Time is the most important resource in mental health care

Time is the most valuable thing we can offer people struggling with mental health problems and we have a basic human right to getting this time when needed. It’s very easy to overlook this so let me give you and example of a hypothetical but typical case.

A young woman is sitting with her GP and begins to discuss the people she hears telling her to cut herself, kill herself and kill her family. She looks over her shoulder to find them and is clearly distressed, confused and upset by what’s happening. She describes living alone and her family relationships seem to have come undone for, at the time, unrecognised reasons. Help is offered. The GP refers her to a community mental health team as an urgent referral given the apparent intensity of her difficulties. She is somewhat reluctant but agrees to attend the community mental health team. (1 hour including GP consultation letter writing phone calls etc).

Her initial contact is with a psychiatric registrar who details her history, family circumstances and a description of her current difficulties. (1 hour clinical interview). Her second meeting, two days later, is with a consultant psychiatrist and a clinical psychologist, who jointly review the details of the initial meeting she had with the registrar with her, and come to an initial understanding of her difficulties and develop a treatment plan (1 hour). In the interim she has also met with a psychiatric nurse who has offered to visit her in her home and does so within the first few days of her engagement with the mental health service (3 hours).

At this point much that has been achieved is preliminary, with the purpose of starting some interventions, developing relationships and helping to provide some degree of psychological containment. Medication is prescribed, further appointments with the clinical psychologist are arranged as are home visits with the psychiatric nurse.

During the next few weeks things seem to settle a bit. Perhaps the medication is having some benefits, she is sleeping a little better, or the support from the home visits with the nurse which provides some contact with someone who isn’t judging her, or the weekly sessions with the psychologist where the conversations about how she came to be in this situation and how to manage begin to deepen. Given the apparent improvement in her general state, after another week the home visits with nursing cease and visits with the psychiatric decrease in length and frequency to every two months for a period of approximately 15-20 min. Her distress is lessened, she is sleeping better and is talking about her struggles. At this point the home visits have involved 15 hours (5 visits @3hours each including travel and clinical admin) and psychiatric reviews 2 hours (3 visits at 40 min/visit over three weeks). The psychologist has met with her for 3 further hours at this point for ongoing psychological therapy.

During the sessions with the psychologist it becomes clear that a long history of abuse, separation, neglect and bullying have plagued this persons life. The voices she hears reflect the painful shame she felt having been sexually abused by an uncle who would spend nights in the family home drinking with her parents. Her parents had significant alcohol and substance abuse difficulties and many of her basic needs for security, nurturance and attachment were not met and she was grossly violated in her family home. Reports of these abuses were made as they emerged to the appropriate authority. Mental health social workers began to get involved with the family at this point with a strong connection between the families overall patterns of relating and her distress becoming evident. An initial assessment and several family meetings are arranged.

She spoke in therapy of the incidents of abuse and how her reaction to these experiences involved imaginarily transporting herself to a different place. Feelings of intense fear, hate and loathing at what was happening coupled with the helplessness of being a child meant she had little option but to remove herself from the experience psychologically: what might be termed dissociation. And then the abuse happened again and again and again. So she adapted to this horrific reality by exiting contact with what was happening to her in the world and her perception of and connections with the world, and retreated into herself. An adaptive break from reality, a psychic retreat: what the mind does under extraordinary stress and strain. During these periods of dissociation she would hear the voice of her mother scolding her. And while unpleasant it represented the source of her emotional security, something she could retreat to psychologically that was familiar. She could not fight or engage in flight. She would likely have died or at least felt she was in more danger. Fear protected her and she froze and psychologically retreated. It is during weekly sessions over a period of two years since the initial contact with mental health services (80 hours + 20 admin) that this understanding begins to surface. Years of pretending it didn’t happen are hard to undo. A lot of delicate and patient listening allows this process occur. This process was frequently derailed by turbulent interactions with her family, her reluctance to take medications and subsequent conflict within the community mental health team about the relevence of medication and various other interventions. Finally she simply refused to take her medication. This was approximately 1 year since she had begun taking it, and much of the problems she had presented with continued; she continued to hear voices and experience fear although not to the same extent or frequency. She also hated the side effects of weight gain, emotional numbness and not being able to think clearly that came with them. Fortunately her ceasing taking her medications against medical advice did not create any major difficulties, a risk she was willing to take. The emotional support she was receiving through her psychological therapy and the intermittent involvement with psychiatric nursing (another 20 hours over the two years in the form or home visits during particularly difficult periods of time) proved to be extremely important. Her psychiatrist also maintained a good willed relationship and largely positive rapport. The social worker had made some useful progress working with her family and things seemed to be improving with increased contact with siblings and her parents who had begun to acknowledge the extreme difficulties they had created for her as a child. Not surprisingly it turns out that both parents had been the subject to abuses themselves as children. (Social workers hours at this point 25: 6 family meetings and several phone calls and contacts w various family members).

