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Suicide

How far should a medical team go to prevent a young woman from ending her life? Does there ever come a point at which the individual has the right to decide?

Samantha is coping with the recent death of her mother. It's been a turbulent few years - drug binges in her teens, then bulimia. She's now twenty two and is finding it difficult to cope.

She's prescribed antidepressants but stops taking them when she's plagued by terrifying thoughts and images of killing herself. These persist and, over the coming months, she makes two serious suicide attempts and is admitted to hospital several times.

Samantha is detained under the Mental Health Act for her own safety and is diagnosed with borderline personality disorder. The recommended treatment is psychotherapy. She's also offered antidepressants but the team don't think she's overtly depressed.

Samantha refuses all treatment - she's terrified of antidepressants and doesn't want to talk.

Three months on, she's discharged as the team don't think being in hospital is helping her. But her family believe it's the safest place for her.

When Samantha gets home she spends most of her time online on suicide chatrooms. The family monitor her activity and their concerns about her suicidal thoughts trigger further admissions to hospital.

However, the team are reluctant to keep her in hospital for long. They want to encourage her to take control of her life and engage with treatment, which she is still refusing. In contrast to most patients who are suicidal, Samantha seems to have the capacity to refuse treatment.

The senior psychiatrist on the team feels uneasy about the pattern that's emerging. He consults the clinical ethics committee to consider the best course of action. He also wants to know what constitutes capacity in this suicidal young woman.

Joan Bakewell and her panel discuss the issues.

Producer: Beth Eastwood.

Photo credit: Chris McGrath/ Getty Images

Available now

43 minutes

The Panel

Deborah Bowman, Professor of Ethics and Law at St George’s University of London

Cleo Van Velsen, Psychiatrist and Psychotherapist at East London Hospitals NHS Trust

Alys Cole-King, Psychiatrist at Betsi Cadwaladr University Health Board and Royal College of Psychiatrists’ spokesperson on suicide and self-harm


Support Organisations

Samaritans is available for anyone struggling to cope round the clock, every single day of the year. They provide a safe place to talk where calls are completely confidential. Get in touch by phone or email or find the details for the local branch online

Phone: 08457 90 90 90

Email: jo@samaritans.org

http://www.samaritans.org

 

Staying safe provides practical, compassionate advice and links for anyone in distress and feeling suicidal.

http://www.connectingwithpeople.org/StayingSafe

 

U Can Cope is a 22 minute film and self-help resources with links to national support organisations

http://www.connectingwithpeople.org/ucancope

 

PAPYRUS and HOPELineUK

If you’re a young person and you’re considering suicide, or you feel depressed or like you’re not coping with life, HOPELineUK, provided by the organisation PAPYRUS, is a confidential helpline service staffed by trained professionals who can give support, practical advice and information.

PAPYRUS can also offer help and advice if you’re concerned about someone you know.

Helpline: 0800 068 41 41

Email pat@papyrus-uk.org

Text 07786 209 697

http://www.papyrus-uk.org

 

CALM, the campaign against living miserably is a charity aimed at preventing male suicide in the UK. Calls to their helpline are anonymous, confidential, free from a landline and will not appear on itemised bills.

Helpline: 0800 58 58 58 (daily 5pm-midnight)

http://www.thecalmzone.net

Your Comments

I am appalled by the ethics of psychiatry and this programme underlined this for me.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

The controversy around Borderline Personality Disorder is not that it is a stigmatising diagnosis so much as it is an invalid diagnosis and that it takes away all context to someone’s state of mind. All psychiatric diagnosis lack scientific validity but BPD has been called a sophisticated insult as it completely ignores the persons, usually a woman’s, life experiences.

Samantha was offered intense therapy and refused this. This is her right. Individual therapy can be gruelling.

Family therapy when every other option had been tried or rejected. Her family obviously cared about Samantha's well-being but the usual rules of psychiatry were used to avoid conversations with them until the family therapist was engaged.

In Western Lapland they have the best results in psychosis in the developed world and they also use this method for all their patients if they think it appropriate. There method is called Open Dialogue. They meet with all the people who is important to the distressed person; family, friends, employer, teacher etc. They may meet every day for up to two weeks and then every week or so. They also offer other help. They do not offer drugs for the first few days and everyone is involved in the decision as to whether take them. Most importantly they do not talk about the family or distressed person outside of the network meetings except about practical matters about organising meetings and such like.

Open Dialogue is a consensual process where the distressed person and their friends and family determine how often they meet with the treatment team. There are no forced conversations. This seems ethical, unlike forced psychiatry or the option of intense psychotherapy or no other help.

Open Dialogue is also called Needs Adapted Treatment as it about providing what the distressed person and their network needs.

In my opinion Open Dialogue is not a medical intervention as it a way of conducting a conversation with people who know each other to help them understand each other, and in particular someone who is distressed in their network. This is something any of us might find useful.

Imagine if this, a kind of family therapy, had been on offer straight away to Samantha and her family? This programme might never had been made as she is likely to have recovered much sooner with no hospitalisation, forced treatment, police intervention, stigmatising diagnosis or any other of the damaging things talked about in the programme.

John Hoggett

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THANK YOU for a brilliant program.

I would like to disagree with the commentator who seems to call for the term "personality disorder" to be dropped as unhelpful, for the following reasons...

1) The term "personality disorder" is helpful to mental health professionals. Everyone would help address the stigma of mental health better by promoting the understanding of the jargon, rather than removing it.

2) I understand that that studies in the USA have shown that DBT has evidential support as an effective treatment for BPD (borderline personality disorder).

3) On BPD specifically:
I believe BPD only affects 2% of the population, its comparative rarity means it is usually misdiagnosed as "depression" in the UK.
As discussed in the program, because BPD affects the ability to relate to others, it presents unique challenges to the therapist, which the DBT approach addresses.

BBC, keep up the fantastic educational work you do !

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Hardly a surprise that it was only when the 'family psychiatrist' entered the scene that a solution was found.

He spoke very articulate English, not the convoluted jargon that your 'experts' used. 

He thought outside the tedious psychology boxes and used his own judgement.

It was such a releif just to hear his voice after all the previous twaddle: like walking into sunshine after being cooped up in a windowless room.

Brigid Gardner

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Today’s episode has angered me. Although I know the reasons for my anger are not your fault, I feel that psychiatric hospitals and the Mental Health Act have  been shown in the wrong light.

