Intricate and inextricable knots

'O time, thou must untangle this, not I.
It is too hard a knot for me to untie!'
Twelfth Night - act II sc ii

I am not just a collection of interconnecting muscles, nerves, blood vessels and bone. On its own my body is a miracle of complex engineering, but within this body there are many complex chemical and electrical interactions and reactions all with different functions - perhaps I could see these as the fuel and lubricant which ensures the machinery keeps working effectively - there are hormones which determine my readiness for creating children, my moods, my appetite. Then there is the product of my mind, my thoughts, the core of who I am. This is indefinable in purely physical or chemical terms, although some argue that even the most complex of human interactions are just the result of biochemistry, I tend towards believing that there is something intangible, the essence of who I am, which I call the Human Spirit, or soul, so there is a spiritual side to consider.

When I consider all three aspects of who I am I recognise that there is no part of me that does not impact on the others. So when I fall over in the street, which I did recently, it is not just my hand which is hurt. That, it has to be said was the first part of me to connect with the shock of hitting the ground. In short succession, physical pain, was followed by a wave of grief - I wanted to cry. Then I caught sight of the shocked faces looking out of the bus window as it passed. Grief was replaced by embarrassment and then shame. Then my personality came to the fore as a kind passerby offered some help and I waved her away and too quickly got to my feet. The blood in my circulatory system was unable to keep up with what I, as me, wanted to do, so I nearly collapsed again, the physical working in opposition to my spirit. You get the idea - if anyone had asked me what part of me was hurting I could answer, honestly; my hand, my shoulder, my ribs, my knees, my pride, my sense of independence, my self confidence, my conscience (guilt for refusing a helping hand). Had I been taken for medical treatment only those parts of me which were evidently hurt would have been treated.

Too often we experience health services which treat only one aspect of our person. So we treat the 'flu, but neglect the emotional impact of feeling drained physically. The plaster cast, sets the bones and supports physical healing, but the emotional cost of a physical trauma is neglected until it becomes unavoidable.

I have been thinking about this silo approach to well being recently in regard to mental health and disability. Too often services and benefits tend to separate physical disability from mental illness or emotional challenges. This is why so many disability assessments have been running into difficulties and result in so many appeals which are overturned nearly 70% of the time. The reality is that 'seen' difficulties are the most easily identified and therefore treated or managed. It does not require a hard pressed NHS service to take time to investigate or have to spend time on treatment when presented with bruises or broken bones. When presented with emotional or mental distress, time is required as well as to change the approach from 'What is wrong with you?' to 'What is causing so much distress?'. The first question allows the professional to decide how to fix the problem, the second question opens up the need for a more long term intervention. Often Mental Health interventions are time limited when mental health issues require time and relationship, something that a six week hourly intervention cannot offer.

The thing is if you can help me to manage my emotional and mental responses to the physical pain or trauma I have experienced it is more likely that the physical therapies and interventions are likely to help me recover from or manage my physical challenges. Equally if you can help me address the physical causes of my exhaustion then I am more likely to be able to manage feelings of depression and anxiety.

I have been reflecting on my own recovery in these terms and recognising that persevering with looking after my physical health will help me to continue to manage my mental health. It is common sense, it also makes financial sense when applied to a resource-and-time-poor NHS. Yet I have to piece my recovery plan together from different silo'd teams under my own initiative. I am effectively the wellness hub for my own recovery.

When I worked within criminal justice I was privileged to be part of an multi-disciplinary team made up of police, nhs, probation and charities staff each working with individuals to address the complex factors which were stopping them from reforming and ending their offending careers. As long as an individual undertook to manage their own offending behaviour, our team would provide a range of support to help them with housing, employment, substance misuse, education etc. It was effective and when the people we were targeting were responsible for 80% of local car, thefts and burglaries was arguably an excellent investment. Even with the costs involved it was still cheaper than prison for most of the people we worked with.

