The how to and not to guide of mental health care... a reflection

The how to and not to guide of mental health care... a reflection

Usually twitter is my go to place for talking about living with mental illness, working in mental health. I have found a community where I am given opportunities to learn; from colleagues across the NHS and beyond about good practice, innovations and latest evidence. I find it a place in which I can share, both my successes in the field of nursing and my own creative ideas, but also my experiences of mental illness, and in return I have found that I have received a multitude of support and encouragement. This inspires me to continue, to do better, to get better. You  see on twitter I can be Rachel the wearer of many hats; sometimes all at once.

Another benefit that comes from engaging online, is the opportunity to hear the patient and the care givers voice. A true reflection of the realities of mental health care, sometimes care that deserves celebration as a person is supported to move out of their darkness, but more often of care that is fragmented, unsafe, uncaring, and wholly inadequate.

As Rachel with mental illness, I navigate the same systems and services as my patients, I have similar hopes that I will receive 'good' or even 'adequate' care be but I also experience the same hardships.

I started to tweet about my appointment with a psychiatrist yesterday (I believe this is only the third I have had and seen in the last 14 years) as I reflected on how it was everything I could have hoped for, yet how I shouldn't have had to wait for 14 years to simply feel listened to and not end up feeling worse/ more traumatised by my interaction with a mental health professional as a patient. I realised that it had become a pretty long thread. And as simply and impulsively as that I decided that I needed to convert it to a blog.

Reflection is something that we are expected to do in nursing, asking ourselves what do we learn from this experience? How could we address an issue that arose? How has the experience impacted on practice? Are you able to support yourself and your colleagues better? It is part of every day practice for me, but also forms an essential part of re-validation.

I have recently embarked on private therapy (believe me, I don't get paid enough to afford it, but I hope that the financial sacrifice will be worth it; and I also appreciate that most of my patients are not in the privileged position that I am in). As 'homework' reflection is something I have started to do more of; using similar prompts that I do as a nurse. Attempting to be consistent in writing a blog may be a way of motivating me to continue to practice this; as my motivation for self care is pretty poor at the moment.

As I reflected on the appointment the main thing that emerged was how I as a patient wanted to make my voice heard. The result is controversial perhaps, but I have put my nurse hat aside, my patient hat on and here is the result. My experiences of mental health care; the white and the black, the good and the bad. A 'how to' and 'how not to' guide to mental health care. It is not actually meant as a how to guide, just my way of reflecting). All of the how to's come from yesterdays appointment, all of the how nots come from the previous experiences I have had...

How to do things well (according to me anyway) 

A) On treating a ‘fellow professional’:  

• You have read up on their notes already (this applies to anyone that you are meeting with for the first time), and start the conversation acknowledging that when they were last seen they were a student mental health nurse. 
• You ask where they work. You explain that there will be occasions that you will see each other on a professional capacity, but do not work for the same organisation so there is not a conflict of interest, according to professional bodies. You make it implicit that if the person does not feel comfortable alternative arrangements could be made. 
• You make the person feel that this is truly confidential; you do not say anything like 'if you say something that concerns me about your ability to practice I will have to report it'; you don't need to, the person in front of you knows these things already. By not saying it, you have not instilled in them fear that anything the could say might jeapordise their position, if misinterpreted.
• You change your approach. You know that the person in front of you is likely to have access to their own assessment tools and come to their own conclusions. You don't patronise them by asking 'do you feel hopeless, helpless, worthless' (just as you shouldn't any person in your care) you know that you can get the answers you need by asking in different ways.
• You take into account that the person is likely to have knowledge about their symptoms and possible treatments, but you also, appreciate that in this relationship they are the patient and they are coming to you as you are the expert and they also seek answers.
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B) You ask what happened to you.

• You do not ask the person what is wrong with them you ask what happened to them. You ask this after you have established rapport with the patient. Taken the full history. You go back to the start. The person aged 16 (or there abouts in my case) who first started experiencing mental health difficulties. This means that they are more likely to speak about the large Ts of trauma; where in the past they may have focused only on the current small Ts. (It has only been in the last 6 months or so that I have been ready to speak about those, and the psychiatrist gave me that opportunity). 
• If a person does speak about the 'large Ts' for the first time, you use words such as 'that must have been difficult for you' or 'thank you for helping me understand you better'.