I have been in a psychiatric ward twice in the past two years and although I have never been detained, I have been threatened with section 136 and 2. I have spent a total of ten months in a psychiatric ward and therefore I know of many people that have been under the Mental Health Act for different reasons. During this program section 2 was explained as a way to keep someone safe from hurting themselves or others, although this is primarily the reason for sectioning someone, there are other reasons too. For example: if someone has severe generalised anxiety, to the point they can’t leave their house, they may be detained as a way of getting them to hospital and giving them therapy in a different environment with trained staff. The staff are trained in restraint and so when taking the person with anxiety out on walks, they can use restraint to get them back indoors if anything was to happen.

Section 3 was then described as a section that is only used when a diagnosis has been made and an individual needs to stay in hospital for therapy - this is also incorrect. Detaining someone on section 3 can be used after section 2 when someone is still at risk or has not improved since their previous section and can be lifted at any point if taken into a tribunal.

During both of these sections, medication wouldn’t have been “offered” it would have been forced into the patient. If the patient refuses medication whilst on section, they may be restrained, stripped and injected with their medication.

Also, throughout the program there was no talk of section 17, which would have been given to the patient before they were made informal and discharged. Section 17 allows a patient to have either escorted or unescorted leave from the hospital.

I feel that the program should have contained other points of view of psychiatric wards as well, as care varies from hospital to hospital and there are different types of wards: open, medium secure and high secure - each serving a different purpose. It was clear that the patient who’s story you were telling didn’t have the best care and I thought that the psychiatrist did not know exactly what she was talking about.

Finally, the program addressed suicide as a choice and not necessarily linked to a mental illness. For someone to get to the point of feeling that they need to end their life, there is no question about it that they are suffering with an illness - even if that illness is something slight. No one should have to face suicide, but sometimes it is not always an option, in some cases it’s forced on an individual by society. The brain can only cope with so much and rapidly it will deteriorate, causing illness. Other cases of illness may simply be a chemical imbalance in the brain from birth. However, at NO point should someone be given the choice of suicide. Help should always be at hand for those who need it.

I hope my thoughts on the program will be considered for future programs. Although I have negatively reviewed the program in this email, I wish to say that I enjoyed listening to how different cases of illness are treated so differently.

Yours Sincerely,

Siobhan Redfern

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Samantha got better – we are told – in the end. > Great! But she was v lucky because she came from a well-to-do family prepared to take infinite time & spend plenty of money on her treatment. Others are not so lucky. Samantha was fully uninterested in the treatment offer; then near program end she found a psych with whom she bonded.

26:20 Samantha says "I am so erratic & impulsive without it (her drug of choice): but even though I would act on impulse with it of course, the days would be a lot easier, I would be a lot calmer and I would be, able to deal with things in a different light."

My point is that prescription of her drug of choice not only takes the guilt out of her self-medication but establishes basis of trust with shrink; they have something to offer her. There is no point in responding with a moral panic style response; then to say "Alcohol is fine!"

Of course we are in realm of hypotheticals but this could become the basis for her to enter into a proper therapeutic relationship. If her drug of choice were alcohol, then she could obtain it without problem even though it damages her bodily organs (liver, kidneys etc) much more than e.g. Class A drugs cocaine, heroin provided they are not injected.

In my opinion her use of drugs should be seen as a positive factor in the case; she is correctly self-medicating.

Furthermore as one of the experts says; there is a massive stigma around suicide.

Of course a proper discussion would entail a much longer discussion of all the issues involved; this is an attempt to offer a different point of view.

Tim-Jake Gluckman

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Excellent programme on Suicide. Very helpfully described the complexities and the difficult position of family and clinicians as well as patient.

This would be very good materials for training MH professionals. Very good to hear the degree to which the clinicians expressed their confusion as well.

Thanks again

Mike Oates

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Emotionally, suicide is enormously intense and distressing: 'holistically', it is disturbing that we live in a world where some people attempt suicide: ethically, attempted suicide is challenging for clinicians. The programme covered these issues well.

But there is also the question 'can attempted suicide be a legal choice - is it the case that for some suicide attempts, the law does not allow for the suicidal person to be treated ?', and the programme 'ducked that question'.

The answer, is that our law does not state that a suicide attempt automatically indicates a lack of the necessary mental capacity a person needs to possess in order to refuse treatment: Samantha arguably lacked that capacity, because she seems to have wanted to be treated at some level. But mental capacity is assumed to be present by English law, and unless incapacity 'can be proven', or some sort of relevant mental illness can be established, our law does not say 'that you can intervene in a suicide attempt, simply because it is a suicide attempt'. Joan Bakewell asked if 'suicide can be rational' which is a logical question, but 'can suicide be legal' is the more fundamental question.

Mike Stone

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I listened to today's episode regarding suicide with great interest, having experienced a lot of the same things as the subject of the programme. However, I did not have the luxury of booking in to a private clinic when I wanted to, nor did I have bodyguards to keep me safe. I felt the programme featured an unrealistic scenario. I received all my treatment within the NHS and continue to do so. I have had long waits for psychotherapy and have frequently had to cope at home because there are no beds at my local hospital - indeed, sometimes no beds in the whole country! Had your programme featured a person treated within the NHs, I think it would have been very different, and could have had a tragic ending.

Yours,

Rebecca Cassidy

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I have to express my thoughts regarding the relentlessly depressing subject matter today. I am a retired pensioner and spent my working life as a university lecturer.  I listened to your programme and although would normally have sympathy for anyone suffering suicidal tendencies I merely became more infuriated with the whole subject.  I ( fortunately) missed the beginning of this broadcast and so was unsure what the woman's background and 'means/income' was.  It became clearer and clearer that she was certainly not short of a 'bob or two' - due to the number of taxis that she leapt into and drugs purchased, which only added to my lack of sympathy. 

I feel suicidal myself after listening to this programme and what started as a bright and constructive day has been ruined by your over indulged - long drawn out - subject matter. I wonder exactly to whom it was being pitched - as I am sure that there are very many like me who just wanted to turn off.  I shall avoid this programme in the future and enjoy my Thursdays !

