Acute psychiatry is all about risk. Yes, there are the treatments and therapies, the diagnoses and late-night trips to the police station but ultimately it all boils down to a simple question:

Does this patient present a risk to him/herself, or to anyone else?

Don’t imagine that it’s just people attacking other people and taking overdoses either. There is risk from self neglect, or risk that a patient (whilst well meaning) might put themselves in harms way accidentally. There is a girl on the ward at the moment who is fascinated by the colour red, and while that sounds relatively innocuous it means that she is vulnerable. People wearing red on the street, for example, she will approach without caution or inhibition. Same goes for red cars on the motorway. She may mean no harm, but that doesn’t mean she’s not at risk. Equally, a patient experiencing a manic episode is just desperate to express his love and admiration for a certain important political figure, but has already been pounced on by four armed guards once whilst trying to kiss said person’s feet and so puts himself in danger despite his relatively harmless intentions. Both of these people are under section because of these risks, as they have little insight into their respective conditions and simply cannot understand why it is that they should not go and touch a car on the M1 or spring upon a politician and hug him.

Surely, though, I hear you mutter, saying that the entirety of acute psychiatry is based on that one question is outrageous when you consider the variety of diagnoses and drugs and management intricacies of these patients?

Consider, then the answers to the above question. If a person does not present any risk to themselves of anyone else, then the first thing of import is that they do not need assessment under the mental health act. They don’t need admitting, either – they can go home and live in the community. Their liberty will not be restricted. Don’t get me wrong – a ‘no’ answer is a far cry from solving their problems but it is the first step. If the answer is a yes, then a whole raft of measures need to be put into action to control that risk, and there can be significant friction with patients and their families in the process.*

Controlling risk is a difficult thing. For starters, you can’t know what is going on in a patient’s head precisely; when they say they feel that they don’t want to wake up tomorrow does that mean they are likely to act to prevent that return to consciousness? Or simply that while they might prefer to not be alive, they won’t intervene to end it all? When someone is having delusions of persecution, believing that no-one is to be trusted and that they may come under attack at any time, how do you tell whether they are likely to lash out, or hide away? Do you let them go to the shops, knowing that it is an important part of their preparation to go back into the community and resume as close-to-normal a life as possible, but also that they believe that everyone in the shop is planted there to watch them?

Having answered all of those questions, you then need to decide how you are going to manage them – deciding how often to check up on them (people are, occasionally, checked up on every 5 minutes 24 hours a day), what medications and other therapies to use, what resources would be appropriate. Balancing all of these things is the reason that a psychiatrists and mental health nurses exist, and it is the real work of acute psychiatry.

It’s just worth remembering that the whole web of services that constitute psychiatry are driven by changing the answer to that one question from a positive to a (reasonably) consistent negative.

It’s even more worth remembering that whilst I was being told about this, I was thinking not about risk, but about the patient, lost and confused or desperately wishing to die, and why wasn’t that the first priority?

Then I remembered that you can’t treat dead people. Sometimes you have to prioritise, and sometimes it’s ugly when you do.

*although there can be plenty of friction, sadly, when you choose not to admit someone as well.


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