At this point the psychologist has already hugely exceeded the standard amount of time and the allocated maximum time allowed to spend with any one patient given the long waiting lists in the service. The pressure to allocate this slot to another person is building. Someone else with just as valid a need is not receiving psychological assessment and therapy. This reality also shapes the limits on the psychiatrists, nurses and social workers time. Her own reflections are that the psychological therapy is important to her and not yet complete. In a way she’s only just started. Her psychologist agrees and seeks permission to further extend for another six months although both know this will not likely be enough time. She has made progress and there is concern about how things will go for her if the therapy is not allowed continue. She has identified the difficulties in her childhood that directly relate to her psychotic experiences, has had a supportive series of relationships and interactions with mental health staff that have helped her come to some understanding about how her difficulties have developed and begun to learn ways of managing herself in the world. She has learned to consider her thoughts of suicide and hallucinatory experiences as responses to overwhelming trauma which validates and helps her live with them. These are the normal responses of a person exposed to extraordinarily painful and utterly unbearable experiences. And she has begun the long and difficult journey of coming to terms with the abuse and neglect she suffered as a child, the profound sense of loss of the family and home she wished for and the years of (adaptive and necessary) denial of her lived experience.

The total hours to support her up to this point was substantial (175 hours). Her reliance on services will likely require approximately 120 hours/ year of direct contact with various staff. The capacity for a service to provide in depth psychological and psychotherapeutic care, coupled with supports during times of crisis, psychiatric reviews, and family based interventions, over a prolonged period of time is extraordinarily important and shockingly, extremely rare for the majority of people who attend public mental health services. It is rare even that an understanding of how someone’s difficulties develop. By this I mean going beyond simply identifying adverse childhood experiences as a part of a psychiatric interview and subsequently doing nothing about this. It is rare that someone actually takes the time to explore someones difficulties and their past and seek to help make sense of them and their current struggles and problems. The main reason this is rare is because it takes a great deal of time.

The bottom line is that this work is not only in depth, highly skilled and essential but extremely time consuming. It is also extremely demanding work for the therapists and mental health staff who travel this road. Demanding but incredibly important and well worth doing.

The most important resource a mental health service needs at its disposal is highly trained people who can give time. The people who give this time need to be psychologically and psychotherapeutically trained to an advanced and sophisticated level and be expected to operate in a genuinely ‘bio psycho social’ manner (Not the current bio bio bio framework that operates despite the propaganda to the contrary). People who can work through such a process and understand trauma and its impact on our psychological and emotional lives. A culture of tolerance, willingness, understanding and going the distance must contain this resource of time but without it little can be done to help. And these people regardless of background training, must work in an environment that advocates and supports this effort. Currently services often mitigate against it happening at all by placing demands and limits on in depth relational work that smothers the relationship potential of any one mental health clinician. Arbitrary limits on numbers of sessions or demands to see high numbers of people in short periods of time are two typical such limitations. Does our fictional service user benefit if her psychological therapy is cut short after 6 months? Or worse, 3 months? Does she navigate the crisis if there is no one do provide out of hours care? Does her family ever start to heal if there is no social work capacity to do this work?

After three years of weekly therapy with a psychologist, intermittent support from nursing staff, help from a social worker who dedicated time to working with her and her family, two monthly visits with a psychiatrist things have improved for our fictional, but somewhat typical person. And maybe her care was ok, good enough to help and be of real value to her.

If you have a mental health problem your chances of coming to terms with it, of resolving things within yourself, almost certainly includes spending time, often a lot of time, with people who can truly meet your experience with compassion, understanding and knowledge. Sadly the chances of this happening are very slim, and the culture of ‘managed care’ that is emerging is likely to impose further inhumane and mindless limits on this precious resource.

If you attend mental health care ask for this: I would like to spend time with someone who is trained to help me resolve the traumas and difficulties in my life, even if I’m unsure what this looks like right now. I would like to spend enough time with them until I believe my difficulties are resolved. If I don’t like them or can’t connect with them or they can’t connect with me, if they don’t know how to help me or have an approach that doesn’t suit me, I would like to work with someone else. If someone can’t articulate this at the time, we should hold this hope for them. We all have a right to this. The UN charter states that every individual has a right to the highest possible attainable level of mental health. We all must demand this from our services so that when we or our loved ones need it, it is there.

