- why won’t professionals answer patients’ questions
- Ask the mentalists – Boundaries
- Ask the Mentalists – Artificial Language Barriers
- Ask the Mentalists – Charting
- Ask the Mentalists – PRN Lorazepam
- Question for MN
- Newbie Questions
- What happens to well-meaning professionals?
- What if your patients are smart?
- A question regarding suicide
- Ch-Ch-Ch-Ch-Chan… Oh You Get The Idea
(Guest post by jessa)
I’m kind of on a quest. In trying to figure out how to make mental health care better, I’ve tried to figure out what has gone wrong. What happens to turn people who went into this profession with the genuine intention of helping people into people who harm their patients egregiously without noticing or caring? I haven’t really figured this out.
I don’t think that most professionals intend to harm their patients, though I am certain that there are some who do. I have posited a few possibilities. In my undergraduate thesis I proposed that part of the problem might be “goal displacement.” That would mean that in the process of trying to achieve a goal, such as better mental health for patients, there are lower level goals that are implemented as a matter of policy, such as doing cognitive behavioral therapy. When the original goal is displaced by the lower level goal, meaning that it is the lower level goal that gets all the attention and energy, things can go awry. If my focus is on implementing cognitive behavioral therapy without keeping in mind the original goal of increasing good mental health, I cannot adjust my lower level goal if/when it starts to subvert my original goal. I won’t stop implementing cognitive behavioral therapy with jessa when it seems to be worsening her mental health because I probably won’t notice because I am not evaluating the sucess of the lower level goal by how much it helps to accomplish the original goal. If cognitive behavioral therapy is the goal, I have succeeded; if improving jessa’s mental health is the goal, I have failed. So I think I am helping jessa when I am actually harming her.
I have also posited that some of this problem might be a result of not allowing for enough ambiguity in life and in the education of professionals. If professionals are taught that each diagnosis has very clear causes and that they are the same for every patient, they will try to fit their patients into those molds rather than considering the plethora of alternative causes, treatments, outcomes, and other possibilities.
I’m not settled on either of these answers. I suspect that there are a lot of things contributing to this problem. What do you think some of them might be?
Okay, here’s my take on things that might send well-meaning MH professionals awry. I’m mostly going from a nursing perspective here:
1. Physical/environmental constraints: Developing a good therapeutic relationship and earmarking time for patients can be easier in some settings than others. As a CPN on an assertive outreach team, it might be (relatively) easy. Doing it on an acute ward with 20 deeply psychotic patients, a shift to coordinate and one of your staff having gone sick is another.
2. Bureaucratic constraints: Endless filling-in of notes, care plans, risk assessments, referrals etc. An unfortunate consequence of the current legal climate of, “If you haven’t documented that you’ve done it, then you haven’t done it.
3. Workplace politics: Managerial politics from on high, ward politics around you.
4. Top-down directives: Your CBT example is a good one. Policymakers have declared CBT to be the gold-standard therapy, therefore everyone gets CBT whether it’s helpful or not.
5. Inexact tools for the job: Even in the hands of the finest doctors, therapists and nurses, psychiatric treatment remains a hit-and-miss, trial-and-error affair. This applies both to medication and to psychotherapy.
6. Stress/professional burnout: Unfortunately this happens to too many nurses under the pressure of all of the above and more.
7. The need to do things that may be against the patient’s immediate wishes: detaining under Section 5(4) of the Mental Health Act, physical restraint, rapid tranquilisation, strict meal plans and restricted exercise for people with eating disorders. Even if these are done entirely for the right reasons, that doesn’t stop them being distressing for the patient.
8. Competing priorities between professionals, patients and their families: In some cases – particularly in child and adolescent mental health – this can involve families acting clearly against the patient’s best interests. I can think of a few cases I’m involved with now where that’s the case. How does one avoid alienating the family without sending the kid down unnecessary diagnosis/treatment routes?
There’s probably more that I could think of, but these’ll do for now.
