Transcendental Medication – Irregular Perceptions Of A Mental Health Services Consumer

Have you ever been under observation at a hospital psychiatric unit? Do you know anyone who has? I have, and as an enthusiastic people watcher I have observed some unusual things.

Marketing teaches us why people buy. It tells us what they expect from the products they purchase and what emotional and physical needs motivate them to take an action, specifically, to make a purchase. It suggests that all actions are driven by the human desire to rid oneself of discomforts brought about by changes in life. When we are hungry, for example, we prepare and eat tasty food until the pain of hunger is displaced by intense satisfaction. When we get hungry again, we eat again. The process is repeated automatically.

Does the repeating process itself fill a need or serve someone’s purpose besides our own? We know that the purpose of a machine can be understood by its function. It does what it is designed to do. By watching its actions we can determine its purpose.

Because the actions people take are always to remove pain and replace it with happiness we might suppose the design purpose of our discomfort is to cause us to take action. After all, this is what we do. To rid ourselves of discomfort we must perform certain things and we must figure out how to do so. And we must think about what we are doing to some extent. We are always thinking, always processing information, always seeking and applying solutions for ourselves and for others. Even in our sleep. It never stops and we are told if we meet the requirements it will continue mercifully forever. Perhaps the process is the purpose, and our purpose as well. Perhaps the process accomplishes something important to the designer, if there is one.

The extreme change in my life by the incarceration certainly created discomfort in me. It caused me to intensely seek relief. I was highly motivated to regain comfort. I was told, “It is up to the doctor.”

I was placed under observation because someone with the authority to insist wanted to know if I was a significant threat to others. If there was any question about it, I suddenly had the opportunity to establish myself firmly as a reasonable and well behaved citizen who could be trusted to live peaceably with his neighbor regardless of what I might have done to raise the question. Did I succeed?

Yes, and no.

Most of the patients were much angered by the disruption of their lives but also attempted to demonstrate the ability to think and behave rationally. The unit staff shepherded us around, made observations, and simply wrote them down for the doctors. The patients also made observations in order to evaluate their plight and to strategize accordingly. My plan was to simply be polite, answer questions intelligently,and to avoid conflict with the staff. After all, someone who had the power to get an answer wanted to know if I was dangerous.

Some patients succeeded in the plan quickly and were released right away. Others stayed longer. Upon release they were expected to report to community mental health centers for followup and ongoing evaluation. And to take medications regularly. They did not forget if medication was refused during the hospital stay the patient was immediately stripped of his clothes, publicly paraded to a bedroom, strapped down and shot in the butt with a tranquilizer guaranteed to induce sleep for as long as the doctor wished. I opted to swallow my bitter pill voluntarily.

Upon release my need was to stay out of the hospital. After describing the various services I would receive from the neighborhood mental health facility by the polite case manager assigned to me, I found the featured benefit for my cooperation was freedom from further hospital incarcerations. I would also be considered for training and job placement if I feigned gratitude. I could do things the hard way or the easy way.

Well, life goes on, so they say. I am still wondering who got me into this long standing life style 34 years ago at 26 years of age and why. As far as I know I had not harmed anyone, if that matters. When I ask about it the doctor or case manager shows disinterest in my query by changing the subject and not answering. At one point a doctor advised me to inquire at the original hospital instead of just telling me herself. The original hospital said they no longer had the records.

As a marketer, my observation is if a need is not met by a specific solution the person with the need will sometimes find his general situation does not change over a long period of time. Sometimes it never changes. Like the guitar player who dreams of stardom and never achieves it, his actions to become a star are repeated by him forever. Perhaps the desire for such things is built into us all and is nothing more than a motivator. If allowed to achieve his goal, the want to be rock star would not function as intended. Would you kill the goose that lays the golden eggs?

To the mental health providers, my need was not the issue. The need being met was the community’s need to believe I had been rendered harmless and would be kept that way. That is what staff in Government funded mental health systems are paid to do. It was decided by them that a life time of forced medicating would achieve and maintain the desired outcome. For compliance I was paid a small monthly entitlement check, an apartment in a subsidized building, and the promise that I would not be hospitalized again if I kept taking the so called medicine. That was the sum total of the benefits to me.

Mental Health Clinics

Clients to mental health clinics are usually not admitted arbitrarily. The process usually consists of an initial interview with a community worker or a mental health professional. If a client is considered in need of residential or out-patient treatment at a mental health clinic, an extensive history of the mental illness will then be recorded. Such assessments will also include interviews with other doctors and family physicians who have noted the onset and progress of the ailment.

