half hours.

Miles 19-22 were the hardest. I was trying to run for a minute, then walk for a minute. My legs were really hurting. My right arm was starting to cramp and my calves were refusing to contract anymore. My muscles were running out of the sugar they needed to push me along and no matter how much Lucozade I gulped, no matter how many jelly babies I took from the crowd, the sudden burst of energy I was waiting for failed to materialise. I was struggling to pick my legs up off the floor. I had adopted the shuffling, sliding gait of a toddler who is trying their parent’s shoes on. I was looking at the floor, my back was hurting. I stopped running and started walking again. If there was one thing that that was more painful than the running, it was the walking. Muscles seizing, cramping, spasming. Stopping was worse still. I really wanted to wrap myself into a ball on the side of the road. I wanted my mum to come and rescue me. I just wanted it all to end. I had begun the day with the wildly optimistic plan of finishing around the four hour mark. As the run went on I moved the goalposts somewhat and hoped for 4.5 hours. I later revised this to being able to finish the race that day, then to being able to complete the race without the St John’s Ambulance brigade dragging me off the route wearing a shiny blanket. By mile 21 I just wanted to live. I tried to stretch out the tension in my muscles. Perversely my muscles were as loose, pliable and flexible as they had ever been, no doubt due to their three hour warm up.

Having lived in London for a few years, after mile 21 things started to look more familiar and I became aware of how little there was left to do. Granted ,I was in tremendous discomfort, and granted, I still had about an hour of it to go, during which time it was unlikely to get better. Still, 5 miles left through streets that I knew well. I started to lift my head a bit more. “Keep going Keir” “You’re looking great Keir” “Almost there Keir” the crowd shouted. And I ran. Slowly. I caught up with one of the MIND runners who had overtaken me earlier. We chatted for a bit, but he couldn’t match my pace and dropped back. I disappeared into my head and began counting my steps. Every time I got to a hundred I started again. Sometimes I lost concentration so started again. With my brain distracted from the torture I was putting my body through, the final miles started to be eaten up. Then came the ultimate humiliation.

I could hear a rumbling in the crowd. I heard extra shouting. I heard children laughing and calling excitedly. A shadow fell in front of me and from behind my left shoulder he came. Running like a serious athlete, tall, proud, a huge grin on his massive head. I had just been overtaken by a seven foot beaver. There were two miles to go. With effort I thought, I could catch that beaver. But there was nothing left to give. The beaver disappeared into the crowd of runners in front and I resigned myself to always thinking of myself as a crap marathon runner.

We ran past big ben.1,2,3,4. Past the houses of parliament 38,39,40, past St James Park, 89,90,91. As I reached the corner before Buckingham Palace I heard someone shout my name. I looked up and saw John, my friend since playschool, beaming at me from the hoard of spectators, urging me on. I also spotted that the beaver was in sight. I pointed my finger at the beaver. “Him” I shouted to John “I’m going to beat him”. The muscles that had been so slack for the past miles, so wasted and exhausted when trying to run to ‘get a good time’ suddenly realised that there was someone trying to beat me. My pace increased. I pulled ahead of the beaver. I was going to beat him. No matter that I was going to finish long after I had expected to. In this matter at least I was going to win. The beaver turned his head. He saw me go past. He saw me looking at him. My heart sank as the beaver picked up his pace. He came up fast behind me, legs pounding, tail flapping behind him. I tried to run faster and found myself not jogging but running, not running but sprinting. With a hundred yards to go and 26 miles behind me, after having hit the peak of exhaustion, after wondering if I would ever finish this bloody race, I found myself galloping towards the finish line with a seven foot beaver hot on my heels.

The pace was too much for him and he dropped back. I flew across the line like I had won Olympic gold in every event. No matter that fifteen thousand people had finished before me, I had won.

It took me about an hour to find my wife afterwards. Mainly because I spent a lot of time lying on the ground hugging myself, wondering how badly you had to be hurting for the St John’s people to drive you to your family on their little milk float. I made it to the MIND reception where I was showered and massaged and then we headed to the pub. Ian signed up to run for MIND next year while I seriously considered chopping my foot off to stop it hurting. Never again. Not for a year at least anyway.

In this age of terrorism, cctv and increased surveillance many people are concerned at the amount of cameras that follow their every move. Not me. Flicking through the BBC coverage it appears that I ran though London wearing a fluorescent top during one of the most heavily covered sporting events of the year and I didn’t show up on camera once.

