I’ve been reflecting on times when I’ve felt trapped during conversations with patients and their families.

Times when whatever I seemed to say, I tangled myself further into an endlessly looping web of discursive constriction.

I was reminded of R.D. Laing’s book Knots, which is a gleefully brusque collection of various traps of thinking.

Here are some of my own examples.

This one is from my time on the medical wards:

Patient’s family: “We don’t agree with your diagnosis. Do some more tests”

Me: “Did you have any specific alternative diagnoses or additional tests in mind?”

Patient’s family: “Don’t ask us. You’re the doctor!”


If I try to assert my medical opinion I get shot down, but if I try to divest it I get shot down too. An infinite regress of rejection.

A second example, this time from early in my career in psychiatry:

Patient seen in A+E: “Admit me or I’ll kill myself”

Me [after lengthy consultation]: “Ok, let’s admit you”

Patient: “No. I won’t come into hospital”


I had no idea what to do. The opening statement felt more like a threat than a presenting symptom. The patient appeared to have turned up in A+E specifically to pose me a choice and then categorically turn both self-imposed options down. It was checkmate, I was lost.

Both examples can be boiled down to “I want you to help, but I won’t let you help”.

So how do we untangle these knots?

As I have now learnt – from insightful senior colleagues and patients themselves – the key to escape is to recognise why you’re stuck. And talk about it.

What lies beneath the tangle? Defense? Confusion? Weaponry?

The first example is a double bind ­­– damned if you do, damned if you don’t. The fix is to either do or don’t but explain why you’re not damned for it. In the example given above, we explained the diagnosis again as a team – giving the option of disagreement but making it clear that we were firm in our convictions.

The second example, as well as being a double bind of sorts, is also a false choice ­– there were other options available, like the patient not being admitted but not killing themselves. Fostering some responsibility in the patient and getting them to work with us, not against us was the key to progress in that situation.

I don’t exactly look forward to more knots, but unbinding myself, or watching others unbind me, is an education.

About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

22 Responses to Knots

  1. JWilliams says:

    With regards to the Patient’s family’s thoughts on not agreeing with your diagnosis.
    This really relates to the situation that has been highlighted following the death of S.Sparrowhawk or LB (laughing boy) under the care of Southern Health NHS Trust.

    As a mental health care professional, you see an individual for a very limited period of time.
    It is clear that the family felt that your time limited assessment was not representative of their lived 24/7 experience of their loved on. Yet instead of exploring that further with them, utilising the specialist training that you have received / were receiving, you expected the family to hand hold and guide you? They were very accurate to highlight to yourself that you were the doctor. Despite disagreeing with your time limited assessment. As you’re aware, unlike other areas of medicine, psychiatry is more aligned with ones best guess. Ones best guess is that which even fellows within your profession often disagree about. If the family thought the diagnosis did not fit, then considering they had the greater knowledge of their family member then it is something you should respect, as opposed to ignoring them and jumping back onto Laings circle.

    Going back to LB, the family recognised the symptoms of his epilepsy and tried to explain this to the mental health care professionals. Yet this was disregarded as the MHCP knew best.

    LB later died.

    • Thanks for the comment.

      As the post states, the diagnosis in question was a general medical one, not a psychiatric one.

      And in the example you give, there is no double bind – the family offered more information, not a rejection.

  2. Zead Said says:

    Recognising the traps that are laid for us is important. When I first started and experienced these, I found it so frustrating that I couldn’t “think” my way out of such a conversation from where I stood. I have found, over time, that the best solution is to change one’s own stand point.

    When I recognise the trap, and sometimes it’s not obvious, I often find the issue is nothing to do with what is actually being said by the patient or family. The emotions, fears, systems, whatever you want to describe them as, that are driving these people to say such things are incompatible with the cognitive ability to process such strong and driving emotions and express them truly. This happens to everyone, often to small degrees and we don’t even know it because it’s not “pathological” at lower levels. When I note what’s happening, and try to delve deeper into what emotion is actually the driver behind the statement, I find it’s like unlocking a door, and the flood wave comes out of what is really bothering someone.

    The best example I can think of right now is a lady presenting with “bipolar disorder”. Very difficult to engage, had seen a string of people and disengaged, and I was next in the firing line so to speak. The conversation was hard, circles of despair, willingness to engage and a desire to prove how hopeless we all were, along with an exceptional gift of intelligence. When I felt things were going nowhere, I asked, somewhat disjointed to what we were talking about, “How are you feeling? Right now? At me?”. It was a gamble, it wasn’t what I would have done in the CASC, and (probably) not if I was supervised. The result was great, she was angry and frustrated. “Do you want to shout at me?” She couldn’t. So I gave her permission, I showed her the rules didn’t apply in the room. I swore (not at her of course!) as an example of what could be said, and no one could hear. “What is it you want me to understand?”. And there opened the floodgates, once the outpouring of her frustrations and hatred at what was happening in her life outside of the room came out, I knew I could speak to her. Not against the hardened shell of frustrated desires and defences she had built against the next criticism, but openly in a place she felt safe.

