This paper was originally presented to a meeting of psychiatrists and other mental health workers in July 2004. I was inspired to write it by 'Danny', one of the patients mentioned in the talk. Not long after I gave the talk, 'Danny' was found dead. I have updated the paper accordingly. Another motivation was provided by my experience of the attitudes and behaviour of the staff at Forest Lodge Low Secure Unit of Sheffield Care Trust.
This paper is about certain styles and patterns in the language that we professionals in the mental health services use to communicate about patients, often in formal reports but also orally, to colleagues and to patients themselves. I suggest that these styles betray a defensive way of thinking that denies certain realities about our work, and are pejorative for the patients concerned. With the use of examples I suggest alternative ways of communicating that acknowledge our responsibilities and are less demeaning of patients and of our professional work. Nearly all concern patients and services in the forensic mental health sector, although I believe that the issues I raise are also relevant to other sectors.
I contend that none of us who work in the mental health services have chosen easy jobs. The tasks we set ourselves are difficult and challenging. We are the recognised experts; we are highly trained and well paid and we do our best to help our patients. Yet they appear to frustrate us in our efforts, the results of which often fall short of our aspirations.
When we are unable to understand patients or when we feel limited in our ability to help them, we seek ways of coping with our frustration, disappointment, guilt, and so on. One way of doing this is to account for what has happened using language that subtly implies that the locus of the failure of our efforts lies with the patient. We have this privilege because we are more powerful and we are in charge of the formal language that we use to communicate about patients. The expressions that we choose are often pejorative for the patient and, especially when communicated to him or her, run contrary to our stated aims of, say, enhancing his or her sense of self-worth.
Instead of doing this, we can choose language that more fairly acknowledges our own responsibility for the systems and the practices that, in our expert judgement, we deem are going to benefit patients; the patients themselves are not responsible for what these are or even choose which ones, if any, may be appropriate.
Below I discuss some examples of the expressions we use to anaesthetise our unease or discomfort when events challenge our authenticity as experts. Accompanying each one is a different way of expressing what has happened or is happening. We have a choice which to use and we shouldn't become pedantic about this. However, although the alternative expressions may hurt us, they may be fairer to the patients concerned. All are direct quotes from reports, letters, oral opinions, etc. about patients. They are drawn from diverse sources and not just the author's place of work. In all cases the names have been changed.
We cannot help everybody all the time. For example, I undertook cognitive therapy with a patient, Jim, who was diagnosed with delusional disorder. His beliefs also included the idea that the staff in the hospital, who were in reality trying to help him, were all part of a conspiracy to prevent his beliefs from being accessed by the public. Jim was hostile, belittling and cantankerous. (Nowhere in this paper do I deny our right to use such negative expressions about patients when they are apposite; and indeed it is important that we are free to do so.) After a considerable number of sessions of therapy, Jim still held on to his unusual beliefs as strongly as ever and I was feeling battered and undermined.
How do I console myself with the fact that I am a highly trained, highly experienced, well-paid, recognised expert on psychological disorders and yet, having set myself a task which I am expected to complete, I did not achieve my goal? I might say:
Jim has proved resistant to treatment.
Now, did Jim have this attribute 'resistant' before he met me? Where is this property of 'resistance'? Surely it is a property of the methods that I chose to try to help Jim. I might therefore say instead,
My efforts to help Jim have not been effective.
Here is another example on the same theme. I recall watching a television programme some years ago about a pain clinic that followed the treatment of three patients with chronic pain. Two of the patients did very well, much to the credit of the staff who were helping them. However, one patient made no progress at all. The clinical director explained this at the end of her treatment, by announcing:
She did not want to get better.
Instead, he might have simply said:
Our team has failed in its task
Why did he not say this?
Consider now this statement made to me by a patient called Danny.
They've told me I'm untreatable.
I had been Danny's psychologist at the hospital where I worked and I used visit him informally at another unit. He told me the above one day when I went to see him; he said that he was being discharged from the Unit and I asked him why.
Where is the attribute, process or activity that allows us to define Danny as 'untreatable'? I suggest that it belongs to the people who communicated this information to Danny. It is their difficulty, their limitation. But they have transferred ownership of it to Danny. If they had retained responsibility for this, perhaps Danny would have informed me thus:
They've told me that they are unable to help me.
How often do we say something like the following?
Donna is a very puzzling case.
This sounds a fairly innocuous statement to make. But where is the locus of the 'puzzlement' or 'puzzlingness' in this situation? It is surely not in Donna, but in the person who made the statement. Can he or she not bear the feeling of discomfort that we all experience when we are floundering in our professional work? If this person can, then he or she might instead say:
So far, I haven't been able to understand Donna's problems.
Now consider Yasmin. Based on our expert knowledge and assessment, we decided that Yasmin would benefit by being transferred to our unit. Unfortunately things did not work out in the way we predicted. Yasmin's problems, her behaviour, and her mental state are unchanged. We have been proved wrong. How do we cope with the unease and disappointment that we feel about this? One way is to put the burden on Yasmin:
Yasmin has not yet made the anticipated progress at the Unit.
