The first and foremost duty of mhs is to treat the ill patient so he gets better. (*a) What does ‘better’ mean, though? Good question. Because doctors, nurses and psychotherapists should be able to justify the treatment they’re offering (or forcing on) the patient. They should know what it is intended to achieve, what the range of possible outcomes are, the degree/effectiveness to which it may work, what are the alternatives and so on.
When is it time to trial Clozapine for a treatment-resistant schizophrenic already four or more relapses into his career?
Is SOTP the right pathway for a first-time sex offender? Will it be effective for a sadistic personality disorder (*b) multiple child abductor rapist?
Which first choice antidepressant should a GP prescribe for a person consulting him for the first time with depressive sx?
Similarly, the types of therapeutic relationship/nursing approach a nurse uses will depend on whether the patient is floridly psychotic, a seven foot fighting machine, a manic who’ll keep the rest of the ward up all night if you don’t put him in the (locked) high care area, a terrified young person who’s only heard horror stories about mental hospitals, a borderline or an unsuccessful suicide ready for another try.
The common element is what choices do I make to a) manage the challenges this patient is presenting right now and b) so that by the time they leave hospital they are in a place where they have a good chance of staying out.
Making those decisions is quite hard enough, thank you management. Often you have to do a bit of trial and error, altering or reversing your decisions as you go. Maybe diagnosis becomes clearer, maybe the patient calms down, medication starts working, you start getting through in your 1:1 talks. (Nowadays, what I described above sounds laughably simplistic. There are scores of obstacles – in the form of regulations, protocols, forms, blah – to you making those decisions. Dozens of overpaid suits have the right and power to stick their spokes in your wheels.)
The professional has to consider how seriously or mildly ill the patient is, the degree of urgency and risk, past success or failure of other treatments, work out how much information the patient is capable of following, be straight about the best and worst case outcomes, the disadvantages and side-effects, gain the informed consent of the patient and balance it all out into a choice of treatment. Not easy.
With psychotic illnesses, the MHA allows the psychiatrist to skip the informed consent part – though there are safeguards, hurdles and paperwork making it harder with more on the way.
*a) At least that’s how it used to be. Before Quality Assurance, targets, the internal market, DEI, and internationally imposed ‘standards’ such as ‘Least Restrictive’ and ‘Reducing Restrictive Interventions’ diluted that goal so much it became as ineffective as a homeopathic dose.
*b) Don’t believe these don’t exist just because they got taken out of the DSM. I’ve nursed them up close and personal. And no, SOTP will not work. A series of six, simultaneous rapid-fire lead injections is an effective cure though.
So, I’m looking at how MHS would have to recalibrate to place treatment at the top of the tree, as our first and foremost priority. At the same time I’m looking at how and why this desirable state of affairs is currently obstructed, even prevented.
For now, let’s stick with the commonest illnesses and treatments, ones most people have heard of, worry about and know someone who is a sufferer. Depression, anxiety, Bipolar and schizophrenia. Let’s start with depression.
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