Time is the most important resource in mental health care

Mental Health Care Reform Needed Now

A paradigm shift, dramatic practice change and revolution of mental health care is required: URGENTLY!

We must radically re think our approach to mental health care. It is not enough to drag along partially paying lip service to the relevance of alternatives while the overwhelming majority of people in mental health care receive nothing more than a brief periodic medication review and a medication only approach to their treatment. This is utterly inadequate, unscientific, misleading and ineffective. We must move forward. We cannot allow this sham prevail any longer. The real tragedy is that we know a great deal about how to move things on. There are several things lacking: a poorly informed or hampered political leadership who continually re boot to a medical led approach. A profound lack of knowledge or motivation amongst the leaders in our health and mental health services about the limits of the current system and what’s required to change it. A profound lack of resources properly allocated and structured to deliver the intensive comprehensive variety of psycho social interventions needed. The following are some key points that must start to shape how we deliver mental health care:

1. There are no diseases or illnesses. Depression is not a disease or illness. Schizophrenia is not a disease or illness. These are categories that are invented to describe sets of experiences, behaviours, psychological and emotional phenomenon. These categories are neither valid nor reliable. There is no underlying biological neurochemical imbalance, or biomarker that has ever been discovered for any of the major categories of disorder or diagnosis that have been described
a. This does not mean these categories don’t point to extreme difficulties, problems, suffering in the minds and hearts, thoughts and emotions, behaviours, lives, relationships and the histories of people seeking mental health care. These difficulties do exist and must be addressed meaningfully
b. This does not mean we cannot acknowledge the immense suffering that occurs or understand this suffering credibly in a non stigmatising way. We do not need a fabricated medical diagnosis to operate effectively in a non stigmatising way

2. Diagnoses don’t help, they harm. Diagnoses increase stigma, they don’t decrease it. Understanding on the other hand is a powerful, therapeutic, transformative and pragmatically helpful exercise and endeavour. Giving a diagnosis (while sometimes seemingly reassuring) does none of these things; a diagnosis in and of itself does not offer understanding or explanation. Telling someone they ‘have depression’ tells them nothing about how they came to experience what they are experiencing that is labelled depression. How do we know you have depression? because you have a loss of motivation , anhedonia, etc. What does it mean that you experience loss of motivation, anhedonia etc? That’s because you have depression. The ‘diagnosis’ doesn’t tell us anything more about the difficulties already described. A diagnosis is supposed to tell us what the underlying problem is, but mental health diagnoses do not do this. Dr Terry Lynch’s book ‘Depression Delusion’ presents a fantastic description of the difficulties as this relates to depression (http://www.recoveryourmentalhealth.com/my-next-book-depression-delusion-volume-one-the-myth-of-the-brain-chemical-imbalance-publication-date-02-sept-2015/) Does this mean that people don’t get depressed? Not at all, of course they do, its simply inaccurate to call it an illness akin to a physical illness.

3. Formulation is a helpful, useful, pragmatic, sophisticated and flexible means of collaboratively understanding a persons difficulties that leads to solutions, interventions, therapeutic direction, support and other mechanisms of helping and addressing difficulties. Lucy Johnston has done a remarkable job making the case for this approach to mental health care. We should base services on a collaborative formulation of mental health difficulties and not on a diagnosis of a fabricated ‘illness’ model of mental health difficulties (https://www.canterbury.ac.uk/social-and-applied-sciences/salomons-centre-for-applied-psychology/docs/resources/DCP-Guidelines-for-Formulation.pdf)

4. All problems are ultimately understandable, and some never will be. With time, care and patience, almost all mental health difficulties can be understood in some way that is useful. Some never will be, but this is a minority, and does not automatically prove the existence of some underlying brain pathology that must be treated medically. Having spent many years with hundreds of people suffering serious and severe mental health problems (including psychosis, mania, depression etc) it strikes me that with some time and effort understanding of how a persons problems have developed and how the create suffering is almost always possible.

