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