The staff at mental health clinics usually consists of psychiatrists, psychologists, mental health nurses, and support personnel who are specially trained. The scope and activities of mental health clinics in America generally falls under the purview of the CMHC (Community Mental Health Centers). This body issues licenses to clinics and centers for the practice of mental health-related treatment.

Considering that mental health crises do not always announce themselves in advance, a mental health clinic or center usually offers twenty-four-hour emergency services. These include inpatient hospital referral, since many cases are diagnosed in hospitals while the client is under treatment for other health problems.

Mental health problems affect people from all age groups, and American mental health clinics also offer services specifically for the aged as well as children and adolescents. The reasons that commonly lead to a referral for elderly persons range from senile dementia and Alzheimer’s disease to problems related to chronic alcohol abuse. Mental health problems typical to the aged fall under the category of geropsychiatric medicine.

Teenagers and young adults often find themselves in need of mental health services because of substance abuse, inherited mental problems, and Attention Deficit Disorders (ADD).

The services available at mental health clinics necessarily include group therapy, individual and family counseling, and a social awareness cell. The latter would be staffed by personnel who could explain the various issued surrounding metal health in layman’s terms to clients and their families. They are also an integral part of the evaluation process.

What the Patient Protection and Affordable Care Act Means for the Future of Mental Health Care

The Patient Protection and Affordable Care Act was passed in March last year, and aims to improve all aspects of our country’s health services. One aspect that will be further improved is the field of mental health care.

Inadequate coverage and lack of programs that educate the public about mental illness have plagued the United States for some time. With the enactment of the new law, a number of new provisions aim to change people’s perceptions about mental illness and offer programs and other initiatives to help those who need mental health care. Some of the provisions include:

Medicaid improvements (including expansion of eligibility) that will allow more people to benefit from mental health services
New options for people with disabilities
Improve coordination and communication between primary care and mental health services
More...

Basically, this means that, over time, individuals with mental illness will have access to health insurance that includes mental illness and substance abuse services, providing people with unprecedented assistance and cooperation from the government. Other services include prevention programs, new insurance plans for long-term community care, and more.

Patient Protection and Affordable Care also aims to improve health services in the workplace. This stipulates that starting in 2014, employers can offer greater incentives for positive lifestyle practices or employee participation in health promotion programs. PPACA also created a grant program to help small businesses provide comprehensive workplace health programs. Grants will be given to employers who are eligible to give their employees access to health initiatives in the new workplace.

Grants will begin in 2011 with $ 200 million allocated for a period of five years. PPACA outlines that a comprehensive workplace health program must be made available to all employees and includes health awareness initiatives (including health education, prevention screening, and health risk assessment) as well as supporting environmental efforts (including workplace policies to encourage healthy lifestyles, eating healthy, increase physical activity, and improve mental health).

A better workplace atmosphere in terms of awareness of mental illness is very important, because knowledge about mental health is not well known in the workplace program. It has been learned that employees want to become more understanding of mental illness and ways to treat it, and the Patient Protection and Affordable Care Act aims to achieve that.

Mental health services will undergo a major renovation with the government’s commitment to overall health care reform. Those suffering from mental illness will find it easier to seek help and others will find more information about mental illness to create a better understanding of how this health service operates. By creating a more cohesive health care system for mental illness, our society will not only be more fluid in its operations, but also more knowledgeable and, therefore, better for it.

Who’s Who In Mental Health Service – GPs, Psychiatrists, Psychologists, CPNs And Allied Therapists

When a person is experiencing psychological or emotional difficulties (hereafter called “mental health problems”), they may well attend their GP. The GP will interview them and based on the nature and severity of the persons symptoms may either recommend treatment himself or refer the person on to a specialist. There can seem a bewildering array of such specialists, all with rather similar titles, and one can wonder as to why they’ve been referred to one specialist rather than another. In this article I give an outline of the qualifications, roles and typical working styles of these specialists. This may be of interest to anyone who is about to, or already seeing, these specialists.

The General Practitioner

Although not a mental health specialist, the GP is a common first contact for those with mental health problems. A GP is a doctor who possesses a medical degree (usually a five-year course) and has completed a one-year “pre-registration” period in a general hospital (six-months on a surgical ward and six-months on a medical ward as a “junior house officer”). Following this a GP has completed a number of six-month placements in various hospital-based specialities – typical choices include obstetrics and gynaecology, paediatrics, psychiatry and/or general medicine. Finally, a year is spent in general practice as a “GP registrar” under the supervision of a senior GP. During this period, most doctors will take examinations to obtain the professional qualification of the Royal College of General Practitioners (“Member of the Royal College of General Practitioners”, or MRCGP). Others qualifications, such as diplomas in child health, may also be obtained.

