TheRight to be at Risk
Lecture given at the Critical Psychiatry Network Conference on, "The Limits of Psychiatry," London, 13 June 2003
Joseph H. Berke, Director, Arbours Crisis Centre, London. e-mail: firstname.lastname@example.org website:www.jhberke.com
What is a Risk? Well, it is usually seen as any action or potential action that may serve as a threat or danger to life and limb, for oneself or to another. ‘Risk’ carries a negative connotation. Something ‘bad’ may happen.
In a larger sense, ‘Risk’ refers to a change of state or status. This may be positive or negative. Really, we are talking about the process of being alive.
To be at Risk is to Risk to be alive. At any moment the consequence of being alive entails sudden unforeseen changes which may enhance or endanger health.
But since risks involve people, it is important to ask, who is at risk? Well children are at risk when they go out to play, they may get run over by a car, or just when they play at home. Lots of kids are injured are killed in common household accidents. Then parents are at risk for having children and for losing them. Marriage is a big risk. For wives: that their husbands will beat them. For husbands: that their wives will nag them to death. Similarly slaves used to be at risk of having sadistic owners and owners used to be at risk that their slaves, that is, their capital, would run away.
As we can see ‘risk’ is not an self enclosed entity. In human terms it is something that happens to someone, but inevitably severely affects another. Risk involves a subject and object. In other words, it is a vectored event. Hence one person’s injury is always another person’s misery.
In many countries teenagers take big risks by having to undergo military service ( injury or death) or by not choosing to undergo military service (social rejection, impoverishment). Similarly the mothers of many of my friends feel at terrible risk when their sixteen or seventeen year olds choose to go into combat units, for the kids, a big part of the process of growing up. If their mothers try to prevent this, they risk emasculating or stifling them (a living death for those they love). But otherwise they risk losing them (a sudden death in military action).
Risk is part of life. No risk, no life. Moreover it is an interpersonal process. It has to be. We are all part of a social field. A ripple here entails a ripple there, even at the far end of the universe. RISK IS A RIPPLE IN INTERPERSONAL FIELD.
Since I have long worked in the field of psychiatry, or anti-psychiatry, as RD Laing and David Cooper used to say, these remarks are an introduction to focussing on these very same issues as they affect people who get themselves diagnosed as mental patients, and others who have to deal with them. These are a legion of mental health professionals and unprofessionals. I would include among the latter category editors and writers for newspapers who ‘make a killing’ selling scare stories about schizophrenics.
RD Laing once told me that there is a fundamental difference between neurotics and psychotics. A neurotic is someone who bothers 20-30 people. A psychotic is someone who bothers at least 50- 60 people. As for diagnosis, it is part of a process which RD Scott, who used to be head of the Crisis Unit at Napsbury hospital, called closure. That is the point when a person is seen as a risk, and socially cemented as ‘a bad, alien irresponsible other.’ It also is the point when a person gains a label as a ‘dangerous other.’
This same process is now happening with RISK. It has come to my attention in my capacity as the director of and therapist at the Arbours Crisis Centre in North London, because the the area health authority, under which we operate, now insist, as part of a new policy, that practically everyone that comes to the Centre, in or view, as guest, not patients, be registered as a risk and put on a RISK REGISTER. In other words.In other words, Risk has now become an additional diagnosis. While the ‘Risk Register’ has become a new form of hospital file or pathological or criminal categorisation.
A few moments ago I referred to the tendency of slaves to run away from their owners. This risk also carried a psychiatric diagnosis. DRAPETOMANIA. So slaves who absconded were not seen as men trying to be free, but as mentally sick, irresponsible entities. This labelling process, which preceded DSM-4 by several years, was a nifty form of invalidation, making a mental invalid out of a social in-valid.
I am not against assessing risk. I do it all the time whether I shop on Oxford Street, travel abroad or try to help new guests at the Crisis Centre. What I am against is the way that social authorities are insisting that this assessment takes place and the consequences of their new policies.
