The Capacity Games

As I walked into the room he was laying face down on the bed, arm hanging over the side and bleeding heavily. A constant stream of blood was trickling out into the ever increasing pool on the floor. He was seemingly unconscious and very pale. I applied some significant pressure to the wound in the bend of his arm whilst trying to find out what had happened. It turns out that he wasn't unconscious but just playing dead. Within a minute or so he was up and talking, full of bravado and attitude. I applied a pressure dressing to the wound and bound it up relatively tightly. 

In terms of numbers he was OK. His pulse and blood pressure were stable and was showing no signs of shock despite the blood loss. That said, he needed to go to hospital. Clearly this was a cry for help and I wouldn't be happy leaving him on his own. For a suicidal self harmer however, he was surprisingly up beat. Very chatty, very well spoken and extremely knowledgeable about mental health law. He quickly made it very apparent he was not going to be going to hospital under any circumstances and was well aware that currently the ball was in his court. I had hoped some well chosen words and my power of persuasion could have made inroads with him but he was as determined as he was smug. 

Plan B then. If I couldn't force him to go to hospital, then I had to bring the most relevant bits of hospital to him. I discussed options with him and we settled on getting an out-of-hours GP to visit to ensure the wound was clean and appropriately dressed and then contact a mental health crisis team who WILL visit within two hours. Well, that's what they are supposed to do! He was happy with the plan, his dad was happy with the plan and seemed in good spirits. I wasn't happy with the plan but that was probably fed by the compulsion to do something for someone in crisis and not getting my own way. The patient had capacity so this was the best I could do! At a stretch the fact he was drunk could effect his capacity but I was able to have a more than rational conversation with about the pros and cons of staying and going and depute my disagreement with his opinion, it was after all his opinion and ultimately, his choice.

*REMEMBER THIS MOMENT* At this point, no ambulance had arrived, so I phoned control, to tell them that the patient was refusing treatment so no ambulance was required. 

"We also have the police running on this CAD, would you like them cancelled too?"

"Rog, patient is compliant and isn't being aggressive. Cancel police."

"Rog, thank you, red base out."

I explained to the patient and his dad that I needed to go and get my paperwork and phone various people to arrange the referral. I needed to speak to our Clinical Support Desk, the GP and the Mental Health crisis team and that could take a little while to get the ball rolling.  What I did assure them of, was that I wouldn't be leaving until I knew exactly when someone would be coming.

I went down to the car and started my phone calls. Midway through my first conversation there was a knock on the window. It was the dad looking rather panicked.

"He's done it again, I can't wake him, it's bleeding everywhere."

*face palm* 

I hung up the phone and rushed (Ambulance Run - above average walk) into the house and back upstairs. As I got to the landing I could hear the blood pouring onto the wooden floor. He was now lying on his back, other arm hanging over the edge of the bed and blood was literally pouring out of him. He was white as a ghost and unconscious. Again, I applied pressure and held his arm as high as I could. I was now in an extremely awkward situation. *REMEMBER THAT MOMENT* 

I was on my own with a bleed I was struggling to control. I had cancelled the ambulance and considering I had already waited 40 minutes and one never arrived, the chance of getting one instantly was minimal. I had also cancelled the police, who in this situation could be of great use!

"You see the radio on my belt, twist it off, hold down '*' to remove the key lock, then hold down '#' (priority) for me."

His dad followed my instructions and within a couple of seconds the radio started ringing. 

"Hold down the button on the side for me."

"Red base, patient has cut himself again, I need the police and an ambulance as a priority, I'm struggling to control the bleeding." 

"Rog, will do that for you now, nearest ambulance is some distance away, sorry!"

"Right, take the key off my belt loop, in the boot is a big black bag with 'Paramedic' written on it. Bring me that bag please."

Off he ran (Non-ambulance run - Actual running - Weird phenomenon). I managed to apply a pressure dressing to the arm which seemed to do the trick. This time bound even tighter than the first! On his return I got his dad to hold the arm in the air, allowing me to do other stuff. His blood pressure was in his boots so I got a cannula in him (for the medical lot, an orange in the back of the hand, sadistic git that I am) and started running some fluids through. The patient gradually became more coherent and was soon back and telling me to go away and leave him alone. Unfortunately for him and luckily for me, the leaving alone option was no longer viable.

