It’s What’s Right With You That Will Fix What’s Wrong With You

I revisited this article that I wrote in 2008 and only had to take a few words out.  If there are any Mental Health Unit staff out there who read this and think “what nonsense, she is out of date on this”! – please contact me and I will gladly edit each and every time. Eileen

It’s what’s right with you that will fix what’s wrong with you.

There is great talk every decade or so about “what is good mental health?” and “how can we focus on promoting good mental health rather than only providing reactive resources?”.

If we were to draw up an ideal: then Mental health services would be accessible at early stages of depression for instance, bypassing the GP and offering a “talking therapy” approach rather than waiting for the diagnosis to become critical before a service can be accessed. Often a simple “future focused” conversation with a therapist who is curious about your resources as an individual, who wants to know more about your strengths and coping strategies rather than only showing interest in analysing your past –  can help people get back on track.

Imagine having a tooth ache and having to wait until the tooth completely decayed before you were able to see a Dentist – how incredible that would be yet this is exactly the case for many people who feel vulnerable or are at risk of losing their way and losing their confidence, which in turn hampers their effectiveness in their everyday life.

Imagine too that if you didn’t get an early intervention service and you slipped into addiction or clinical depression and then were expected to recover in a system that offered the shabbiest, the most miserable of environments within the health service. Depressed? you will be.

What doesn’t cost any extra funding at all is existing staff training structure being tinkered with, at the very least, to include how effective “being nice” to a patient can be. I am not in the least embarrassed to say that. Throughout my work within mental health – the one thing that continues to astonish me is that when I ask patients for feedback on what works for them, the response always includes small personal interactions with staff i.e. “she said I was kind and that she had seen me helping someone, that reminded me that I am worthwhile” and “he said I had good coordination, that reminded me when I was in the school football team – that was a good memory”.

This for me is the fundamental importance of good mental health treatment – reminding someone of their core being; who they are; when they achieved; their resilience; their qualities – because that is what will always get us back on track when we lose our way.

As a Solution Focused Brief Therapy (deShazer ’85) Practitioner, I have firm ideas of how Solution Focused Brief Therapy fits into that in real and practical ways that are cost effective and efficient.
When we work with teams from the NHS, we start with the basic importance of making small creative changes in the built environment; then we focus on lessening the state of anxiety and a reminder that as human beings how being around people who are even more anxious than us can throw us further off kilter.

Staff are encouraged to “catch someone doing something healthy” and comment on it. To elaborate on this: if staff are trained to look out for signs of good mental health in any small way (having a coherent conversation for just a moment can be a huge move on for some patients) this can be instrumental in the journey towards recovery. If ward staff are only charged with monitoring their safety rather than any strength or resource – this opportunity is lost.

I have not been to every psychiatric unit nor every closed unit so am totally prepared to be educated by those units and wards who already adopt such an approach.

The first night on these units can be scary and chaotic and the start of a downhill slide towards worsening mental health. Courtesy and respect for and towards the patient can go along way to helping a patient find their way back to emotional safety – I would like to see any Hospital Finance Director try to argue that “there is no room in the budget” on this issue.

Our charter for a Solution Focused Short Stay Psychiatric Unit would look something like this:

Empathetic care and domestic staff

Surly staff make anxious patients.For many patients on the ward, the colour of the uniform worn by domestic and those worn by care staff merges into a “staff” uniform and everyone can be influential in their well-being and gradual recovery.

Well maintained environment

Shabby environments induce a loss of hope. Peeling posters, broken furniture, blaring music and stuffy, smelly rooms to shuffle about in just add to the chaos. Clean, comfortable soft furnishings, pretty pictures, fresh flowers or plants have an incredible influence on how we feel.

Nutritious diet

There is enough research published on this issue and how it affects our behaviour and emotional state for it not to still just be on the agenda for change

Stability and Security
If you, the reader, asked yourself what adds to your stability and security in your everyday life – peace and quiet would come in their somewhere I think. Your own bed being yours and not given to someone else if you go away for the weekend might also be in there; a structure and framework to live within, rather than a “get up – do what you want after medication, then shuffle around some and then go to bed after medication” might also be in there.

Mind-numbing inactivity makes for mind-numbing

Table tennis is good, so is snooker but would a couple of Easel’s; some Sculpture Clay, a couple of games that encourage something creative and spiritual; some singing groups just to get air in the lungs – be out of the question?

