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Restoring relationships at the heart of mental health care

Ruth Hunt speaks with psychiatry professor LINDA GASK about the lack of continuity in healthcare provision

ANYONE who uses mental health services will know that the lack of continuity of care is a major problem. You may see a psychiatrist at one appointment but someone else at the next and then be expected to share sensitive details about your life and illness with them too.

You may find that the criteria for accessing the services has changed to such an extent that you are no longer offered help and instead are left to deteriorate further. 

It would be hard to argue that continuity of care isn’t an aid to recovery or, indeed, lifesaving. So why is it so absent in mental healthcare?

The easy answer would be to blame the cuts in mental health services. However, emerita professor of psychiatry and author Linda Gask says these problems predate any cuts. 

“Because of the way services have been configured, this isn’t a new thing. It’s been happening for some time,” she says. 

“Somehow the patient and professional relationship and its importance in helping people recover has been downgraded and ‘achieving numbers of contacts’ and ‘finding the optimal service re-design’ has assumed pre-eminence. 

“Services will often now be defined by what they won’t offer rather than how they may help, with no options available if you don’t fit the criteria.

“Instead, patients get shuffled from one team to another, each time having to place their trust in professionals, only to be told a decision has been made that they are not quite right for that level of support and get moved on again.”

The impact on service users is clear. Ron, who previously had a good relationship with his psychiatrist, suddenly found that, instead of having regular appointments with this consultant, he saw locum after locum. And each time he was asked to repeat his story.

As Ron’s story involved sensitive childhood trauma, he felt that, without the compassionate relationship he had experienced with his first psychiatrist, he could no longer trust the community mental health team that had one time helped him so much.

“A service user like Ron should be able to know there is a clinician who knows their story and takes care of it,” Gask says. 

“I expect a psychiatrist to be working hard to engage a service-user, not assuming they are automatically willing to share difficult things about their lives with them.

“It takes time for a clinician to try and understand how and why someone feels the way they do. However, the way mental health care operates now, it can feel impossible for anyone to get to know anyone else very well.

“No connection is made because it will only be broken again. The professionals retain their detachment and the service-user has to become an ‘it’ rather than a person so they can be processed in a system.”

Having to deal with these constant changes in teams and clinicians can mean there is a very real risk of patients disengaging from services. This should be seen as a provider problem. But it isn’t.

“Those who drop out of services can sometimes be deemed ‘unmotivated’ by mental health staff,” Gask adds. 

“The service only gets engaged again when they present in extremis and are deemed ‘detainable.’

“Fortunately, many people with more severe psychotic illnesses are followed up by an assertive outreach team or an early intervention team and so get a better deal in this sense, as at least there is a dedicated team devoted to trying to engage them.”

But for other groups, such as those with a dual diagnosis or service-users who have additional needs such as physical or learning disabilities, services can be scarce or absent altogether.

Many people who are diagnosed with “personality disorders” are often told that they cannot receive any help, even when an ongoing relationship with a team member could be lifesaving.  

Young service-users who have had a good level of care may struggle to find anything like the same level of support when they reach adult services.

Rather than those in need being able to access timely help, it is more the case that they have to wait, becoming more and more unwell, before they meet the criteria and the door to services swings open.

So, what can mental health staff, clinicians and managers do to improve the continuity of care for mental health service-users?

Gask says: “On a personal level, it is about thinking how can I help this person to get what they need? If I cannot help them, who can? How can I facilitate them to access that help? If it isn’t available, what can I do?

“If the person doesn’t really require specialist help, how can I support their GP and/or the third sector to provide that care?

“At a service level, it is about developing specialist skilled teams to deliver help for more service-users with complex problems but making sure these teams in turn provide the right support to GPs.

“This will help to ensure service-users who need help for which services have not been clearly commissioned can still be offered some help.

“It also means fostering a culture of dialogue, trust, respect and co-operation to ensure that the worker who makes the initial contact with a service-user is not told that their assessment is of no value because they do not belong to a particular profession or work in a certain team.

“At a commissioning level it is about asking the question, what are we not doing? What services aren’t there that should be? What isn’t working? It may not be possible to change this, but we still need to talk about it.

“At the moment it may seem hard to achieve any of these things, but these are not new problems and they will not all be solved simply by more investment.  

“A person should never be thought of as ‘not quite right’ or ‘just right for a service.’ The support that they are offered should be ‘just right’ for them.

“This means most of all ensuring that there is the opportunity to develop a continuing relationship with someone skilled enough to aid them in their recovery.”

Linda Gask is the author of The Other Side of Silence. 

Ruth Hunt is the author of The Single Feather (Pilrig Press). 

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