    I’m looking at what I have written and realise that my fingers have run away typing. I have no idea what the lesson learned is I’m trying to pass on. Maybe I’m exhausted after night shifts, maybe I felt like writing a story, maybe I’m just recounting one of the “good” moments in psychiatry and hoping you may find it useful. Whither way, I hope it’s worth the read.

  3. Sunseeker says:

    Whoever Zead Said is I hope he/she knows they are in the right job and doing the right thing.

    I so recognise the “I want to kill myself/I’ll admit you/no don’t admit me” exchange. From my perspective it is all about, I can’t take this anymore, I really want your help but when you offer it I am so scared it won’t work, that you will move on and I am so tired to keep trying to fight my urges and to try and focus on the mindfulness on the chaos and hurt I would leave behind, but iI just can’t cope and it is so bad I just want to kill myself. Maybe you don’t always have to unpick the knot – perhaps just sit with it, hold its hand. I suspect it will start to unravel enough for you to smooth the frayed ends. What it takes of course is time – that rarest of all commodities.

    • What a great comment. Thank you.

      • Sunseeker says:

        You’re welcome. It’s a dialogue that feels it is repeated every time I’m in crisis and after suicide attempts. A source of anger and frustration to me and no doubt those who have tried to help. For the sake of your patients please keep on noticing it and keep challenging it.

  4. alex green says:

    Tricky one. In the accident and emergency example, I read it as being ‘i want to be respected, and when you try to help me by offering an admission, you aren’t respecting me.’ Offering an admission means being dismissive of the patients attempts to tackle their own problems, sometimes over many months/years. I could be completely wrong of course!……it’s just my reaction. What do you think?

    • I agree with you that admissions aren’t a panacea and are completely wrong for some problems – but when the patient comes in asking for an admission that’s a different kettle of fish, and to offer one in those situations isn’t disrespectful but at worst sometimes unhelpfully acquiescent.

      • alex green says:

        What percentage of people ask to be admitted, as compared to being offered an admission, or asked to stay under the mental health law for assessment, treatment and their safety?

  5. Experto Crede says:

    Maybe its not actually “I want you to help, but I won’t let you help”. Could be “I want help, but not from you but that’s all I am offered when in crisis”

    Not a personal attack or condemnation of yourself or even your profession. Much more I think a comment on trying to stay alive while having some insight and struggling yet again with a rigid crisis system that takes every single ounce of strength to negotiate your way through. When actually you need those reserves of strength to keep you from killing yourself.

    So it can feel like a risk asking for help – offered it and all your energies have to go on talking to multitudes of A&E and MH professionals ; not offered it and it is confirmation that you have to die.

    What I would much prefer to see are out of hrs drop in services for those in crisis where you can just go and be. No talking necessary, no referrals, no assessments, just supportive environment. Doesn’t need any MH professional presence or input . Just a real place of safety . Used to happen in some areas before the cuts.

  6. alex green says:

    The whole thing is when you switch the punishment and rewards in a Skinner box, unpredictably. What are the effects going to be? Everyone gets confused and stressed, and start misunderstanding each other. Worse, the problems can spread, and due to doctors seeing many people during their work, the scope for the suspicions and fears to spread is enormous. For example, a discrepancy between facial communication and language communications can occur, based on previous learning. Next time someone asks for an admission, an emotional response of doubt might arise, which the patient might interpret as something else.
    I know psychiatrists manage very well in circumstances which would cripple most people, and for this they deserve my admiration.

  7. alex green says:

    Regarding ‘double binds’ do you just work from the premise that the logic appears contradictory because not all the premises are stated. It would be mad to reify them. They are a pseudo problem surely?

  8. alex green says:

    Admit me=reward. (Self/doctor) Kill myself=punish (self/doctor) (reward self, invalid premises to reward doctor)
    The curious thing is whether killing yourself can ever be a reward. In my imagination I think of Laing going to a Scottish Presbyterian church being taught about love in a cold church with hard pews and ‘suffering is good for the soul’ type sermons, (or punishment is reward.) It moralising sadism really……

  9. Judy says:

    Echoing the comments of others. Ithink it is easy to underestimate the distress of relatives and patients. In my experience getting a diagnosis come s at best months (often much longer) after you first start worrying about a relative. As a relative you have no experience of mental illness , but the diagnosis when you look it up on the internet just doesn’t fit. But no one has really talked to friends and realtives to find out what is happening the rest of the time. Then you keep getting asked by professionals , what do you think, what do you want, what do you think might help. The answer to all of these is i have no idea which is why we are here!!!!!!!!! Then if you do think of something it is almost always not available anyway.

