As a Mental Health First Aid Instructor, I train people to support people with mental health difficulties in a variety of ways, one of which being to “Encourage (them) to seek appropriate professional help”.
With 70% of people who die by suicide not having been in contact with mental health services in the year before death – I feel it is an important message, to try and help people access services, which may then hopefully prevent their distress from reaching the point where they are so desperate that they see suicide as an answer. If Mental Health First Aiders (or anyone) can help someone to a) recognise that the distressing symptoms / emotions they are experiencing are possibly suggestive of a mental health problem, b) understand that mental health issues are very common, part of the normal range of human experience and response to stress or difficult circumstances, and nothing at all to be ashamed about, – and c) recognise that there are many different things that may help them to feel better, from self help startegies, relaxation, peer support, to medication and a variety of therapies; then of course that is all to the good. Hopefully that will lead to some people seeking and getting help that otherwise would not have done so. Or even just begin to understand their mental wellbeing.
However, when we encourage people to seek help – “appropriate professional help”, often by going to their GP in the first instance, how likely are they to actually get that? How long will it take? Will the help they receive be “appropriate”? It’s something that I have discussed with several MHFA Instructors – something that concerns us. If we’re encouraging people to seek help, are we sure that it is actually going to be there?
Of course the answer is sadly going to be no – in many cases. We can’t be “sure”. We know there are problems, waiting lists, shortages, geographical variations in provision. But we can talk about what “should” be there. What should happen when you go to the GP. What kinds of help you might receive.
The Improving Access to Psychological Therapies programme aims to make counselling services more accessible, and reduce those waiting lists. It has had a degree of success. But is it going about things the right way?
“Stepped Care” – is a principle whereby a person referred, or self-referring to the service is assessed, and directed to a type of support which is considered most appropriate to their level of need. People with mild problems with stress/anxiety, for instance, might be encouraged to attend a group stress management programme. Then there is Guided Self Help, where a Psychological Wellbeing Practitioner takes the person through a range of exercises and lessons aimed at challenging the negative thinking patterns or behaviours which come with, and fuel, anxiety and depression. This is taken further with Cognitive Behavioural Therapy. There are computerised options which some people may prefer to the face to face option. There are also other types of psychoeducation – helping people to understand what influences their mental health and what they could do about it?
The third “step” does mention access to other types of therapy, especially in relation to specific diagnoses, such as Post Trauamatic Stress. But I would be interested to hear people’s experience of how possible it actually is in practice to access therapies other than CBT on the NHS.
I have had a couple of encounters with this model of access. A few years ago I was referred, I remember taking the assessment call at work, sat in a meeting room on my own. I was severely depressed, and occasionally suicidal. I was obsessing about death, and couldn’t understand how CBT could help me with that. After the call I felt deeply alone and upset, and cried for half an hour in that little room. The person on the phone had said “Do give us a call if you things get worse” – I thought the whole thing really unsatisfactory. “There’s a waiting list, I’m afraid”, they couldn’t tell me how long. I suggested I could maybe access some counselling through my work Employee Assistance Programme, but was told that was a bad idea, for some reason.
So. Eleven months later… I got my counselling. I never found out how CBT might help with my thoughts of death, because, my mental state being what it is, the worst had passed. I had endured several months of severe depression, luckily come out the other side – and so when I sat before the counsellor to discuss my problems, and be given homework to try and work on my issues, the topics which arose were totally different than they might have been when I actually first asked for help. Don’t get me wrong, it was still worth doing, in a way. I got to identify and work on some of the issues which endure even when I am in a better state of mind, and probably contribute, over time, to the risk of relapse.
