Mental Health Mental Health MattersMatters

Dr Anthony DuncanDr Anthony Duncan

A good time to talk.A good time to talk. There is a potential for Coroners and There is a potential for Coroners and

Mental Health Professionals to talk past Mental Health Professionals to talk past each other.each other.

As “risk” is assuming such a high profile As “risk” is assuming such a high profile this could become more and more of a this could become more and more of a problemproblem

This potential can be minimized if we This potential can be minimized if we better understand each others roles and better understand each others roles and work closer together.work closer together.

Mr David BYRNEMr David BYRNEEuropean Commissioner for European Commissioner for

Health and Consumer ProtectionHealth and Consumer Protection ““Risk versus benefit”Risk versus benefit”

European Voice Conference “Farm European Voice Conference “Farm to Fork”to Fork”

Brussels, 22 November 2001Brussels, 22 November 2001

Are we in danger of being Are we in danger of being overcome by "risk overcome by "risk

paranoia"?paranoia"? Do we suffer from "risk dyslexia"? Are we Do we suffer from "risk dyslexia"? Are we

weighed down by "risk overload"? weighed down by "risk overload"? We can't have a risk free society. We can't have a risk free society. Yet we cannot have a free for all Yet we cannot have a free for all

especially in areas touching on public especially in areas touching on public health considerations. health considerations.

We need deep reflection on these We need deep reflection on these questions. Perhaps they are not capable questions. Perhaps they are not capable of satisfactory resolution in a neat of satisfactory resolution in a neat package. package.

Today’s TasksToday’s Tasks

Talk about risk and risk management.Talk about risk and risk management.

Talk about the different working models of Talk about the different working models of coroners and psychiatrists and the coroners and psychiatrists and the potential for talking past each other potential for talking past each other

Comment on the role of the Coroner’s Comment on the role of the Coroner’s hearing for families and health hearing for families and health professionals in achieving closure after a professionals in achieving closure after a death.death.

And then……… And then………

Talk about concepts of Mental Talk about concepts of Mental Disorder and Illness, and how they Disorder and Illness, and how they are related. are related.

Managing severe personality Managing severe personality disorders.disorders.

And then any other topics of interest!And then any other topics of interest!

What is risk?What is risk?

The change of something happening The change of something happening that will have an impact on objectives.that will have an impact on objectives.

It is measured in terms of It is measured in terms of consequences and likelihood.consequences and likelihood.

We live in an era where there is a We live in an era where there is a great distrust of professionals and great distrust of professionals and

institutions.institutions. A quick scan of the Sunday paper finds stories A quick scan of the Sunday paper finds stories

about alleged misspending of public monies by a about alleged misspending of public monies by a number of government departments.number of government departments.

The risks of GE.The risks of GE.

The risks of aerial spraying to control pests.The risks of aerial spraying to control pests.

The risk of lahars on Mt Ruapehu.The risk of lahars on Mt Ruapehu.

Poor practice by a variety of professionals.Poor practice by a variety of professionals.

The Tipping Point The Tipping Point by Malcolm Gladwellby Malcolm Gladwell

‘‘How little things suddenly can make How little things suddenly can make a big difference.a big difference.

Hush Puppy Shoes.Hush Puppy Shoes.

The folding of paper, and epidemics.The folding of paper, and epidemics.

Risk assessment and management.Risk assessment and management.

Managing RiskManaging Risk

Since the mid 1950’s a more formal Since the mid 1950’s a more formal approach to managing risk has evolved approach to managing risk has evolved out of the manufacturing and insurance out of the manufacturing and insurance industry.industry.

Healthcare risk management approaches Healthcare risk management approaches have developed since the 1960’s.have developed since the 1960’s.

They originated in the USA.They originated in the USA.

Australia and New Zealand are Australia and New Zealand are in the early stages of in the early stages of

acceptance and acceptance and implementationimplementation..

Accountability for health care outcomes Accountability for health care outcomes is an area of recent focus.is an area of recent focus.

Learning how to manage risk effectively Learning how to manage risk effectively enables managers and health care enables managers and health care providers to achieve improved outcomes providers to achieve improved outcomes by identifying and analyzing the wider by identifying and analyzing the wider range of issues and providing a systemic range of issues and providing a systemic way to make informed decisions.way to make informed decisions.

Risk perception.Risk perception.