Random Statistics

Distance run – 26.2 miles

Lucozades consumed – 6

Number of attractive girls shouting my name during race- Hundreds

Number of attractive girls shouting my name since race has finished – 0

Number of Masai Warriors overtaken – 6

Number of blisters – 3

Metres run backwards after realising I really did want that jelly baby – 2

Children shouting in pain after holding out their hand to be slapped as I ran past – 3

Number of Beavers beaten to the finish line – 1

A great day.  Do have a go if you’re considering it.

Use A Little Restraint: Why People Who Self Harm Must be Forced to Stop.

Lets start by saying that I self harm.  I self harm regularly in a way that society tends to approve of.  Most Saturdays  I strap on my rugby boots and on a good day,  for 80 minutes large, hairy men will charge at me while I try to knock them over.  On other days I am punched, stamped on, scraped with studs, or just hurt.  Over the years I have broken my nose, chipped my teeth, ripped the skin under my chin open, split my forehead and all last week, sported a big purple eye.  I play rugby every week, not seeking pain but knowing full well that it is inherent in this activity.  The pain and damage that it gives me is worth it in terms of the other benefits that I receive. Now obviously playing rugby isn’t the same as cutting lines in my thigh, but I’m arguing that that both activities are on a spectrum of things that damage you but come with some reward that makes it worthwhile.

Now its interesting that nobody cares about my self harm in the slightest.  In work I spend a lot of time with people who regularly self injure, where others aren’t that bothered about their self harm either.  At work I try to point out the link between self harm and suicide, offer to help and support people who want to stop and encourage them to care for themselves in ways that don’t involve hurting or punishing themselves.  I never forcibly stop them. The people I work with all live in the community and can make informed decisions about how to live their lives.  If they want to stop self harm I’ll  do my best to help.  If they don’t I’m  still there (although I might let them know how I’m  affected by it).  Self harm is their understandable way of coping which they do because it works.

On the ward, it is a different story.  The people I work with tend to have long standing thoughts of suicide.  When that chronic risk becomes acute they might be admitted.  What is interesting is that it becomes an unspoken part of someone’s care on the ward that they must immediately stop all forms of self harm.  It doesn’t matter that self harm wasn’t a factor in their admission, it has become one now.  Usually the acute period of suicidality passes fairly quickly, but because those who have self harmed for years have suddenly lost their only way of coping the risks go through the roof. Those who cut carefully with blades are ripping cans open, smashing crockery, banging their heads on the wall and (potentially most lethally) tying things around their neck in a quest to get whatever benefit they usually receive.  It is at this point the person tends to want to get out of hospital asap and it is at this point that the enforced self harm abstinence really comes into its own. While the client articulately tells people they don’t want to die and just wants to go home, we can’t let them go until they fit our model of wellness, which tends to involve them presenting with healthier coping methods than they have used in years. 

With people who don’t want to stop self harming (and weren’t admitted to do so) psychological intervention to help them stop rarely works.  Instead we prescribe different intensities of observation ranging from being checked on once an hour to being followed constantly by 1 or more staff.  At times we can administer a PRN dose of heavy staff to physically stop whatever behaviour we find intolerable.  As the risks increase the number and weight of the staff rises proportionally and eventually we decide that the only solution is large staff in an environment far away from us.

We can wonder about why MDTs need someone who has no intention of stopping self harm to be self harm free before they are discharged.  We can spend even longer wondering how a period of stability can be achieved when long standing coping mechanisms are forbidden, everything is scrutinised, no leave or time alone is allowed, any emotional response to this treatment is written off as part of the diagnosis and if you do try to hurt yourself in a way that no one would have batted an eyelid at in the community, 3 heavy men will hold you on the floor in a vague reanactment of one of your most traumatic experiences. 

Looking at this rationally we can see that if you want to seriously upset and disregulate someone, following the above “care”plan might well be the perfect way to do it. 


Its worth thinking about why situations like this come about.  I hear others say that they are kicked off the ward as soon as they self harm but for some clients, ward based self harm is more effective at keeping you on the ward than locking yourself in the nursing office.    It makes sense that we let people make their own decisions about how to manage their distress in their own homes, but why do we have to forcibly prevent them on the ward?