What do I learn from this when applied to health? Well first there was a concept of 'end to end management' from the point of arrest to the point of end of sentence. Our team picked people up and worked with them through court, into prison, out of prison and to the end of licence or community sentence. If they re-offended they came back to the same team to begin again.

What if health and social care teams in hospitals and the community were integrated and worked in the same place? What if every person who has undergone significant surgery, or who is managing a significant physical disability has access to evidence based mental health well being practices as part of their recovery? What if mental health was seen as part and parcel of recovery from significant physical illness? What if we stopped separating off mental health units from the rest of the hospital except for those requiring the most intensive mental health support? What if we actually practised our interventions on both physical and mental health as if there were parity of esteem? What then?

Do Staff need to be Taught Compassion?

Sometimes I need time for blog posts to 'percolate'. The reasons vary, from me recognising that I need to consider the possible impact of what I am putting out there on others, to needing time to formulate my thoughts and feelings on a subject. I wanted to write about compassion in Mental Health settings since an incident before Christmas, but hesitated because my initial response was purely an emotional response to the distress of a friend. Before putting my thoughts in the public domain I needed to allow time and perspective before putting my thoughts down in black and white.

My friend is a diagnosed Schizophrenic who battles against his labels and the medicalisation of him as a person, who is more than his often disputed diagnosis. A few weeks before Christmas he suffered a major 'meltdown' - in his words. The first I knew of it was when he phoned me from the ward and asked me to visit him. This article could deal with the ongoing battles he has with his mental health team regarding his view of his auditory and other hallucinations or of his need for ongoing medication, but more than that I needed to highlight the lack of compassion he told me about on his admission to the PICU.

Over a period of some time he had been struggling with the increasing belief that he was a psychopath and therefore a major threat to those around him. He was terrified because he was convinced by these beliefs. Instead of understanding how terrifying these beliefs must be to him and the fears that they created in him about the threat he posed to those around him, some staff started to tease him, laughing about him being a 'serial killer' and even using the term 'path' when talking to him. 'Alright, path', 'harmed anyone recently, path?'.

It is a single individual incident involving one person that I know. What has concerned me most is the basic lack of human understanding and compassion for an individual clearly in distress and need. By definition, to be admitted to inpatient care in this day and age, indicates that by all clinical standards, this person is in urgent need of help. In the world outside I would expect the usual level of ignorance about mental health in general and Schizophrenia in particular, but inside a specialist Mental Health unit, surely even a modicum of professional pride and self respect dictates a better response than taunting a mentally ill man?

I try to be balanced in my consideration of such troubling incidents. I have tried to find reasons for members of staff responding in this way:

1) Stress and pressure - under-staffing, ongoing constant change and cutbacks, bring a weariness and cynicism, probably unthinkable in the early days of most of these staffs' careers?
2) Lack of adequate training about the symptoms and perceptions of Mentally Ill people who are in crisis?

Unfortunately, neither of these reasons adequately provides any acceptable rationale for the appalling lack of empathy and understanding displayed. I know in my twitter feed I can be political in my responses to the current state of the NHS, but I do believe that there is an ideological and moral battle going on for all of our public services. When patients, services users and others in need, stop being people and become units and target statistics, then the raison d'etre of our social care and health services is under severe threat.

If a person ceases to be a person, but becomes an obstacle to completing paperwork, or sitting in an office 'getting through a shift', it stands to reason that it is only a small step to not being able to see why you should 'waste' any human compassion on 'them'. And there it is: 'Them' and 'us'. There has been a rhetoric in public life which has separated us into 'camps' of rival 'tribes' of the 'deserving' and 'undeserving'. We are not in this together - or at least that has been the effect of much of the discussion in public around Benefits and other cuts to services. So the ironic comment that 'my job would be ok if it weren't for the people I work with.', ends up being a default which in turn

informs our actions towards 'those' people.