Technical expert looks at probability Technical expert looks at probability and consequences.and consequences.

Lay person’s perception determined Lay person’s perception determined by factors including by factors including Degree of familiarity with the activityDegree of familiarity with the activity Degree of personal control that cab be Degree of personal control that cab be

exercised over the activityexercised over the activity

Degree to which exposure to risk is Degree to which exposure to risk is voluntaryvoluntary

The distribution of the risks or benefitsThe distribution of the risks or benefits

The potential of an event to result in The potential of an event to result in catastrophic consequences catastrophic consequences

Whether the consequences are dreaded.Whether the consequences are dreaded.

Risk thermostats.Risk thermostats.

We are all set a little different.We are all set a little different.

Has an impact on career choice.Has an impact on career choice.

Has an impact on how the past is Has an impact on how the past is seen to influence future decision seen to influence future decision making.making.

Same information different Same information different response.response.

Individualists. Individualists. Stress market forces and individual responsibilityStress market forces and individual responsibility

Egalitarian Egalitarian Our group knows best, we plan and act accordingly Our group knows best, we plan and act accordingly

Hierarchists Hierarchists Expect protocols to work, trust the experts, do Expect protocols to work, trust the experts, do

more research.more research.

Fatalists Fatalists Why bother things just happenWhy bother things just happen

We are the first generation We are the first generation of practitioners in the risk of practitioners in the risk

management society.management society.

Risk is to a large extent socially Risk is to a large extent socially constructed.constructed.

Most people will fly and driveMost people will fly and drive

Many won’t have cell phone towers Many won’t have cell phone towers near their homesnear their homes

As living has become less As living has become less dangerous we focus more on risks!dangerous we focus more on risks!

Especially on those we are exposed Especially on those we are exposed to, but have no control overto, but have no control over

Perceived to be caused by others.Perceived to be caused by others.

More powerful than us.More powerful than us.

We focus on risks out of our We focus on risks out of our controlcontrol

Much more public concern about Much more public concern about dioxin that diabetesdioxin that diabetes

Much more concern about Much more concern about environmental carcinogens than diet.environmental carcinogens than diet.

Agent Orange compensation meeting Agent Orange compensation meeting held in smoky RSL clubs.held in smoky RSL clubs.

Emerald Pools fall.Emerald Pools fall.

12 year old falls to his death in a national 12 year old falls to his death in a national park in Utah in the USA.park in Utah in the USA.

Parents sued the park authority for Parents sued the park authority for inadequate warning signs.inadequate warning signs.

Attorney Kathryn Collard had argued in Attorney Kathryn Collard had argued in the appeal that several warning signs the appeal that several warning signs posted in the vicinity of the pools were not posted in the vicinity of the pools were not specific enough to warn of the dangerspecific enough to warn of the danger

The case failed.The case failed. "The Middle Emerald Pools could be made perfectly safe "The Middle Emerald Pools could be made perfectly safe

by installing around it a 10-foot-high chain link fence with by installing around it a 10-foot-high chain link fence with spikes on top," said Tuesday's decision. "But few would spikes on top," said Tuesday's decision. "But few would want to visit such a site. Zion officials have to decide the want to visit such a site. Zion officials have to decide the extent of safety precautions that can be justified in a extent of safety precautions that can be justified in a scenic park.“scenic park.“

Collard was not available for immediate comment Tuesday. Collard was not available for immediate comment Tuesday. Even if the signs posted had warned of algae, as Collard Even if the signs posted had warned of algae, as Collard had suggested they should have, the 10th Circuit had suggested they should have, the 10th Circuit questioned whether park officials would then be required questioned whether park officials would then be required to add signs explaining how to identify algae or warning of to add signs explaining how to identify algae or warning of the hazards of rocks not covered by algae.the hazards of rocks not covered by algae.

It is a risky world out thereIt is a risky world out there

If risks were better quantified and If risks were better quantified and managed.managed.

Nothing would ever go wrong.Nothing would ever go wrong.

So if anything goes wrong So if anything goes wrong

Somebody should or could have prevented Somebody should or could have prevented it.it.

Professional actions as Professional actions as assessed socially as well as assessed socially as well as

objectively.objectively. Suicide and homicide are terrifying.Suicide and homicide are terrifying.

Media portrayals tend to be polarized between then Media portrayals tend to be polarized between then being inexplicable or inevitable.being inexplicable or inevitable.