The GP is thus a doctor with a wide range of skills and experience, able to recognise and treat a multitude of conditions. Of course the necessity of this wide range of experience places limits on the depth of knowledge and skills that they can acquire. Therefore, if a patient’s condition is rare or, complicated, or particularly severe and requiring hospital-based treatment, then they will refer that patient on to a specialist.

Focusing on mental health problems it will be noted that whilst the majority of GP’s have completed a six-month placement in psychiatry, such a placement is not compulsory for GP’s. However, mental health problems are a common reason for attending the GP and, subsequently, GP’s tend to acquire a lot of experience “on the job”.

Most GP’s feel able to diagnose and treat the common mental health problems such as depression and anxiety. The treatments will typically consist of prescribing medication (such as antidepressants or anxiolytics) in the first instance. If these are ineffective, alternative medication may be tried, or they may refer the patient to a specialist. GP’s are more likely to refer a patient to a specialist immediately if their condition is severe, or they are suicidal, or they are experiencing “psychotic” symptoms such as hallucinations and delusions.

The Psychiatrist

This is a fully qualified doctor (possessing a medical degree plus one year pre-registration year in general hospital) who has specialised in the diagnosis and treatment of mental health problems. Most psychiatrists commence their psychiatric training immediately following their pre-registration year and so have limited experience in other areas of physical illness (although some have trained as GP’s and then switched to psychiatry at a later date). Psychiatric training typically consists of a three-year “basic” training followed by a three year “specialist training”. During basic training, the doctor (as a “Senior House Officer” or SHO) undertakes six-month placements in a variety of psychiatric specialities taken from a list such as; General Adult Psychiatry, Old Age Psychiatry (Psychogeriatrics), Child and Family Psychiatry, Forensic Psychiatry (the diagnosis and treatment of mentally ill offenders), Learning Disabilities and the Psychiatry of Addictions. During basic training, the doctor takes examinations to obtain the professional qualification of the Royal College of Psychiatrists (“Member of the Royal College of Psychiatrists” or MRCPsych).

After obtaining this qualification, the doctor undertakes a further three-year specialist-training placement as a “Specialist Registrar” or SpR. At this point the doctor chooses which area of psychiatry to specialise in – General Adult Psychiatry, Old Age Psychiatry etc – and his placements are selected appropriately. There are no further examinations, and following successful completion of this three-year period, the doctor receives a “Certificate of Completion of Specialist Training” or CCST. He can now be appointed as a Consultant Psychiatrist.

The above is a typical career path for a psychiatrist. However, there are an increasing number of job titles out with the SHO-SpR-Consultant rubric. These include such titles as “Staff Grade Psychiatrist” and “Associate Specialist in Psychiatry”. The doctors with these titles have varying qualifications and degrees of experience. Some may possess the MRCPsych but not the CCST (typically, these are the Associate Specialists); others may possess neither or only part of the MRCPsych (many Staff Grades).

Psychiatrists of any level or job title will have significant experience in the diagnosis and treatment of people with mental health difficulties, and all (unless themselves a consultant) will be supervised by a consultant.

Psychiatrists have particular skill in the diagnosis of mental health problems, and will generally be able to provide a more detailed diagnosis (i.e. what the condition is) and prognosis (i.e. how the condition changes over time and responds to treatment) than a GP. The psychiatrist is also in a better position to access other mental health specialists (such as Psychologists and Community Psychiatric Nurses or CPNs) when needed. They also have access to inpatient and day patient services for those with severe mental health problems.

The mainstay of treatment by a psychiatrist is, like with GP’s, medication. However, they will be more experienced and confident in prescribing from the entire range of psychiatric medications – some medications (such as the antipsychotic Clozapine) are only available under psychiatric supervision and others (such as the mood-stabiliser Lithium) are rarely prescribed by GP’s without consulting a psychiatrist first.