This year, I have had a number of health issues, surgery, a fall, – which combined with a background of extreme uncertainty and change to produce in me some extreme health anxieties and obsessions. It reached a pitch that it was becoming difficult to live with, so I again sought help. This time, it took about a month before my assessment, and then a couple of months after that before I was able to see a counsellor. Or in this case, a Psychological Wellbeing Practitioner – for Guided Self Help. Again, my specific health anxieties had subsided somewhat. I have a long history of learning about my mental state and lots of strategies which I put in place to try and de-fuse the crises when they occur. So I do a lot of work on my mental health anyway. But every so often it gets worse, feels out of control, feels like I might lose my grip and fall into the abyss. That’s when I ask for more support. I want to feel better in the moment, but I also want to find out what causes this endless cycle. Not just get rid of the immediate symptoms, but work on whatever issues I have underneath that cause me to fall into negative patterns.
CBT, to some extent, ignores those underlying problems. It doesn’t matter what causes you to be prone to negative self beliefs, if you can learn how to notice when you are doing it, challenge it, and train yourself to respond differently. For some, that’s enough. But for others, like any kind of therapy – physiotherapy for instance – you learn the technique to deal with the problem, the pain. You put it into practice, the pain gets better, goes away. You keep it up for a bit, but then forget about it because you no longer have the pain to remind you why you are doing it. But of course, after a while, in the absence of the good practice of your exercise technique, you slip into bad habits and the pain returns. So it is with CBT. You may know the principles, the techniques, the exercises – but sometimes you slip, and because the initial problem is still there underneath, your emotional pain returns.
When working on my Counselling course last year I read an article which suggested that this was a major problem in the priority that CBT has gained in NHS treatment. It is measurable, and very effective in the short term for many people. All great for suggesting cost effectiveness in a cash strapped service. But – is it as cost effective as we think, if it means that patients keep coming back? If someone like me, with life long issues with depression and anxiety has repeated relapses which mean I end up back on a waiting list – what is the cost of those multiple short term fixes? And would it be more or less than a longer term bout of a different type of therapy which would explore what has caused my underlying issues, work on them and potentially resolve them? If there is a tumour which you could either treat with a drug which would shrink it for a time, but then it would grow again, and need repeated treatments to hopefully keep it under control – each time risking that it will grow out of control and become really dangerous – or you could cut it out and use chemo or radiotherapy to try and eradicate it all together. Which do you do? Which is more cost effective? Which is more clinically effective?
Anyway. So I am currently undergoing “Guided Self Help”. It is interesting. Funny – because on more than one occasion my counsellor is taking me through things I actually teach. Stress Buckets. ABC. Negative thinking. I know this stuff. It’s not to say it’s useless. It isn’t. Knowing is different than doing. It is useful to have someone else help you to look at these things. And deadlined homework to make me think about it. But I do spend a lot of time thinking about whether it is a good use of the time of qualified counsellors.
I mentioned that last year I did the PG Cert in Interpersonal and Counselling Skills at Leeds Beckett University. I had been planning on carrying on to become a qualified counsellor myself. I still might. But it means another two years to to a PG Dip, and placement /counselling commitments which come at a cost I can’t currently afford.
We have a massive shortage of counsellors. Given the length of time, and financial investment that is needed to become qualified to BACP registration level – surely we need to ensure that those counsellors are used to best effect when they are employed within the NHS?
So why are they being used to deliver some of the same messages we teach in MHFA? Is it necessary? Is it about trust? That patients wont listen if these messages don’t come from someone “qualified”? Or is it that the counsellor has to monitor the patient to check that the problem isn’t more serious than initally thought – that the patient doesn’t need more help? That would make some sense, but how would he tell? I have hardly had the opportunity to speak, in the several sessions I have had. I fill out my questionnaire. He checks in on my thoughts of suicide or self harm – a simple assurance that I have no plans to act on them. I do my homework, sometimes writing some quite intense thoughts – but he doesn’t really review them much. We move on, to the next lesson. Indeed in my first and second session I actually felt like crying afterwards because I had been talked at so much. Talked at about things I know, I teach. And inside I was screaming “I just want someone to talk to!”
Person Centred Counselling. Psychotherapy. How does one access that, if, like most of us, the prospect of £40 a week for private therapy is a pipe dream?