Perhaps the first and most serious of these consequences is: THE PATHOLOGISING OF RISK. By implication this leads to the pathologising of life. After all, everything one does or doesn’t do is a risk. Does this mean that life is a sickness?
Secondly, this process takes place out of context. There is a register which itemises risks like suicide, violence, etc., but no mention of the context in which these risk take place. Some registers do have references to stressors, like certain DSM categories, but there is no attempt to link the potential danger with the context it may take place. This is my same objection with DSM-4. Diagnoses are not linked with context. In both instances we see the decontextification of life.
By implication the avoidance of context involves the reification of reality. And not just this. It involves turning reality into unreality. Life processes do not exist outside of a context. Or call it figure and ground. or call it event and social field. Each is an essential component of the other.
Thirdly, and without being too paranoid, the Risk Register is a form of social control which can lead to a totalitarian or fascist domination of ordinary life events. Notably, it is easy to get on the register, but there is no set way of getting off it. The same holds true for psychiatric categorisation. I have a psychotherapy patient who has striven for years to overcome a diagnosis which remains like a black blot of his medical notes. It follows him everywhere and all his attempts to erase it have failed.
Fourthly, the risk register, instead of diminishing risks, adds to them. at the Crisis Centre we try to overcome risk like suicide or self-mutilation by containing them, ie contextualising them, with and by personal relationships. But like with medical notes, it is taking up so much time to write, file notes, and register them, that it detracts from the time one can spend with the guests. This itself makes for an anti-therapeutic or a risk increasing process.
Finally life involves the need, I would say the right, to be at risk. Otherwise there would be no maturation, no invention, no excitement, no passion, no change.
The counterpart to the right to be at risk, is the right to take risks. The mother who allows her so to go into the army, or even just to leave home, is taking a big risk. She may never see him again. Similarly I could never have founded the Arbours Centre, without the willingness to take on big risks, professionally and financially. But more than that, in order to help people become free from their inner demons and outer constrictions, we had to allow the possibility that some people would hurt or kill themselves. So in a sense, we were gambling and continue to gamble with peoples lives, and also gambling with our capacity to prevent these outcomes.
Now, I shall present three examples from my work at the Arbours Crisis Centre where we took big risks in order to help people escape from the intra-psychic, inter-personal and biochemical straight jackets in which they had been imprisoned, or in which they had imprisoned themselves. Two worked out well. One did not.
But before I do, let me briefly describe the work and structure of the Arbours Centre.
The Crisis Centre was founded in 1973 in order to provide intensive personal and psychotherapeutic support for severely disturbed and disturbing individuals and families. It is located in a large Edwardian house in North London. Three psychotherapists who live there on a full time basis. These are the Resident Therapists (RTs) and the Centre is their home.
The RTs invite people to stay with them who might otherwise be in mental hospital. They are called ‘guests’, not patients, in order to convey hospitality, a ‘treat,’ not a treatment. Many residents or guests have been in hospital before. Our aim is help them to shed, or never take on, their learned role of mental patient, or institutionalised other.
The RTs are themselves supported by a core group of psychotherapists and psychoanalysts who serve to co-ordinate and become a transference focus for every intervention. These are the Team Leaders (TLs). For every stay, a team is formed to work with the guest and with his or her family. This consists of an Resident Therapist, Team Leader and often an Arbours trainee or professional on placement at the Centre. Unlike conventional group therapy, where there may be one or two therapists for a group of patients, at the Centre there are two or three therapist per guest. This allows us to work at close quarters with very chaotic individuals and support each other as well as the guests. (For further information call 208 340 8125 or refer to the Centre’s website: www.arbourscentre.org.uk as well as to two anthologies written by therapists and guests connected with the Centre: Berke et al (1995), Berke et al (2002)).
With all this is mind, I shall now discuss three examples of risk taking on behalf of guests at the Centre:
‘Sue’ from Newcastle:
Some years ago we received a call from social worker with Newcastle Social Services.
