I would be extrememly grateful for any opinions you have on this dear readers, as I want to take this to my NHS trust in the hope some of the ideas and viewpoints are viable… the goal being to improve service to patients, and to give professionals more confidence and room to utilise their unique ways of caring, leading to a higher sense of satisfaction for all involved.
Its a bit messy and not the finished draft, but pre-tweek, i’d soooooooo appreciate your views if you have some time to read it. Danke Danke 🙂
The number’s for the numbered points have disappeared in the copy and paste transfer…as have all the references! I’m sure we all know why, anyhoo, the main bones are here!
Good Doctors are never forgotten. Good practice changes lives. Poor practice can destroy them.
Anxiety, Mental Illness & Ethics for Change
Guidance to Treat Anxiety alongside other Mental Health Issues – For Primary & Secondary Care Workers
1. The True Scale of Anxiety in ‘Mentally Ill Patients’
2. Anxiety Kills!
3. A Safe Place is Vital…
4. The Things We All Feel When Were Mentally Unwell
5. Simplify and Believe. When Will The Culture of Distrust Dissolve?
6. The Questionnaire
7. 6 Ways to Nurture Hope…
8. 6 Things We Will Do For You (Immediately)
9. 6 Weeks Alone – Mind The Gap
10. 6 Steps to Great Care – Back to Basics…
11. No More Double Standards – Say Goodbye To Stigma
Guidance to Treat Anxiety alongside other Mental Health Issues – For Secondary Care Worker
Ethics – We Are ALL Equals – We Are Partners
2. Onto Secondary Care…A Patients’ Experience – ‘Doubt Culture’
3. Knowing the patient is an expert
4. Knowing the professional is an expert
The True Scale of Anxiety in ‘Mentally Ill Patients’
Anxiety is associated with
– OCD 
– Bi Polar 
– Anxiety disorders (social/general anxiety) (obviously)
– Several Personality disorders 
– Schizophrenia 
– Anxiety can be easily triggered as a response to health appointments , especially if disclosing frightening and/or difficult to describe symptoms 
– Continuous bouts of anxiety have an enormous impact on both body and mind; the pressure on the heart can lead to fatal cardiac arrest 
Anxiety amongst the mentally ill is a serious, wide reaching and sometim3es fatal health concern. It is so common amongst mentally ill patients, it would probably serve GP’s to view it as a way of life for many/most sufferers of a mental disorder; or a character/personality trait developed by a habitual and damaging response/reaction to stimuli. This allows professionals to not only look out for certain anxious behaviours, but to expect them. As an example, a patient may not exhibit an overt or obvious response when asked to describe a sensitive experience, but if the GP is expecting signs they are much more likely to notice small changes. For example – slow withdrawal from conversation, stuttering, displaying nervous energy with the movement of their limbs, changing posture, fidgeting, trying to change the subject, or their tone of voice etc
Anxiety is linked to fear, and it negatively impacts upon several very important brain systems , flooding the body with damaging hormones and negative neurological reactions.
Leaving sufferers to cope with the multiple malfunctions of several brain systems is dangerous. Recognising the impact of anxiety, and understanding its prevalence amongst the mentally ill population, are both key for addressing the complex problems it can cause for body and mind, especially if it is a long term issue. It requires treatment of its own, in order to minimise further damage to mind and body
A Safe Place is Vital…
Anxiety is likely to make the patient feel scared and internally ‘charged ’as their brain launches it’s ‘fight or flight stress response’…The Importance of providing a safe and supportive environment/place for the patient to talk, is vital for good practice
The Things We All Feel When Were Mentally Unwell
The short questionnaire (below) addresses mood, emotions, feelings, anxiety, stress, opinions from family/friends and current coping level. Reaching an exact diagnosis of certain mental illnesses can be complex and requires time and expertise; but this questionnaire provides an overview of whether or not somebody is suffering from –
– ‘Generalised Poor Mental Health’
Simplify and Believe. When Will The Culture of Distrust Dissolve?