They could happen in any family.They could happen in any family.

They must not and should not.They must not and should not.

They will not if mental health professionals do their They will not if mental health professionals do their jobs right.jobs right.

And Coroners are in the ideal place to make sure And Coroners are in the ideal place to make sure they do.they do.

Changes in Mental Health Changes in Mental Health Services.Services.

A move to more community service A move to more community service provision, and a reduction in the provision, and a reduction in the number of institutional beds.number of institutional beds.

Working in a society where there Working in a society where there have been major changes.have been major changes.

Dramatic increases in life choices for Dramatic increases in life choices for people.people.

Increasing drug abuse and markers of Increasing drug abuse and markers of family breakdown.family breakdown.

Roles Roles

Psychiatrists bring their general Psychiatrists bring their general knowledge to the specific, to guide knowledge to the specific, to guide their actions in the face of their actions in the face of considerable uncertainties.considerable uncertainties.

Coroners use information obtained Coroners use information obtained from a certain and specific case to from a certain and specific case to make more general make more general recommendations.recommendations.

PART 4 — INQUESTS PART 4 — INQUESTS

Section 15 Section 15 Purpose of Inquests.Purpose of Inquests.

1) A coroner holds an inquest for the purpose 1) A coroner holds an inquest for the purpose of—of—

(a) Establishing, so far as is possible,—(a) Establishing, so far as is possible,— (i) That a person has died; and(i) That a person has died; and (ii) The person's identity; and(ii) The person's identity; and (iii) When and where the person died; and(iii) When and where the person died; and (iv) The causes of the death; and(iv) The causes of the death; and (v) The circumstances of the death; and(v) The circumstances of the death; and

b)b)

Making any recommendations or Making any recommendations or comments on the avoidance of comments on the avoidance of circumstances similar to those in which circumstances similar to those in which the death occurred, or on the manner the death occurred, or on the manner in which any persons should act in such in which any persons should act in such circumstances, that, in the opinion of circumstances, that, in the opinion of the coroner, may if drawn to public the coroner, may if drawn to public attention reduce the chances of the attention reduce the chances of the occurrence of other deaths in such occurrence of other deaths in such circumstances. circumstances.

What is the Coroner’s What is the Coroner’s Task.Task.

Or what should it be.Or what should it be.

Micro Micro

MacroMacro

AloneAlone

With othersWith others

Psychiatric Training.Psychiatric Training. Taught how to extrapolate from minimal Taught how to extrapolate from minimal

information, ie see patterns, establish and information, ie see patterns, establish and check out hypotheses.check out hypotheses.

Learn the art of formulation, which tries Learn the art of formulation, which tries to establish some order on chaos.to establish some order on chaos.

Learn how to do risk assessments, and Learn how to do risk assessments, and how to weigh risks.how to weigh risks.

Learn to feel confident to take decisions, Learn to feel confident to take decisions, in a situation of under resourcing, in a in a situation of under resourcing, in a system not configured the way you would system not configured the way you would want it configured. want it configured.

Clinical AccountabilityClinical Accountability

Somebody must be held accountable!Somebody must be held accountable!

For the outcome?For the outcome?

I can only be responsible for my decision I can only be responsible for my decision making process not the outcome.making process not the outcome.

Reviews should concentrate on the Reviews should concentrate on the decision making process!decision making process!

Systemic AccountabilitySystemic Accountability Clinical practice occurs in a system.Clinical practice occurs in a system.

Built by othersBuilt by others

With particular ideologies. With particular ideologies.

Community focusedCommunity focused

Funder provider split, and private Funder provider split, and private provision of residential care.provision of residential care.

Social AccountabilitySocial Accountability Welfare provisionsWelfare provisions

State role in employment marketState role in employment market

Drug and alcohol PolicyDrug and alcohol Policy

Gambling policyGambling policy

Family values.Family values.

The technologically disenfranchised.The technologically disenfranchised.

The role of the Coroners The role of the Coroners Court in Guilt and Court in Guilt and

Expiation.Expiation. One function of the hearing is to One function of the hearing is to

allow closure on a death.allow closure on a death.

Often by this stage a considerable Often by this stage a considerable reworking of “the truth”reworking of “the truth”

We do not speak ill of the dead.We do not speak ill of the dead.

