Assessment – Patching the Soul

I’ve hesitated in writing about this topic, because I know things are extremely difficult in mental health services at the moment in this country. I don’t want to sound as though I think it is easy to do things differently. When teams are being cut it is very hard, and I am also retired now from clinical care so I am not in the firing line any more.

But what I’m going to talk about goes way back beyond the present problems- as long as I can remember. When I was younger, it pervaded the decisions I had to make when I saw a person in A&E who was unfortunate enough to live on the wrong side of the red felt pencil line in the on-call copy of the Manchester A to Z. It’s the problem that led one senior psychiatrist a few years ago to respond to me in a research questionnaire that no other speciality defines itself more adamantly by what it does not do than mental health. Its important to also say that I am not here referring to the awful burden staff carry when trying to find a bed for a person who needs admission; when they can spend all night phoning around the country. I know they are trying desperately to help the person who is in immediate need of care. I’m talking about what happens at the front line contact- when a person is referred by their GP, or seeks help- long before their problems have reached the point where admission is indicated.

We talk a great deal about patient and service user centred care in health services, but what we deliver and receive is not always that. The `Goldilocks Principle’, which applies in many areas from climate study to economics, states that something must fall between certain margins, rather than reaching extremes. The earth is a Goldilocks planet as it falls within a planet’s habitable zone. So what does have this to do with health care? Well, in mental health care the situation is often the reverse of the Goldilocks story. Instead of one person and three bowls of porridge, which may or may not be right for them, we have the reverse. Three people and one bowl of porridge. A service often defined by what it will not offer rather than how it might help, with no other options available for the people who do not fit these criteria. The decision not to help the other two people is often accompanied by the statement ‘we are not commissioned to provide X,Y……’ This is not a new phenomenon. It existed beyond the current cuts, but they have made it worse.

Now, there may be so little on offer that even access to that single bowl of porridge is limited or absent. Or a person may be told that their health will have to deteriorate further before the service will accept them. ‘Go away and come back when you are just right, even though we all know that is going to make it even harder to provide the help you need in the long run.’ And I know this is not a new phenomenon in the inner city populations where the lack of opportunity for early, timely intervention means a person may only be offered help, even though their GP has tried and failed to get them care for some weeks, at the point beyond which they no longer believe that they need it. So they then receive it under the Mental Health Act.

But when we do get the opportunity to re-build services- and its difficult to have seen thirty years of changes without hoping that something will change again at some point for the better, we need to try and ensure that what is provided is not simply about matching the person to what is on offer. This is what results in the multiple assessments with different teams which service users find so difficult, demeaning and pointless. This doesn’t have to mean allowing a person to choose exactly what they want, like Goldilocks did. We know that has problems not only of cost-effectiveness but the risk of causing harm. It is about having a dialogue in which all views are considered.

On a personal level -It is about thinking- ‘How can I help this person to get what they need’? If I cannot help them- who can and how can I facilitate them to arrive there. If it isn’t available what can I do?

At a service level it is considering how, if the person doesn’t really require specialist care, how can we support their GP, and/or the third sector to provide that care- and if we are ill equipped to do that, how can we find out.

It is also about ensuring we are not ‘cherry picking’ those people who are easier to help to improve our outcomes but trying to meet the needs of the people we were commissioned to help.

At an organisational level it is not only about developing specialist skilled teams to deliver help for more service users with complex problems, but making sure these teams in turn provide the right support to generalists. This will help to ensure service users who need help for which services have not been clearly commissioned and ‘fall between the cracks’ can be offered appropriate care.

It also means fostering a culture of dialogue, trust, respect and cooperation to ensure that the worker who makes initial contact with a service user is not told that their assessment is of no value because they do not belong to a particular profession or work in a certain team.

At a commissioning level, it is about asking the question ‘what are we not doing?’ ‘what isn’t there that should be?’ and ‘what isn’t working?’ for people with mental health problems- who will be able to tell you very clearly. It may not be possible to provide it, but we still need to talk about it and work out what can be done rather than what cannot.