First to my aid was the police. They helped me with everything I was doing and also attempted to convince the patient that now hospital was a must. He was having none of it. 

"You can't section me, I'm old enough to make my decisions and I'm not going to hospital. There is nothing you can do to make me go."

"I think you'll find we can."

"What powers are you going to use to take me from my own home, a place of safety, right here and now. You can't do anything legal and you know it."

The poor copper looked a little stumped and unfortunately had no answer for him which somewhat undermined his authority.

Although the patient had apparent capacity to refuse treatment, on balance I now felt I had reasonable grounds to use the Mental Capacity Act to enforce treatment. As far as I was now concerned he lacked capacity to make an informed decision and didn't appreciate the severity of his injuries. Unfortunately for the patient, he came up against someone with greater knowledge of mental health law than him. I was able to quote section 4(B) of the MCA at him and outline why the deprivation of his liberty was necessary. My rationale was because my proposed treated was wholly or partly for the purpose of giving life saving treatment to him and that, as the medical professional currently in charge of his wellbeing, I was well within my right to ensure he got treatment.

I explained all this in quite a self gratifying speech which left the patient looking rather deflated!

"Aaaaahhh, you just got schooled on the law by a paramedic, aren't the police supposed to know more?! Embarrassing!"

I felt a little awkward but luckily the copper took it on the chin and seemed happy to follow my lead and confirmed to the patient that I could do what I was saying. I also backed that up by telling him that under section 6 of the MCA he could be retrained by the police to ensure said life saving treatment happened and to prevent further harm to himself or us. Faced with three people who were much more well read on mental health law than he was, he quickly got on board with what was going to happen and became compliant. 

When the ambulance arrived he came voluntarily and was most apologetic to all of us. His initial reluctance to go to hospital was easily explained......

5 hours earlier......

A 23 year old guy who suffers from bi-polar and depression, who has a history of self harm and suicide attempts, is feeling particularly low. He is feeling suicidal and wants some help. He tries but fails to get hold of his crisis team. They simply don't answer the phone. Because of these feelings, he has been drinking heavily but being self aware enough to know that he is likely to do something stupid, he self presents and his local A & E. He tells the triage nurse he has been drinking and is feeling very low and suicidal. He said he just wants to die. 

The hospital is very busy, majors and minor are full and the waiting room is at bursting point. The triage nurse listens to a young guy tell her he has been drinking and apparently takes no notice of his medical history and wish to die, so puts him in the waiting room where he waits.....and waits. After 4 hours he got up and left. His cry for help had been ignored by mental health services and his local hospital.  He got on a bus and went home where he carried on drinking. And drinking. 

He then smashed a glass, picked up a shard and rammed it into the crook of his arm. He then called his dad who was downstairs, to tell him what he had done. His dad phoned 999.

"My son has self harmed, he is bleeding from his arm quite heavily."

"OK sir, help is on the way."

"23 year old male, self harm, serious bleeding, access OK"

Luckily I was only round the corner so was on scene within a minute or so. I grabbed all my stuff and headed up the path for my first mental health of the night......

A patients outcome, positive or negative should not be based on luck. Luck that I was close by. Luck that his dad was in the house to find him bleeding when he did. Luck that the bleeding was stopped and he was quickly treated. This should be the basic of mental health care. There are services in place to not only treat this demographic of patients but to safeguard the risks that are associated with their conditions. A patient in crisis and at significant risk of harm should have instant access to their crisis team. Time and time again mental health services are impossible to access outside of 'Mon-Fri 9am-5pm'. It just isn't good enough. With the glaring failings in an understaffed, under trained and underfunded system, the safety net is always A & E. However, combine deep cuts, fed up staff and lack of training with winter pressures and a waiting room full of time wasters and the basics are simply overlooked. 

There was no RAID (Rapid, Assessment, Interface and Discharge) or other liaison service made available or seemingly in place to allow a quick assessment of him. There was also no apparent risk assessment. After only 5 minutes with the guy and a limited knowledge of the Pierce scale of suicidal intent, I had him at a high risk of significant harm. His medical history and presentation alone raised enough Red Flags to warrant a rapid assessment. Instead he was left to his own devices in a waiting room of a busy hospital. Hardly the place for a vulnerable, suicidal young adult to be left. This job highlights the woeful inadequacies of mental health care from top to bottom of the NHS. When will this improve?! 