Lots of mixed feelingsLots of mixed feelings

Ambivalence.Ambivalence.

Guilt Guilt

ReliefRelief

Anger Anger

By the time it comes to By the time it comes to the Coroner’s Court.the Coroner’s Court.

We as a family are pure as the driven We as a family are pure as the driven snow.snow.

The deceased never had any problems The deceased never had any problems until he/she went to the Mental Health until he/she went to the Mental Health Service.Service.

If only they had done what they should If only they had done what they should have done (and we told them what to do) have done (and we told them what to do) he or she would still be alive.he or she would still be alive.

What might the health What might the health professionals say?professionals say?

We could not hospitalize him We could not hospitalize him because he did not meet the criteria because he did not meet the criteria of the Mental Health Act.of the Mental Health Act.

And doing so would have prevented And doing so would have prevented the outcome.the outcome.

It is not my fault.It is not my fault.

I am as pure as the driven snow.I am as pure as the driven snow.

Of course I would have detained him Of course I would have detained him is I could.is I could.

It is the fault of the Mental Health It is the fault of the Mental Health Act.Act.

What do these two series of What do these two series of statements have in statements have in

common?.common?. An assumption that in an ideal world An assumption that in an ideal world

all dangers should be predictable all dangers should be predictable and manageable.and manageable.

““It would not have happened if……”It would not have happened if……”

The real world is not a safe and The real world is not a safe and friendly place!friendly place!

What was the family’s What was the family’s thinking in the time thinking in the time

immediately around the immediately around the death?death? He really was difficult He really was difficult

If only he had / had not…….If only he had / had not…….

If only we had / had notIf only we had / had not

What was the health What was the health professional thinking at the professional thinking at the

time of the last time of the last assessment? assessment?

At the time, based on past experience I At the time, based on past experience I felt the best course of action was……..felt the best course of action was……..

I really did not think he was a risk to I really did not think he was a risk to much of a risk.much of a risk.

And I judged the risk of other courses And I judged the risk of other courses of action to be greater.of action to be greater.

How did they weigh the How did they weigh the risks before deciding what risks before deciding what

to do. to do. To the individualTo the individual

To significant others To significant others

To the system as a whole. To the system as a whole.

The The medicalisation of medicalisation of

sufferingsuffering

My son has been diagnosed My son has been diagnosed as having a mental as having a mental

disorder.disorder. And there is no service for him.And there is no service for him.

If nothing his done he will kill If nothing his done he will kill somebodysomebody

The Doctor has diagnosed an The Doctor has diagnosed an Antisocial Personality DisorderAntisocial Personality Disorder

Mental Disorder (DSM Mental Disorder (DSM IV)IV)

A clinically significant behavioral or A clinically significant behavioral or psychological syndrome or pattern that psychological syndrome or pattern that occurs in an individual.occurs in an individual.

And that is associated with And that is associated with Present distress (painful symptom) orPresent distress (painful symptom) or Disability (impairment in one or more Disability (impairment in one or more

important areas of functioning) orimportant areas of functioning) or With a significantly increased risk of With a significantly increased risk of

suffering death, pain, disability or an suffering death, pain, disability or an important loss of freedom.important loss of freedom.

Cautionary StatementCautionary Statement The purpose of DSM-IV is to provide clear The purpose of DSM-IV is to provide clear

descriptions of diagnostic categories in descriptions of diagnostic categories in order to enable clinicians and investigators order to enable clinicians and investigators to diagnose, communicate about, study and to diagnose, communicate about, study and treat people with various mental disorders.treat people with various mental disorders.

The clinical and scientific considerations The clinical and scientific considerations involved in categorization of these conditions involved in categorization of these conditions as mental disorders may not be wholly as mental disorders may not be wholly relevant to legal judgments, for example, relevant to legal judgments, for example, that take into account such issues as that take into account such issues as individual responsibility, disability, individual responsibility, disability, determination and competencydetermination and competency

Mental Disorder.Mental Disorder.

An abnormal state of mindAn abnormal state of mind Of continuous or intermittent natureOf continuous or intermittent nature characterized by characterized by Delusions, or by disorders of mood, Delusions, or by disorders of mood,

perception or volition or cognitionperception or volition or cognition

Of such a degree that itOf such a degree that it

Poses a serious danger to the health Poses a serious danger to the health or safety of that person or of others or safety of that person or of others oror

Seriously diminishes the ability of Seriously diminishes the ability of that person to take care of himself or that person to take care of himself or herself.herself.