A simple test (questionnaire) should be immediately offered to a patient who reports mental health difficulties. This method of asking relevant questions is popular because it can help ‘frame’ and highlight specific issues. People often find it hard to describe what they are feeling and thinking when they first b3ecome mentally unwell, and confusion is common; the questions act as helpful prompts where-by the patient can recognise themselves in the description
1. Do you feel overwhelmed by your emotions or feelings?
2. Do you experience any anxiety related symptoms, such as shaking, numbness, feeling fearful, panicking, a racing heart beat and/or shortness of breath
3. Do you feel you have little control over your thoughts?
4. Do you have problems with sleep? Too much/Too little?
5. Do you feel like you have too much energy/too little energy?
6. Have family members/partners made concerning comments about your health and/or behaviour?
7. Do you experience mood swings that are moderate to severe?
8. Are you finding it difficult to cope with daily life? What is most difficult?
9. Do you think your emotions/feelings/behaviours are outside of cultural norms?
10. Do you worry about your emotions/feelings/behaviours getting worse?
11. Do you think your job/family/social life would become unmanageable if your symptoms either – persisted over a long period, or intensified (got worse)?
6 Things We Will Do For You (Immediately)
1. Assign specific care workers to your case, who you will see each time you visit primary care (GP/Mental Health worker), and the same goes for secondary services (MH Worker/Psychiatrist). This is to help build trust, familiarity and confidence in relationships. Too many people involved in one case often leads to gaps in care including missed medication, lost prescriptions, different opinions; and sometimes different diagnosis’s are made, by multiple professionals. Dealing with ambiguity, inconsistency in diagnosis, constant questioning and ‘chasing up’ medication, can and does increase stress/anxiety for patients. 
2. Using the original questionnaire for simplicity and continuity, further appointment’s with your GP/ MH worker will be used to uncover what issues are most pressing and problematic (emotions, compulsions, insomnia, anger, depression etc). The patient can usually identify what problems stem from their ill health if they are asked about specific symptoms. Asking questions about very common symptoms does not require secondary specialist knowledge; therefore the GP’s and MH workers in primary care can pass on valuable clues (from the information given in primary care) to secondary care. (For example, if Bi Polar is suspected, questions about racing thoughts, risky behaviour and sleep patterns could be explored by primary care professionals. These sorts of pertinent questions may help the patient to recognise/describe specific troubles ()
3. We will explain to you, the differences between counselling, group therapy, community projects and CBT etc, as relevant to your NHS trust. GP’s and MH workers should be familiar with all the available therapies in the area, so patients have a good idea just how different the therapies are from each other. You will discuss together what you think will work best
4. We will tell you what services are available in your area/budget/trust, the services provided by public/private and charitable organisations should all be included
5. Referrals – We will work with the patient and ask for their input for any referral. The documents should state the patient’s feelings/opinion and should ALWAYS be supported by the MH worker or GP. A good professional advocates for their patient’s needs. Your case workers will listen to you and accurately discuss your problems with outside help or secondary services, if needed and wanted by the patient. Need will be assessed on the severity of the symptoms, the distress of the patient and the extent to which their illness impacts upon the patient’s life, and the lives of their loved ones
6. As soon as a patient expresses concern over their mental health, the questionnaire and an information pack should be given to them immediately. The pack should contain details of who does what in that trust, as well as tips relating to self help, self awareness, internet forums and websites (signpost to reliable and agreed upon sites). Personal stories of recovery and hope can be profoundly inspiring, so these should also be included in the info pack.
7. Finally, it should contain simple strategies – for managing feelings/emotions/anxiety/mood swings/depression etc (such as :- deep breathing, yoga, guided meditation, exercise, distraction techniques, time with friends, reaching out, joining a group, eating a healthy diet, hormone treatments etc)
6 Ways to Nurture Hope…
1. We will acknowledge how hard/scary/draining/isolating life is, when your mentally unwell
2. Whether your mental health problems are short or long term, severe or moderate…we will do everything we can to improve things, so that your quality of life is as good as it can be
3. Whatever your diagnosis, there is a crossover of treatments all relevant to ‘poor mental health including anxiety.’ We will discuss styles and typical outcomes with you, before choosing the help best suited to you. Medication, Meditation, Spiritual awareness, CBT, Counselling, Anger Management, Alcohol/Substance Abuse specialists, Emotional regulation, Art Therapy, Exercise, Diet, Other Interests, Self Esteem Building, Volunteering, Finding your passion, Creative works; and Studying, are tried and tested ‘therapies’ that may help you. It’s a very individual choice, and all patients have the potential to improve their quality of life if they feel personally connected to one or more of these things
4. You’ll hear lots of different titles on your journey. GP, mental health worker, community psychiatric nurse, psychiatrist, psychologist, counsellor and therapist – to name a few. These different professionals have in common; various skills and knowledge in the MH field, and a commitment and obligation to improving your health
5. Armed with practical/simple/appropriate treatment(s), and good care, we hope to give you skills and tools to alleviate some of the daily pain/distress associated with your poor mental health.