C) You ask the person for their assessment of the situation and give yours 

• You ask the person what they think is the presenting problem; whilst you are the expert in the field of medicine, they are the other expert in the room. 
• You then explain your professional opinion, and conclusions, using clear evidence and examples; as to why your assessment and theirs differs; this allows your understanding to become our understanding. - in my case by explaining that my depression was depression, but was the result of emotional dysregulation as oppose to cyclothymic depression and educating on the subtle differences emptiness, loneliness as oppose to sadness and guilt. 
• You focus on a persons strengths; what they are able to do and not what they can not, the area in their life in which they continue to excel.

C) You don’t shy away from the ‘diagnosis conversation’ 

• You ask the person their views on diagnosis, but don’t avoid talking about diagnosis, and thus remove some of the stigma around it. You talk about how a previous diagnosis can be changed as new information comes to light, or different symptoms/behaviours emerge. -Some people find a diagnosis helpful and I am one of them.

D) You work with the person to discuss treatment options  

• You give options, explain the pros and cons of each. You agree with the person what medication can be increased, what can be added and what options there are if things don’t work out, this conveys the message that there is hope.
• It also means that this isn't the end of your relationship - in the past I have NEVER had a follow up despite medication or diagnosis changes.

E) You give the person in front of you time and understand that they may be struggling with keeping to theirs

• If the person is a little late to the appointment you appreciate that this may be due to their struggles and is not a reflection on their desire to get better and so accept this.
• You work in a way that makes the person feel that they are the most important thing in your diary - The assessment for over an hour and a half and I didn't feel rushed once.
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How things are when they are done badly

A) treating a ‘fellow professional’: 

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• You tell the person that they have to tell their university, or employer about their condition or disability, or a risk to self, even though it is apparent that their mental state does not place them at risk to others or affect their ability to practise safely and effectively. You tell the person that if they don’t you will have to. - Thankfully my placement facilitator was angry that I had been told this. But the result was that I lost all trust in my ability to be a nurse and a patient. - I came to you for help, you were a hindrance. 

B) You give a diagnosis in a letter of discharge  

• You are a psychiatrist and know that you are going to discharge the person from your care, after changing their diagnosis altogether. The person finds out in a discharge letter to their GP. They have had no explanation or been offered no opportunity to discuss what it means to them. 

C) You are a NICE evidence based personality disorder service yet say that the person does not meet the criteria for your care

• Instead of an assessment you simply reject the referral. Leaving them no access to evidence base therapies such as dialectal behaviour therapy.
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D) You change treatment but with no option for a review – at the end of the first assessment  

• You do not offer a follow up. Not even a phone call. You do not give the person the opportunity to discuss their response to the treatment that you have initiated other than with their GP.
• You puts a lot of added pressure onto the GP and expect them to manage any side effects (as well as any risks if the treatment isn't effective).
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E) You reject someone because they missed an appointment, when they had shown clear motivation in the first place to get the appointment and do not allow them to be re-referred for 12 months.

• If a person does not attend an appointment, despite showing clear motivation in calling every few days to put pressure on getting that appointment, you decide that they have chosen not to engage and that this is not due to their symptoms worsening, or their self esteem telling them that they do not deserve to receive help.
• You do not even try to find out, you do not call them. Or write a letter. You just reject them.
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As I conclude my reflections, I think about how my experience of psychological services has not been all that negative. Seven years ago I was offered individual and group psychotherapy. This allowed me to move on from someone who had not had a consistent full time job was actively suicidal and led a pretty chaotic lifestyle, to a person capable of starting the journey to becoming a mental health nurse. I will be ever grateful for that, but does that mean I should not expect help again?

I also come to the conclusion that is is interesting that the very symptoms of EUPD are the very things that services exacerbate - the feelings of rejection, anger, unstable relationships. I also have to come embrace and understand better that what I thought was a mood disorder is likely to be a personality disorder alone.

And finally when I put my nurse hat on, I realise that this is not about individual practitioners that got it wrong, but often people that were trying to do their best, in services and systems that curtailed them, simply couldn't cope with the demand. 

 And that's it. My first ever blog post.

Thanks for reading!