Z, I’d definitely like to hear of more causes like these if you have them. But I’m also thinking more along the lines of what makes professionals deal with these things poorly. Perhaps it is that all of these things you listed, and more, bog well meaning people down, dishearten them to the point that they don’t find it worth trying anymore, more like your #6.
What is it that keeps them from taking on all these challenges? What keeps professionals from dealing with these challenges by doing things like saying, “policy says I need to do CBT 3 times a week with you, but CBT seems to work to your detriment, so I am not going to do it and I will document why I did not do it, policy be damned”? Maybe it is a herculean task to ask the grunt level professionals to advocate for their patients in that way, in which case #6 would probably explain why they don’t.
Less advocating for patients, and more just being honest: what keeps professionals from saying, “I know you hate CBT and I too notice that it works to your detriment, but the policy says that I have to do it 3 times a week with you. That policy is in the hope that the CBT will work eventually since it does seem generally helpful, but I agree that this sucks for you”? Are the professionals not noticing when things aren’t working? If so, why aren’t they noticing? If they are noticing, why don’t they say anything to their patients about it? I know that sometimes having a patient get mad at the professional can be a valid part of the therapy, but for the most part, it seems that it would be beneficial for both the patient and the professional to be on the same side. It is not conducive to therapy for the patient to have the constant sensation of being persecuted. Even if she isn’t actually being persecuted, but is only caught up in a bureaucracy where she is the only one who doesn’t know what is going on, her sensation of persecution can’t be rightly called paranoid or delusional.
Then, the next question, since much of the problem seems to be bureaucratic; what is it about managerial-level mental health care professionals that they insist on putting all of these blockades in the way of their colleagues? Is there a lack of communication up and down the ranks?
I am about to qualify. Only 7 weeks left….
I have been very lucky in the sense that I went for a job interview for a staff nurse post a couple of weeks ago, and surprisingly despite the fact that I was a nervous wreck, I got the job !
I’m alternating between being very happy and excited…and being so frightened that I want to run for the hills.
The past few weeks I have been pondering how I am going to be able to do my absolute best for the people that come onto the ward, whilst dealing with all of the issues that zarathustra has outlined above.
A good team makes all the difference.
Where is the ambiguity? It’s over there in a box.
Neville Shunt’s latest West End Success – It All Happened on the 11.20 from Hainault to Redhill via Horsham and Reigate, calling at Carshalton Beeches, Malmesbury, Tooting Bec and Croydon West is currently appearing at the Limp Theatre, Piccadilly. What Shunt is doing in this, as in his earlier nine plays, is to express the human condition in terms of British Rail.
Some people have made the mistake of seeing Shunt’s work as a load of rubbish about railway timetables, but clever people like me who talk loudly in restaurants see this as a deliberate ambiguity, a plea for understanding in a mechanised mansion. The points are frozen, the beast is dead. What is the difference? What indeed is the point? The point is frozen, the beast is late out of Paddington. The point is taken. If La Fontaine’s elk would spurn Tom Jones the engine must be our head, the dining car our oesophagus, the guards van our left lung, the cattle truck our shins, the first class compartment the piece of skin at the nape of the neck and the level crossing an electric elk called Simon.
The clarity is devastating. But where is the ambiguity? Over there in a box.
Shunt is saying the 8.15 from Gillingham when in reality he means the 8.13 from Gillingham. The train is the same, only the time is altered. Ecce homo, ergo elk. La Fontaine knew its sister and knew her bloody well. The point is taken, the beast is moulting, the fluff gets up your nose. The illusion is complete; it is reality, the reality is illusion and the ambiguity is the only truth. But is the truth, as Hitchcock observes, in the box? No, there isn’t room, the ambiguity has put on weight. The point is taken, the elk is dead, the beast stops at Swindon, Chabrol stops at nothing, I’m having treatment and La Fontaine can get knotted.
La Fontaine’s Elk:
2 parts Vodka,
1 part Cointreau,
1/2 teaspoon Maraschino liqueur,
A slice of orange slice,
A dash of lemon syrup,
Shaken, not stirred, with plenty of ice.