Faithfully Nicholas Mills

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Thank you for the above programme, which I’ve just heard on Radio 4.  Having suffered from prolonged episodes of suicidal ideation myself, I had a keen interest in the matter; and I thought you managed to cover the subject very professionally, striking a very fine balance between being informative, critical and sensitive – while NOT being sentimental.  First-rate, intelligent broadcasting.

I am also writing in because my own story might be of interest in that it presents a challenge to the view – expressed by several participants in your programme – that people experiencing suicidal impulses should not hesitate to “reach out”, and that “help is available”.  In the course of my own tribulations, I had occasion to experience contact with the medical and psychiatric professions.  In all cases, I found the interventions to be so cack-handed as to be downright life-threatening: I felt more suicidal after than before.  So I decided it was best to give that lot a wide berth. Eventually, after three decades of crushing loneliness and desperate soul-searching, I managed – through my own efforts – to uncover and resolve the underlying mental distress which was responsible for the suicidal impulses arising in the first place.  I am now in a mentally and emotionally stable state, which has been the case for around two years, and which I achieved without the use of drugs. 

Alex Hunter

 

I have just listened to the programme on suicide. It was a magnificently dramatic construct, brilliantly edited, totally absorbing. The individual voices were completely captivating in that each seemed easily and utterly credibly to incarnate their own existence. The narrative thread was perfectly unwound. The subject matter, which could so easily have been handled in a way which was overly portentous and leaden, was thought through with courage and clear-sightedness. The subject matter could hardly have been of greater importance in that it was about life and death in its most direct and raw form.

Congratulations to the makers of this programme, which I listened to almost with bated breath. On a visit to London last year I saw Joan Bakewell in the street near the National Gallery. Were I to see her now I would certainly be that annoying person who just has to say how much I admire the work she does. However, I really do not know who scripted the text and/or carried out the editing work. Not knowing who is largely responsible, in some sense, only increases the admiration I feel for this wonderful programme.

Diarmuid Drury

 

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I have just listened to the effectively-presented programme on the case of a young woman with chronic suicidal urges. Clearly an extraordinary case, it served the purpose of the programme well.

I was struck by the fact that the family were able to spend large sums of money in their great efforts to prevent the girl from killing herself, though it became clear that much of their intense and well-meaning effort was counter-productive. It was only when a psychiatrist managed to enable her to speak with him without any intervention by the family that, gradually, real progress began to be made.

 

Reference was made to the Samaritans in the programme but I thought it was a shame that this dimension was undeveloped.  It sounded unlikely that the young woman contacted Samaritans from all we heard (though we can’t be sure) but what the organisation offers is well-trained listeners whose fundamental credo is that callers themselves determine their life or death choices, though of course a Samaritans listener’s skill lies in engaging with the caller in their exploration of their own perceptions of their troubles without making any judgements, just gently asking empathetic open questions. Some Samaritans have had more experience of chronically suicidal individuals than your ‘experts’ said they had had in the programme.

 

Peter Roberts

 

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I just would like to say just how riveting this episode was.  The tortuous, tricky business of staying neutral and allowing the various voices space was well done.  I am now retired and have some distance from general practice where this could and did crop up.  What came over in this program was just how redundant psychiatric labelling can be.  Borderline personality disorder label did not help her.  It just perpetuated the drama. The family therapist knows how a family have to be held and everyone in that family has to feel safe, and that holding will take time.

A brave program.

Jeremy Vevers

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Thank you, this was an amazing programme - sensitive, insightful, honest, and almost too moving to bear. I was a bit surprised, though, that there was no representative from outside the professionals, for example a philosopher or a faith person. What this poor Samantha desperately needed/needs (don’t we all?) is someone to love her, as she is, not trying to change her, though change may result from feeling being loved, just as you are.  The family (desperate, loving people) are too close to the situation to be able to solve it (solution is often not possible, depends on how we define it, I suppose).

Anyway, thank you again, this was a most important programme, one of which Radio 4 can be proud. 

Janet Watford

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"Personality disorder" is an unhelpful modern psychiatric convenience for medics who wind up in this blind alley. What the psychiatrists are saying even more than usually is that they don't have a clue. A rigorous behavioural approach to Samantha and her family would leave her with a clearer idea of her responsibilities to self and society and would assist us all in evolving her life plan in whichever direction it takes.

 

Alastair Deery

Programme Transcript - Inside the Ethics Committee

Downloaded from www.bbc.co.uk/radio4

 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE THE ETHICS COMMITTEE

 

Programme 2 – Suicide

 

TX:  23.07.15 

 

PRESENTER:  JOAN BAKEWELL

 

PRODUCER:  BETH EASTWOOD

 

 

 

Bakewell

In today’s programme we tackle our most sensitive subject ever - suicide.  If you are affected by any of the issues raised here you will find more information and support at the end of the programme. 

 

The question we ask is how far should a medical team go in their efforts to prevent a young woman from ending her life?  Does there come a point at which the individual herself has the right to decide?

 

Welcome to Inside the Ethics Committee.

 

This story begins in 2010 when Samantha is 22 years old. She’s had a very difficult few years.  Drug binges when she was a teenager, then bulimia when she was 19.   Now she is having to cope with the recent death of her mother from breast cancer.  The death devastates the whole family.  Samantha is the youngest of five children and lives at home with her father.

 

Samantha

When my mum passed I just kind of went on autopilot.  I wasn’t in touch with my emotions at all, I didn’t know how to grieve, didn’t know how to process anything.  When something big would come up I’d just go do something, just leave the house to compensate with not feeling the feelings.

 

Bakewell

Samantha tries to keep herself busy - waitressing, seeing friends. She even goes abroad for a while, but by the end of 2010 she starts falling back on old habits – being out a lot and binging on drugs.

 

Samantha

I just turned to the thing which I’d turned to since I was 14 to deal with the emotions which I didn’t know how to deal with.  I’d binge for like three or four days and yeah I just really started to yo yo.  I would just wake up, my heart was pounding out my chest, it just started to take its toll.

 

Bakewell

Samantha spends several weeks in bed.  Her family are getting increasingly worried about her. They call the family GP who prescribes antidepressants.  Samantha’s not keen on taking them but eventually agrees. Two days later she’s terrified by how she’s feeling.