There’s two main factors at play for me. The first is that the majority of mental health staff come to work to make people better.  Our training prepared us for people who would come in with simple problems, we would dispense our wisdom and they would recover and be grateful.  It is almost impossible for staff to look at someone under their care bleeding profusely and feel they are doing a good job.  Stopping self harming is a kind of recovery and if people won’t get better, we will make them better.  I’m sure this starts out with the most caring and compassionate motivations but after a few weeks of wrestling much of the empathy will have evaporated.

The second is how painful it is to see someone hurting themselves.  There is the immediate visceral impact of seeing damage occurring, the emotional reaction to seeing someone in so much distress and the psychological trauma of watching someone causing damage to themselves. When we combine people who see their role as preventing harm with people who use harm as a way of coping we manage to whip up a perfect storm where the more we help, the more abusive we are perceived. Given no obvious other way of helping we do everything we can to prevent harm occurring and lose sight of how much added distress, trauma and risk our help is causing.  Regardless of the clients wishes, we will join the long list of other people in their lives who forced them to do what we wanted.

I see the above frequently and I suspect it is replayed across the country. I worked with a man recently who was only ever violent when he was in hospital.  He was no longer suicidal but couldn’t be let off the ward until the behaviour that only occurred on the ward had stopped occurring on the ward.  

My solution is for organisations to have a team to think about these complex dynamics that are so hard for us to see when we are caught up in them.  The NICE guidelines for borderline personality disorder describe teams who support the organisation to formulate, assess and respond to complexity and risk in thoughtful ways.  A 3rd mind that can ask the question “Why do we keep doing this when it makes it worse?” can be invaluable.  

So often I find that staff caught up in these situations are utterly miserable.  They can see that they are actively harming someone with their help but feel powerless in a system that knows only higher levels of restriction in response to risk.  In my ideal world admission would rarely be used and when it was, the benefits/costs would be thought about beforehand.  At the very least on every care plan we would rubber stamp “do not detain in hospital for behaviour we wouldn’t consider detention for in the community”. In models of organisations that work with people, a strong emphasis is placed on the value of a thinking space.  I regularly hear that this can’t happen and that action is valued much more.  If staff can’t be given space to think and reflect then specialised teams might need to do their thinking for them.  This might involve changing the culture of the organisation so that risk is thought about in a different way.  I have 2 fears.  One that this will only begin to happen after someone who is far more dangerous as an inpatient accidently kills themselves on the ward.  My other fear is that this happens time after time and we still can’t learn from it.

Now blanket approaches to managing risk are rarely successful and its most beneficial to think about everyone individually.  I’m not advocating for inpatient environments where anything goes, but for thoughtful consideration of how people respond to an environment and how we respond to their presentation.  If nothing else, let’s think about our role in someone’s change in presentation. Most importantly, lets ensure we are never a part of someone being sent miles from home to be forced to stop something that was never a factor in their admission.

All thoughts appreciated @keirwales

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

 Much of this was inspired by a conversation with @graffiticymraeg who’s blog is far better than mine

All the above reflects themes expressed much more articulately in The Ailment

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,



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

An Overview of “Personality Disorder”

This is a little collection I put together for the people I was training with the other week.  I’m sure there are loads of gaps so if you think something essential is missing do let me know.  Hope you find it useful.

Personality Disorder services in the UK

Doing The Work

This is the Ministry of Justice Guide to working with people with Personality Disorder.  Lots of stats, facts and figures

This is the Guide to working with people diagnosed with personality disorder, written by people with personality disorder


This talks about other ways of thinking of ‘manipulation’

This brilliantly encapsulates how once we have a picture of what someone is like in our mind, everything they do can be twisted to fit that picture:

This again highlights the damage a label can do:

(see the nice guidelines for more on stigma)

What works?

This gives an overview of MBT, DBT, TFT and GPM.  GPM is interesting (something similar over here known as “Structured Clinical Management”) as it is delivered by generic workers rather than specialists. 

Schema therapy   –

Therapeutic Communities – My favourite way of working with people:

What “should” we do?

NICE Guidelines Self Harm

NICE Borderline Personality – The personal accounts of people who have been through services are really interesting.  Also gives an overview of different interventions.

But services might be a bit more like this:

What makes the work hard?  This isn’t the best copy but this is an excellent article that describes the impact complexity can have on staff.

This talks about Trauma Informed Care and why ‘what we usually do’ often isn’t helpful.


