The Question Mental Health Services Need to Ask Before Labeling a Patient 'Too Difficult'

“He/she is difficult to engage.” It’s a term I have often heard used by psychiatric staff when talking about patients. I was described as “difficult to engage” when I was under mental health services and now that I run a Suicide Crisis Center, I frequently hear the same phrase used by psychiatric staff who signpost to us.

The phrase makes it sound as though it is a failing or difficulty within us, an inability we have to make good use of the service being provided to us. In reality, it’s more likely the service was not providing what we needed and so we didn’t engage. That’s not a criticism of the service, but rather a recognition we are all individuals with our unique needs. The same service is highly unlikely to be appropriate for everyone. I wonder why statutory services don’t instead use the phrase: “We haven’t been able to engage this patient.” This places some responsibility on the service, instead of placing all the responsibility on the patient.

I felt I was failing when I was repeatedly told I was “difficult to engage” or “unable to engage.” I still do. The language used still makes me feel there is something lacking in me, which meant I couldn’t find statutory mental health services helpful. The label can have a lasting and profound impact upon the patient. It may make you feel like you cannot be helped.

It was in 2012 that I first came into contact with mental health services. I experienced suicidal crisis, following a traumatic experience and was subsequently diagnosed with bipolar disorder and a post-traumatic stress disorder (PTSD). I was placed under the care of the National Health Service crisis team and struggled to connect with them. A different crisis team member would come out to see me every day. It was too much for me to be able to try to connect with so many different people.

When you’ve been through a traumatic experience, it can be hard enough to trust and connect with one person, let alone a whole team. It was also painful to repeat information about the traumatic event to each different team member. It meant I was constantly reliving the experience.

This was one of the reasons why statutory services didn’t work for me. My particular experience of trauma created challenges for me in accessing the service. The type of services, which would have helped me, didn’t seem to exist at that time. So I set up a Suicide Crisis Center and a Trauma Center with the type of services which would have made a difference to me. Our services have evolved to provide what our clients say they want and need.

My difficulty in engaging with statutory services showed me clearly that an individual approach is needed and we cannot provide the same thing for every client. We need to listen carefully to each client and understand what their needs are. A small number of our clients feel unable to be supported by more than one member of our team when in crisis. In our experience, it has been predominantly men who have told us this. It was perhaps hard enough for them to take the step of opening up to one person. It would have been too much to try to do the same with another person.

For many crisis services, this would be a huge challenge, and maybe impossible to provide. We know if we don’t provide it, then the client may not continue with us. We might never see them again. If they are at risk of suicide, we have to find a way to provide it, if we can. A client who was at high risk of suicide spoke to me some months after his crisis and said, “If you had passed me on to another person, I wouldn’t have come back.”

My experience of becoming a service provider has shown me the responsibility we bear in trying to do all we can to provide a service that is individually tailored to the person and meets their needs. It’s on us to try to help a person to engage, not to simply expect that they will. If a person wasn’t engaging, I would feel it was my responsibility to ask the questions.

Why have we been unable to engage them?

What do we need to do to make it possible for them to engage with our service?

How can we ensure we do provide what they need?

If we feel we can’t, then how do we help them to access a service which can?

I never had the experience of being asked by mental health services, “Why aren’t you engaging with our service?” Perhaps if I had been asked, we could have explored together why it wasn’t working for me and what might have helped me. If we don’t ask or explore these questions, then the person may disengage completely and may be left with no services at all. If you are feeling suicidal, then that disconnection from services places you at much greater risk.

We cannot simply label people as “difficult to engage” and somehow categorize it as the problem of the patient. We have a huge responsibility when providing services and part of that is to ensure we do all that we can to help a person to survive.

“Zero suicide” has been talked about in recent years as an ambition. In my opinion, “zero suicide” is about doing all we can for each person to help ensure they survive. It requires us to really consider what each individual needs in order to survive and do everything we can to provide it. If we place labels on a person and consider it to be their issue they can’t engage with services, we may fail to keep trying. We need to be tenacious in helping people to survive.

Joy runs a Suicide Crisis Centre in Gloucestershire. They have been providing services for three years and have never had a suicide of a client under their care. Click here for more information about the Suicide Crisis Centre. 

If you or someone you know needs help, visit our suicide prevention resources page.