Several things:
1. Unfairly,mental health nursing has a rep among general nurses as an ‘easy option’, thus leading the lazy to decide to work in it, so you get a larger number of lazy fuckers on the job than elsewhere.
2. Stigma and medical attitudes – although this is changing,psychiatry used to be seen as a career dead end, the sort of place you steered your worst, dullest, least inspiring medical students. Because after all, they won’t kill anyone directly and who gives a crap about a load of nutters who won’t get better anyway. As I said, this is changing, but there ARE more crap medics in psych than other disciplines and this IS the reason.
Not saying that there aren’t loads of excellent doctors and nurses – I’ve dealt wit nothing but great people at my local trust. But the above does hold, I’ve seen it in action and it’s especially obvious in older staff who is there because they want to be and who is there to do as little as possible.
Your first point just inspired a minor rant from me, but then I have just had the night shift from hell
http://notanotherstudent.blogs.....ption.html
cellar_door, your point is pretty much the same as mine. Mental health care is really hard. It probably isn’t easy even for the best and brightest, but if the dimmest are being shuffled in, mental health care will be atrocious.
DeeDee, your points are heartbreaking. I expect they are true, that these are at least part of the problem; but as I see it, psychiatry needs the best and brightest. It requires a people who can think in those very clinical, logical, mathematical sorts of ways, but who can also notice when those ways of thinking aren’t working and think in nuanced ways that allow for great ambiguity when necessary. And they need to be able to flip back and forth between the two and meld them together. Those people who can only think like robots and computers: I’m not discounting their intelligence, but that sounds better suited to other branches of medicine.
well, the problem is, the best doctors used not to do psych, period. As I said, that is now changing – you will notice loads of excellent SHOs around the country and dire, ageing consultants (and good consultants too, but they aren’t the problem)- the legacy of past prejudice.
‘the legacy of past prejudice, I totally agree, it makes it very difficult to implement new practice. Several reasons, most of the older professionals who were trained many years ago, have not updated their knowledge, and unfortunately, several are in managerial positions.
Funding is also directed into the fashionable services eg. Assertive Outreach and Crisis Resolution, as you have noted from another thread, services such as Rehab fall by the wayside, in fact, they were not even specifically mentioned in the National Service Framework.
My Trust also recently closed one acute ward and are now closing one of the two rehab services left, the closure of the acute ward resulted in bed occupancy for the remaining acute wards at 120%, and service users who should be in acute have been transferred to rehab. What will happen next is anyone’s guess.
We have the opposite problem, a lot of patients who should be in rehab living almost permanently in our acute wards.
i’m voting with DeeDee on this one
Hi, I’m new round here as an adder of comments, but have been visiting the blog for a year or so. I have been qualified for 8 years.
I have found that some of my colleauges just don’t really care about anyone in any deep way. OK, they care in a superficial way and will make sure someone is somewhere they are safe (ie. not going to harm themselves or self neglect etc.) or make sure they are taking the tablets they have been prescribed, but ultimately they are doing this as it’s a matter of procedure and little thought seems to be paid to the deep issues affecting that person.
I find that very few are able to build therapeutic relationships as they are scared of boudaries and being ‘guilty’ of being too ‘close’ or to ‘friendly’ with the person above and beyond the traditional nurse-patient relationship, if that makes sense. I’m lucky where I work as a few of us are a bit more humanistic than I have encountered in other teams especially on wards (we are community team), but I still feel I am the only one here who sees the ‘patients’ as fellow victims of a cruel, messed up world and can totally empathise with how they feel.
This could, in part, be due to the fact that for the last 31 years since the age of a bout 5 when I realised what death was I have spent hours upon hours pondering about life and in particular human suffering and the impact that society, family, love, drugs, alcohol, music, the media, war, money, genetics, loss, luck, chemistry, diet, the environment, the weather and all the other factors play in determining a person’s state of mind at any given time and I don’t think that psychaitry is really about much of this at all, it skirts around it a bit, but I find it totally inaddequate.