And finally

A very articulate account of what it’s like living with BPD

Online resources:

Lots of stuff for clients to work through – All DBT flavour

Sunday night chats on twitter #BPDChat – Also with a DBT flavour.

Keir Harding provides Training, Consultancy and Therapy around complex mental health problems via


Below is a way of talking about complex emotional difficulties without talking labelling them Personality Disorder.

An important area of mental health that is getting increasingly recognised is the way people express various forms of emotional distress. It can cause various behaviours:

People harm themselves, for example by cutting their arms
Drinking unsafe amounts of alcohol
Taking illegal drugs regularly, excessively or irresponsibly
Misusing prescribed medications (or those available over-the-counter at pharmacies)
By impulsive and reckless actions that could have have serious consequences, like driving too fast or having unsafe sex
Chaotic eating patterns – such as bingeing, vomiting, abusing laxatives or continuously eating too much.

In addition, people with these problems often have repeated difficulties in relationships in ways like this:

Never keep friends very long
Cannot hold down a job
Isolated and lonely
Violence in intimate relationships
Over-sensitivity to criticism
Argumentative with people in authority
Feeling very abandoned when left alone or people leave
Unable to cope with making any decisions without help
Often switching between loving and hating family members.

Many people will experience these things at some time during their lives, perhaps in response to stress, but some are severely troubled by many of them for most of their lives. These could be called ‘long-standing emotional problems’, and they often go right back to childhood. In mental health services they are sometimes known by diagnoses like ‘complex needs’, ‘personality disorder’, ‘borderline’ or ‘severe and enduring non-psychotic disorder’.

Although it is not always the case, people with these types of difficulties have usually had difficult childhoods, with adversities like repeated trauma, or physical, emotional or sexual abuse, or neglect and deprivation, or several severe losses and bereavements. On the other hand, some people who suffer very harsh childhoods seem to be somehow ‘protected’ from the long-term psychological damage it can do. Unfortunately, there is no easy way of finding out who will have more problems and who will have less – although research is always being done to help us understand these matters better.

People who suffer in these ways often do so silently, without getting any help and often feeling guilty or ashamed of how they ‘are’. They often do not even know that they have a problem that others have too – and can become very isolated and lonely with it. In fact, these problems are very common, and increasingly recognised. The reason people behave the way they do, and have the difficult relationships they do, is usually to deal with their feelings, and to try and cope with them. But their actions often do not help enough, and they can make matters worse.

Very commonly, the behaviours can be confusing and upsetting, and this is as true for the people themselves as for those around them. This is because there is a lack of information and understanding about how these things arise, unwillingness to think and talk about them, and little knowledge about what can be done to support someone in this sort of emotional turmoil.

Although it is often the easiest route, there is recent research and NICE guidelines which suggest that medication is not usually the best way to deal with these problems. In the NHS, psychological treatment often helps, and this may take different forms. However, short-term ‘quick fix’ treatments and therapies are rarely very much help. Some psychiatric services are good at helping people with these problems, but because the number of people affected has only recently been recognised, many mental health staff do not yet have good training to deal with it.

In this situation, one of the things that can be very helpful is to help people to feel less alone and ‘odd’ – and for this, other people who have suffered similar feelings are usually better than professionals at understanding what it is like.

(This was taken from the Emergence website)

And those are some things that might help you understand whatever personality disorder means and what might help.  Again, if something is missing let me know.



Why are people with Personality Disorder so manipulative?

Those with personality disorder are manipulative.  This is a fact.  At least, you would think it was a fact if you heard it as many times as I have coming from the mouths of people in the caring professions.  Whenever I’m doing training on personality disorder, there is rarely a session where this fact isn’t voiced at some point.  When it does come out, it isn’t spoken in a timid, tentative way, but with the full throated confidence of someone speaking a truth universally acknowledged.  It is a fact as certain as death and taxes, and because people are so assured that it is a fact, the presence of a service user with a diagnosis of personality disorder in the room does nothing to encourage them to censor their views.

I’m going to spend some time thinking about manipulation, what we might mean by it and whether this is another way of interpreting behaviour in a way that might help carers keep caring.