5. Medications may help some people some of the time, but they do not cure mental illnesses, have many drawbacks, and offer many people little or nothing in the way of help. Joanna Moncrief in her book ‘The Myth of the Chemical Cure’ presents a brilliant, evidenced based critique of the evidence for and against the use of psychiatric drugs. Her description of a drug model of prescribing, allows for the reality that medications help some people some of the time, without relying on a disease or illness model of mental health (https://www.youtube.com/watch?v=IV1S5zw096U)

6. Psychological, interpersonal and social difficulties including trauma and poverty are a primary cause of much of the mental health problems that people experience, far more so than genetic or biological factors. This should point to a preponderance of psychological, social, and psychotherapeutic interventions in our mental health services, with a minimal reliance on medication and hospitalisation. The opposite is currently true. It is very likely you will be offered a medication only approach if you attend a mental health service. It is very unlikely you will have adequate access to professional psychological care, professional psychotherapy, advanced/professional social care or structured evidenced based psychosocial interventions, groups, programs or therapies

7. It is not dangerous to question the use of medications in addressing mental health problems; it is dangerous to massively over rely on them and use a medication only approach to mental health care, as is currently the case. It is dangerous to suddenly stop taking some medications so only do so under medical supervision

8. A credible alternative movement has been developing for many years, with key critiques of the current ‘disease model’ or ‘illness model’ paradigm coming from both within the ranks of the medical profession and psychiatry and outside from journalists, service users, psychologists and others. We are very lucky to have one such critic in our country, Terry Lynch, GP (author of the fantastic book ‘Depression Delusion’). This movement (often unfortunately called the anti-psychiatry movement) which voices criticism of the current model and offers an alternative road forward has been articulated clearly in many ways. Most recently in an excellent review of the issues by Professor Peter Kinderman of Liverpool University in his book ‘A Prescription for Psychiatry’. But historically by many other highly credible leaders in the field e.g. Joanna Moncreif ‘The Myth of the Chemical Cure’, Robert Whitaker ‘Anatomy of an Epidemic’, Richard Bentall ‘Madness Explained’ and Peter Breggin ‘Toxic Psychiatry’. For anyone seeking a genuine reform of mental health care, this body of thoughtful, evidenced based critiques and understandings should be reviewed and acted upon. A movement called the International Critical Psychiatry Network has been established and is promoting a campaign to abolish psychiatric diagnostic systems such as ICD and DSM (CAPSID). The call for reform is coming from both within and outside of Psychiatry. http://www.criticalpsychiatry.net/wp-content/uploads/2011/05/CAPSID12.pdf

In his book, Professor Kinderman offers a prescription for mental health services. I am summarising, paraphrasing and quoting the central elements below. We should adapt these recommendations without delay.

1. Get the message right. We need to change our whole framework of understanding from a ‘disease model’ to a ‘psychosocial model’

2. Drop the language of disorder, symptom and illness. We must stop regarding peoples very real emotional distress as merely symptoms of a diagnosable illness

3. Be careful with medication. We should sharply reduce or reliance on medication to address emotional distress. We should rely on a ‘drug based’ approach to medication use and not a ‘disease based’ approach, as articulated by Joanna Moncreif

4. Offer holistic psychosocial services. Services should be equipped to address the full range of peoples’ social, personal and psychological problems and also address prevention

5. Offer non-medical residential care

6. Establish democratic multidisciplinary teams that can be lead by members of all disciplines, and are not automatically led by a Psychiatrist thereby automatically frontloading the disease model in considering how mental health problems are conceptualised

7. Plan for mental health and well-being alongside other social, rather than medical, services

The messages in Professor Kindermans manifesto are vital and we should listen and take it seriously. A change must happen sooner rather than later. A massive increase in funding for non medical, psychological and psychosocial interventions and for staff who are expert in the delivery of these interventions is required if we are to move beyond the current paradigm. A significant political and managerial change in ethos is required. It seems likely that until voters start to demand these things from their political representatives the change process will be allowed languish. While some changes have been made, we are a very long way from a genuine and substantive reform of our mental health services.

Mental Health Care Reform Needed Now

The Role of Trauma in Mental Health: The issue cannot be ignored any longer

There is no doubt that trauma is a major contributor, and likely cause of the mental suffering of many people who are given diagnoses for mental illnesses. This has recently been established and articulated by people like John Read. You can see him talk about it here http://youtu.be/Y6do5bkUEys

What is most impressive about this issue is the extent to which childhood adversity and trauma is associated with future mental health difficulties. The relevance of trauma vastly outweighs the relevance of biological or genetic factors. And yet the overwhelming majority of interventions people receive are designed to ‘treat’ biological ‘illnesses’. Medications will not address early traumatic experiences. Psychotherapists and psychologists have known this through the therapeutic process for decades. As a psychologist it has become abundantly clear that early experiences shape profoundly the quality and nature of our health and mental health. This has always been evident even looking back in time through the lense of sometimes hazy memory. Listening to people’s stories over the last two decades (almost) has left me in no doubt. However, it is encouraging to see research establishing this reality in a different and very solid way. No longer is this just the opinion of some psychologists and therapists. John Read points out that trauma, particularly cumulative or multiple trauma (the various forms of child abuse for example) multiplies the risk of developing psychosis many many times over. If trauma was somehow magically erased from our society the incidence of psychosis would reduce by about one third. This is a massively important public health concern. The Advese Childhood Experience Scale research has also established firmly the role of early trauma in all sorts of negative health outcomes both physical and mental. The US centre for disease control now views early trauma as a major public health issue.

