No issue getting there
Dearest daughter, I don’t remember there being an issue getting you to the appointment that morning. You’d met the mental health nurse a couple of times before and liked her. Vibe is really important to you, and you liked her vibe — easy-going, not one of those hand-wringing types who get emotional over your plight.
The appointment
She asked how you were getting on with the increased dose of duloxetine. You said you didn’t think it was working, that you needed something stronger. She told you it takes time to build up in your system, so you needed to give it a few more weeks. I guess this wasn’t what you wanted to hear.
Then somehow the conversation turned to your weight. It’s such a blur — I can’t remember exactly how, and I fear I might have brought it up, trying to shift things onto something more positive because you were only a couple of pounds off the target weight the ADHD consultant had said you needed to reach to get back on medication. If it was me who raised it, I’m so sorry.
The scales
The nurse asked if you wanted to be weighed — no pressure, just if you wanted to. You said yes. I think you believed you had put on weight.
You kicked your trainers off and looked at the dial. Bad news. You were actually lighter than when you were weighed at therapy a few days earlier.
I could feel myself beginning to panic. My body knew we were entering dangerous territory.
I think the nurse said something about you not being far off target, that it was achievable. And then the escalation started.
The escalation
This bit is all very blurry. I think you said something about how unfair it was — how were you supposed to get better? I tried to explain your impossible situation: not allowed ADHD medication because of your low weight, even though the psychiatrist said it would indirectly help with the BPD. And the eating disorder service not seeing you because of your BPD, so how were you supposed to put on weight?
And then I think you swore and said you just needed help.
And the nurse told you not to swear.
And I was thinking: a) I don’t blame you for swearing; b) why is she focussing on the swearing and not on you asking for help; and c) oh no, telling you not to swear is like a red rag to a bull. She’s given you something to be really angry about.
And now you’re shouting — you have a very powerful carrying voice — and you’re swearing and saying you don’t want to live any more. And she’s saying you’ll have to leave if you don’t stop with the shouting and swearing.
And I become tearful. I don’t usually burst into tears at your appointments, but I’d just come back from a few days away with work and I was exhausted. So I guess this was me becoming dysregulated too — but in a different way to you. And my tears made you worse, because you hate it when I get upset.
Suddenly other people rush into the room — a woman I don’t recognise and a receptionist — asking if everything is OK. You’re in tears, shouting about how useless they all are. They say you are upsetting the other patients. I’m scared they’re going to call the police because you’re saying no, you’re not going to leave — not because you want to stay, but because you’re in fight mode.
I leave the room
I suggest I leave. I’m hoping that if I make me and my tears the problem, I’ll give you and the nurse a chance at a fresh start.
The plan seems to work. You agree to stay, the nurse agrees too, and I sit outside in the corridor.
You’re still shouting, so I can hear what you’re saying. You’re telling her you hate your life, it’s unbearable, you want to die.
Sweet tea
The two women sit me down in the corridor, I feel obliged to explain that I don’t usually get tearful but it’s just all too much today. The receptionist offers to make me a cup of tea and insists on putting sugar in it. I say yes even though that’s not how I drink it. The other woman says she’s also a mental health nurse. She says that her colleague is brilliant and she’ll calm you down.
I’m thinking, I’m not so sure.
I can hear you begging the nurse to be sectioned, but I can’t hear her answers. I’m guessing she’s saying no, because you’re still shouting and crying.
The tea comes. It’s actually quite nice. The two ladies are so lovely, saying how hard it must be for me.
Eventually you stop
You pretty much stop talking. The door opens and you come out. I say thank you to the nurse. I don’t know what for.
I don’t remember leaving. I don’t remember driving.
The next thing I remember is us in the supermarket — we’d driven straight there because it was our weekly shop day. It was our usual routine. We were on autopilot. We’d nearly finished when my phone rings. It’s the nurse, saying she’s made a referral for you to the crisis team and they’ll be calling shortly. I explain we’re in the supermarket, could they wait an hour. I hear her pause — she seems thrown by the fact we’ve gone shopping — and then says yes.
We get home. There is no call.
You’ve calmed down by then, and we laugh about how it’s a good thing it’s not an emergency any more.
The call that came eventually
They call the next day, in the afternoon. I hand you my phone and listen as you tell the man you’re no longer a threat to yourself. He doesn’t seem to ask any follow-up questions.
I want to be part of the conversation, but you are avoiding eye contact. You don’t want me involved. And yet I am part of it all, aren’t I? That’s the problem with being so close and bearing so much of the brunt — when it comes down to it, if you don’t want me involved, I can’t be. You’re an adult now.
A few days later, you get a letter saying you’ve been discharged from the crisis team.
What I can’t stop thinking about
Here’s what stays with me from that morning: we were both dysregulated. Both of us. I was crying, you were shouting. Both of us were overwhelmed, both of us struggling to cope.
But my distress was palatable. Yours was not.
I got tea. I got kindness. I got sympathy. Two lovely women telling me how hard it must be.
You got told to stop.
And I sat there, sipping sweet tea, listening to you beg to be sectioned through a closed door, feeling guilty that they were so kind to me and not to you.
The zero tolerance problem
The NHS has a Zero Tolerance Policy. It’s designed to protect staff from violence and abuse — and I understand why it exists. Being shouted and sworn at is horrible and there is never an excuse for violence.
But here’s what I’ve learned: the NHS policy was never supposed to apply to people who are mentally unwell. The original guidance explicitly says that withdrawal of treatment shouldn’t apply to anyone who is mentally ill. And yet, in practice, shouting and swearing in a GP surgery can get you warned, removed from the patient list, or even threatened with the police — regardless of whether you’re in crisis.
The frustrating thing is that de-escalation training is apparently mandatory for NHS staff. From my limited experience, I’d say it isn’t fit for purpose.
A different kind of training
I’m not singling anyone out for blame because I struggle with this as well – I think most of us do. Our nervous systems are set up to respond to shouting and swearing as a threat, not a cry for help.
What I wish existed — for NHS staff and the loved ones of people with BPD — is effective training that gives us tools to stay calm and connected when someone is shouting, not tools to shut them down.
Because the shouting isn’t the problem. The shouting is the symptom. And responding to the symptom while ignoring the cause doesn’t help anyone.
