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annwfynI've seen a few less than happy social media posts over the last couple of months from people who have felt let down by the NHS and the support that is available for those with MH difficulties. In a couple of cases I kind of got the impression that some of the upset was caused by the NHS not being able to offer a level of support which, in my experience, doesn't exist. I mean, maybe it does in America. Maybe it does if you have lots of money and can go private. I'm not sure. But it's not something I've seen in the UK in a number of years navigating the NHS mental health provision. I also know that sometimes the NHS is not exactly clear or open as to how to get access to the help it DOES offer (there is a story here about how I wound up in hospital one time as a result of this) and that can be very frustrating.
So I thought I'd write a blog post aimed at providing a bit more information on psychiatry, NHS MH services, third sector additional support services and how to navigate the system. I add this disclaimer - this is based on my experiences as a patient in the NHS in three different regions, as an administrator in a psychotherapy centre in London, and as a fundraiser in a couple of care charities in Scotland. It's not exhaustive, I don't know loads of things and if anyone has any corrections they can make, I beg that they do.
This is just me writing down some facts which I thought might be useful in giving people new to the NHS MH services a realistic view on what they can and should expect, and how to get it.
1. Getting a psychiatrist - how do I get to see a psychiatrist? Do I need to do this to get help? Does it take a long time?
Annoyingly, in my experience, there is no single answer to this. In London, for example, there were two 'streams' of treatment for MH problems. One was the counselling stream (talking therapies etc) and one was the psychiatric stream (psychiatrist and drugs) and you could only be referred to one. What's even more exciting was that if you had a psychiatric diagnosis (so, bipolar, schizophrenia, most things that weren't depression and anxiety) you would be refused access to the counselling stream, even if you were deemed 'too well' for the psychiatric stream.
I note, I was refused access to the psychiatric stream for REASONS (never made clear to me) and eventually only got my referral once I'd been admitted to hospital which was less than ideal. In a better world, I'd have got a referral from my GP which is the other way of doing it. If you do get a GP referral then you'll probably wait for at least a month to see someone, and I think I've heard figures ranging from 6 weeks to 3 months in the places I've lived.
As to whether it's needed - I think it depends on what you need. In general, GPs seem to be fairly OK at arranging something like a short CBT course or prescribing first stage anti-depressants and are a lot more accessible than psychiatrists (and often better at the touchy feely talky stuff, frankly). If you have more complex mental health needs you probably need a psychiatrist and they are the only way to get access to anti-psychotics, or to be registered with your local Community Mental Health Team who would give you a dedicated psychiatric nurse to talk to, but I'm not an expert.
2. So I'm going to see my psychiatrist. How can he/she help me? How often will he/she see me? What kind of emotional support will they provide?
Yay! You've got a psychiatric referral! The first thing I desperately want to say is that your first meeting will be long, rambling and essentially unsatisfying. You may get lucky and be the one person I know who has clicked with their psychiatrist immediately and got the exact diagnosis they wanted and felt utterly understood and in sync with their psych. But the odds are not in your favour. My experience of initial diagnosis (which I've had once) and meeting a new psych (which I've done four times) is that it actually consists of a long and frustrating session where you explain things to this apparently moderately disengaged person in a suit who occasionally says 'hrm' while you go over all the stuff you said to your GP and the nurse at the screening phone call, and have said to your loved ones, and the Samaritans and the nurse at A&E and every single person you've ever fucking met in a desperate attempt to get help and now you're saying it again and they don't even seem to care.
I've always felt this after my first psychiatrist meeting, both with the two psychs I didn't like and the three psychs I ended up really really liking. The reality is that the psychiatric relationship, in my experience, is a complex beastie and takes time to build trust and understanding. After four years in Glasgow, my lovely psych here will tell me when I'm overreacting, and will tell me when things are much worse than I am admitting, and is normally right, even when I disagree. He can do this because he knows me. Of course he had zero ability to do this after the first meeting, because I was a stranger, and also a stranger with a condition which has the well known side effect of impairing judgement.
He still isn't emotionally nurturing. That isn't really his job. I mostly blame Hollywood for this - they've created the myth of a psychiatrist who wants to hear about your relationship with your mother and sees you regularly to work through your issues. Maybe this happens in America, but in the UK that is a therapist's job, not a psychiatrist. Psychiatrists are there to provide a diagnosis ("Sally, you have bipolar disorder"), write a care plan telling your GP what meds to give you (they don't even prescribe meds themselves), and I guess to act as a gatekeeper to some other services which might help - to get you a dedicated Community Psychiatric Nurse in the Community Mental Health Team, for example, or to make a referral to a specialist support service such (if you have Huntington's disease) Scottish Huntington's Association who have dedicated support workers, or (if you're an addict) the local addiction support service. In Scotland these are very often charity care organisations working in conjunction with the NHS. My personal experience is that those charities often have a remarkable level of specialist knowledge and can be total lifesavers.