Every assessment of every persons in mental health care should now include a comprehensive review of early trauma. All mental health professionals should be highly trained in working therapeutically with trauma. Currently this is not the case, very few disciplines have any comprehensive understanding of early developmental processes and the impact of trauma on our development. I include psychologists in this group, although the problem is less so in this group. Most mental health professionals are poorly equipped to assess, understand and facilitate healing from early trauma, despite the enormous role it plays in so many peoples mental health difficulties. There is a wealth of information to facilitate this healing drawing from PTSD literature and psychological interventions ranging from exposure therapy, to psychodynamic and psychoanalytic theoretical and therapeutic understandings to the work of people like Peter Levine. Looking at things from a problem specific angle, like paranoia or depression, we also find a great deal can be done to help psychologically and psychotherapeuctically. So why is this not the driving force of interventions for those people who present to mental health services? Primarily because clinicians are not looking at people who have been hurt, wounded, abused and traumatised, they are looking at illnesses. Looking at people as if they are illnesses obscures the lived experience and reality of people’s developmental pathway towards the mental health difficulty.

In short, mental health services need to become at least in part, sophisticated and expert trauma healing services. The evidence is overwhelming. We must adapt to this understanding.

 

 

 

The Role of Trauma in Mental Health: The issue cannot be ignored any longer

Mental Health: An urgent need for reform

Mental health has never been more in need of reform and investment. This blog will reflect on the developments occurring around the world that could and should be applied in Ireland and elsewhere.

The first and primary issue requiring reform in mental health is conceptual and philosophical. It would be easier if a particular type of therapy, a number of psychologists or something concrete were ‘the’ central need for reform. These things are indeed also required and will be reflected upon in future posts. However firstly a thought on philosophy. It is the ground from which all else grows. If the philosophy is flawed, all mental health care that follows from it is also flawed. The current system is based on a disease or illness model of mental health. This presupposes the existence of discrete biological diseases or illnesses that can be diagnosed and treated. This is the most fundamental problem with modern mental health care. There are no biologically based illnesses, there are no diseases. This of course doesn’t mean that people don’t suffer or experience low mood, terrifying paranoid ideas, extreme anxiety etc. It simply means these things are not accurately thought of as illnesses.

The first thing we as a society need to do is rethink psychological distress, emotional pain, mental anguish and events that seem extreme and hard to understand. All things can be understood with sufficient time and patience. We must dispose of the disease model and drop the language of medical intervention to stop ourselves repeating the same errors.

Why do we need to make this change? So what if we call depression an illness? The problem with this frame of reference is the likelihood that a medication only approach follows and a cessation of thinking. We don’t need to understand why the person is depressed anymore. It’s sufficient to say they are depressed, because depression is an illness. But this is flawed. Why a person becomes depressed is extremely important. This understanding has enormous consequence for how we might consider helping. An example. Someone has lost their job, lost their marriage, and has a history of childhood abuse. They become deeply depressed and meet criteria for the illness ‘major depressive disorder’. Do we really believe that the problem is a chemical imbalance in their brain that needs to be addressed by medication? Of course not. Help with these specific problems is most likely to benefit this person. The help that might help may be different for different people; psychotherapy, behavioural therapy, social support, occupational therapy, lifestyle changes, exercise, peer support etc. There are many things that might help. Including medication. The fact that a psychoactive substance might help is not the issue. People have always used chemicals to alter how they feel sometimes very effectively. However this does not prove the disease model, and the medications can come with risks, dependency, side effects that all should be understood. Drugs also don’t help many people and even harm some. And they certainly don’t address the underlying difficulties. So back to the point. Why change? Why not use an illness model? Because it stops us thinking about what might be helpful and points inaccurately to a non existing disease that obfuscates the nature of anyone individuals depression.

We should without hesitation switch to a collaborative formulation model which allows for the development of an idiosyncratically based understanding of each persons depression or anxiety or schizophrenia. This shared understanding points to problems and possible solutions. This may at times point to drugs, but almost always won’t, certainly not in the long term and certainly not as a stand alone approach to treat illnesses.

 

 

 

Mental Health: An urgent need for reform