6 Weeks Alone – Mind The Gap
In the time period between an individual expressing concern over their mental health to their GP, and the beginning of treatment from secondary services, care is often scarce; leaving a gap in service at a time when support is critical…To address this – Using the questionnaire as the basis for the first few appointments, will add structure, and hopefully encourage GP’s and MH workers, to increase the number of times they see the patient, before they refer them to other services. This will facilitate more detailed reporting of symptoms and issues; and the increased support may foster healthy feelings of trust between patient and professional
6 Steps To Great Care – Back to Basics…
1. Show Kindness – at ALL TIMES…
This is so overlooked and undervalued. Kindness is priceless, it feels like the opposite of fighting for your care, and it is a sign of great respect. I feel valued as a person whenever someone is kind to me.
2. Know your area. Know the local services. Know their telephone numbers. Communicate with the people who work there. Know exactly what is on offer.
3. Team Diagnosis…Patient & Professional Together– You are with a patient for an hour a week maximum; and it is unrealistic to presume you can diagnose a complex illness in one hour. However, it is a failure to patients that it takes 7-10 years to diagnose someone using current methods. All professionals involved should continue to use the questionnaire (or something similarly simple and inclusive). Only professionals qualified to diagnose MH problems will need to ask other specialised questions based on symptoms.
4. Acknowledging Patients Expertise/ Self-Help Possibilities- Whether depressed, anxious, disordered or psychotic…emotions/moods/feelings/behaviour and relationships are all tested by mental health issues. Treatment can exist without an exact diagnosis in some cases, but for long term illness, a diagnosis is essential to the patient if they wish to become an agent in their own care; the internet and published materials are great resources for a patient seeking recovery. Communicating with others (on forums and blog sites) who have the same problems, is often therapeutic. We feel less alone, less strange, less ‘lesser’. Sometimes a diagnosis is all there is for a person who has lost everything. This is important to remember throughout treatment, because when our identity and lifestyle changes completely, the illness is sometimes the only thing left in life. A diagnosis is not only a medical guide/tool for professionals, it is necessary for the patient to be diagnosed as soon as p[possible, so that medications and treatments don’t run the risk of being untimely and inappropriate, or at worst, cause more harm than good
5. Stigma and Discrimination – Culturally, mental health is largely misunderstood, and many patients are mistreated and judged as a result. Sufferers are often socially isolated, emotionally spent, ashamed; many have to cope with losing their job, and end up relying on benefits. Further problems can arise from the inability to care for self and home, leading to more negative feelings and associations for the patient. Effort from both primary and secondary professionals is needed, to develop new methods of working with patients, where-by their personal insight into their illness is explored, utilised and recorded for diagnosis purposes. Patient and Professional should work as a team from the start. Reduced time scales for diagnosis and significant improvements to patient health will hopefully be seen quickly after changes to practice are made
6. Change– Reflective practice and sharing skills with colleagues will enable MH workers to ensure they tick all the right boxes from now on, through team work with the patient, and if necessary or helpful, involving family too, can give great insight into the patients issues, as it is family friends and partners who see the issues day in day out
Ethics – We Are ALL Equals – We Are Partners
1. If the relationship is seen as being based on two equals, professionals would be correctly deemed as being paid very well to provide a service to vulnerable patients, with standards to adhere to, ethics to be aware of, and good results as measured by the patient and the workers involved.
2. At the beginning of each session, the patient should be given the ‘write up’ from the previous session, to check for any mistakes or misunderstandings. This process will help ensure that the details of each appointment are fully and honestly recorded. This procedure would also eradicate the issue of resolving disputes between staff and patients – relating to incorrect, offensive, misleading and/or problematic paperwork; written months or even years previous.
Onto Secondary Care…A Patients’ Experience
I am a MH patient, diagnosed with BPD and Bi Polar disorder and my relationship with the MH services has disintegrated beyond repair. I found the appointments’ consistently pushed for recent evidence, even if it wasn’t there. My memory was seriously impaired by the 3 different psycho active drugs I was taking, (against my will and at a great cost to my health) so I found it continually difficult to recount the week’s events. However, I had many memories of several periods of ‘mania’ and depression that had occurred months and years before, but each time I referred to these past episodes, they would again ask about the previous week. I became aware that they would not believe me until they saw some outwardly sign. It took years before they saw me in a manic phase, on a particularly manic day, and as soon as they witnessed it, they re diagnosed me again and insisted I got a taxi home due to the danger of me being run over. I also recall being depressed and reporting this to the psychiatrist for a number of sessions, and I noticed each time, that he didn’t write it down. The next week I arrived at my appointment in floods of tears, and I was documented as ‘very depressed’.