 

Samantha

I was walking just up my high street and I suddenly got very disjointed from my reality and I just got this influx of quite violent suicidal thoughts and images and I’ve never had anything like this.  And the scare it kind of gave me – I just ran back home, got into bed, cried loads.  I instantly called my brother who told me to call the doctor, they prescribed me the medication, I didn’t tell him about the suicidal thoughts because it was so shocking. And he just said – sometimes you get worse, you just have to ride it out.

 

Bakewell

But the next day, the suicidal feelings are so overwhelming that Samantha stops taking the drug altogether. One of her brothers has severe mental health problems and he tried to take his own life soon after starting an antidepressant. Her older brother, who’s been trying to help her, notices a sharp decline in her mood.

 

Brother

It went from her just being fatigued and fundamentally depressed to being extraordinarily depressed and suicidal.

 

Samantha

I suddenly was very detached, I went very linear into just wanting to kill myself.  I didn’t even know how I got from A to B so fast.  I just found myself getting lost in this dark kind of world.  I couldn’t be around my family – we’re a very close family but I suddenly looked at them in a very different light.

 

Brother

If you were trying to implement any positivity into her mind she would get aggressive and so the thought manifested herself and she wouldn’t let go.  And that escalated and escalated and escalated and obviously through time manifested into a reality.

 

Bakewell

At the end of September 2011, Samantha takes an overdose.

 

Samantha

I’m not known for doing the best things to myself but this really was quite scary and you know I’ve been through this before with my brother – he tried to kill himself on quite a few occasions and I just – I never thought I would do it – ever.

 

Bakewell

The family checks Samantha into a private clinic for a month. She’s had hospital treatment for addiction problems before and the family hope this will help.  Being away from the house and the family does bring Samantha some relief but, after a few weeks, she is once again plagued by suicidal thoughts and impulses: it’s as though her mind is telling her what to do.

 

Samantha

I had no control over what it was saying and it was just constant bashing at me and it made me feel like everyone is better off without you and you’re just a waste of time.

 

Bakewell

Samantha is discharged from the clinic and her brother goes to fetch her.  The family doesn’t understand what’s happening to her and is desperately worried.

 

Brother

I wasn’t comfortable with her leaving the clinic, something felt very off.  On the drive back I could feel that she was erratic in her mind.

 

Samantha

On the way back again I was getting these voices, it felt like I was almost like electrified, like just high volts going through.

 

Brother

We got back to the home, everyone was happy to greet her, she just went straight up to her room, had nothing to say to anybody.

 

Bakewell

Shortly after, Samantha tries to take her own life again.  Her family calls an ambulance which takes her to hospital. She has sustained major injuries - broken both ankles and fractured four vertebrae.  She has spinal surgery and both legs in plaster casts. She is then transferred to a private hospital for rehabilitation and physiotherapy.  Just before Christmas, and several weeks after her suicide attempt, she is discharged.

 

Samantha

Learning to walk again was such a focus for me that maybe it took my mind off things – I don’t know.  I would do jigsaws and start knitting – I was in a very calm head space for what I had been in the months prior.  And then February things started to rapidly deteriorate and it was like something internal had shifted.

 

Bakewell

Samantha’s family gets her admitted to a private hospital for a week or two.  Talking therapy is on offer there but she refuses to participate. When she gets back home she is distraught – she’s still obsessed with ending her life. 

 

Samantha

I was in a real state.  To get me through the day I was taking about 10 sleeping tablets and they weren’t giving me the effect of putting me to sleep, they were keeping me awake.  I thought I was in the matrix, I thought things were controlled by aliens and I really lost touch, I was petrified.

 

Brother

She’d be totally erratic in her mind, I’d get phone calls that she had just seen someone who wasn’t there talking to her.  She had episodes that I didn’t know how to relate to.

 

Bakewell

By the spring of 2012, Samantha’s family are so worried about her that they persuade her to attend a private clinic where she is detained under the Mental Health Act on what’s called a ‘Section 2’.  This enables doctors to assess her mental health for 28 days.

 

Samantha

I didn’t trust my family, especially when I found out that they pushed for the Section 2.  I voluntarily went and suddenly you get trapped and I guess you feel like a caged animal sometimes, you know, you don’t have your free will to do what you want to do.

 

Bakewell

After 28 days, she is placed on a ‘Section 3’, for treatment. The following day she’s transferred to the NHS. What’s strange for Samantha is that she’s now in the same hospital as her brother, who has his own mental health problems, she’s just on a different ward.  The psychiatrist working there meets Samantha for the first time. 

 

Psychiatrist

I knew that she was a very high risk of suicide.  She was striking in that she wasn’t overtly depressed or low, she did speak about feeling low, although there were no other objective symptoms of her being depressed.  When people are severely depressed there might be a sort of slowing down of their cognition affecting either their understanding about their life, their ability to sort of make decisions around what’s happening to them, a very flat – facial expression.  Whereas Samantha didn’t have any of those symptoms and she was very clear in her thinking.  She was quite animated and articulate.

 

Bakewell

Samantha is diagnosed with borderline personality disorder. The psychiatrist lists the reasons why.

 

Psychiatrist

The very severe suicide attempts, which seemed to be very impulsive, the emotional instability sort of leading to those attempts and she also gave a history of difficulties with her emotional state from the age of 16.  She’d used a lot of recreational drugs which she may have been using to regulate her emotional state.  And difficulty with relationships.

 

Samantha

I remember going back to my room, I had my iPad and I did some research and it didn’t – it didn’t really resonate with me at all and funnily enough a couple of my friends on the chat rooms had borderline personality disorder and when I told them about my diagnosis they were like you don’t seem like the type to have borderline personality disorder.

 

Bakewell

Borderline personality disorder is a controversial diagnosis as the psychiatrist explains. 

 

Psychiatrist

I think what’s challenging about it is that sort of the recommended treatment is intensive psychotherapy which very many patients aren’t able to engage in because it requires an ability to have a trusting relationship with a therapist which is exactly what they struggle with.  So you’re left with a big gap between what’s recommended and what you can actually do.

 

Bakewell

Individual and group therapy, several times a week, is what’s on offer at this hospital.  But for Samantha even one session is too much.

 

Samantha

When the doctor asked me to participate in certain groups I didn’t want to, I was just very resistant, I was very angry, I was being held against my will, I didn’t see the point, I didn’t want to get better.

 

Bakewell

Patients with borderline personality disorder are also at risk of becoming depressed.  While Samantha doesn’t appear depressed, she describes feeling low. She’s offered antidepressants, but she refuses.  She’s terrified of them. 