Are Mental Health Service Are Mental Health Service there to manage Mental there to manage Mental

Illness?Illness? Words like illness, disease and sickness Words like illness, disease and sickness

have been defined in various ways.have been defined in various ways. You can have a disease without feeling You can have a disease without feeling

sick or being ill.sick or being ill. One essential feature of illness and One essential feature of illness and

disease is the assumption (from disease is the assumption (from physical medicine) that they are physical medicine) that they are biological conditions afflicting the biological conditions afflicting the “person”, and can be potentially be “person”, and can be potentially be “fixed”.“fixed”.

The medical model fits for The medical model fits for some mental disorderssome mental disorders

Especially “Mental Illnesses’Especially “Mental Illnesses’

Ie “Diseases” that can be seen as an Ie “Diseases” that can be seen as an affliction which can potentially be “fixed” affliction which can potentially be “fixed” so the person returns to normal.so the person returns to normal.

SchizophreniaSchizophrenia

Manic depressive illness, Unipolar Manic depressive illness, Unipolar affective disorder, Anxiety disorders.affective disorder, Anxiety disorders.

Medical modelMedical model Symptoms are epiphenomena the doctor needs Symptoms are epiphenomena the doctor needs

to decipher to get to the diagnosis.to decipher to get to the diagnosis.

The doctor prescribes treatment for the The doctor prescribes treatment for the disorder.disorder.

The patient takes the treatment, and gets The patient takes the treatment, and gets better.better.

And thanks the Doctor and the rest of the team.And thanks the Doctor and the rest of the team.

Allows you access the Allows you access the sick rolesick role

It is not your fault.It is not your fault.

It is out of your control.It is out of your control.

We have the therapy to get you We have the therapy to get you better.better.

Most of these illnesses can Most of these illnesses can be treated reasonably wellbe treated reasonably well

If If The person accepts the sick roleThe person accepts the sick role Takes the medicationsTakes the medications Comes to terms with the illnessComes to terms with the illness Avoids substance abuse.Avoids substance abuse.

Treating these conditions Treating these conditions remains the core business remains the core business

of Psychiatristsof Psychiatrists The further away from this core one gets The further away from this core one gets

the less relevant medical training and the less relevant medical training and “being a Doctor” is“being a Doctor” is

However However There are understandable societal There are understandable societal

expectations that we can “fix” everyone expectations that we can “fix” everyone and everythingand everything

““He must be mad, look at the way he acts”He must be mad, look at the way he acts” And when we can’t, we have failed!And when we can’t, we have failed!

How near to core psychiatry How near to core psychiatry was this case?was this case?

The further away (both in time and The further away (both in time and scope), the less we can be expected to scope), the less we can be expected to be responsible for.be responsible for.

We are not society’s fix it squad!We are not society’s fix it squad!

Changes is suicide rate are largely Changes is suicide rate are largely socially determined, and intervention socially determined, and intervention needs to be societal to change the rate.needs to be societal to change the rate.

Welcome to the mind of a Welcome to the mind of a Psychiatrist.Psychiatrist.

I do as much assessment as I think is need to allow I do as much assessment as I think is need to allow me to feel I can reach an understanding of the me to feel I can reach an understanding of the person, and make a diagnosis.person, and make a diagnosis.

Weigh the risks and decide on a course of action.Weigh the risks and decide on a course of action.

I then wait and see how things pan out and if I then wait and see how things pan out and if necessary have another crack.necessary have another crack.

There is never enough time to cover all the bases, There is never enough time to cover all the bases, and the law of diminishing returns means near and the law of diminishing returns means near enough is good enough! enough is good enough!

Most the moves I make are good ones!Most the moves I make are good ones!

It is a risky world out It is a risky world out there!there!

I am never dealing in situations where there is I am never dealing in situations where there is a choice between a course with no risk and one a choice between a course with no risk and one with lots.with lots.

I decided on a course of action light of clinical I decided on a course of action light of clinical experience, a gut feeling, knowledge of the experience, a gut feeling, knowledge of the literature, social supports and resource literature, social supports and resource constraints.constraints.

I fill out risk assessment forms and other parts I fill out risk assessment forms and other parts of the paper trail under great duress.of the paper trail under great duress.