I find my self working with others more as a philospoher than within the rigid confines of psychiatry. I befriend people and from that the care flows quite naturally in the way I would care for my family, my neighbour, anyone suffering (ie. everyone). This involves may clashes with doctors, management etc. but I find this absolutely necessary in order to be true to myself.
Also, management where I work are not nurses, they are ex care managers and OT’s etc. they seem to be chosen because they are good at managing and keeping things ordered and because they can please the management layer above and produce all the right figures when needed and they just filter down all the ridiculous agendas from up above and snarl at you if you dare to challenge it, saying ‘that’s how it is, we have to do it’.
If you are someone who doesn’t like to rock the boat (I like to capsise it where psossible) then you will just go with the flow of stupidness and some people I know do that and knowingly compromise themselves, but can just about live with it to keep their jobs, but others don’t seem to care at all, they seem like knuckleheads to me, they would go round and kill all the ‘patients’ if managent told them too and if they wouldn’t then the NHS would employ people desperate and dumb enough who would.
I was a patient back in 1968-1974 when I often had reason to ask myself why so many uncaring people had entered a ‘caring’ profession. I was ‘written off’ as suffering from chronic schizophrenia and turned into a zombie with ECT and heavy drugs. Nobody seemed interested in finding out what was causing my social withdrawal, depression, lack of motivation/interest (I never had the so-called positive symptoms of schizophrenia, only the negative). My ‘symptoms’ were made very much worse by the drugs given to treat it! The cause of my distress was not a brain abnormality, yet mental health staff saw fit to swiftly start changing my brain. I lost five years to the mental health system, a casualty of the rigid application of the medical model.
Fortunately, I’ve been fine since I stopped my medication (against medical advice) in 1974 and jumped out of the net. With a mind unclouded by psychiatric drugs, I was able to leave my troubled home, build up a life for myself: return to study and obtain a first-class degree, become happily married… I now work in mental health for an organisation affiliated to Mind.
How much have things changed since the way psychiatry was practised over thirty years ago when I was a patient? Often it seems, not much. I agree with ‘jbarber’ one of the problems is that many of the older professionals who were trained many years ago have not updated their knowledge.
The post by ‘non compliant’ reminds me that some professionals, such as he or she, do have the necessary empathy to get alongside their patients with understanding. It must be very difficult for you, non compliant, to be working within the narrow confines of psychiatry. I think others may have started off like you and then, sadly, changed over the years. Staff, as well as patients, can become victims of an inhumane system. But I note that you have been qualified for eight years. Good on you. And please, for the sake of those of us whose lives were almost destroyed by damaging and inappropriate psychiatric treatment, keep on being true to yourself.
I try my best to help people with regards to medication, I am not ainti meds, but I think they should be used short term in most caeses and not at all in many. So many times I see people prescribed anti-depressants when they are depressed because they are lonely or finding it hard to come to terms with ageing, or other factors that would make you feel low and could be dealt with by practical support, talking etc. Also, people prescribed anti-psychotic meds beacuse of delusions that stem from extreme emotional or mood reactions to outside events, internal worries/stress or even drug induced internal turmoil that can also be treated with understanding and helping the person re-orientate themselves with day to day life on a more practical level. Drugs may help, but usually the way they are prescribed it is a slippery slope and I have seen more people damaged by them (and of course bloody ECT which I have seen destroy people’s brains) than I have actually helped by them. Once they are commenced, if not planned for a short course, which I have never seen, then people get stuck on them and the damge to their brains and bodies begins. I can see the case for a very few people to be on meds long term, but on the whole none are required in my opinion and other support would be more beneficial to the persons wellbeing.
just wanted to add, that as a nurse I try were poss to get the least amount of meds necessary presecribed for them and even none if I can ie. an over eager GP wanting to give lonely mrs A some citalopram, I try and stop this if I feel it is not warranted.