 

Two weeks after being detained under the Mental Health Act on Section 3, Section 3 is withdrawn. The psychiatrist explains why.

 

Psychiatrist

We didn’t think that it was really benefiting her, in that she would just spend most of her day in bed.  I guess some people might argue well it’s keeping her safe.  It’s a difficult decision to make because obviously the risk is there but what are you doing by keeping her in hospital?

 

Bakewell

Now that the Section 3 has been removed, Samantha is free to leave.  But the team encourage her to stay, which she does.  A discharge date is agreed but one night shortly before, Samantha makes another suicide attempt. She is transferred to A&E for treatment and then returned to the psychiatric hospital until she is more stable. 

 

Having now spent three months in hospital, she is discharged.

 

Well joining me today to discuss the case now: Dr Alys Cole-King, Psychiatrist at Betsi Cadwaladr University Health Board and Royal College of Psychiatrists’ spokesperson on suicide and self-harm and Cleo Van Velsen, Psychiatrist and Psychotherapist at East London Hospitals NHS Trust, specialising in borderline personality disorder.

 

So let’s begin with that diagnosis we’ve heard so much about, exactly what is it Cleo?

 

Van Velsen

Well borderline personality disorder is one of the personality disorders described in our psychiatric classification system.  And borderline personality in particular is based on an idea of somebody having a rather unstable sense of self, perhaps as represented by an eating disorder.  It’s associated with moods that can go up and down.  Impulsive decisions, substance misuse, suicidal thoughts and actions.

 

Bakewell

And what causes it?

 

Van Velsen

Well there is some evidence that aspects of personality are inherited, early adverse environmental experiences can contribute and then perhaps difficult stressful situations later on can precipitate.

 

Bakewell

Now we’ve heard it’s a controversial diagnosis – why?

 

Van Velsen

Personality disorder has a particular type of stigma associated with it.  Most psychiatrists would accept that the notion of personality disorder can sometimes be hard to define but it’s kind of indispensable for understanding certain types of presentation.

 

Bakewell

Alys, what’s your reaction to this discussion about the diagnosis?

 

Cole-King

Well it absolutely resonates with me in terms of the stigma because actually stigma stops people from seeking help, stops them from receiving help and it is a huge problem particularly with suicidal thoughts, self-harm and suicidal behaviour.  For example, about a million people a year die by suicide worldwide and probably 20 times as many attempt to take their life – we just don’t talk about it.

 

Bakewell

Well now she talks about being in the matrix and being taken by aliens – what’s going on here?

 

Van Velsen

I think that would very much fit in this notion that she goes into brief periods of time where she loses some touch with reality.  Also there’s quite a difference between – as if she’s in a matrix into I am in a matrix – and that’s the borderline dynamic that you’ve got of being almost on a borderline and constantly falling to one side or the other.

 

Bakewell

Alys, if someone wants to end their life is it correct to assume that they’ve got underlying mental health problems?

 

Cole-King

There will be a greater proportion who do have a diagnosable mental illness but suicidal thoughts themselves is not necessarily due to having a mental disorder and it’s not necessarily that they want to end their life, it’s just they do not know how to cope with the turmoil or the distress they’re in and if they can be persuaded to seek support they can find a way through.

 

Bakewell

Now we’ve heard that she was detained under the Mental Health Act, first under Section 2 and then under Section 3.  Cleo, can you explain what these different sections mean?

 

Van Velsen

Yes.  Section 2 is when somebody is detained to prevent harm to self or others.  When perhaps there’s a query about diagnosis so that you have the power to detain somebody for 28 days in hospital.  In order for assessment it requires two doctors and an accredited social worker.  Section 3 lasts up to six months and that is when the diagnosis has been established and the section is put in place in order to treat.

 

Bakewell

How do people respond to that? Alys.

 

Cole-King

Well for some people they can become very distressed.  I think you’d be surprised how with compassion and really trying to engage with the person that actually people can come to see that they will benefit.  But certainly in the very early stages it can be really tough.

 

Bakewell

Now Samantha has made three attempts on her life, so why can’t she simply be detained until she’s better?

 

Cole-King

Well sometimes, particularly with people who are suicidal, I think the heightened suicide risk can actually be quite short-lived and sometimes keeping people safe and if required using the Mental Health Act is a recognised treatment plan.  But clearly in order to help somebody you need to find a support that they’re happy to accept because you cannot do support to somebody, it has to be something they accept, then you work together.

 

Bakewell

Well we’ve heard that the treatment recommended is psychotherapy and she is refusing psychotherapy, what can be done about that Cleo?

 

Van Velsen

Well I think that one needs to work on motivating her.  There’s a whole literature on motivational interviewing and engagement of people with personality disorder.  One of the problems is if you admit somebody with this kind of presentation to an ordinary psychiatric ward, perhaps where there are lots of people with other disorders, that environment isn’t always conducive, that’s why I tend to have worked in specialist units where you can in a way have a psychological environment going right from the beginning.  And I do feel for the psychiatrists because what happened was, it seems, she just took to her bed in a regressive state.

 

Bakewell

Yes.  Now if she had agreed to psychotherapy would that put her on the road to recovery?

 

Van Velsen

Samantha agreeing to have the psychotherapy would be a sign of her getting better.  So what one wants to do is to open the choice and there are a range of types of psychotherapy for borderline personality disorder that can be very effective.  The other thing to bear in mind is that the research quite clearly shows that people with borderline personality disorder can mature out of it.  So an intervention plus that can help somebody move on.

 

Bakewell

Right, well now let’s return to Samantha’s story.

 

It’s mid-July 2012 and Samantha is back home after a three month stay in hospital. She is spending all her waking hours online.

 

Brother

She was obsessed with her iPad and it became such an obsession and she was so secretive about it that we had to know what was going on.  At the times that she would go to the toilet that was the times when you’d get a quick two minute break where you can go in and that’s when I noticed that she was on these suicide forums, she was talking to other people from these chat forums.  She used her laptop as well because they had webcam sessions.

 

Samantha

You know some days it was just bringing light to the situation, because you’re there with people that are going through similar things which you are, just being able to communicate and also communicate behind a screen, which gives you the ability to hide behind yourself yet communicate.  It was a blessing for me during those times in a way.

