On judging your patients

The thing about working in mental health is that it can be appallingly easy to turn into an insufferable know-it-all. This is partly because the second you tell someone what you do for a living (and I write this as a psychologist, rather than a nurse or an occupational therapist, for example) they ask you lots of questions. This means that you get to feel very clever and wise as you discourse on the ’causes’ of mental illness, or as you briefly summarise how one accesses mental health services (no one ever asks how you access physiotherapy – they just trundle off to the GP. But mental health seems hidden in the shadows and no one ever seems to know that you usually need to trundle off to your GP if you’re worried). But very quickly, this can feed your ego. The fact is that many of us in health do have very specialist training and that we have worked damned hard to ‘make it’. I think people who ask about our work usually do so because of a genuine interest and often they expect some sense of expertise (though perhaps not pomposity). The problem, I think, is not so much in how we relate to the public at large, but how we relate to our patients.

To be perfectly frank, it’s really easy to end up with a mindset which informs you that you are, fundamentally, better than your patients. Often, we work with people with offending histories, with significant relationship problems, with addictions, with thoughts of suicide, with financial problems or with less education than we have. Think about how most of us get our sense of self; what make us feel good about ourselves – our physique, our job, our car, our hobbies, our salary, our partner, our house. If your lifestyle meets a certain set of social conventions it’s really easy to become superior, to see every patient as another set of problems You will almost certainly have seen a health professional who made you feel like that at some point – who made you feel small and stupid and insignificant. I’ve seen at least three like that. I hated them all. I never went back to see any of them. I had that luxury. Many don’t. Many get stuck with professionals like that; professionals they ultimately despise.

Much of this attitude is reflected in the ‘should’ attitude. ‘He should stop drinking’. ‘She should stop self-harming’. ‘He should lose weight’. Never mind that lots of health professionals drink too much, that many of us are overweight, that lots harm their bodies (and perhaps minds) through drug use – our patients ‘should’ do what we think they ought. One of the more vigorous campaigns of recent years has been the anti-smoking one – aside from the ban on smoking in public places, most hospitals are now smoke-free, which means that if you want to smoke you either have to walk miles to the nearest exit (hospital sites are often enormous) or you have to find a corner and hope no one sees you, much like a schoolchild, except you’re probably thirty years too old for school. And that’s just for the staff – there has been enormous emphasis on stopping mental health patients from smoking. This seems well-founded – people in MH services are more likely to smoke, to have poor physical health and to die earlier. But one thing that’s always struck me is that if I was often highly-stressed and if I didn’t have the things that keep me pretty solid – my job and my interests and regular holidays – I’d need something which took the edge off the worry. Most people who smoke say it takes the edge off – people who drink too much often say something similar – so would I smoke? Possibly. Would I drink? We know that one of the main reasons people drink is to deal with unpleasant emotions, so again, perhaps I would. On top of that, if I was an inpatient in a psychiatric ward I may well smoke just to pass the time. They are often not, it must be said, the most stimulating of environments.

So I am, evidently, sympathetic to alcohol and tobacco use because in my experience it is usually symptomatic of something deeper. I was thinking about this today because today I told several of my patients that smoking probably helped their mental state and that trying to reduce their tobacco use was probably unwise (as an aside, most people I see are in their 80s and a small part of me thinks that if you’ve been smoking for sixty years maybe I should just let you get on with it, especially if you also happen to – and brace yourselves here – enjoy it). I was muttering about this on Twitter earlier when the esteemed Alex Langford (@psychiatrySHO) asked what I thought of crack use as a coping mechanism. I told him that, fundamentally, I believe people cope in the best way they know how. I don’t think taking crack is how I would choose to cope with the things that make my life more difficult, but then, I have a lot of other coping strategies – I have friends and I write and i have the luxury of being able to pay for cinema or theatre tickets to escape my worries. Not everyone has those things and not everyone knows they exist. I grew up in a family in which alcohol was a no-no, so I never learned that it could make you forget your worries. That’s a relatively unusual experience, but the fact I don’t drink to forget doesn’t mean I’m better than someone who does drink to forget – maybe they have more to forget than I do. Or maybe I was just lucky enough to have a bigger bag of tricks than they.

But this goes for many things – self-harm is a coping mechanism for many people. So is eating. So is getting angry. So is telling people you’re considering killing yourself. One of the most awful phrases in mental health is ‘maladaptive coping strategies’ – a phrase I am ashamed to say I used to use before I really thought about what it meant. These days I try to be a little less sanctimonious. Most people do what they need to do to survive. If they’re hungry they steal. If they’re lonely they’ll try to find a way to be looked after. If they’re in pain they’ll find a way to express it. And if life has been so ghastly that you can’t express it through words or by asking for help, you need to be more creative, even if that has some negative consequences. A&E staff can sometimes be dismissive of people who attend following self-harm, but at the very least they will patch you up and provide you with something approaching care. Getting drunk might lead to a terrible hangover but at least you were free of your demons for eight hours. If you’re isolated and lonely casual sex can be a really good way of feeling loved, even for a short time – and, just for reference never, ever underestimate the importance of being touched by another living, breathing person, even if it does occur in less-than-ideal circumstances.¬†Getting angry and assaulting someone might land you in court, but at least you weren’t small and frightened and vulnerable to harm from another. The trouble is that not all professionals see it like that – for many, it’s a case of ‘do as I do’, or, perhaps, ‘do as I say’ (as I said, we’re not immune to coping in many and varied ways ourselves). What this frequently means is that we judge our patients; that we look down on them for not being good enough or trying hard enough – perhaps feeding right into their own fears about not being good enough and not trying hard enough. But more than that, we implicitly tell those patients that the mechanisms thy have learnt are incorrect, are unworthy. You know what? In my experience, many patients already think that, at some level. I don’t think it’s unreasonable for mental health professionals to provide something a little more sophisticated, a little more constructive and a little more compassionate.