Recipe for paranoia

I recently saw in the Education Guardian a description of how to make a staff member clinically depressed. It was too frighteningly true to reproduce here - I was left hoping that it wouldn't give anyone ideas...

It does strike me though, that there is a similar recipe for paranoia. There's no chance of an individual carrying out this plan fortunately. Actually it's more of an accidental recipe, and it depends on mental health systems rather than individual relationships. This is also a caricature (if you've read Delivering the world from its exhausting boredom) that is knowingly dramatic but seeks to bring together a set of images of reality in a familiar and useful form.

The first ingredient in this version of the recipe, although there could be many variations, is an admission to a psychiatric hospital. Imagine. You must be thinking you're in pretty deep shit when you wake up. You'll quite possibly be wondering why you got there and what's going to happen to you. The seeds are set for paranoia already: the uncertainty, the questions, the doubts.

Then you meet your consultant. She explains where you are and who she is. She tries to make you feel at ease: she just wants to find out how you are and what's going on, and she's there to help you. There's no rush, we've got 28 days to assess you. Despite all the words though, you feel there's something menacing about her: she seems a bit distant and machine-like, as if she's following some sort of instructions or procedure.

Around you there's all sorts of strange things going on, and you've also got to live with a whole load of other crazy people. Some of these will be nurses ;-) and they've each got their techniques and approaches for caring for you, some of which will probably be helpful. But there are so many things going on it's not easy to assess what's helpful at this stage, or how you should be conducting yourself. There will also be plenty of advice from your fellow patients, also somehow contradictory, and some of them could well be really paranoid...

Another thing that you could well be feeling at the moment is anger. There's a lot of anger in society today, and expressing your anger inappropriately can be one of the triggers to getting you into this sort of hospital. Even if you're not usually an angry person, it's quite possible that your developing sense of injustice is beginning to make you feel quite irate. And anger is a natural defensive reaction to feeling cornered and powerless.

Anyway, a week goes by. If you're on medication you're probably feeling pretty sick at this stage as your body adapts. You're hoping that your body will adapt and you'll feel better soon, but the evidence from your fellow patients is not too hopeful. Your consultant returns. There may only be one more meeting before your assessment period is over, although obviously nurses and social workers and other more junior doctors will also be involved in the process. She's still quite nice and reassuring and she's not going to jump too quickly to any diagnosis, but there is this one thing...

Now this one thing may be quite clear and relevant to everyone, especially if its a body under the stairs, but you're a more complex case, more borderline. The hospital, and especially the consultants, have a duty to carry out risk assessments as well as psychiatric assessments. This is the other key ingredient in this recipe. We all have some skeletons in our closet, we could have just split with our partner, our dog could have died, or we bought a golf club to mess about on the park. You've had a hard time recently, and you don't think that this one thing that they've picked up on is very relevant to the situation, but they seem to think it's much more important.

This is where we come back to the Guardian article. It's the small things after all that really trouble and disturb us. When we have family arguments we often find that the real issue is a really small misunderstanding, but these small misunderstandings can multiply remarkably. And the really upsetting thing is that it's so small it should be easy to resolve, but you still can't make each other understand...

If you're cruel you'll confound and disturb someone by causing small difficulties and changes, and then rebuke them remorselessly for their failures and inadequacies, thus causing mental distress. If you're caring for someone's mental health problem you probably don't want to do this at all, but it seems that the risk assessment compels you to enquire about that one thing, and your patient's anguished reaction of denial and avoidance rings alarm bells that force you to continue the questioning.

Finally, the diagnosis. They didn't want to tell you earlier because they thought it would upset you. You're showing symptoms of paranoia - and you'd better not argue because that'll only make it worse...

Everyone can help in this situation, and I look forward to a time when we won't need advocates, but in the meantime you'd better write down your local advocacy scheme's number somewhere handy.