As for how often your psych sees you? Well, my experience is that it varies, but it won't be often. When I was an actual in-patient, in a psych ward, with a lock on the door, I saw a psychiatrist twice a week, where I grovelled to be allowed out. As an out patient, I've had very short periods of seeing a psych twice a month, while I was considered to be hypomanic/manic and he had doubts about my level of insight. At other times, I've had a mixed affective state and see him once a month and he's just kept tabs on me through my CPN. If I'm stable, it's somewhere between 2-4 months. I am aiming to get it down to a 5 minute meeting every 6 months.
It will absolutely never be on demand, unless you are delivered to your psych by the police. If you need someone you can call up and talk to if you're struggling, that'll be some kind of community psychiatric nurse - either via your local community mental health team, or via your local crisis team. You do need to be registered with a psychiatrist to access this quite often I believe.
3. So I've got my psychiatrist but I don't like them. They have given me a diagnosis I disagree with/they won't provide me with the support I think I need/they won't prescribe my preferred meds. What do I do?
Well, I believe you can request to change psychiatrist via the community mental health team where you're based. You can also change CPN (community psychiatric nurse) if you don't click which I've done once. Before you do put in a request to change psychiatrist, I'd recommend giving it a bit of time to settle.
First of all, the internet is not always right when it comes to your diagnosis. It turns out, for example, I don't have ADHD despite the internet tick list telling me I DEFINITELY did.
Secondly, it might be worth to give you psych some time to settle, get to know you and review your case. It's hard for them to judge you based on a single meeting. Sometimes diagnosis change (I am currently on two diagnosis of type one bipolar, two diagnosis of type two bipolar and a current diagnosis of 'let us not dwell too much on the divide. I've also had OCD, BPD, CPTSD and ADHD all floated as 'we could talk about this' and then dropped as 'probably actually not' later on).
My experience is also that every single psychiatrist will initially refuse to prescribe or recommend any medication with a rep as being addictive or having a street value and will always change their mind later on once they decide you're a responsible adult. At this point I can mostly request zoplicone and diazepam at will from my GP. It's on my care plan that I can ask for a week's supply whenever, just because I feel like I need it. If I do that every week, that will go away, because no one wants to feed an addict. But I never have, so it doesn't.
This is after my being told I couldn't have benzos in Scotland when I first moved here. And after I was told I couldn't have them after the accidental overdose. Basically, I don't think I believe their first offer of meds is ever the final one.
4. This is all too much. I can't wait. I can't cope. I'm in actual danger and I'm going to hurt myself now if no one sees me. What do I do?
If you are in real danger then I'd recommend going to A&E and asking to speak to the duty psychiatrist. This isn't always successful - I know multiple people who have ended up in beds in A&E for freaking ages waiting for a bed or have been sent home with their caregivers but there is a duty psych there who should speak to you if you ask for them.
My experience is also that how they react to you differs hugely depending on your diagnosis - I seem to get a much nicer response with a bipolar diagnosis than friends of mine do with BPD diagnosis, for example. But in theory, if you're in real danger they should try and find you somewhere safe. My other bit of experience is that there is a weird catch 22 where if you acknowledge you're in danger, they think you're OK. I've only ever been admitted when I've said 'I don't want to hurt myself but I'm scared they will make it' or 'I feel compelled to hurt myself'. Any other time, I've had 'go home and we'll send the crisis team tomorrow' at best. Having said that, based on my experience of the crisis team (visit you at home, multiple times a week) vs in patient treatment (horrible hospital, awful food, actually less attention from the staff), I consider 'go home and we'll send the crisis team' to be a win.
Also, if you're under the care of a psychiatrist and you present at A&E, A&E will tell your psych/CPN. I know this. My CPN has phoned me on the Monday to say 'what happened at the weekend, Sally? Why were you in A&E? Come in and see me today, please'.
(Also, Sam, I miss you. You were an excellent CPN.)
5. So I'm not under the care of a psychiatrist, but my partner/flat mate/loved one is and they are scaring me. What do I do?
If they are under the care of a psychiatrist I think that normally means they are attached to a Community Mental Health Team. You can call that team and say there is a problem and make an appointment that you take your loved one to.