A psychiatrist, as a rule, does not offer “talking treatments” such as psychotherapy, cognitive therapy or counselling. The latter may be available “in-house” at the GP surgery – some surgeries employ a counsellor to whom they can refer directly.
Psychologists and allied mental health staff typically provide the more intensive talking therapies. Some senior mental health nurses and CPNs will have been trained in specific talking therapies. It is to a Psychologist or a trained nurse that a psychiatrist will refer a patient for talking therapy. These therapies are suitable for certain conditions and not for others – generally, conditions such as Schizophrenia and psychosis are less appropriate for these therapies than the less severe and more common conditions such as depression, anxiety, post-traumatic stress disorder, phobia(s) and addictions. In many cases, a patient will be prescribed both medication and a talking therapy – thus they may be seen by both a therapist and a psychiatrist over the course of their treatment.

The Psychologist

A qualified clinical psychologist is educated and trained to an impressive degree. In addition to a basic degree in Psychology (a three year course) they will also have completed a PhD (“Doctor of Philosophy” or “Doctorate”) – a further three-year course involving innovative and independent research in some aspect of psychology. They will also be formally trained in the assessment and treatment of psychological conditions, although with a more “psychological” slant than that of psychiatrists. Psychologists do not prescribe medication. They are able to offer a wide range of talking therapies to patients, although they typically specialise and become expert in one particular style of therapy. The therapies a particular psychologist will offer may vary from a colleague, but will usually be classifiable under the title of Psychotherapy (e.g. Analytic Psychotherapy, Transactional Analysis, Emotive therapy, Narrative therapy etc) or Cognitive Therapy (e.g. Cognitive Behavioural Therapy (CBT) or Neuro-Linguistic Programming (NLP) etc).

The Community Psychiatric Nurse (CPN)

These are mental health trained nurses that work in the community. They will have completed a two or three year training programme in mental health nursing – this leads to either a diploma or a degree, depending on the specific course. They are not usually “general trained”, meaning their experience of physical illness will be limited. Following completion of the course they will have spent a variable amount of time in placements on an inpatient psychiatric unit – this time can range from twelve months to several years. They can then apply to be a CPN – they are required to show a good knowledge and significant experience of mental health problems before being appointed.

CPNs are attached to Community Mental Health Teams and work closely with psychiatrists, psychologists and other staff. They offer support, advice and monitoring of patients in the community, usually visiting them at home. They can liaise with other mental health staff on behalf of the patient and investigate other support networks available (such as the mental health charities).

Some CPNs will be formally trained in one or more “talking therapies”, usually a cognitive therapy such as CBT (see “Allied Therapists” below).

“Allied” Therapists

Many “talking therapies” are offered by non-psychologists – for example, mental health nurses and mental health occupational therapists can undertake a training course in a cognitive therapy like CBT. After successful completion of the course, the nurse will be qualified and able to offer CBT to patients. The length and intensity of these courses can vary dramatically, depending on the type of therapy and the establishment providing the course. Some are intensive, full-time one or two week courses; others are part-time and can extend over months and years. Perhaps a typical course will be one or two days a week for two to three months. Formal educational qualifications are not necessary to undertake these courses, and they are open to “lay” people with little or no experience of the NHS mental health services. Of course this is not necessarily a problem – it may even be considered a positive point!

Some of those therapists thus qualified will offer their skills as part of their work in the NHS – for instance, a nurse or CPN may offer cognitive therapy to a patient that has been referred by a psychiatrist. Unfortunately this is relatively rare at the moment, presumably due to the reluctance of the NHS to pay for such training for their staff. As a result these therapies are more accessible on a private basis.

Summary

An individual with psychological difficulties will normally attend their GP in the first instance. The GP will usually have encountered similar problems with other patients and can offer a diagnosis and appropriate treatment. If the condition is unusual or particularly severe, the GP can refer the patient to a psychiatrist. The psychiatrist is able to access a wider range of treatments (medications and hospital care) and can, if necessary, recruit other mental health professionals to help the patient. This system perhaps works best with the severely mentally ill such as those with psychotic symptoms or who are suicidal.

The Mental Health Services in the NHS are generally less well suited to those with psychological problems of a less severe nature – the moderately depressed, the anxious, the phobic etc. The availability of “talking therapies” is limited in the NHS, with long waiting lists or even no provision at all in some areas. This appears to be due both to the cost of training staff appropriately and the time-intensive nature of these therapies.

For those with such conditions, the main option is to seek help outside the NHS. There are some voluntary organisations that offer free counselling for specific problems such as bereavement or marital/relationship difficulties, but more intensive therapies (such as CBT or NLP) are typically fee based. Your GP or local Community Mental Health Team may be able to recommend a local private therapist.