 

Psychiatrist

Initially we were quite concerned about her being on a suicide forum.  She was quite clear that it wasn’t a suicide site as such, it was just a space for her to express how she was feeling.  I was half convinced but I also was concerned that she was spending so much time preoccupied with suicide and spending so much time with other people who were equally preoccupied with suicide.

 

Samantha

I was on there for all of my waking day, speaking to these people.  And you build bondings with them in a weird way and suddenly when they leave it’s a very uneasy feeling.  The thought of anyone else ending their life was quite sad and we’d all be great words of wisdom for each other but just none for our self.

 

Bakewell

But Samantha’s online activities take on a more worrying direction – she’s begun looking for ways to end her life.  She buys some drugs and hides them. But her brother has been tracking her emails.  And when Samantha tries to end her life again, he steps in.  Samantha is furious.

 

Samantha

People say people that are suicidal are selfish because they want to end their lives but you know they don’t know what I’m going through entirely.  I felt like it was selfish of them to want to keep me here.

 

Brother

I think that was enough evidence to say look come on, it wasn’t a cry for help, she tried to kill herself only because we had the edge on her that we protected her from that one.

 

Bakewell

Samantha spends three weeks in hospital.  She’s then home for a few weeks but her suicidal thoughts become so worrying again that the family checks her into a private clinic.  When Samantha is discharged, another three weeks’ later, her brother suggests she move in with him.  He wants to try and help her.

 

Samantha

So I stayed with him and we talked during nights and he’d help me and you know a couple of weeks later same thing comes where I just had enough.

 

Bakewell

It’s now November, a few weeks since Samantha’s last hospital stay. She visits her father at the family home.  Her brother is waiting for her when her dad drops her back at his flat.  But rather than coming in, she jumps into a taxi and disappears.  Her brother suspects she’s going to buy more drugs. Her phone’s off so he can’t track her. Her email password’s been changed… but he remembers the location of where she’d bought drugs before.  He alerts the police and they make their way to intercept her.

 

Psychiatrist

She was brought to hospital by the police on a police section, which is a section 136, and she was assessed as having chronic suicidal urges.  Although again she didn’t seem overtly depressed, she was very clear and articulate, she seemed to have capacity around her decisions to end her life effectively.

 

Bakewell

Samantha is kept in hospital but is not being detained under the Mental Health Act.  She can discharge herself at any time.  She is still refusing therapy. Her family want her kept in hospital.

 

Brother

I can see their perspective but they weren’t living the day-to-day and I saw the growth in her attempts.  When you’ve had that experience and you’ve dealt with that first hand if you hear that she’s going to try and kill herself she is trying to kill herself. 

 

Psychiatrist

The family were understandably concerned and we did spend some time sitting down with them and talking to them about the difficulties that this is the treatment that we would recommend.  Samantha has the capacity to choose or refuse that treatment.  And we can’t enforce it.  I was deeply concerned and I thought that she was – was a very high risk of suicide but I felt there was little more that we could do other than to try and engage her in getting some treatment for herself.

 

Bakewell

Five days after being admitted, Samantha decides to leave.  The psychiatric team make plans to support her in the community.

 

Samantha

When it came time to leave I remember the nurse saying – so shall I call your family.  And at this point I didn’t know that it was a choice, I was like – do you have to?  And he said no, it’s completely – it’s your right.  So I said no I don’t want them to be called.  So I left.

 

Brother

I know it’s illegal and there’s confidentiality elements but given the circumstance it took me to call up the hospital to find out that she’d been released and she’d gone AWOL again.

 

Bakewell

Joining Cleo Van Velsen and Alys Cole-King, to discuss this case, is Deborah Bowman Professor of Ethics and Law and St George’s University of London.

 

Deborah, let’s begin with you and ask your overall impression of this story so far.

 

Bowman

Do you know I’m sitting here listening and just feeling absolutely torn.

 

Bakewell

It’s desperate for the family isn’t it?

 

Bowman

It’s appalling, it’s awful.  And families are often in a very difficult position, particularly in relation to mental health where they may be called upon to give additional information or their description of how somebody is behaving and it’s helpful to the team, it’s an act of love but it also means that they’ve become the surveyor, if you like, of their family member.

 

Bakewell

So what can families do to help?  Alys.

 

Cole-King

Well I think the key thing is showing their love and support and I recognise that sometimes it’s really hard to talk about it and actually research of families who’ve been bereaved by suicide they were asked could you tell your loved one was suicidal and it’s so poignant because all these families were saying yes, I was really worried about them but I didn’t know how to broach the subject, I was scared that it would upset them, that it would ruin the relationship.  And so I would always urge people to never be afraid to talk about it.

 

Bakewell

Cleo?

 

Van Velsen

I just would like to add that although it mentioned some discussions with the family because the family have been so involved in trying to help her I think that perhaps having some family intervention to further the process could have been useful.

 

Bakewell

And Deborah?

 

Bowman

The more we can move away from the idea that everybody’s autonomous and exists as an individual with no reference to anyone else the better because actually autonomy is always about our relationships and the sense we make of the world.  Having said that of course there are legal constraints on what you can share with the family in terms of the information you can share and how involved you can be with the family but if you’re thinking about a therapeutic intervention with the family that seems to me to be a very sensible way.

 

Bakewell

Right well now Samantha’s online a lot and going to suicide chat rooms, now what do we make of that Alys?

 

Cole-King

Suicide forums where people go online to talk about ending their life is actually really unhelpful because when people are really suicidal and very distressed their ability to think about solutions are very much narrowed.  If somebody’s very distressed and suicidal themselves they can actually be made more distressed when they hear about others.  And if only somebody would contact, for example, Samaritans where they’re given the time and the space with somebody who’s there to listen, people then could be supported to thinking about other alternatives to suicide or self-harm.

 

Bakewell

But are there any chat rooms that are safe for people who feel incline to take their own lives?

 

Cole-King

Yeah absolutely, so for example Big White Wall – it’s an online anonymous community but they have in real time online wall guides to make sure that the conversation is safe and people don’t come to harm.  And I think it’s really important now that the medical profession, in fact the whole of the NHS, need to be aware of all the changes in social media, it’s now a patient safety issue, that as psychiatrists we need to understand what media our patients are using and to advise them accordingly.