I hope, if anyone ever did revamp mental health services that they took a glimpse at the result of the many Placebo trials that have been instigated around the world and at least keep an open mind on what these trials have shown – not least that often, it’s just the time spent with patients during trials that actually plays a big part in recovery. Research on placebo trials show this time and time again:

Following an analysis of 96 anti-depressant trials between 1979 and 1996, Seattle psychiatrist Arif Khan found that in 52% of the trials, the effect of the drug could not be distinguished from the placebo.Khan suggests that the placebo response with SSRIs may be so high because patients in these trials get a lot of attention. On average, they spend 20 hours being asked detailed questions over a two month period. This compares with the 20 minutes a month of attention a typical patient gets when being treated with the same pills by their local doctor. (Source: The Guardian: Make-believe medicine 20/6/02):

Also from Andrew Leuchter, Professor of Psychiatry at University of California:
“We like to think that we give people treatments and they get better but we don’t actually know in any individual why they get better. However one of the factors is undoubtedly the time we spend with people and the feeling of being connected which that gives patients”.

The tests raised the tricky questions about whether mainstream medicine should be so sniffy about placebos. If they are having observable physical effects on the brain, just as drugs do, what exactly is the difference? Some researchers believe that mainstream medicine should think about placebos in terms of making positive use of them, rather than treating them as a nuisance factor. They might also point the way to new treatments.

Research also shows how people in other countries respond in a different way to placebos. A study last year looked at the results from double-blinded trials for stomach-ulcer medication around the world. The average placebo response rate was 35% for the US, but in Germany it shot up to 59%, in Denmark – 22% and in Brazil – 7%. The reasons for the differences is unknown.

Timothy Walsh, a psychiatrist at Columbia University found that the placebo effect has grown in recent years. A higher percentage of depressed patients get better on placebos that they did 20 years ago. A major reason for this is almost undoubtedly “rising expectation ; “it is an intriguing thought that massive drug advertising campaigns don’t just sell more drugs, they may actually make them more effective”. (Source: Jerome Burne, Medical journalist).

Placebos seem to trigger irrational responses in patients as well as the profession, Leuchter revealed what happened once his anti-depressant trial was over and he told the placebo responders that they hadn’t been getting a drug. Nearly all immediately relapsed and demanded to be put on a real drug. Only one spotted the faulty logic and declared that if he could make himself happier without the drugs, so much the better.

I am curious about these trials, as all practitioners should be, but what they clearly indicate to me is that human interaction; someone colluding with the patients in the belief that recovery is possible and creating a “watershed” between illness and wellness can be incredibly effective.
This report from Melissa Healy, in the Los Angeles Times that reinforces that:

In one 2002 study at the University of California, Los Angeles, one-third of patients reported relief from symptoms of depression (and had changes in brain function that reflected that improvement) when treated with Obecalp. Patients with Parkinson’s disease have observed their tremors decrease, those with chronic aches have felt their pain ease and hypertensive patients have seen their blood pressure fall — all in response to Obecalp (which is just Placebo spelt backwards!)

The incredibly powerful impact of “influence” between professionals and patients has always fascinated me – perhaps it’s because we need people to reflect back to us that we are cared for and especially so when we are anxious and vulnerable. I have seen many patients being transformed from their feelings of worthlessness following a simple gesture of courtesy from a professional charged with their welfare.

I have always been fascinated too by the power of placebos because of the questions that they generate: how can it be that because one human being says to another human being “this will help”, that a substance that is nothing more than sugar actually does help? Similarly, “Healers” fascinate me: how can it be that because one human being says to another human being “I am taking away the pain”, that pain goes away.

I have a theory (although, as deShazer advised, I usually lie down until it goes away) that these truisms can be harnessed for better use in the mental health system.

Given that we only get 4,000 weeks in a lifetime, it does seem such a shame to spend so many of those weeks tracing the pathology of the problem when so much research tells us that human beings can be greatly affected by the raised expectation theory of the placebo and the patience and time given to the recipients of placebos. There is an answer there somewhere.

I always start my training programmes with one statement “the mind is a powerful thing”. In all these years, I have never had anyone disagree with me.

© Eileen Murphy 2008