On Time, in MH services.

Please note: this piece refers to someone with a traumatic history. Please be careful if this may cause you distress.

I’ve not written a post for some time, it’s been a little hectic after our new arrival. I simply haven’t had enough time. Work has been extremely busy, there are lots of young people who need help and support and nowhere near enough time to see them.

It’s a precious commodity, time. It also something which I think we undervalue and are losing in mental health services. The cuts are biting hard, there are fewer people to see more people who are struggling and there isn’t enough time to give them.

There has been an increase in the desire to ‘do’ therapy with people, we need to increase access to psychological therapies. It’s hard to argue with the idea, but to what are we increasing access? And for whom?

No one denies that we need to be able to offer people something which has at least a chance of being effective but we’re getting very caught up and misled when it comes to evidence based therapies in my opinion. There are many concerns with this approach and others do it better than I (see Trisha Greenhalgh’s writing for example) but part of the issue is that we try to fit people into the model before we’re even sure what that problem is. We then seek to deliver and evidence based therapy for a problem that we have, subjectively, identified as the problem. I think part of the problem is not taking time to get to know the person and where the problem fits within them.

Irvin Yalom is a psychiatrist and existential therapist who I think writes beautifully about the nature of therapy. His thinking is of a kind which I continue to find helpful in my work, one which really resonates is when he reflects how easy it can be to give someone a diagnosis when you first meet them compared to when you have met with them weekly for a year. As you spend more time with them, you get to know them, not just the problem and your view of what the problem is changes. So what is more helpful? A quick diagnosis or getting to know the person?

Time is a huge issue for services in a number of ways. Think of DNA’s. Most trust have policies on this and rightly so, time is precious and the time of professionals is expensive time. But who are we missing? Recently NCSIH reported on young people who die by suicide, there are many shocking figures in their work but one which jumps out is only 1 of 7 young people who die by suicide are in contact with services (the figure for adults is 1 in 4). I know that there are a number of complex factors related to people who die by suicide and how this links to well being, but that figure seems worryingly low. We have to get better at seeing the people who need us most.

I think we have to think whether we are services for people who can walk through our doors or are we services for people in the locality.

How many sessions is enough? What is recovery? These are other questions which, dependent on time are fundamental to how mental health services are devised. 6 sessions for this, 8 for that. There is no room for the person to be known here.

How long do we give someone to get to know us? We ask people to talk about their fears, their shame, their self-hatred, disgust, their hopes their dreams.

Should we develop services so we can see many people for a very short time and ‘do what we can in the time we have’ or stick to evidence based (and time limited) interventions?

I have met with many people who have told me things which haunt them, many come with ‘no history of X’ written on their notes, yet, with time and trust, they tell me that X has indeed a place in their history.

How long is long enough? How much time do we have in services? Well, consider this, below, written to me by someone (I have their full consent to anonymously use this as it helped me so much I wanted to share it). This person was remarkable, had been through so much, both before they were in services and when in services. This person wanted to talk to me but when we met they couldn’t speak, I sat and waited (silence is often the most treacherous sea to navigate in a therapeutic situation). This happened a few times (I did check that they wanted this), I then asked if it would be easier if they wrote down what they wanted to say, this was too difficult but eventually they did write, a single word. They said they wanted to explain why it was so difficult, why they needed so much time to write, why they needed me to wait, why they couldn’t look at the word on the page this is what that letter said:

 

You wonder why I can’t talk, can’t look at words once they’re written down? I’m ashamed. Ashamed that it happened, that I feel these things, ashamed that I have to talk about them, that they bother me so much. Ashamed that I’m weak. Ashamed that I’m crying, ashamed that it makes me feel sick. By saying something, writing something I’m letting you into my darkest secrets, things that for some reason I often feel should stay that way. Because as soon as I say those words, as soon as I admit to feelings I automatically make myself vulnerable – and that scares me. That scares me that I’m no longer in control. That someone else has that hold over me and it makes me want to hide it more. The words themselves have so much association in my head that looking at them, actually saying them, makes me feel sick, makes me think about things I shouldn’t think about and makes the memories all the more real because I’m admitting it did have an effect on me, that it does bother me and it reiterates every suppressed feeling inside of me, until al I want to do is cry. And sometimes I can’t even do that.

Was I right to give this person time? I believe so, completely. Did I reduce their symptoms? I don’t think I did. I may have made it easier for them to talk to someone else, for them to be able to engage and move forwards. I think that it was useful, it was helpful. More importantly they did. But how do I capture that as a valuable use of my precious time?

More importantly, how do we, the powerful, grant people like this person, time? How do we let them know that often, coming to see someone when you’re struggling with your well being is not at all like having a ‘broken leg’ (the parity analogy so often cited)? People have little problem saying to a professional ‘I’ve got a broken leg’ but letting people in to ‘my darkest secrets’ IS different. You need a relationship with someone, you need to be able to trust them, a lot. This takes time and it varies how much depending on the person. Parity is important but we must remember that talking about our lives is different.

These days you can hear the clock ticking, there are so many people waiting to be seen this inevitably impacts on services.

The NHS is increasingly a business first and foremost and we have to accept the fact that competition is now a reality for our work. What models of care fit this best? That’s a fairly easy one, boundaried, time limited, structured ones. With clear outcomes which are measurable. What happens to those who’s outcomes are harder to capture? I can remember whilst training working in an service for adults with ‘complex needs’ and asking what the goals were for one particular person. She was in almost constant distressAim 1: keep her alive, aim 2: keep her out of hospital, aim 3: try to help her manage her extremely overwhelming emotional pain which was almost constant.

How do we evidence that? How do we show it’s working? Are these goals which people who commission services value?  We have a duty to consider all these  important questions.

How much time can we give people? How much do they need? Do we know?

The clock is ticking for the people we see and for us.

 

Dr Gordon Milson 

May 2014

Further reading:

The NCISH documents are well worth reading. Their reports are accessible and informative although they still shock. For the figure quoted above (14% of 10-19 year olds were in contact with services at time of death) see this write up: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2008.01938.x/abstract

If you want more info on this or other papers tweet @ProfLAppleby or @NCISH_UK they are both very helpful and happy to share findings.

For an example of Trisha Greenhalgh’s writing on EBM see: https://www.rnzcgp.org.nz/assets/documents/Publications/JPHC/June-2012/JPHCGuestEditorialGreenhalghJune2012.pdf

Irvin Yalom, where do I start? For the idea stated above see ‘The Gift of Therapy’. I still refer to thistext regularly and would recommend it to all who seek to help others by talking and listening.