So, mental health care in the NHS. Discuss.

The Three Stooges

“43  year old female, chest pains”

This job set the tone for what would turn at to be a very familiar night shift. I exhaled in frustration when I saw the address. It was one of the many regulars on our patch. She was a wine-drinking alcoholic; she always called for chest pains, always went to hospital and was always rude and obnoxious. Tonight would prove to be no different to the norm. We stomped up the concrete stairwell, navigating our way past the vomit on the stairs. Lush! Her door was wide open like it always is. We walked down the landing to her bedroom like we always do and found her lying on her bed smoking a fag like we always do. Then followed a very familiar conversation.

“Hello again”

“Alright luv”

“What’s the problem tonight?”

“I got chest pain”

“Same as before?”

“Yeah”

“Can we do an ECG?”

“Yeah, go on then”

We do the ECG and all her obs. They are all normal like always. 

“Shall we pop you up to hospital?”

“Yeah, I need to see a doctor.”

"Still got the pain?"

"Nah, but it should be checked out."

So, without any fuss he all walked (she staggered) arm in arm to the ambulance. We drove to the same hospital as we always do, where I gave the same handover as I always do. On to the next!

“37 year old female, suicidal, taken an overdose, police on scene”

We all say that the first job sets the tone and shifts have a theme but they really really do and I don’t know why! This address was also well known to us. It was the residence of the most abusive drunk in our area. I say abusive, she abuses the police and most ambulance crews but for some unknown reason she loves me! We pulled up next to the police car, which seems to be a permanent fixture outside her flat. In the hallway outside was one of the coppers.

“Good luck, she kicks off every time I go inside”

Sitting there in her underwear and dressing gown, she swigged vodka while smoking a roll-up. Her face lit up as soon as she saw me.

“Heya babe, tell the pigs they can go and you don’t need them”

As much as calling the police 'pigs' wasn’t acceptable, in all honesty, their presence was only going to make things worse and I knew they’d be only to happy to leave.

“I’m happy to deal with this, I know her well, she’ll be fine with me”

They were only too happy to leave and were gone near enough before I'd finished the sentence! It was the same story, drinking vodka to excess, self harmed her forearms, refused hospital and then there was a 45-minute battle to convince her to go. Sometimes she wins and sometimes I win. Tonight I won. Hospital was the plan and all we had to do first was go through the charade of collection her ‘valuables’ (vodka) and hiding them so they can’t be stolen. After completing this ritual we headed off and handed her over to the less than enthusiastic nurse. 

We left the hospital to go and get fuel and hopefully a Wild Bean coffee and a pre-packed sandwich. It really is 'gourmet on the go'! Well actually it wasn't because we never made it. We were flagged down by a member of the public for what appeared to be an unconscious man in the street.

“u/k male, unconscious, running call”

We called it in and were sent down a CAD number. It shouldn’t have surprised me that he was well known to us. I had picked him up yesterday about 200 yards down the road. In fact, he was being picked up 3-4 times a day, each time by an ambulance and each time taken to hospital. The problem is, each time, the hospital sober him up enough to be able to walk and then either sit him in the waiting room until he walks out or discharges him. He walks up the hill to the shops, buys more booze, drinks said booze and passes out again. The hospital are not willing or able to invest time in fixing the problem & we have no ability to anything else with an unconscious drunk person other than take them to hospital. The cycle will continue until he stops drinking or dies. The latter seemed most likely. 

Tonight, he was lying at the bus stop next to his empty bottle of scotch. He was face down and had wet himself. I often wonder what he was like before this. What kind of life did he lead? What family does he have? What friends did he have? Now there appears to be no one. The only people around him are the members of the public who call 999, the ambulance crews that take him to hospital and the nurses that kick him out. What can we do?! We scooped him up off the floor and onto our bed. We did the usual obs and then drove the half-mile to hospital. We got the usual looks of distain from the nurse and rolled him onto the bed. To be fair to the nurse, we had just brought in three abusive alcoholics in as many hours, but still……not our fault!

Alcohol is something that the NHS does not do well, a bit like obesity. We only treat in the short term when it is too late. Very little is done when warning signs are there. Accessing services is far to difficult and it is a lot easier to just give a bag of fluids and let them go than find out the cause and refer to the appropriate places. It’s a shame, if they invested in prevention rather than cure, the long term saving could be huge. Shame no manager or politician is ever that long sighted.