For many years my appointments began with – How have you been this week? They then wrote down the answers, checked the dosage of meds, changed it or kept it the same (depending on their analysis of me; even when it was in direct conflict with my reported feelings and mental state). I asked for practical tips, strategies, and ways to get better many times; but it seemed the appointments weren’t about improving my health. Just proving my ill health. Over and over again
1. Knowing the patient is an expert – Because he/she lives with the illness 24/7. Self reporting of symptoms needs to be met with less suspicion and episodes should be documented as described by the patient. Several studies show that doctors and patients ideas about their quality of life, differ greatly, academics confirm that reliable and consistent measuring must come from patients. 
2. Knowing the professional is an expert – Because she/he has learned about the illness. However, until the professional knows the patient, he/she is a stranger to the individual. An illness does not exist separate to its vessel. The person and the illness merge to make a specific set of problems and (hopefully) solutions and no two cases are ever the same. This ethics lead outlook highlights the sense and benefits associated with simply believing the patient and accurately recording their descriptions of any relevant experiences. Observing Signs and symptoms in the Psychiatrists Office will have limited use, for the person is not in their home environment, neither are they comfortable, and many are afraid of powerful medics controlling their life. All these issues trigger covering symptoms during an appointment, in these cases it can take years before the professional sees any signs of proof of illness. For these reasons it is essential that all MH professionals reflect on their practice, in the hope of seeing that the patient’s experiences have to be the base point and beginning point of the journey to diagnosis, and logging the patient’s version of events, does not imply that the MH professional is agreeing or not agreeing. As mentioned earlier, talking to the people who have relationships with the patient, can provide enormous insight into issues, where as now, involving loved ones in diagnosis is virtually unheard of
Diagnosis – ‘Proof proof and more proof’
Re diagnosing by many different psychiatrists is another common problem. ‘Requiring excessive proof of symptoms’ seems to be a key issue for MH professionals. This illuminates the ‘doubt culture’ of the workers who question and distrust the judgement of patients, colleagues and team members, and insist on going back over the facts again and again and again. This is clearly not a patient focused approach. I personally suffered a lot of distress during the 7 years it took to me to re-state difficult information from the depths of my memory banks. This type of practice portrays the disbelief that seems to be part and parcel of the system; and further delays diagnosis and treatment options. I was once given a 300 questionnaire to fill in to see if I had BPD when I had been diagnosed with it 3 times at that point! 300 questions to be dealt with on anti-psychotics is a tall order for even the strongest of patients, as the memory is seriously impaired …
GP’s should be given back the power to insist on a psychiatric appointment for the patient, if the patient feels he/she needs to be seen by a secondary MH professional. Often the information being given to the GP may be indicative of a particular disorder, and this pertinent and specialist information needs to be heard and recorded (not lost in the process). When discussing my MH symptoms with my GP, he wholeheartedly agreed with me when I suggested he may miss or misinterpret vital clues/signs/reports of significant and relevant emotions/reactions/events/habits and/or periods of instability 
Patients should not and cannot successfully be assessed for any acute and enduring mental illness, based solely on a GP’s skills, due to the secondary nature of diagnosis and treatment. But, the NHS’s reluctance to help patients get an assessment from a qualified practitioner shows discrimination in practice, due to stigma, which always leads to further suffering for those with a mental illness. 
No More Double Standards – Say Goodbye To Stigma
Both physical and mental ill health problems often need the help of a secondary care specialist. A referral is a request for further investigation, diagnosis and treatment. Sadly, the actual numbers of requests that lead to an appointment with a MH professional are miniscule, compared with referrals to physical secondary care services. The double standards are indicative of stigma and discrimination again, attitudes based on stigma still exist within mental health and its associated care.
Multiple requests for help to secondary services that are refused (by secondary MH workers), without ever meeting the patient, will no longer be tolerated. The stigma has allowed a neglectful and uncompassionate attitude to flourish amongst MH professionals; and the current system includes multiple barriers to treatment and recovery; the same barriers and discrimination would not be tolerated in secondary care for physically ill patients.
Good Doctors are never forgotten. Good practice changes lives. Poor practice can almost destroy them.