As a warning - if someone fails to attend a LOT of appointments they may not be able to make any more/may be discharged. I know this isn't ideal, but I know how hideously oversubscribed all MH services are and how they are struggling to see a lot of people who are desperate for help and so I sort of understand it.
So I thought I'd write a blog post aimed at providing a bit more information on psychiatry, NHS MH services, third sector additional support services and how to navigate the system. I add this disclaimer - this is based on my experiences as a patient in the NHS in three different regions, as an administrator in a psychotherapy centre in London, and as a fundraiser in a couple of care charities in Scotland. It's not exhaustive, I don't know loads of things and if anyone has any corrections they can make, I beg that they do.
This is just me writing down some facts which I thought might be useful in giving people new to the NHS MH services a realistic view on what they can and should expect, and how to get it.
1. Getting a psychiatrist - how do I get to see a psychiatrist? Do I need to do this to get help? Does it take a long time?
Annoyingly, in my experience, there is no single answer to this. In London, for example, there were two 'streams' of treatment for MH problems. One was the counselling stream (talking therapies etc) and one was the psychiatric stream (psychiatrist and drugs) and you could only be referred to one. What's even more exciting was that if you had a psychiatric diagnosis (so, bipolar, schizophrenia, most things that weren't depression and anxiety) you would be refused access to the counselling stream, even if you were deemed 'too well' for the psychiatric stream.
I note, I was refused access to the psychiatric stream for REASONS (never made clear to me) and eventually only got my referral once I'd been admitted to hospital which was less than ideal. In a better world, I'd have got a referral from my GP which is the other way of doing it. If you do get a GP referral then you'll probably wait for at least a month to see someone, and I think I've heard figures ranging from 6 weeks to 3 months in the places I've lived.
As to whether it's needed - I think it depends on what you need. In general, GPs seem to be fairly OK at arranging something like a short CBT course or prescribing first stage anti-depressants and are a lot more accessible than psychiatrists (and often better at the touchy feely talky stuff, frankly). If you have more complex mental health needs you probably need a psychiatrist and they are the only way to get access to anti-psychotics, or to be registered with your local Community Mental Health Team who would give you a dedicated psychiatric nurse to talk to, but I'm not an expert.
2. So I'm going to see my psychiatrist. How can he/she help me? How often will he/she see me? What kind of emotional support will they provide?
Yay! You've got a psychiatric referral! The first thing I desperately want to say is that your first meeting will be long, rambling and essentially unsatisfying. You may get lucky and be the one person I know who has clicked with their psychiatrist immediately and got the exact diagnosis they wanted and felt utterly understood and in sync with their psych. But the odds are not in your favour. My experience of initial diagnosis (which I've had once) and meeting a new psych (which I've done four times) is that it actually consists of a long and frustrating session where you explain things to this apparently moderately disengaged person in a suit who occasionally says 'hrm' while you go over all the stuff you said to your GP and the nurse at the screening phone call, and have said to your loved ones, and the Samaritans and the nurse at A&E and every single person you've ever fucking met in a desperate attempt to get help and now you're saying it again and they don't even seem to care.
I've always felt this after my first psychiatrist meeting, both with the two psychs I didn't like and the three psychs I ended up really really liking. The reality is that the psychiatric relationship, in my experience, is a complex beastie and takes time to build trust and understanding. After four years in Glasgow, my lovely psych here will tell me when I'm overreacting, and will tell me when things are much worse than I am admitting, and is normally right, even when I disagree. He can do this because he knows me. Of course he had zero ability to do this after the first meeting, because I was a stranger, and also a stranger with a condition which has the well known side effect of impairing judgement.
He still isn't emotionally nurturing. That isn't really his job. I mostly blame Hollywood for this - they've created the myth of a psychiatrist who wants to hear about your relationship with your mother and sees you regularly to work through your issues. Maybe this happens in America, but in the UK that is a therapist's job, not a psychiatrist. Psychiatrists are there to provide a diagnosis ("Sally, you have bipolar disorder"), write a care plan telling your GP what meds to give you (they don't even prescribe meds themselves), and I guess to act as a gatekeeper to some other services which might help - to get you a dedicated Community Psychiatric Nurse in the Community Mental Health Team, for example, or to make a referral to a specialist support service such (if you have Huntington's disease) Scottish Huntington's Association who have dedicated support workers, or (if you're an addict) the local addiction support service. In Scotland these are very often charity care organisations working in conjunction with the NHS. My personal experience is that those charities often have a remarkable level of specialist knowledge and can be total lifesavers.