An inpatient goes AWOLAn inpatient goes AWOL•Goes to parents house.Goes to parents house.

•They ring the ward, and say “he is They ring the ward, and say “he is OK, says he is not suicidal and his OK, says he is not suicidal and his friend will bring him back later in friend will bring him back later in the afternoon.”the afternoon.”

•Staff have concerns, as he has been Staff have concerns, as he has been suicidal, but parents say no please suicidal, but parents say no please don’t come, this is the first time he don’t come, this is the first time he has accepted he needs help.has accepted he needs help.

The friend decides to take The friend decides to take him for a drive before him for a drive before

returning him.returning him. He jumps out and kills himself!He jumps out and kills himself!

What does the inquiring Coroner need to What does the inquiring Coroner need to consider?consider?

• What were the risks of other actions such as What were the risks of other actions such as going out, and putting him under the Act, going out, and putting him under the Act, without parents consent.without parents consent.

• Were they appropriately weighed up ?Were they appropriately weighed up ?

• What should happen in the next 10 similar What should happen in the next 10 similar cases?cases?

Importance of not Importance of not invalidating good invalidating good

practice.practice. What were the alternative possible courses What were the alternative possible courses

of action?of action?

What might one usually be expected to What might one usually be expected to weigh up in such a situation. weigh up in such a situation.

How often are practitioners called on to How often are practitioners called on to make a decision in similar circumstances?make a decision in similar circumstances?

What would be the usual expected What would be the usual expected

outcomes of the various options.outcomes of the various options.

How close to core How close to core psychiatry was this?psychiatry was this?

What is the appropriate level of What is the appropriate level of recommendationrecommendation

Whose subsequent decision Whose subsequent decision making needs to be targeted making needs to be targeted

What are the resource What are the resource implications of recommendations, implications of recommendations, and does that need to be and does that need to be commented on.commented on.

Management of Management of Borderline Personality Borderline Personality

Disorder.Disorder. Therapeutic risk taking.Therapeutic risk taking.

There is a high chance this condition There is a high chance this condition will be fatal if we do nothing or will be fatal if we do nothing or contain, so lets try to do something contain, so lets try to do something positive.positive.

AetiologyAetiology

Possible genetic predisposition.Possible genetic predisposition.

Usually terrible childhood experiences.Usually terrible childhood experiences.

These leading to problems sense of self and These leading to problems sense of self and self worth.self worth.

Problems with affect control, affect Problems with affect control, affect regulation, tolerance of negative affect and regulation, tolerance of negative affect and impulse control. impulse control.

These people do not have These people do not have a treatable illnessa treatable illness

But they are distressed and distressing.But they are distressed and distressing.

Very low self esteem Very low self esteem

Chronically empty Chronically empty

Chronically suicidalChronically suicidal

Very impulsiveVery impulsive

What helpsWhat helps

Treat any superimposed illnessesTreat any superimposed illnesses

Establish a good working alliance, and at Establish a good working alliance, and at first take no risks until you can be sure first take no risks until you can be sure there is no superimposed illness.there is no superimposed illness.

Containment is often counter productive Containment is often counter productive as it leads to increased regression, as it leads to increased regression, feelings of powerlessness and increases feelings of powerlessness and increases the already very high chance of suicide.the already very high chance of suicide.

The long term prognosis The long term prognosis with treatment is quite with treatment is quite

good.good. As long as they do not kill As long as they do not kill

themselves in the meantime.themselves in the meantime.

Theraepeutic risk taking is Theraepeutic risk taking is appropriate.appropriate.

BUTBUT

Only in the well selected Only in the well selected patientpatient

Acutely if you don’t know the Acutely if you don’t know the patient, and there is no management patient, and there is no management plan admit them.plan admit them.

HoweverHowever

For carefully selected cases it is an For carefully selected cases it is an appropriate management approach. appropriate management approach.

To feel confident to work in To feel confident to work in this way clinicians need to feel this way clinicians need to feel

supported.supported.

These people have a disorder in part These people have a disorder in part caused by others, via neglect and or caused by others, via neglect and or abuse.abuse.

People can help fix them, but cannot be People can help fix them, but cannot be responsible for them except in crisis.responsible for them except in crisis.

These conditions are often fatal, and we These conditions are often fatal, and we have to accept that!have to accept that!