"Would the CC take a cutter?"
"I beg your pardon. We take people." (I said in a defiant, almost pompous manner.)
"This a girl with a long history of cutting herself all over, arms, hands, breast face, stomach. She has been doing it off and on for 7 years. Now is 23. Been in hospital many times. Had stopped for awhile but now is doing it again."
(After thinking about it a bit. ) "We don’t take cutters. But we do take people who happen to cut themselves. Anyway, if she wants to come to the Centre, let her come on such and such a day in the afternoon."
"We’ll send someone with her."
"No, if she wants to come, let her come by herself.’ (This was a test of her motivation, and after hearing the ‘hi-story,’ it also expressed my hope that the consult would never materialise.)
To my horror at the exact appointed time, a small, thin girl with a mop of long hair appeared at the door. Scars covered her arms and face. Long hair drooped over her face. I could hardly hear her. As she conveyed a long story of self mutilation, I found myself, to my surprise, getting an erection. As the girl looked like a twelve year old waif, and was hardly sexually enticing, on the outside, that is, I was amazed and fascinated by my response and stored the information in my mind for future consideration.
My becoming sexually aroused is not a criteria for a person becoming a guest at the CC. But motivation certainly is. I have noted over many years that motivation is a main criteria for a successful stay at the Centre. Because Sue did manage to travel to the Centre by herself, and on time, Rod, my RT and myself decided to accept her. But we were uncertain about that we could accomplish, all the more so because she was highly drugged up. In fact she had been sent to us accompanied by seven drugs:
2 major tranquillisers
an anti depressant
a minor tranquilliser
a mood stabiliser or vitamin
Oil of Primrose
Every psychiatrist who saw her had been apparently been so appalled by her condition that he added or changed drugs, but didn’t take her off them. I thought it was essential to see her base line emotional state. So I proposed a drug holiday. She readily agreed. But the house GP wouldn’t hear of it. Too risky, he said. She might cut herself.
I replied that of course she is going to cut herself. It is our job to see how, in what circumstances so we can begin to make sense of what is happening with her. He refused to sanction the drug holiday. He would only concur, if we got additional psychiatric cover, for him. ( He wouldn’t take the risk) This we did from a psychoanalyst and consultant psychiatrist who knew me well and trusted me, even though he himself remained dubious about the proposed drug holiday. Anyway, within days at the Centre, she was cutting so bad, she had to spend hours in the local emergency room being stitched up.
Sue had three team meetings a week with her. One was on Wed at 5 PM. I recall that I used to come away from this meeting so anxious, so agitated, that I could barely answer the phone for fear that I would be told that Sue had killed herself. But Rod and I continued to meet and talk with her, thereby providing the containing context, into which her cutting took place and from which it gradually diminished.
And as the cutting diminished, she regained her voice. It seemed that a boy had asked her to marry her. She didn’t know what to do, She love him but was terrified he’d go off her once he saw all her scars. She was also terrified of sex. Then it dawned on me that this was the denied feeling that had aroused my erection. She was so scared of sex that she had evacuated her excitement into me. The talking continued. The cutting stopped. Then after six weeks, she suddenly announced, that she was gong back to Newcastle. She felt better. We asked her to stay longer. She seemed to be getting stronger day by day. No, she had decided to return to Newcastle to marry the boy. And this she did.
Once this happened, Rod and I never heard from her again. But we remained worried for a long time afterwards. That was our task. To cope with her anxiety.
‘Jane’ from Essex
Not long ago the Centre was referred a nineteen year old girl whom I shall call ‘Jane’ from a council closer to London. She was what one might call a tear away child. Lots of self harm, drugs, promiscuity, vandalism, petty criminality, arson, you name it, she did it.
When Jane came for an initial meeting, she was accompanied by a multipage Risk sheet detailing suicide risk (HIGH), violence (LOW) although it should have read high. Self mutilation (HIGH). The sheet could also have included bolshie quotient, (VERY HIGH). Oh yes, she was also two months pregnant.