Off we went for fuel, this time we made it. The sandwich was rank and the coffee was a poor substitute to Costa but beggars can’t be choosers! After the start to the shift we had had it was a necessity! We went off and did a few more jobs to a different hospital and at about 2am came back to our area. We handed over our drunken teen to the staff and booked them in. I walked through the busy waiting room and what did I see?! All my regulars sat in a line on the bench together! The Three Stooges! That image summed up how the NHS treats alcohol and mental health. A sad sight but one that amused me! 

“Evening all!”

Policing Violent Healthcare

It is with great pleasure that I can welcome back Inspector Michael Brown, highly revered police blogger of Mental Health Cop and award winning Tweeter @MentalHealthCop to guest blog on Trying My Patients. His work on mental health policing has won him acclaim across the country and is highly regarded as 'the go to guy' for all things mental health. Enjoy!


***WARNING: This post contains some graphic descriptions some may find distressing ***

"23 year old female, self harming"

The area where I worked as a sergeant had a hostel on it for women. The people who stayed there had various backgrounds, most of them troubled. It included domestic violence victims in need of temporary accommodation; those rehabilitating from substance use / abuse as well as being used as a 'step-down' facility for people with mental health problems. You can imagine the police service were there most days for a range of reasons.

I went there one New Year's Day with a probationary police constable I was working with - she'd won a "shift with the sarge" and it was my evening assessing how she was getting on now she was 'independent' of her tutor constable. It was a night shift, just after midnight that we were called to staff asking for help with a resident who was self-harming. The name of the woman was given to us over the air, because she was a "regular user of police services" owing to her propensity to get drunk and self-harm and she became foul and abusive when was she did. She was already 'banned' from one Accident & Emergency department in the city because of her relentless abuse of medical staff and she was flagged on the ambulance systems as someone who should always attract police support. 

We turned up quite quickly. I'd remarked to my inspector just before being despatched that the evening had been quite dull so far - as 01/01 night shifts often are - and flippantly stated we could do with a 'decent job' to keep us all awake. The inspector had stared at me the way I often now find myself staring at ignorant young sergeants!

We were ushered by a member of staff through the corridors of the hostel and into her room. We walked into what first looked like a blood bath: she'd cut her arms to shreds - she was incredibly drunk, bleeding heavily and muttering whilst banging her head off the wall. The cuts were not superficial. You could see the flesh cut centimetres down and the skin was widely split across the wound. Staff had attempted first-aid and to at least get dressings covering the injuries. She'd pushed them away and hit one of them, determined to hurt herself more. They sort of looked at us as if to say, "Over to you." We hadn't been told that ambulance were on their way, so just in case, I asked again.

She was scratching at her wounds, as if to pull them apart - I noticed a knife and a razor blade on the bed, red sheets soaked in blood. I did what all good sergeants do and patronisingly said, "Let's see how you handle this, then!" and let my probationary constable try talking to her. She did really well - the fact it had no effect whatsoever was nothing to do with any lack of empathy or effort to engage: it was almost certainly going to fail. I remember saying, "Let's just get the weapons away" and we each took hold of an arm whilst we passed the implements to staff.

We sat, holding her arms, getting covered in blood to the wrists waiting for ambulance. They turned up after about ten minutes. They tried what we'd already tried and failed and were also shouted at and abused for trying to get covering dressing on the wounds. It was explained again and again that she would need to go to hospital and it was me doing the telling after what seem like ages of trying to persude. This only seemed to make her more agitated. I found out later that the woman had a history of being sexually abused, had serious PTSD and personality disorder problems and she had real difficulty with men, especially male authority figures. Great! - nothing much I could immediately do about being a uniformed male police sergeant built for rugby with a special line in not messing about!

She was still bleeding, but the paramedics had said there wasn't a lot they could do. We tried to lift her to her feet, but she pulled away. Her arms were slippy because of the blood and she was frantic. She was going to have to be handcuffed otherwise we couldn't move her. Watching paramedics trying to just wrap something 'round her arms after we'd handcuffed her to the rear and she was starting to get violent wasn't happening ... she was just going to have to be shifted as is.