    Ditto but even more so the suicidal patient, they are in deep deep distress and have used the last piece of eneerrgy to get to you. Thye knwo the only thing on offer will be hospital, but noone really wants to go to hospital and anyone who is suicidal is ambivalent anyway as what they really want to do is die.

    They want help and support and are expressing their pain. Then they get implicitly told they are being unreasonable, of course they are unreasonable they are in deep distress, panic, horror and fear. Then a doctor or nurse wants them to make a rational decison!

  10. Experto Crede says:

    Remembering an ‘event’ where I thought I was diligently focusing on counting the 9 screws in the wall panel of the interview room in an attempt to mindfully ground myself and distract from voices. Psychiatrist notes read that I was ‘repetitively touching imaginary objects that were not there’ !

  11. Experto Crede says:

    And if I was more skilled could write a radio farce on the endless questions and circular dialogues on ‘are the voices inside or outside your head’ !

  12. alex green says:

    You’re a professional, why don’t you do something! Must be what psychiatrists hear often. How often do doctors ask relatives or friends for observations on their patients between appointments? How much variation can you expect? How much emphasis can be placed on what they say in determining treatment?

  13. alex green says:

    Vicious circles in thinking (a type of behaviour) can occur when exposed to a situation which evokes shame, fear or ridicule. Any of the statements above could have created an avoidance, and the rest are indirect effects, or resonances. The circle can be broken by reversing the avoidance with approach. (No, I AM worth it!)
    What do you think?

  14. alex says:

    S/he has a personality disorder, therefore x,y,z………X,y,z, therefore s/he has a personality disorder…..applicable to many other diagnoses. A loop of discursive constriction? C.f Theodore Millons Borderline personality disorder, – he warns professionals against pseudo knowledge (unsuccessfully).
    Any thoughts on risks?

  15. alex says:

    A bit sad that Alex has not found my comments worth commenting on, so I shall spell out my problems with diagnoses like “personality disorder”. One big problem is that how do you prove someone has recovered? It then gets said that ‘the disorder is not prominent at the moment.’ This doesn’t sound very scientific, because you can’t prove it false. Giving someone a lifetime diagnosis which could very well.destroy their life, because nothing they say has any truth whatsoever, is really a crime.
    If I were to say Alex Langford has a personality disorder, no one will be remotely.interested in what you say ever again. You will find yourself completely isolated. Then, if you get upset about the unfairness of people’s reactions to you, then that will be evidence of your maladjustment. Even to people who know nothing about psychiatry, it becomes obvious that the scope for harm is considerable.

  16. Anon says:

    I don’t think the first example – Dr your diagnosis is wrong…you are the doctor we don’t know what diagnosis there should be – is a double bind or a rejection. It is quite possible to know that something is not something while not knowing what it actually is! If I was shown a guitar like instrument and a musician told me it was a cello, I might be certain it wasn’t a cello but need a musician (or at least someone with a bit more knowledge than me) to say it was a ukulele. And while I may be able to articulate that ‘that instrument is far too small to be a cello’ when it comes to medical diagnoses I may not be able to articulate just quite what is ‘wrong’ with the suggested diagnosis even though I ‘know’ that it IS wrong.

    Again, turning to the second example it depends how you choose to interpret it. I tend to agree with others who comments that say the person is probably confused and ambivalent BUT it could be seen a different way. ‘Admit me or I will kill myself’ – statement of fact, not a request for help or suggestion of what should be done – a statement does not need to have an effect on the doctor in order to have meaning. Simple communication of fact to the doctor, not a threat or a request. This ‘fact’ remains the same at the end of the consultation, and by saying they will not go into hospital, the patient is simply saying ‘I will kill myself’ rather than ‘I have asked you for help and am now rejecting it’. By seeing it from this perspective other avenues are open for exploration – why then come to A&E?, what does the patient want? are we underestimating risk by assuming that informing of suicide intention implies a desire to get help and get better?

    What both the examples show, as presented in the blog post rather than with the extra information no doubt available in the real situation, is how taking a doctor centric view of communication can lead to restrictive interpretations underpinned by somewhat negative assumptions about the difficulties presented by ‘these people’.

  17. Pingback: Knots – Thinking Clearly

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