After listening to her story, I was impressed by her strong desire to come to the Centre and and effect some changes in her life. Why Arbours? She had heard about us from her CPN and and wanted an alternative to the previous place she had stayed, a therapeutic community which she described as a very authoritarian regime. She thought and hoped that we could and would be different.
Significantly the long risk sheets that accompanied her did not mention any of the the risks that really frightened her: emotions, thinking, feelings and especially, relationships, closeness, intimacy.
The sheets did mention make some attempt to examine stressors like drug dealers and exploitative boyfriends. But there was no linking of these people with her experience. More important, the basic context in which her life unfolded was barely considered: a very unstable, unbounded, uncontaining. unsupportive family ( even as a teenager her parents had never allowed her to have a key to her house, nor her own room) and her involvement with a Pentecostal, authoritarian Church.
At the Centre Jane first talked unceasingly, Otherwise she remained sullenly silent, a silence so intense and obnoxious that I sometimes found myself nodding off.
Then Jane started to miss meetings and stay away from the house for hours at a time. This was the key to the whole intervention. She fully expected us to yell at her, tell her off, throw her out. Instead we decided after considerable thought and discussion to hold our anxieties ( which I can tell you were intense) and casually comment: oh we didn’t see you yesterday.
Jane was amazed. At the other community, a dozen therapists and residents would have hounded her ( as she put it) to death over a 5 minute lateness. She said our not doing this was the key to her sticking the course and taking the risk of engaging with us.
Over seven months Jane became one of the strongest presences in the house, talking to others, cooking meals, and getting bigger. Then we began to worry she would have the baby before she left the Centre. Interestingly, the men at the Centre seemed to like the idea. But all the women therapists were appalled. Another anxiety unfolded. We are not registered to have a baby at the Centre. We would have had to sneak it in. But could we afford to do so.
Anyway, Jane did leave to have a sort of reconciliation with her parents who allowed her to come home before the delivery. She was given a small room and did have a successful birth. A month later she returned to the Centre. We all held the baby which appeared be thriving.
‘Pierre’ from America
My third example concerns a young man who has spent years in some of the best psychiatric hospitals in Paris and the States frustrating some of the best psychiatrists of his generation, and his parents alike. Despite a huge expenditure and varied drug treatments his situation waxed and waned without obvious reason. Occasionally he would seem to get better, that is, live at home, go to work and socialialise, and other times he would withdraw into a cocoon of complaints about the pressures inside his head.
Pierre came to the Arbours Centre after many months in a major NY Research Facility where a variety of drugs had been tried, all to no avail.
He had two stays at the Centre. During the first stay he showed a remarkable change, Within two weeks he had come off all medication ( in my opinion, far too fast), and showed a lot of insight into the social and emotional pressures which bedevilled him.
Pierre went home (again far too fast) where he suddenly start to socialise and returned to work in his family’s business. This seemed to be an impassioned flight into health. It was all too good to be true.
Then things slowly started to fall apart again as his sadness and underlying depression began to assert itself. But he remained in psychotherapy (with a colleague from the Centre) and seemed to be making some progress in containing the pressures he felt.
About six weeks after returning home, his parents went away together for the first time in ages, with my encouragement. And on the same week, his sister suggested that she would be getting engaged. The following week he was overcome by raging jealous feelings with which he couldn’t cope. He made a sexual advance towards a neighbour. This was ‘the straw’ that his parents couldn’t tolerate. They called me in a panic. Could he come back to the Centre.
It so happened that Phil, the male RT who had been on his original team and to whom he related well was on holiday prior to leaving the CC after working there for several years. He was well liked and the whole CC was quite depressed about this. We had to decide whether to take the risk of welcoming Pierre back to the Centre, or not. The choice had to be made quickly. The only alternative seemed to be another round of hospitalisation. The house was keen for him to return.