 Most definitions of manipulation use the terms like clever, skilful or artful, implying a conscious use of talent on behalf of the manipulator. Based on this definition, we all manipulate the people in our lives in that we consciously try to get them to do what we want.  Being good manipulators, we hope to do this while keeping people liking us.  This is the skill.  It is not the forcing of our will onto others but being able influence people while keeping them on our side.  The problem that people with personality disorders have is that they are awful manipulators. Very often in my life women who are older than me tend to mother me.  If I look a bit flustered or helpless, they will frequently step in and do things for me that I’m perfectly capable of doing myself.  At the end of it, we all tend to like each other a bit more.  I’m in their debt and they feel they’ve been useful.  You can argue that this is a skilful bit of interaction, but based on the definition above, you could also argue that I’m manipulating people.  Let’s contrast this with me walking into the office and shouting “If someone doesn’t give me a lift into town, I’m going to fucking kill myself and it will be your fault.”  I have no doubt that the people in the office would indeed take me into town.  Whether they would ever want anything to do with me in the future is another matter.  Again, lets have a think about what might be the actions of a skilful arch manipulator, and what might be someone with really ineffective ways of getting their needs met.  A good manipulator gets what they want and people like them.  A bad manipulator gets what they want and people resent them.

It wasn’t a million years ago that I shared the ‘personality disorder = arch manipulator’ view. I used to work in a team where at least once a week a man would phone to tell us he was suicidal.  What followed would invariably be a 30 minute phone call where I desperately tried to get him to tell me he would be ok.  He rarely did.  Every suggestion of what to do had already been tried.  Every option had been explored and found wanting.  It said on his careplan to phone when he was suicidal and here he was phoning.  Now what was I going to do about it?  The answer was always nothing particularly useful.  While I was being berated for my incompetence I tended to feel powerless, useless and for someone who came to work to make people better, pretty bad at my job.  It would be fair to say that I hated the way he ‘made’ me feel and I know that many of my responses on the phone were far more about me trying to ‘win’ than they were about trying to provide care.  Because he had phoned weekly for years, I knew the actual risk of him committing suicide was pretty static and that the phone calls didn’t reflect a significant change.  In my head this guy was sat at home planning different ways that he could torture me.  I saw him rejoicing in my discomfort, raising his fist in the air (as I did) when he felt he’d refuted an argument and hanging up the phone after a particularly vitriolic exchange happy with a job well done.  My team were very helpful in supporting me with my view of him and we would have many conversations that built up a picture of someone whose sole pleasure in life was my misery.

It’s hard to be particularly caring to someone who at best, I wished would leave me alone.  Because I took the majority of his phone calls, I sought out some supervision to help me manage what I viewed as a cruel individual.  The supervision was not an enjoyable experience as rather than help me to manage a trouble maker, the supervisor started pulling apart the foundations of the power crazed manipulator I had built up.  He asked me what the service user was looking for when he called and what in his life might explain the way he interacted the way he did.  He got me to see how unhelpful the picture I had of the client was and even worse, how I might be exacerbating and maintaining some of the very things that did my head in.  That was the first time that everything I thought I knew about personality disorder had been challenged and now I reflect on it, the first step towards me choosing this area for my career.

The point of the above is that I can sympathise with the view that people with personality disorder are manipulators and it’s a view that I’ve held myself.  Now let’s try a different way of looking at things.

Within DBT (Linehan 1993) manipulation would be viewed as poor interpersonal effectiveness.  Most of us come from a background that helped us to be effective.  We know how to get our needs met while keeping people on our side.  We know that when we raise the intensity of our communication by being more assertive or even hostile and rude, we run the risk of damaging the relationship with that person.  We generally know that if we need help someone will do something and that we can say no to requests that are unreasonable.  People with personality disorder haven’t come from the same background and as a result, they don’t have the same skill set as the average person in the street.  They might have come from a background where your needs were only met if you screamed blue murder.  They might have come from a background where people modelled that threats and violence were the only way to get people to do what you want.  They might have only been cared for when they were physically hurt or they might never have been taught to put their feelings into words.  They might….and on and on.  The gist of this is that we will see peoples past relationships in their present ones if we look for them.  If we look hard enough, we can see how people have been taught to interact the way we do.  If we’re being brutally honest with ourselves we might see how what we do keeps some of these problems going.  If we only spend time with people when they’re in crisis, if we only increase input when they self harm or we reduce our contact as soon as they’re ‘doing well’,  we can be playing a big part in keeping some of the more difficult to manage behaviours going.