I remember looking at the paramedics and without speaking we were each thinking, "She's going in your vehicle, isn't she?!" Both of us looked horrified at the idea. "Come on, mate - she's drunk, injured, mentally ill and restrained by the police." No - they weren't having it. She was too violent to be conveyed in an ambulance and this wasn't for discussion apparently! Today, I'd have said, "One of you get in the police car then!" but as an ignorant young sergeant it didn't occur to me. So she went in a police vehicle without paramedics who resumed to something else - Costa Coffee, I'd imagine - wiping their hands of this healthcare situation and off we went to the nearest A&E.

Turns out, it's the one she was banned from. The receptionist looked at us and tried to start saying "No" but I said, "Come on, she's handcuffed and restrained by two police officers, she's bleeding and we can't move her miles to another A&E -somebody's got to see her, surely?!" It was like gatecrashing a party - you were in, but you knew you weren't really welcome. No coffee offered this time, as it often was in A&E. They cleared out a cubicle of its trolley and 'stuff' and placed a thin mattress on the floor. The woman had become more hysterical as she'd arrived in the bright lights of A&E and started head banging. Two other female officers from my shift had arrived and they took control of her whilst we got our breath back. She was finally able to be safely searched by two female officers, who'd had change to get "gloved up" and more razor blades were found.

After about an hour she was seen but she spent the whole of that hour trying to headbang and being restrained to stop her doing so. It was an hour of fighting police officers so who knows what kind of physiological strain she was subjecting herself to. I'd now be saying various other things to nursing staff, about NICE Guidelines and my fears and restraint related injury, but at the time I had no idea about these things. She spat towards the Doctor when he arrived and abused him severely so we were shortly afterwards ordered to leave the A&E department!! No healthcare at all. "Get her out!"

As the four of us, placed this poor soul back in a police vehicle - this time a caged police van for the safe transport of disturbed detainees, often mistaken for a 'dog van' - we had two choices. We try another A&E or go to police custody. I thought about asking the grumpy custody sergeant that night whether he'd like to detain a physical injured, mentally ill, untreated intoxicated detainee?

Another A&E it was: a four mile drive off our division to the area where I'd worked as PC. It felt like familiar territory as I'd almost lived in this A&E for four years. The woman was placed in a side room and actually became somewhat calmer, escorted by the two female officers who had come to help. My partner that evening and I started to think about getting ourselves cleaned up from blood and spit and I was asking this young officer whether she'd had her HepB jab from her GP - police officers don't get routine HepB, you have to ask your own doctor - she hadn't! "I strongly advise you ..." etc., etc.. Got to look after your cops.

The woman went on to get assessed under the Mental Health Act and was sectioned sometime late on the 02/01 after many hours being guarded by the cops and resented by the NHS.

But it was as we stood discussing HepB that the evening took a really interesting turn: A nurse tapped me on the shoulder and asked, "Officer, could you just speak to this woman, she's been shot!" I saw a young woman holding up her hand and you could clearly see a gun shot wound. it was Sophie Ellis, Charlene's sister. At that stage I had no idea who knew what about the incident so had to treat it as me being the first police officer to know ... well, I had asked for an interesting evening and my inspector said, "I told you to keep your mouth shut!"




To read the Mental Health Cop blog check out his website! Well worth a read! It's the one-stop-shop for all things mental health.

You can't fool me........

"27 year old female, multiple seizures"

Another day, another dollar! We were on a late shift and were busy clock watching, timing our jobs nicely to hopefully be off on time. Unfortunately we got a late one! Couldn't be helped, it was a Red 2 and because of the nature of the 'life threatening' condition she got the ambulance + FRU response. Repeat seizures or status epilepticus is indeed life threatening and can cause permanent brain damage if left untreated. We shot round to the address and arrived at the same time as the FRU. We all piled into the house, met my a friend at the door. Apparently they had been watching TV and she just started seizing and had continued on and off for 15 minutes now. I was first into the living room. She was lying on the floor, surrounded by friends, shaking violently. Foam sputum protruded from the mouth and her eyes were staring blankly at ceiling. Her arms were in a decerebrate position and her toes were pointing downwards. This is normally a sign of severe brain damage. This meant only one thing........She had done her homework. 