 

Bakewell

What about when a patient like Samantha is being detained under the Mental Health Act for their own safety, do they take the technology away from them, do they take their laptops away?

 

Bowman

I mean generally not but there have been one or two people who are patients, for example, who have written about some of the difficulties that their wish to engage with social media, for example, have caused the team.  And I also wonder about when somebody is on the section, we are trying to support somebody to the position of living their life and making choices, so that’s a negotiation about the choices that they are able to make.  And there’s vast fictional literature on suicide, would we confiscate certain titles?  You know those sorts of questions are really head hurting when you start thinking about them.

 

Bakewell

Right, well let’s continue with the real life story now.

 

It’s mid November 2012. Samantha has discharged herself from hospital after a five day stay.  She catches a train to buy drugs again and then checks into a hotel. Several hours later her brother, accompanied by police, track her down. She’s released into his care, admits that she’s purchased drugs but begs him to let her keep them on the condition she doesn’t take them. Having the drug matters to her.

 

Samantha

I had an overwhelming sense of comfort.  I was so erratic and impulsive without it, whereas even though I would act on impulse with it, obviously, from one of my previous attempts, the days would be a lot easier and I would be a lot calmer and I would be able to deal with things in a different light.

 

Bakewell

Her brother agrees but the next day it’s too much pressure…. he reads a post from her online which tells him she’s thinking about taking the drug.  He takes her back to the NHS where she is again assessed under the Mental Health Act.

 

Psychiatrist

Again they didn’t find evidence of depression that was impairing her judgement.  Appropriate treatment was psychotherapy, she was refusing that.  And they didn’t believe that detention in hospital was appropriate for her.

 

Bakewell

The team also feel that being in hospital could actually be harmful. 

 

Psychiatrist

She was regressing I think, while she was in hospital, so she would spend all day just in bed, up all night on her iPad, and we were worried that it wasn’t just maintaining the status quo it was actually potentially making things worse.

 

Bakewell

While Samantha is now free to leave hospital, both the team and her family encourage her to stay there until she feels more stable.  But Samantha doesn’t want to.

 

Brother

Having her locked up was a much safer option and in some way way selfish, you kind of wipe your hands with it, you go well this is now your problem.  Her being imprisoned was a lot safer than her not.

 

Psychiatrist

The family’s feelings and concerns are very understandable but I think that the anxiety that they were expressing and the extent to which they were trying to keep her safe was actually maintaining the situation of her handing over the responsibility to someone else, rather than actually shifting that responsibility back to her about engaging in some treatment for herself.

 

Samantha

So with that I went back to my brother’s, I got my suitcase and I got my things and I left and me and my brother’s relationship really did deteriorate.

 

Bakewell

Samantha moves into a hotel.

 

Brother

Although she didn’t want me around I’m going to have somebody watching her and monitoring her and being with her and that’s when I called upon the services of the security that I had working for me and we put them on rotation – 24 hours a day.  Nobody else was taking care of this.

 

Samantha

Now it was I didn’t know how to go about ending my life, I had someone watching me 24/7.  I’d been suppressing my anxiety and feelings with tranquillisers and things like that and I would just be paralysed with anxiety – it was absolutely hideous.

 

Bakewell

Two days after leaving hospital Samantha meets the psychiatrist at the community mental health centre. The psychiatrist wants to arrange support for her in the community.

 

Psychiatrist

The home treatment team were a bit concerned I think about taking her on, given the risks.  So I assessed her with them.  Our plan at that point was for us to meet with her three times a week in the community mental health team and over the weekend she was going to make contact with the bed managers at the hospital.  This was a very unusual situation.

 

Bakewell

Samantha agrees to the community support, as she believes it will keep her out of hospital. She attends about half of her appointments.  She spends the rest of her time in her hotel room on the suicide chat rooms.  Her brother monitors this from afar.  Whenever she leaves, which is rarely, she is followed by body guards.  This goes on for a whole month.

 

Brother

There was always a part in my mind that knew that time is the best healer and that if we could protect her from killing herself that slowly but surely what would seem like an infinite reality of pain and suffering would ease down.  But she was so fixated on the idea of suicide that every day was a challenge to keep her alive.

 

Bakewell

The whole mental health team are worried about her and offer her a stay in hospital, but she refuses.  They suggest that a therapist visit her regularly at the hotel. She’s not keen but agrees in the hope that it will keep her out of hospital.

 

The senior psychiatrist on the team feels uneasy about the pattern that’s emerging. Samantha’s suicidal behaviour is very different to what he’s seen in other patients with a diagnosis of borderline personality disorder.  

 

Psychiatrist (2)

Usually people with borderline personality disorder when engaging in acts of deliberate self-harm or attempted suicide are in a state of greatly heightened emotion and it is usually the extreme fluctuations in their mood that make them prone to such events.  But that wasn’t the case with Samantha, she was calm, gave a coherent rationale almost for why she wanted to end her life and that sooner or later she was going to end it all.

 

Bakewell

As we’ve heard the team think Samantha has the capacity to refuse psychotherapy, a decision which could ultimately cost her her life. The psychiatrist feels this premise warrants closer scrutiny.  He takes Samantha’s case to the Clinical Ethics Committee at the Trust.

 

Psychiatrist (2)

I think Samantha was the first time that there was a controversy of this kind, namely that so many clinicians felt that not only was there a great likelihood of somebody ending their life but that they had the capacity to actually make that decision.  There was something obviously uncomfortable about that and we were acting in contradictory ways – on the one hand admitting her to hospital, on occasion coercively, yet on the other hand saying this is somebody who clearly has capacity to make decisions of a gravity of this nature.  I just felt like the understanding of what constitutes capacity hadn’t been fully explored.  So anticipating that I would be managing her in the community afterwards I really wanted to give some space for thought about that contradiction.

 

Bakewell

I’ll bring it back to our panel now.  Should it ever be left to the individual to decide to end their life?  Deborah.

 

Bowman

It is something that I grapple with constantly.  Ultimately in a small number of cases it is possible for people to make choices that might result in their death.

 

Bakewell

But Deborah do you from personal experience know of situations in which people have made the choice?

 

Bowman

I have known of two people for whom suicide was their choice I believe.

 

Bakewell

Cleo.

 

Van Velsen

I can think of a situation where somebody as a young boy had suicidal thoughts from the age of nine and had had a vast amount of treatment and finally died by suicide at about 32.  And I do think that everything had been done that could have been done to help him.  I wouldn’t say it was rational but I did feel that it had an inevitability about it.