So it's all Yasmin's fault! But who decided she was to be transferred to the Unit? Not Yasmin. She might not even have chosen to come in the first place. Would it be too unbearable for us to put in our report the following?
We thought that coming to the Unit would help Yasmin but so far this has not happened.
Once again suppose, as is not uncommonly the case, that one has taken on a patient, let's call him Imran, for therapy and no progress has been made. What shall we say in our final report?
Imran has proved to be inappropriate for this therapy,
This therapy has turned out to be inappropriate for Imran.
It is our choice.
In a similar vein, suppose that it was our idea that Sally would benefit from attending some groups in our unit. After some time we write a report on Sally in which we state:
Sally has not made proper use of the groups that she has attended.
It is clear from this statement that we were proved wrong. Is there anything to be lost in admitting this? If not, we could say:
We have persuaded Sally to attend some groups but they have not proved useful for her.
Now the staff running these groups might protest that Sally is one of those patients who causes trouble, who is lazy, who goes out of her way to pick arguments, and so on. These things may well be true, in which case should the staff have to take the blame for all this? My answer is that if Sally had none of these attributes then we may well not be seeing her in the first place. We cannot have our cake and eat it. We set ourselves the task of helping Sally with her problems, we offered some solutions, but they did not work. However tempting, I suggest we should not turn round and blame Sally. If a man goes fishing and catches no fish, he does not blame the fish for failing to make proper use of his rod.
The following is the title of a workshop for professionals in the Mental Health Services:
Motivating the Unmotivated: Helping 'Difficult' Patients
The alert reader will notice something in this title that is apposite to the present thesis, namely the inverted commas around the word 'difficult'. Whoever came up with the title of the workshop is apologising to us for using this word. But why use a word for which one has to apologise? And where does the quality of 'difficultness' reside? Is it not in ourselves, the experts, or more accurately in the task that we have set ourselves? (Of course, the word 'difficult' can be used to describe patients who have negative qualities - rudeness, inconsiderateness, selfishness and so on - that would be recognised by anybody. As I explained earlier, I am not proscribing the use of such terms. However, I am sure that this is not the sense in which this word 'difficult' is being used here.)
Also, what determines that such patients are 'unmotivated'? Surely we are only entitled to say that they are 'unmotivated' in relation to us. Without our presence, and without our expectations of them and our own agenda and needs, would they still be 'unmotivated'?
Perhaps another title for the workshop would be:
Helping us to Persuade Patients that the Therapy we Offer is Worthwhile
Sometimes we are in a position to announce that a patient, say Ali, would not benefit by being brought to our unit. Still, this is an admission of our limitations, despite all our expertise. We may therefore say in our report:
Ali is unsuitable for this unit.
Could we not instead bring ourselves to say in our report the following?
This is an unsuitable unit for Ali.
But, surely it is expecting too much of professionals like us to describe ourselves in a manner that sounds rather insulting? Why then use the same word to describe people less fortunate than us? Perhaps we may find the word 'inappropriate' to be a more acceptable way of describing our unit.
Of course you may argue that all of this is academic if Ali never reads or hears what we say of him. But is it not possible that even if he doesn't, our choice of language can affect, for good or ill, the way we think and act in relation to our patients?
And suppose the patient is informed of his unsuitability?
They told me I'm unsuitable.
This was said to me by Danny when I asked him why he was not being transferred to a certain unit whose staff had recently assessed him. Danny had his share of problems before the staff came to assess him. His adult life was blighted by unhappiness, deprivation, homelessness, self-neglect and victimisation. Now, as a result of these people from the caring professions coming into his life, he acquired one more - he was unsuitable for them.
This is the same Danny who, when I visited him, told me he was 'untreatable' and was being discharged. He uttered the two statements within the same minute in our conversation.
Now, it may not be the case that the staff actually used the word 'unsuitable' and Danny may have simply been paraphrasing. (In fact the actual report on Danny said that he was not 'appropriate' for the unit that had assessed him.) I was, however, struck by the way he made the two statements about his being 'untreatable' and 'unsuitable'. He seemed entirely matter-of-fact about it, as though he expected that people would routinely make these kinds of statements about him, whereas somebody else might feel a little offended.
In fact being 'unsuitable' was a recurrent motif in Danny's life. He was 'an unwanted child' (i.e. his parents didn't want him) and he was fostered when he was several weeks old. Once he had left home his life consisted of moving from one residence to another, interrupted by periods of homelessness, because of his 'unsuitability'.
It was the received wisdom that Danny 'suffered from low self-esteem'. Concepts such as 'self-esteem' and 'assertiveness' are, as we use them, inventions of the psychotherapy profession. They make it easier for therapists to locate what they believe are the sources of their patient's problems; therapeutic programmes can then be devised to 'improve self-esteem', and the improvement can be measured by standard scales. I am not saying that this enterprise is invalid, but unless a person is treated with dignity and respect in his or her daily life, and this includes life as an inpatient, then there is little point in having special treatment for 'improving their self-esteem'.
It may have influenced Danny's life not one iota, but could it not have just helped a little for him to be able to answer my question as follows?
They told me they are unsuitable for me.