She was faking. Admittedly she was doing a very convincing job but the first clue was in the eyes! She was staring and focused. Eyes would normally role to the back of the head. The second was that her movement looked forced and calculated. Then, there was a few little tests. Once I took hold of her wrist her 'decerbrate' flexion relaxed. That wouldn't happen. I then lifted her now limp arm, held it above her face and let go. Sure enough it fell to the side of her face. That wouldn't happen! It would hit her face because an unconscious person would have no way to stop it. A conscious person doesn't want to be hit in the face. Finally she made a miraculous recovery after we'd been there only 2-3 minutes! No post-ictal period or confusion at all. I wasn't impressed. I told her to stop faking it. She tried her best to carry on the lie and when asked what meds she took for her epilepsy she named Zarontin and Haloperidol. Unfortunately Zarontin is only used to treat 'absence' seizures, and not the tonic-clonic ones she claimed she suffered with and we saw her fake! As for Haloperidol, well that's an anti-psychotic used to treat schizophrenia! She didn't have any medication on her as she'd 'run out'! Hmmm......I smell a rat. We took her to hospital because that's what she wanted. She wouldn't admit the truth. She even asked us to do an ECG to check her heart. What a waste of time and money for both the hospital and the ambulance. I gave my handover and the nurse recognised her. She was a known faker, a frequent flier, a sufferer of Munchausen syndrome. Oh, and I was an hour late off!

'Munchausen's syndrome is a psychological and behavioural condition where someone pretends to be ill, or sometimes induces symptoms of illness in themselves. Munchausen's syndrome is also known as factitious disorder.'

The cause of it is largely unknown, mainly because the people with it refuse to accept they have it and therefore refuse any psychiatric treatment meaning very little is known about their motives, thought processes or social and family upbringing. I personally think it is no more than extreme attention seeking and a desperation to be noticed. The symptoms of Munchausen syndrome range from faking psychological symptoms such as hearing voices to pretending to have physical symptoms like chest pain. In extreme cases they will go as far as self harm in an attempt to make them ill enough for a hospital admission. Commonly though they'll complain of things like breathlessness, abdominal pain, chest pain, seizures and black outs because they are easy to fake and hard to disprove. Often they'll claim to have had a combination of many such as a fall, then a seizure, and now chest pain. It isn't uncommon for some minor self harming to occur to show an injury from said fall.

Munchausen syndrome differs from hypochondriacs in that sufferers are aware that they are lying and exaggerating and it is calculated. It is a psychological disorder which requires treatment but one I personally have very little time for. Sufferers can spend years jumping from hospital to hospital wasting resources everywhere they go. They tell similar stories and repeat similar symptoms but unfortunately due to the accuracy in the portrayal of symptoms staff have no choice but to repeat all the costly tests to disprove lies. Due to the nature of their condition they become very manipulative people and will stop at nothing to get the attention they crave. There are documented cases where people have died as a result of complications  arising from unnecessary treatment.

It isn't known how common Munchausen's syndrome is, it's hard to quantify and hard to prove. I suspect a large percentage of the patients I go to are faking it for attention but you never really know. There are two distinct groups of people who appear to be affected. Women who are 20-40 years of age with a background in health care like nursing, caring, even EMS and medical volunteers. This enables them to add detail and medical knowledge to their symptoms to gain credability. The other is unmarried white men between 30 and 50 years of age. It is unclear why this is the case. What I have noticed is that Munchausen syndrome isn't just limited to hospitals and my patients but it is commonplace on social media forums such as Facebook and Twitter. People can manipulate a 'following' to receive a constant stream of sympathy negating the need to actually fake an illness or self harm, behind anonymity. Maybe this is where it starts. In a society where ones life can exists solely on these platforms perhaps faking a seizure in front of friends is the next logical step. All I know, is that when these fantasies, delusions or attention seeking acts spill out into our work load it puts us into a dangerous situation of possibly giving drugs that are not needed putting our jobs in jeopardy. Not to mention the grave cost to the NHS in wasted time and resources. It's selfish behaviour and takes a resource away from where it is actually needed all so someone can get some sympathy and attention. Maybe i'm being harsh, but it really annoys me and is criminal. The medical version of perverting the court of justice.

I'm not sure what the best thing to do is. Personally, when someone is faking, lying or exaggerating I tell them. I'm certainly not going to indulge in their game, nor am I going to let them think it is acceptable. You can only treat people who need & want to be treated. These people need but don't want treatment. All you can do is make it as difficult and unappealing as possible for them to do it. Shout from the rafters and point!