It might also be worth thinking about splitting, where people with personality disorder ‘play staff off against each other’ and form special relationships with particular carers.  Splitting in teams certainly happens but I wonder if us staff ignore the part we play.  Instead we blame the client and think of them as an evil puppet master, pulling strings that ‘make’ us act.    Now I come from a background that taught me I was loved and valued.  Despite this I tend to gravitate towards people I perceive as warm, friendly and interested in me.  People with personality disorder have the same tendency.  When in a frightening place it makes sense for them to particularly attach to staff who show the most warmth or have some characteristic that feels safe.  It makes more sense to strengthen that relationship by giving gifts, telling secrets and ‘being good’ for them.  Those staff care.  They need to be hung on to.  The relationship can also be strengthened by distancing yourself from people who are more cold, apathetic, hostile or just different.  By being difficult for the ‘other’ ones or only working with the special ones the special relationship is emphasised . This isn’t a cold, calculated endeavour to cause chaos, but a natural response from someone whose early experience of carers was different to our own.  In The Ailment, Tom Main (1957) gives the example of a baby crying in a room full of people.  They will compete to sooth it and some will succeed.  In an innocent way the baby evokes some rivalries in the people around it.  It might become distressed by these rivalries and might even make them worse in the quest for comfort.  While the baby hasn’t caused the rivalry (or split), its behaviour which draws in some while pushing away other inflames them.  The baby (fairly understandably) is pretty poor at managing the people around him but he does the best with what he has.  The split isn’t his fault. 

We can also think about personality disorder as a difficulty in managing strong emotions.  Often people with personality disorder were never taught to manage their emotions, they had people in their lives who modelled ineffective ways of coping or they learned that only intense expressions were effective.  When on the receiving end of these powerful emotional communications it’s important to remember how well we are able to think when we are at our most frightened and angry.  When working with those who have been taught that the world is out to hurt them or those who are terrified at the prospect of being left alone, it is understandable that strong emotional responses will be a part of many of our interactions.  When angry or afraid we all want to manage the immediate threat and pay less attention to what happens in the long term.  If we can view people as feeling threatened or terrified, if we can understand why they might do all they can to achieve a short term goal again, it is harder to keep that picture of a skilful arch manipulator. 

We started with a picture of people with personality disorders as calculating master manipulators.  We’re now at a place where we might see that some behaviours are exaggerated natural responses while others are the product of poor interpersonal skills.  We might substitute the idea of people intentionally causing chaos with people doing the best they can with what they’ve got.  Holding this in mind is essential for keeping some care in the caring professions.  It is nigh on impossible to care for someone who you think is deliberately trying to hurt you simply for the pleasure it will give them.  If we can ask ourselves why the client communicates in this way and find an explanation in their past then we can keep empathy.  While we have empathy, we can show compassion.

We live and work in busy times.  There is little time to search peoples records for clues from their past.  Action is valued, reflection looks a lot like doing nothing.  We do little good for our clientele when we act without empathy and yet the pressure to act on what is in front of us is immense.  Perhaps next time we feel that pressure to act we might do it with a person who has missed out on some of the skills we have in mind.  We can notice the sense that we’re being manipulated and wonder what that might mean in the context of an unskilful person trying to get their needs met.  It doesn’t mean that our actions will be different but it might mean we might communicate in a more caring way.

We all manipulate.  People with personality disorder are just particularly bad at it. 

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

Linehan, M. M. (1993). Cognitive Behavioral Treatmentof Borderline Personality Disorder. New York: Guilford Press.

Main TF. The Ailment. Br J Med Psychol. 1957; 30:129-45.


As ever, all of the above is just an idea to play with.  Don’t take it as fact.  Other ideas are available...


Suicide Aint Painless

So its suicide prevention week (or month or day, depending what hashtag is being used at the time) and there is much talk of how to help people who feel suicidal. There are lots of people speaking about never having had any training in this area, and lots of service users saying that the response they have had has been awful. As someone who has been responsible for some awful responses in my career I thought I’d share some ideas around working with suicide. Now I’m not suggesting that this is THE way to work with people who are suicidal, I’m not even saying that it works. What I do find is that having these tools and ways of thinking in my head makes me more confident and capable of working with someone who is telling you they want to die. Do excuse the arrogance and I’m sure there are better ideas out there which I’m eager to hear.