 

Bakewell

Well let’s just draw back from the details of this case and ask a more general philosophical point if you like – can one make a rational decision to end your own life?  Deborah.

 

Bowman

Ooh gosh that’s one that has occupied philosophers for centuries.

 

Bakewell

They did it with great honour in some cases.

 

Bowman

Yes, yes.  I do believe it can be rational, I don’t think that’s the case here.

 

Bakewell

Cleo.

 

Van Velsen

In this particular case I have a concern about this notion of whether or not she has capacity.  I don’t think she’s capacitous for this decision about suicide because it’s a result of her mental disorder.  Capacity is about a particular decision and in psychiatry people are able to make decisions about aspects of their physical care but if it results from a mental disorder can mean that it is not possible to say they’re capacitous.  Do I think that some people have the right to die by suicide or make that decision perhaps in the context of a severe physical illness where in some ways it doesn’t seem to be an expression of despair but an existential wish about their life that they carry out.

 

Bakewell

Deborah.

 

Bowman

Intuitively it feels very different doesn’t it.  I do think there are interesting things about the reasons we can tolerate someone’s decision and reasons that we can’t.  And actually is it up to us to take a view on that, when it does it become our business?

 

Bakewell

Right, well let me ask each of you what advice, if you were the ethics committee, would you give to this medical team?

 

Van Velsen

The advice that I would give would be to not agree that her decision is entirely capacitous and continue to engage with her for her to progress.

 

Bowman

I am clear, I think actually I want to understand her capacity much more, what is it that’s available to her and have those options been considered in the context of her capacity?  It seems to me treatments become a bit disjointed from an abstract notion of capacity and I’d like to see that more meaningfully explored.

 

Bakewell

Alys?

 

Cole-King

I would urge them to look again, is everything possible being done to help this person and to actually never give up.  The evidence is that people change their mind and that evidence cannot be ignored.  The goal should be always to prevent suicide.

 

Bakewell

Well What if invites us to rejoin the story, what happened to Samantha. She is in a hotel room. Her movements both real and online are being monitored 24/7.  The question is does she have the capacity to decide to end her life?  The clinical ethics committee gives its view.

 

Psychiatrist (2)

The clinical ethics committee agreed that it was difficult to say with certainty that she had capacity to commit suicide and that was largely based on the view that she was a young person who’d been through the awful trauma of losing her mother, using drugs and living through quite fraught family dynamics.  And fundamentally that she was young and didn’t really have the maturity to assimilate all that and she had the capacity to grow, she had the capacity to learn and the capacity potentially to see things differently.  And that therefore regarding her as having the ability to take responsibility for ending her life was premature.

 

Bakewell

If Samantha lacks the capacity to make her own decisions, taking great control over her treatment could be warranted.  But the psychiatrist isn’t convinced this will help and feels they need a new approach.  Then, news from the family brings things to a head.

 

Psychiatrist

The family said that over the weekend from monitoring her online activity one of the other people in the forum had completed suicide and they were concerned that she was in a suicide pact with this person.  The bodyguards that had been hired by the family had also said that she seemed drowsy.  So we were worried that she’d taken an overdose over the weekend.

 

Psychiatrist (2)

That kind of information just couldn’t be ignored and I felt that if we were going to try and change the rules of engagement it had to be from a point of safety and I didn’t feel it was safe at that point in time and that’s why we arranged the mental health assessment and I did detain her at that point.

 

Bakewell

Samantha is detained in hospital under Section 2, for assessment. This makes sense given that those treating her are starting to doubt her ability to make decisions for herself.  But they are not convinced it would help her feel less suicidal as she is still refusing the treatment on offer - therapy.

 

Samantha

No one can force you to talk, no one can force you to partake in therapy.  It was like you just don’t get it, I don’t want to.

 

Psychiatrist (2)

And that was fine from my point of view because what it offered for me was an opportunity to engage her in discussion in an environment where her safety could be assured.  And I did have some really good discussions with her in hospital.

 

Bakewell

What happened was that gradually Samantha began to trust the psychiatrist.  She also continued to talk to the therapist.  After 28 days her detention in hospital expired so she was free to leave.  But she was still plagued by suicidal thoughts. The psychiatrist felt it was crucial they involve her family.

 

Psychiatrist (2)

She was somebody who was very much embedded in her family, their dynamics were both contributing to the difficulties at the time, despite the very best of intentions on their part but also I felt that they were a possible facilitator of the solution to her problems.  So at that point I decided to make contact with a family therapist.

 

Family psychiatrist

I saw Samantha on the ward, 7th January, and it was very clear to me that it was absolutely no use me joining the regiment of people who were trying to get her to not kill herself.  I thought it was very important that I tried to understand her reality.  All I could do was to say look I might be able to throw some light on this situation, would you agree to see me with the family.  Absolutely not to start with but she wouldn’t mind seeing me on my own.

 

Bakewell

When Samantha was discharged, the family therapist began meeting her at her home.  Over five months they met several times.

 

Samantha

He would get my mind quite active and we would have quite interesting conversations and that I found very enjoyable.

 

Family psychiatrist

And I thought that was the right tone, that we were having interesting conversations.  And having got to that point I thought one could begin to then gradually expand her thinking away from what seemed to be this fixed point, which only made sense if she killed herself.  In a funny sort of way she was rather disconnected from her emotions, her descriptions of all of her family were somehow strangely two dimensional.  And so I felt that something about her development had left her kind of not fully equipped to make sense of relationships.  And that when her mother died I think she was left literally gutted and didn’t really know how to connect to the family as a useful springboard to jump off from.

 

Bakewell

The family therapist met with Samantha’s family too.  After six months Samantha eventually began to join in and, very gradually, over time, her suicidal feelings that had consumed her for so long began to dissipate.

 

Samantha

I started to notice a gradual shift in how my thoughts were obsessing over when I would die and how I would die to kind of considering others and life a little bit more.  And I think I was very resistant to it though because it had become me.  So without wanting to kill myself what and who was I?  And it seemed we all learnt a lot from this experience and we all processed my mum’s death a bit more together.  I’m very lucky I got out of it alive.  They did everything they could to protect me and I’m exceptionally grateful for that.

 ENDS

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