You will be aware of the ongoing manhunt for Abdul Ezedi after the terrible alkali attack in Clapham a few weeks ago. The Metropolitan Police announced last week their working theory that Ezedi entered the Thames near Chelsea Bridge, the inference being he is now presumed dead. The Guardian did a piece on the work of London’s Marine Policing Unit (MPU) to whom the grizzly task falls of recovering bodies from the river and conducting searches, to the extent that it’s possible across forty-seven miles of river from Dartford to Hampton Court.
This post focusses on a passing sentence in the Guardian’s coverage, touching as it does on policing and mental health issues, not just in the Marine’s unit’s work, but for all policing teams dealing with suicide, self-injury or self-harm involving people “known” to services. Having emphasised recovery, on average, of around thirty bodies a year by MPU, the article highlights most are not a result of homicide, albeit those are often the stories making the news —
“Not all are suicidal, some have personality disorders and are known to the NHS and emergency services from previous incidents, according to the officer, speaking on condition of anonymity.”
See what happened there? – language was used to insert a silent dividing line between “suicidal” and “personality disorders” including those who are “known to the NHS and emergency services”. There’s a distinction draw here, between the suicidal and the personality disordered. All according to the officer, speaking anonymously. Of course “known to services” means everything and nothing at the same time: it can relate to someone detained by the police under section 136 of the Mental Health Act 1983 and then assessed, but not found to be mentally ill at all so we need to be careful about thinking “known to services” means anything. It certainly doesn’t mean anything specific without further explanation and some people are known only because the police have presented individuals to the system for assessment.
I’m not sure if the intention in the paragraph was to create the idea those of us with personality disorders are not usually suicidal or whether it was to imply something about the relationship between PD and suicide or about self-injury leading to suicide, but I submit that’s the consequence of this paragraph. The major problem is: there is no clear dividing line between suicide and personality disorder – it’s not one or the other. In fact, PD is associated in many circumstances with a significantly-raised risk of suicide, especially where co-morbid with substance (ab)use and more so for women than men (albeit men are still at risk and account for around 75% of UK suicides).
HORRIBLE TROPES
In my own experience, you can’t discuss mental health for very long before you hear ill-informed ideas about suicide – this remains true of discussions involving professionals in the NHS, never mind in policing and again in my experience, police officers tend to defer to any healthcare professional as an expert despite Coroners having to caution against that. We should remember the campaign from a few years back called “Time To Talk” which found that police and mental health services had some of the poorest attitudes towards those of us affected by these conditions and collisions of circumstances.
It’s ideas like “If they were serious, they’d have done it by now” and ideas that suicide threats or attempts which do not lead to a fatal conclusion mean risk of death is lessened over time because of the apparent lack of seriousness or effort! Actually, as continuing threats and attempts continue, however unsuccessfully, risk can increase for many – alarming so for some groups in some contexts and we need only remember the awful case in Humberside of Sally Mays to see this, where she was turned away from mental health services after presenting suicidal and asking for help.
And there’s the language problem which results from these misunderstandings including labels like “attention seekers” which then cause debates to occur about criminalising people who present on bridges, causing wider impact on others and expenditure of resources, etc.. All from flawed attitudes towards suicide risk. We’ve even known of prosecutions to occur where people in extreme distress who seriously self-injure have been charged with wasting police time because of NHS services ringing the police because of their concern for someone.
You really couldn’t make it up.
HIGH INTENSITY
All of this made me think today of an initiative you may recall from a few years back known as the High Intensity Network (which the Metropolitan Police embraced and which was adopted by several mental health trusts in London). It attempted to focus on people who repeatedly present to the emergency system, causing significant expenditure (sometimes described as wastage) of resources, including on the fringes of crime and anti-social behaviour.
I couldn’t help but think about it when reading the short paragraph I’ve quoted above – I may be wrong to do so, but it just resonated with me for that reason.
The High Intensity concept was a real mess, in the end — it had been supported by NHS England for a number of years and rolled out within the NHS as a consequence of NHS backing and funding (from the Innovation Accelerator Fellowship programme) but it collapsed amidst a service-user campaign which objected to the kind of ideas in the highlighted paragraph and the determination to criminalise some vulnerable people in these kinds of categories – especially female PD patients who were perceived negatively by services. In the end, NHS England wrote to all trusts to insist programmes based on these ideas should be withdrawn — you can read the NHS England letter and access the service-user website in another post.
RESEARCH ON PD AND SUICIDE.
So what is the reality?
There is plenty of research on the topic of PD, self-injury and suicide and you a read some for yourself. Highlights include findings from PD patients in primary care (ie, their GP) because more PD patients who died by suicide had contact with their GP in the year prior to their death than had contact with a mental health trust —
- A 20-fold increase in suicide risk for patients with PD versus no recorded psychiatric disorder.
- A four-fold increase versus all other psychiatric illnesses combined.
- Borderline PD and PD with co-morbid alcohol misuse were associated with a 37- and 45-fold increased risk, compared with those with no psychiatric disorders.
- Read that one again: 37- and 45-fold increase in risk!
- Relative risks were higher for female than for male patients with PD.
- Significant risks associated with PD diagnosis were identified across all age ranges, although the greatest elevations were in the younger age ranges, 16–39 years.
These are significant statistical findings, compared to the population as a whole and those of us affected by non-PD psychiatric conditions. Substance (ab)use significantly worsens outcomes again and they’re higher for younger people are for women.
NB: yes, I’m well aware of the validity of PD constructs – that’s a debate for another time.
REPEAT RISK INCEASE
I’ve also known comments and attitudes like the above feed in to a perception that risk of suicide decreases the more often people self-injure. Actually, recent studies show the reverse is true. – men who repeatedly self-injure are more likely to die by suicide, as are women whose risk rises even more as the frequency of self-injury increases.
The study just linked, above, relates to a long-term survey of hospital attendances for deliberate self-harm in the last quarter of the twentieth century, relative to deaths reflected in national registers in the early twenty-first century.
So for example —
- Thirty-nine percent of patients who had self-injured repeated the DSH.
- They were at greater relative risk of suicide than the single-episode DSH group.
- The relative risk of suicide in the repeated DSH group compared with the single-episode DSH group was greater in females than males (1.8; 95% C1 2.3–5.3) and was inversely related to age (up to 54 years).
- Suicide risk increased further with multiple repeat episodes of DSH in females.
There are other studies about which link repeat self-injury with an increased risk of suicide, in both men and women.
Don’t believe everything you think – much of it is wrong.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2024
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 