Learning The Hard Way
My big introduction to working with suicidal people came when I started doing duty in the CMHT. We had someone who phoned around once a week to say they had lined up their tablets on the table and were going to take them all. I then took on all the responsibility for keeping then alive and got panicky when they couldn’t assure me they would be alright. Very often the conversation ended with them hanging up because they were so frustrated with me, me calling an ambulance to go to their house and sometimes both. It was in the CMHT that I started to pick up the idea that suicide was someone else’s business. One whiff of suicide and I could free myself from any anxiety around being responsible for them by packing them off to A&E or calling in the crisis team to take them off me. While this solution worked wonders for me, it did little for the service user who would tend to be passed around a range of services and sometimes be sent off to a placement miles from home. This was partly to address their suicidal tendencies and partly to do us the great service of not having to worry about them anymore.
I started thinking differently as a result of working in a day therapeutic community for people with personality disorder who were frequently suicidal. This got me used to staying with people who wanted to die but trusting the group to help, not feeling that I needed to fix it. I went on to do DBT and spent a few years working with highly suicidal people and people who manage their distress in ways that are potentially lethal. I think back to the naive practitioner sitting on duty and hoping the phone wouldn’t ring. In a way, this is a gift that might have helped him be more useful. Again, I’m not saying you have to do this, I’m not saying that it will work, I am saying that the more tools you have in your box the more comfortable you will be. Regardless of the effectiveness, feeling more confident might be enough to keep you going.

“I’m having suicidal thoughts…”

