Psychiatrists - they don't know, they don't know!

Encounters with mental health workers still tend to take place in locations and contexts of their choosing. They see us when we are unwell, with the tacit agreement that we will talk about what distresses us and find difficult to articulate - not about those areas of our lives where we have demonstrable skills and competences. Even at the height of a crises they are alongside us for at most an hour out of every twenty-four. But as a peer, I may have been talking to the client before they meet with a worker, and again later in the day, know more about that person’s daily life than the worker, and sometimes find myself intentionally trying to undo their work. The ‘trap of the consulting room’ can lead the worker to imagine their training, delivered in a controlled environment, allows them to see client’s problems clearly, and their therapeutic responses as having an impact quite out of proportion with reality. Equally there is the assumption that the motivation to act, in a routine or novel way, is intrinsic to the individual. But the uncomfortable fact is that it is the behaviour of the worker when interacting with the client, rather than the prescribed model or approach pursued, which will or will not, lead to a rapport that may allow a positive outcome for the few weeks or months the relationship lasts.

The mental health professional works only with that part of the client’s ‘personal story’ they feel able to share with this relative stranger, who in their turn is even less inclined to ‘self-disclose’, adding to the existing power imbalance. The imagined ‘client centred-ness’ of their approach may well leave the service user ready to act on a specific issue - the previewed mental health problem - only to find its implementation leaves them exposed to a cascade of social consequences, requiring many more changes than either they or the worker have begun to contemplate. The individualism in nearly all approaches to mental health ignores our social nature and emphasises cognitive tools rather than the emotional foundations of human action. But when a form of counselling works, it is because the client has come to know and trust the worker enough to find their advice credible (and it is a process of advocacy about better ways to live) based on the degree to which the worker embodies what they assert. The client then acts as much for the worker as for themselves. The only problem is the worker is about to ‘ditch them’ - not because the relationship was a failure, but because it was a success!

Despite being involved in Involvement (participating in the giving of feedback to services, and the training of staff) for the last four years or so, it was only six months ago that myself and others got an opportunity to meet with a group of psychiatrists - and that session took over two years to set up. As the reader might imagine they were less than forthcoming, but one thing they seemed clear about, they were confident that when they see us, they see us the way we really are!

Back in 2007 I penned the following under the title A Few Of The Things A Psychiatrist Should Know - by a Service User, it seems they all still apply!

1/ that to ‘suspend your disbelief’ brings rewards; time spent with the same client when they are well, in addition to when they are distressed, in hospital and in the community, outside the atmosphere of the consulting room and the ward, is the only way to ‘see’ what ‘illness’ might be.

2/ all clients have difficultly explaining to themselves the strange things that have been happening to them, their thoughts and feelings - let alone finding the language to explain them to others. But, though they may be ‘inarticulate’ about their madness, they may not be about other areas of their lives.

3/ whatever the causes of mental distress/disorder/illness, the principal consequence is a ‘misplaced fear of others’, and a subsequent inability to make new and lasting personal relationships, leading to emotional isolation.

4/ despite the above, and often as the result of long experience, a client’s ‘fear of madness’ is probably less than yours!

5/ the client’s need is not for longer consultations, but to be seen by the same doctor over an extended period of time; by the same person in the hospital as in the community - how else can trust be established and the doctor acquire what he/she needs most - accurate information.

6/ what is needed is communication skills, don’t waste time trying to empathise with or ‘get inside the head’ of the client, just try to build a rapport; whereby they can tell you what they think it is important, and you can get the information you need.

7/ clients are afraid, if they don’t feel safe they will appear in worse shape than they really are, and not tell you anything.

8/ the most common complaint of clients is ‘why is this person asking irrelevant questions?’ Unless you can address their concerns, and demonstrate the relevance of yours, you get nowhere.

9/ the fastest way to improve someone’s mental health is to re-establish a regular sleep pattern, healthy diet, daily exercise plus learning to physically relax.

10/ very subtle changes in medication make a real difference to side effects, degrees of sedation and therefore compliance!