Danny's being pronounced 'untreatable' and 'unsuitable' came as a sad epitaph for four years spent in secure hospitals. Whilst he did very well in the first hospital, after he was transferred to the second his behaviour, attitude and outlook deteriorated and the staff had great difficulty managing him. Finally, the labels 'unsuitable', 'inappropriate' and 'untreatable' provided useful service to the Unit in explaining its failure and justifying its decision, made in a matter of weeks, to discharge Danny to a flat in the community. Fourteen months later he was found dead in his flat, having overdosed on solvents. He may have been dead for several days. When his social worker rang me to describe how he had died he was quick to announce, 'When he was discharged, four psychiatrists said he was untreatable'. Words of wisdom, or words of self-comfort? The word that comes to my mind when I think of Danny is 'lovable' and that is how I remember him.
In a similar vein, a patient once told me that he had been considered for a particular secure unit, but then said:
I didn't fit their criteria.
I for one would like to have heard this person say:
They didn't fit my criteria.
The next statement I consider to be emblematic of the attitude of the mental health services that I am trying to highlight in this paper and I shall name and shame the person responsible. In a report, the following statement was made:
Richard's problems do not fit into any of the categories of personality disorder as currently described.
The person who wrote the report is the author of this paper.
One of the least informative pronouncements in any such report is that 'X does not suffer from any recognised personality disorder'. This statement often comes as a kind of grand finale at the end of the report as though it is the product of considerable professional knowledge and wisdom. A different way of expressing what was intended might have been:
The current classifications of personality disorder are not relevant to Richard's problems.
Or for that matter, Fred's, Mary's, Mahmood's, Donna's, Leroy's, Stewart's etc., etc.
Consider the story of Julie. Julie was persuaded to transfer from one secure unit to another one because the first unit was becoming all male. Julie did not wish to go to this unit. After several months there, she was transferred back to the original unit as her behaviour and attitude had deteriorated. How are we to understand why the second unit was unable to help Julie, and indeed why she changed for the worse there? The discharge report of the Clinical Director of the second unit is the obvious place to find the answer. In this report we find the statement:
Julie was unable to establish a trusting relationship with the team.
But who decided that it was a requirement of Julie to achieve this? Not Julie. She did not come knocking on the door of the Unit saying, 'Please take me in; I intend to establish a trusting relationship with the team'. It was the agenda of the Unit that Julie should achieve this. But it is Julie who, yet again in her life, is labelled a failure. Much of the report, which Julie herself read, was in this style, conveying the impression that the Clinical Director was more than a little annoyed with Julie. Would it have been so unbearable for her to have said the following?
The team was unable to establish a trusting relationship with Julie.
The following is the title of a 'heart-sink' document that an NHS Trust circulated to various personnel.
Policy for the Management of Patients who Fail to Engage with Services or Seek to Disengage from Care, in an Unplanned Way
Once again it is the patients who are the failures. Perhaps I am entitled to say that I have written several books but the public have failed to buy them.
The person, or more likely the committee, who devised this title, could have come up with one such as the following:
Policy for what we do when we have Unexpectedly Failed to Engage Patients in our Services
In all the examples that I have given, I have illustrated two ways of describing the events in question. I am not necessarily saying that the first way is always the wrong way and the second way is always the correct way. In recent years, much attention has been paid to 'politically correct' ways of using language; some of this has been tedious and counterproductive and has not really led to any better ways of thinking and behaving. The two ways that I have represented, however, do reflect different ways of thinking about the work that mental health professionals are engaged in. I believe that the alternative examples that I have provided for the statements are more accurate and fairer.
We are all storytellers and each report that we write about a patient is a story, but only one of many that could be told about that patient. The language that we use cannot but reflect our own agendas, namely that we are the experts and that we therefore need to protect ourselves when we have been shown to be wrong or wanting. It does not pay to be unduly pedantic about these things, but I find that when I read a report in which several examples of what I have illustrated are evident, then that report acquires an arrogant and unfeeling quality that appears to read as an indictment against the patient concerned.
I consider that the work that I do is highly skilled. Nevertheless, people often say, 'Anybody can do counselling (or psychotherapy)' and so on. Because much of our work is essentially an interaction between ourselves and another person, it may seem as though all that it amounts to is common sense. However, I believe that to sit down with a patient, particularly one with quite severe problems, to establish rapport with that person, and ultimately to find a way of helping him or her, require knowledge, aptitude and skill. Like everybody else, often enough I fail at my task and I have to find some way of consoling myself and reassuring myself that I am authentic in my role. I feel better acknowledging my failure rather than finding an excuse for it, such as 'The patient was not ready for therapy', or 'The patient has too much secondary gain from her symptoms' or 'The patient does not wish to get better'. I believe that this devalues the work that I do.
If I fail, then I want to know why. I want to believe that there was a way to succeed at the task I set myself but that this eluded me. Perhaps somebody else could have found that way, or perhaps by discussing it with a colleague or supervisor I could have succeeded in my task. Believing this acknowledges the abilities, skills, experience and training that my work demands of anyone, and upholds the validity of my role as a professional and an expert.