Find out what they are. Asking won’t make it worse.
If they’re being vague, let’s get some clarity – “When you say ‘It won’t matter or I won’t be here’ it makes me think you’re going to kill yourself. Are you?”
What are you going to do?
When are you going to do it?
Often I find that being able to talk about the horror that’s in their mind is enough to reduce their distress.
Once we have the What and When of what’s in someone’s mind we can start working on the Why. If we think about suicide being the solution to a problem, try to understand what the problem is.
Sometimes I will use the words above but something like “Can you help me understand why being dead is appealing?” “What would being dead be better than?” “What is so unbearable at the moment that means being dead would be useful?” can be used. You can probably put it better…
Start building hope – “It sounds like it’s this issue and the thought that nothing will change is what’s behind your decision to die. If that issue could be changed would you feel the same way?”
Give examples of similar situations which have changed (or ask them for some).
Don’t solve the problem for them but try to generate alternative solutions to deal with the issue.
Ask if they have felt this way before and gradually felt differently – “It is worth making a literally life changing decision when you’re feeling a way you don’t always feel?” or “You felt this way x months ago, then had y time where things were bearable. Might you feel differently in a few days like you did last time?”
A desperate one – “You have felt like this for x years. We have been trying to change your life for y time. Can we really undo x amout of problems in y amount of time? Can you give it a bit longer before you make a final decision?”
All the above can make a difference. I suspect it’s less about what you say and more about helping someone feel listened to. If your input finishes there you’ll tend to feel pretty good. If nothing has changed you might want to try some things that make you feel a bit meaner.
Attack their rationale for dying.
“I want to be at peace” – What if the afterlife is worse? Some people believe in hell, what if that’s true? What if those ghosts people report screaming and wailing is what death is all about? “We don’t know what it’s like when we die. There’s no evidence. Taking your own life is a gamble. It’s worth gambling if you’re a lucky person…..Are you a lucky person?” (People often cry at this point)
“They’ll be better off without me” – They will not. Almost everyone I work with has had massive trauma in their lives. I will end up working with them if you kill yourself. You know how you blame yourself for everything? They will do that. Their risk of attempting suicide will more than double if you kill yourself. This hell you’re in now, you will be putting them in that.
It can be helpful to describe the horror of a dead body if there’s a chance people will find them. “Do you want their last memory of you to be your purple body covered in blood and sick? Don’t think you will be falling into a peaceful sleep…”
Alternatively – “Are you going to let them win? After all the suffering they put you through it seems unfair that you’ll be dead with people missing you while they carry on with their lives”
Those bits might make you feel awful but might get you some commitment to stay alive a bit longer.
Once we have some commitment we can start exploring ways to stay alive that keep the service user in charge as much as possible.
Get rid of the means to kill yourself – “There’s a million ways to kill yourself out there and if you’re determined you will do it. Can we get rid of that rope/stash/weapon so that you don’t do something fatal on impulse?” Best for them to do it, good for them do to it with someone, ok for them to give it to you. Try to avoid just taking things.
Make it harder to go – I’ve written you a suicide note – “I wont read it. I’ve deleted it. I won’t let you say goodbye to me.” Get them to delete/dispose of it. They can always write another one.
If you have a good relationship – “I will miss you.” “I come to work to help people and it will destroy me if you kill yourself” OR “I will go to court and someone will criticise every aspect of our work together to make it my fault that you’ve died. In my notes somewhere I’ll have written something wrong or written it too late and I’ll get struck off. I might never be able to do my job again if you do this.” This can sound totally self centred by at some point you might just want to say anything you can to keep someone alive. If they’re set on dying, it’s not as if anything you say can make it worse.
And I’ve never done this but if pushed – “You can die. We are part of Europe and there are places you can go that will help you. I’m asking you not to die today. You can fill out an advance directive refusing treatment. It takes a bit of time but it means you can do it. I’ll be honest and I hope you change your mind during that time but it can be done.”
A few more things I might say are –
“The obvious thing to do is get you into hospital and have people force you to stay safe. My experience is that once someone else is responsible for keeping someone alive, everything they were doing to keep themselves safe up until now goes out of the window. If we can consider the idea that admission could be more dangerous for you, can we think other things that might keep you safe?”
“Admission sounds like a good idea but you often cope by cutting. In hospital they will take away the ways that you normally cope so you’ll be feeling like you do now, but without being able to do what you normally do to cope. Can we think of other ways….”
When offering solutions try to make them fit with their normal life – support from friends, family, call lines, more time with people they trust. A change of environment. Even time in a 24 hour Mcdonalds is time spent around people when it’s harder to act on that urge.
“Feel free to talk to me again” lets people know you’re not dismissing them. I always include a warning that I will be no help at all if they phone five minutes before the office closes.
With all the above I’d add the importance of validating someone’s reasoning. “That makes sense.” “If I felt like that I would want rest.” “I would want that pain to stop.” We don’t agree with their solution but we agree with their problem and can see how they thought dying would help.
Rather than tell people to distract themselves, ask what they’ve tried so far. It can sound really invalidating if we suggest things they’ve already tried. Also try to avoid telling people they’re wrong about how they feel. When someone feels like dying, “But you’re doing so well…” isn’t going to fly. If you really disagree, validate their thinking first before offering a different view.
With all these interactions it’s important to try to be curious. If you feel someone is saying one thing but communicating something else don’t be afraid to say that. I sometimes use the preface “This might sound like I’m trying to trick you or catch you out, but honestly I’m just trying to understand…” which can then lead on to “There’s people who jump under a train and there’s people who have no thoughts about dying at all. I’m thinking that you’re sitting here telling me this and I wonder what that means about how determined you are to die. I’m not saying you don’t want to. I can see how much you’re struggling. Can we think about what it might mean together? Does that sound like I’m not listening?” This can often change a conversation from ‘I’m going to’ to ‘I want to’ and urges are easier to work with than firm plans.
What I often hear service users saying is that they were dismissed, not listened to and abandoned. In my experience you can agree solutions that are massively different from what the service user wanted when they walked through the door if they feel you are interested and care. Not admitting someone on the back of a sound rationale which relates to their past/current services can be much more acceptable than “Your notes say admission isn’t helpful”.
Sometimes someone’s desire to die is so acute they might need to be protected from themselves. This is always my least favourite option but short term and with people you don’t know it might be your only one. My gut instinct is for the admission to be short term and that time used to assess and formulate rather than just warehouse. The decisions we make when we understand might be significantly different to those we have to make when caught by surprise.
And I think (to inappropriately use a military expression) those might be all the weapons in my arsenal. Remember that these are tools to use when the service user is on the phone or right in front of you and you’re caught by surprise. There is no substitute for assessing/formulating risk beforehand so that you can act as if this is the 10th time they have been in this situation rather than make all your decisions as if it’s the first time it has ever happened. You will feel more comfortable if you have a plan that the service user has co-produced beforehand. If there’s lots of positive risk (and in hindsight anything other than infantilising, detaining and restricting will be labelled reckless) get senior clinicians and the service user to give the plan their blessing.
I hope this is useful. I think it might have been useful to me when I qualified. Any extra tips and tricks be sure to comment at the bottom. I know I can always learn new things and you never know, it might just save a life. Again, excuse the arrogance of writing something that might be a bit (a lot) patronising but honestly, it’s a genuine response to people saying they felt stuck. Looking forward to hearing your thoughts.