What most of the political rhetoric forgets is that for most staff in public services; NHS, Education, Criminal Justice, they did not enter a 'career path' or to seek 'progression', but most felt a vocation. Vocation cannot be conjured up, nor can its root motive, compassion, be taught or trained. I may attend any number of Mental Health Awareness training events, with input from service user perspectives, but if I fail to see the people I work with as worthy of compassion, then there is no magic bullet which will allow me to tick this off in my professional development portfolio.

Pity cries and walks away, it looks down on those in need. Compassion enters into the experience of the person in need and seeks to understand its causes and, in time, the actions which can be taken together to meet that need.

Don't get me wrong, compassion in public services costs those for whom it is the primary motivation. I would argue that the heart of compassion in many staff is why the NHS is the envy of the world. Day in and day out, committed, compassionate staff come along side the vulnerable and most hurting people in our society. This kind of response to need cannot be trained or imitated. You know it when you see it. I know when staff working with me are seeking to understand the roots of my distress. I know when staff are motivated by more than a pay packet or are just going through the motions. I know when someone, despite the limits of the system, sticks with me until, together, we find a way through to recovery.

I have been on both sides of public service and I know that when I meet staff who recognise our shared humanity, then there is a strong foundation on which therapy and medication can be built. Rather than mock the beliefs of someone in the throes of psychosis, humanity asks, 'What would I want someone to do if it was me?' Relationship depends on trust, therapeutic relationships begin with a compassionate assessment of another human being and their needs - some of them shared by all people, even me. If you view the people you work with as 'them' rather than 'us', maybe it's time for a change of career, or a holiday?

Nanny McPhee and the Therapeutic Relationship

"When you need me, but don't want me, then I'll stay. When you want me, but don't need me, then, I'll have to go" Or words to that effect. It has only just struck me that this quote from Nanny McPhee sums up the crux of the therapeutic relationship. I am into the second month since full discharge and have been reflecting on the transition from needing the support of services through wanting it more than needing it, to finally realising I no longer need the levels of intervention I have previously required.

I recently had an interesting discussion with a friend of mine who is also a service user. He now works as an Expert by Experience and told me about a psychologist colleague who had been arguing with him about the nature of the therapeutic relationship. She believed that such relationships should not be considered as friendships. My friend and I both profoundly disagreed with her. Boundaries and professional distance are essential to ensure the efficacy and the emotional health of both the practitioner and service user, naturally, that's a given. However, there is an emotional bond, or at least there has to be in order for 'unconditional positive regard' to have any hope of developing. If there is not an emotional trust, based on some aspects of friendship, then the relationship may well work to an extent, but, certainly in working with Borderline Personality Disorder, at least, a level of warmth is essential in order to bring about progress. Otherwise how can I learn what a positive relationship established with effective boundaries, but also warmth and compassion, looks like?

I guess it depends what you consider 'friendship' to be. I recognise in my friends different needs and different gifts to me from each one. Some meet my basic social needs. Some are based on shared interests and enthusiasms. A handful are deeply rooted in genuine affection and deep emotional bonds. As someone with BPD much of the therapy I received was focused on my relationships with my therapists. DBT as a therapy model, recognises this and builds in these relationships and working through the ups and downs as they develop to its methods of working.

I find it interesting that when Nanny McPhee first arrives into the chaos and mayhem of the unkempt and undisciplined children, she appears hideously ugly to them. I'm not saying that all therapists are ugly! However, it is a truism when discussing therapy that 'things get worse before they get better'. Part of this process is the setting of boundaries, and the inevitable challenging of behaviours which are generating real distress and pain on the part of the service user. So, in a way there are times when I may find it hard to 'like' my therapist, and vice versa. Such is the stuff of developing relationships of any ilk. If the relationship is allowed to continue and works in addressing the key characteristics of my emotional issues, then my perception of my therapist is likely to become more positive. So with Nanny McPhee, her warts and whiskers disappear, as genuine affection replaces her challenging discipline and the children blossom under her care.

I don't think friendship as an element of the therapeutic relationship need be a threat to the professional. It is a natural part of genuine positive regard and compassionate practice.