As for how often your psych sees you? Well, my experience is that it varies, but it won't be often. When I was an actual in-patient, in a psych ward, with a lock on the door, I saw a psychiatrist twice a week, where I grovelled to be allowed out. As an out patient, I've had very short periods of seeing a psych twice a month, while I was considered to be hypomanic/manic and he had doubts about my level of insight. At other times, I've had a mixed affective state and see him once a month and he's just kept tabs on me through my CPN. If I'm stable, it's somewhere between 2-4 months. I am aiming to get it down to a 5 minute meeting every 6 months.
It will absolutely never be on demand, unless you are delivered to your psych by the police. If you need someone you can call up and talk to if you're struggling, that'll be some kind of community psychiatric nurse - either via your local community mental health team, or via your local crisis team. You do need to be registered with a psychiatrist to access this quite often I believe.
3. So I've got my psychiatrist but I don't like them. They have given me a diagnosis I disagree with/they won't provide me with the support I think I need/they won't prescribe my preferred meds. What do I do?
Well, I believe you can request to change psychiatrist via the community mental health team where you're based. You can also change CPN (community psychiatric nurse) if you don't click which I've done once. Before you do put in a request to change psychiatrist, I'd recommend giving it a bit of time to settle.
First of all, the internet is not always right when it comes to your diagnosis. It turns out, for example, I don't have ADHD despite the internet tick list telling me I DEFINITELY did.
Secondly, it might be worth to give you psych some time to settle, get to know you and review your case. It's hard for them to judge you based on a single meeting. Sometimes diagnosis change (I am currently on two diagnosis of type one bipolar, two diagnosis of type two bipolar and a current diagnosis of 'let us not dwell too much on the divide. I've also had OCD, BPD, CPTSD and ADHD all floated as 'we could talk about this' and then dropped as 'probably actually not' later on).
My experience is also that every single psychiatrist will initially refuse to prescribe or recommend any medication with a rep as being addictive or having a street value and will always change their mind later on once they decide you're a responsible adult. At this point I can mostly request zoplicone and diazepam at will from my GP. It's on my care plan that I can ask for a week's supply whenever, just because I feel like I need it. If I do that every week, that will go away, because no one wants to feed an addict. But I never have, so it doesn't.
This is after my being told I couldn't have benzos in Scotland when I first moved here. And after I was told I couldn't have them after the accidental overdose. Basically, I don't think I believe their first offer of meds is ever the final one.
4. This is all too much. I can't wait. I can't cope. I'm in actual danger and I'm going to hurt myself now if no one sees me. What do I do?
If you are in real danger then I'd recommend going to A&E and asking to speak to the duty psychiatrist. This isn't always successful - I know multiple people who have ended up in beds in A&E for freaking ages waiting for a bed or have been sent home with their caregivers but there is a duty psych there who should speak to you if you ask for them.
My experience is also that how they react to you differs hugely depending on your diagnosis - I seem to get a much nicer response with a bipolar diagnosis than friends of mine do with BPD diagnosis, for example. But in theory, if you're in real danger they should try and find you somewhere safe. My other bit of experience is that there is a weird catch 22 where if you acknowledge you're in danger, they think you're OK. I've only ever been admitted when I've said 'I don't want to hurt myself but I'm scared they will make it' or 'I feel compelled to hurt myself'. Any other time, I've had 'go home and we'll send the crisis team tomorrow' at best. Having said that, based on my experience of the crisis team (visit you at home, multiple times a week) vs in patient treatment (horrible hospital, awful food, actually less attention from the staff), I consider 'go home and we'll send the crisis team' to be a win.
Also, if you're under the care of a psychiatrist and you present at A&E, A&E will tell your psych/CPN. I know this. My CPN has phoned me on the Monday to say 'what happened at the weekend, Sally? Why were you in A&E? Come in and see me today, please'.
(Also, Sam, I miss you. You were an excellent CPN.)
5. So I'm not under the care of a psychiatrist, but my partner/flat mate/loved one is and they are scaring me. What do I do?
If they are under the care of a psychiatrist I think that normally means they are attached to a Community Mental Health Team. You can call that team and say there is a problem and make an appointment that you take your loved one to.
As a warning - if someone fails to attend a LOT of appointments they may not be able to make any more/may be discharged. I know this isn't ideal, but I know how hideously oversubscribed all MH services are and how they are struggling to see a lot of people who are desperate for help and so I sort of understand it.
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Date: 2020-01-14 08:15 pm (UTC)no subject
Date: 2020-01-16 11:21 pm (UTC)