At the moment it may seem hard to achieve any of these things- but these are not new problems and they will not all be solved by more investment. A person should never be thought of as ‘just right’ for a service. The care that they are offered should be, like Goldilocks’s porridge, ‘just right’ for them. Only unlike in the fairy tale, we should also try and ensure that doesn’t come at the expense of others- the three bears.

One of the side effects of having more time than I used to is that I begin to brood over the meaning of the words I once used without a second thought. It particularly happens on long walks without the running commentary of the radio. In a recent bIog I talked about ‘recovery’. Now I’ve started to think about a word I would never have given much more than a second thought too as a working psychiatrist- ‘assessment’.

The problem with many words in mental health is that they can begin to assume alternate meanings. Use of the ‘active’ and ‘passive’ tense can be important too in conveying a sense of who has the power. There is something very passive about being ‘counseled’ and the act of counseling has itself taken on various meanings from receiving counseling as ‘therapy’, wise counsel as ‘advice’ and being ‘counseled’ as a form of disciplinary act.

I don’t remember as a psychiatric trainee being specifically trained to carry out a ‘psychiatric assessment’. I was taught how to master a psychiatric interview, which considered of ‘taking the history’ (which can sound and feel rather like a rather one-sided action on the part of the doctor, removing something from the patient) and carrying out a mental state examination. I soon learned that for the interview to be effective I had to spend as long actively engaging the patient in thinking I was a person with whom they would be willing to share their experiences, as asking all the questions that psychiatrists are (in)famous for. Later on, I began to research how both GPs and psychiatrists approach the ‘consultation’ as the meeting between professional and patient is commonly known in primary care. Indeed actively ‘consulting’ the doctor conveys more power to the patient than being interviewed or assessed by them. I spent hours, days and weeks observing interactions for my research. I remember the patient who, when asked by the psychiatrist whether he knew if he had had a traumatic birth quite reasonably replied ‘well the Battle of Britain was on at the time doctor’.

Somewhere along the line, the psychiatric interview or consultation became the ‘assessment’ with a list of questions to ask the patient. Changes in the examination system of doctors reinforced this, with the shorter structured OSCEs (Observed Structured Clinical Examinations) with role-played patients, that are probably fairer to the candidates, but reward marks for asking the ‘right questions’ when ‘assessing depression’, ‘suicide risk’ or ‘hallucinations’. I’m as guilty of this as anyone. I teach suicide risk assessment skills. The blurb for my latest book on depression mentions assessment too.

So what’s the problem I have with assessment? Well, when a person assesses another they are implicitly making a judgment about their suitability for something or their ability to achieve particular goals. As a patient I have been assessed for therapy. That’s fair enough perhaps when there are indications as to whether or not a person might benefit rom that intervention. Psychologists regularly carry out assessments perfectly reasonably as not everyone will benefit from their specialist expertise. But how often is this mutual assessment? Are you a person I could talk to?

And so often now I see mental health assessment as a tool to exclude rather than seek to help a person find the help they might benefit from. Its more ‘this person isn’t psychotic or actively suicidal so there is nothing we can offer them’ rather than, ‘this person is consulting me. They are extremely distressed. They don’t understand what is happening to them. How can I help them?’ In our increasingly fragmented health care system everyone is carrying out assessment according to their particular ‘criteria’ while the service user understandably feels they have been ‘assessed to death- when is someone going to help me?’

Can we move away, in mental health care, from this culture of assessment back to one of a consultation, which David Tuckett and his colleagues first described many years ago as the ‘Meeting Between Experts’?

I am the expert in what I am experiencing. You are the expert in what might be effective. In consulting you and providing you with all this very sensitive information about my inner life, I’m an trusting that you as a professional will be able not only to say if you will be able to help me personally, but also that you will do your best to help me access what I need.

I really need your assistance now to navigate this increasingly hostile system of care. I am asking for your help.