Tuesday, 6 November 2007


I started to reply to a post over at Mental Nurse but had to stop. It was becoming a rant and I rather feel it's bad form to go somewhat off topic and to rant on someone else's site. So instead I've shamelessly nicked the theme and can wax lyrical at length, as is my wont. At length, hmmmm. I do "at length" well enough, I do "brevity" appallingly badly. As my nursing colleagues tell me, flawed though I am that at least I'm self aware :-) After a manager wanted to highlight some good practice in our service I've been charged to talk at a conference in a couple weeks time for a total of 15 minutes. 15 minutes?! An impossible task, reinforcing views that managers are out of touch with clinicians and heartless ;-)

Back on topic . . . therapeutic relationships.

The point, well made, is that outcomes of therapeutic interventions is uncontestably associated with the quality of the therapeutic relationship. For some folk in some situations this isn't true. A mother with a newborn baby who has crashing postnatal depression needs to be well, and quickly, evidence is ECT is more effective than medication or talking therapies and has better outcomes than pills, talk or watchful waiting (and less side effects, and half the deaths that tablet treatment results in). As one cheeky colleague has told me sometimes bedside manner counts for nigh on naught and what you want is to be found within the National Grid.

But, for most folk, most of the time, the form of the clinical interaction adds benefits in addition (or even more so) than the content of the clinical event. Psychodynamic psychotherapists would be more extreme, saying their interaction is almost everything.

The content matters too, but as has been said, a clinician with a great relationship doing anything can be useful to most people. A clinician with appalling relationships with their patients doing the "best" intervention is useless to most of their patients. Patients have no trust in the diagnosis, no belief in the formulation, no confidance in the intervention, no conviction they will improve and see no credibility in the interaction.

How the relationship between a doctor and a patient is framed matters, Primary Care are good at looking at this, with Michael Balint's view of "the doctor is the drug" being oh so true.

In 2003 we were told about New Ways of Working for all by NIMHE. In 2005 the Department of Health told us all about New Ways of Working for psychiatrists. More recently CSIP have told us about New Ways of Working. I believe I do a lot of the New Ways of Working malarky already (as do managers, it seems, as they want me to talk for 15 minutes about it).

But really, there's not a whole heap of new stuff to do, is there? I think we used to have it right. So in my corner, at least, we can have medics and nurses and PAMs and clerical staff and managers all working towards patients getting excellent care (we do, the Healthcare Commission says so) with clinicians having the time and space to form meaningful, useful therapeutic relationships.


Jan said...

So Shrink, how do you view "having the time and space to form meaningful, useful therapeutic relationships" in the context of a crisis/home treatment set-up, where contact is brief and staff shifts mean that continuity is difficult, ie pts rarely see the same staff member twice in a row? I've argued that in this case it makes the (albeit rapid) development of some kind of rapport more important than ever, but managers seem to regard therapeutic relationships as a lost cause in this case.

The Shrink said...

Most crisis resolution services and home treatment teams do the bulk of their work in early or late nursing shifts.

As I know from my work in the wee hours this morning, there is work to do at night oo, but by and large that's the minority of the day to day activity.

If you've a service with shifts covering a geographical area, you can't have 100% continuity.

You can strive to optomise continuity, though.

In most services there's a lead Consultant (teams in my hospital and in neighbouring ones all have a full time Consultant Psychiatrist dedicated to just that service). By and learge that should give continuity of medical input.

You can then sectorise the district and have nurses work in geographical patches. This way GPs get to largely see the same staff each time and most of the time patients will see the same 1 or 2 nurses who cover that area through the day/evening.

As well as seeing the same person, MDT discussion helps. Staff can then know the issues to more easily engage with folk rather than starting cold again and patients having to take a deep sigh and start afresh. Good documentation can also assist in this.

A combination of consistant medical input, largely consistant nursing input and good communication is probably the best that can be achieved in the trickier more reactive services.

The Shrink said...

". . . where contact is brief . . ."

I'd not do it, then.

I've withdrawn services where we couldn't deliver a quality service.

If contact is very brief, it stops being sufficiently meaningful. I don't collude with such services. Either the service expands to it does have the capacity to deliver quality care, or demand has to be reduced so it's seeing far fewer folk and can deliver quality care.

Commissioners can then chose how this specialist resource is used, either serving just the most needy few or resourcing it better so it can help oodles of folk.

But seeing lots of folk, with a shabby service, isn't an option to my mind.