But, as it turned out, we were unable to provide a consistent container for the turmoil brewing inside him. Soon after coming he made a pass with a kitchen knife at the Centre’s gardener, while he was talking about his severely sick child. A guest restrained his arm. No damage was done. But everyone was terrified and Pierre was told to leave forthwith. He was admitted to hospital and treated with the very drug which he had previously tried to avoid.
In response his parents were furious with their son, but especially with the Centre and myself. How can we have left Pierre at such great risk? How could we have let them down so badly? I would like to quote briefly from my reply to them:
"Dear Pierre’s Parents,
Thank you for your letter. I appreciate your concerns and anger about what happened. I am also grateful for your taking the trouble to mention that you had been helped by my colleagues and myself.
You also have done a great deal to help Pierre. Obviously there have been many ups and downs and swings and roundabouts in this situation. I am sure that Pierre does appreciate what you have done for him, even though he can be very rebellious and negative too.
There is no easy answer or special cure for Pierre’s condition. What we have tried to do at the Centre is to avoid ‘pathologising’ it. That means to avoid saying it is all to do with his being sick. The point is, is Pierre a ‘mad boy’, a ‘bad boy’, or what? This remains, at least for us, an open question.
In many respects the question became how to control Pierre so he wasn’t destructive to himself or others. Medication is one way. But as I am sure you recall, it had and has serious drawbacks, perhaps the worse of which was to incapacitate him emotionally, mentally and socially. Pierre complained bitterly about this and we took a calculated risk to allow him to reduce his medication and to ‘come alive.’ He may have come alive too fast, too intensely, too irresponsibly, or whatever. He was surely hard to handle, hard to live with. But he did come alive, and for a considerable time he did stop complaining about the pressures in his head. You pointed this out to me.
I asked Pierre not to stop his medication all at once. He chose to do so and suffered the consequences. for him and for yourselves, I think it is important to ask, was it worth allowing him to ‘come alive,’ even in the ways that he did, or to keep him under tight biochemical control?
As you know the medication Pierre has been on carries many risks too. These include leukopenia, or a severe loss of white blood cells, as we have already discussed, and, diabetes.
Essentially the issue boils down to risk management, is the risk of coming alive, in the messy, difficult way Pierre chose, worth the ensuing disruption?"
Subsequently the hospital psychiatrist called me and said Pierre was doing much better. Would we have him back. This is still under consideration. Pierre still has a lot of accounts ot settle with with us and with his parents.
These examples demonstrate that risk is an interpersonal process. It is possible to diminish risk recognising it, addressing it and sharing it. It is not necessary to deal with it by by alienating people and by constricting their lives by drugs. ie by Knocking the stuffing out if them. Main aim is not to stifle them, but to avoid blame, guilt, embarrassment, shame in others who have or might a have a relationship with them. In other words to do with risk one has to deal with the object as well as the subject.
In such a dyadic complexity, there are specific ways to diminish risk:
- De-pathologise it. Avoid Labelling and categorisation.
- Re-contextualise the risk. Containing relationships are an essential part of this process
- Soak up projections, digest them, don’t pass them back to the person struggling with difficult impulses or feelings.
- Encourage benign introjections. Both people and places.
- Through non toxic, non threatening, interpersonal interventions
- Though a safe non toxic physical environment
And where things don’t work out, be prepared to risk FAILURE. Be prepared to carry others’ sense of failure and despair. Be depressed, and as a former guest at the Centre pointed out, be prepared to ‘assume their depression.’
Berke, J. H., Masoliver, C. & Ryan, T. (1995) Sanctuary: The Arbours Experience of Alternative Community Care, London: The Process Press.
Berke, J. H., Fagan, M., Mak-Pearce, G. & Pierides-Müller, S. (2002) Beyond Madness: PsychoSocial Interventions in Psychosis, London: Jessica Kingsley Publisher.
c Copyright Joseph H. Berke, 2003. All Rights Reserved.