Paul KeenanProf. Jim Lucey explains the role of the psychiatrist
My room at St Patrick’s University Hospital has a high ceiling, a wooden desk, a bookcase and a number of comfortable soft chairs. To the left of the desk, a tall window looks north to a quiet garden. Beneath the window there is a small side table with bottles of drinking water and some cups. The room is warm and the furniture is reassuringly familiar to me.
The room does not have the iconic psychiatrist’s couch. Amongst some books and papers on the desk, there is a computer, a reading lamp and a box of tissues. The floor is covered with a carpet and in front of the desk there is a small rug. In another corner of the room there are large filing cabinets. A few colourful prints hang on the walls alongside some certificates of qualification.
There are many other idiosyncratic bits and pieces; some with personal significance and others with none. There are photos on the bookshelves and toy cars sitting on the desk, as well as some shortbread biscuits, a teapot and a kettle on the side table. There are many books on mental health and history.
Of course, in many ways, none of this really matters. This room could be more or less formal, personal or spartan, but so long as it is a space where people feel able to talk, and feel that someone has listened and heard them, then it is a space of value.
Quality of care
When people come to the room for the first time they are likely to be very apprehensive. Many do not know what to expect. Some may anticipate the dramatic portrayal of mental health assessment seen in popular media such as The Sopranos or Analyse This. The reality of the psychiatric clinic may turn out to be more prosaic than expected.
Mental health assessment takes more than the right physical setting or the right location. It is hard to define what makes an assessment work, and even harder to ensure that these elements are in place all of the time. In this regard it is helpful to recall the views of Patricia, an especially wise and forthright recovered patient with a capacity for directness. She explained: “The physical environment for therapy and its quality does matter, of course, but not very much.
“When you are in distress it’s the quality of the care that counts. If you stick the ‘wrong’ people in the ‘right’ office, all you achieve is a nightmare outcome in a nice environment.
“When I was on the ledge, in the depths of my depression, the most important environmental factors were the ones that empowered me to talk, to feel that someone had listened to me, heard me, and given me hope.”
According to Patricia, it is the quality of the therapeutic relationship that engages recovery. These are the human factors that determine the quality of care. So at any meeting, the priority must be to put the patient at ease, in the hope of building a therapeutic bond. It is good to greet each patient, to shake their hand, to smile, and to offer them a comfortable place to sit and relax, as we prepare to talk and to listen.
It is best practice to have read the referral letter in advance and ideally to reread it with each new patient so as to confirm its contents and to establish the facts.
After a brief explanation a discussion ensues about confidentiality. There are boundaries and limitations with any disclosure and it can be reassuring to understand from the beginning how one’s personal information is going to be shared and how it will be used. Sometimes a patient will request to bring a third party into the consultation, at least for a while, and although this may be perfectly reasonable, it is a disclosure and therefore must be informed and consented.
Each patient should be in control of his or her own information. This is their right. Their story is their privileged data and it is an intimate marker of their human dignity.
Very nervous
Despite everyone’s best efforts, a new patient can be very nervous and may remain uneasy for some time. People do not find it easy to share matters that are painful or private.
After a little more time, and perhaps a drink of water, most people feel more able to talk freely. Then it is time to seek permission to share information with other professionals involved in the delivery of the care plan – the referring doctor, for instance. Usually patients have no difficulty with this, but it can be reassuring to emphasise that no third party will gain access to the information, without the expressed permission of the patient himself or herself. In truth, what the blood is to a surgeon, clinical information is to the psychiatrist: a psychiatrist must never unwittingly allow the information to spill or to leak.
Just as in any other clinical situation, a psychiatrist is bound by the rules of confidentiality. Nowadays no reputable clinician denies that these rules have limits.
There is a balance between the explicit clinical commitment to confidentiality and a clinician’s equal responsibility to respect the safety and integrity of others. Confidentiality cannot be a justification for secrecy. It is never legitimate to practise in a way that could place others at risk, and the doctor’s commitment to confidentiality does not place the psychiatrist outside the law.
The matters disclosed at the very first meeting or any subsequent ones are likely to be personal, private, intimate and even distressing. In these circumstances a psychiatrist has only one legitimate purpose: to work towards a full understanding of the problems (this is known as ‘formulation’) and so to develop an agreed plan for care.
If at all possible, these meetings should provide relief and support and lead to greater engagement with the therapeutic process and with the recovery plan.
Wherever this type of connection is made, meaningful conversation can begin. With hope, an alliance develops between the person expressing their suffering and the person hearing their pain, and the response is an offering of care. This alliance can occur in the most unexpected of places and at the moat unlikely of times.
The therapeutic process comes with certain challenges. It can be difficult for a patient and a psychiatrist or clinician to maintain a therapeutic engagement. A didactic therapeutic position is never helpful. A reciprocal relationship between the patient and the clinician means that an objective therapeutic direction is more likely to be welcomed. With reciprocity, truths about recovery may be shared and may be seen as helpful. In the end, mental recovery is better when it is planned with a human perspective.
Experience of isolation
We remain social human beings, but today’s more atomised life is distressing for some at least. In response to a perceived experience of isolation, a therapeutic relationship with a mental health professional can be useful and even life-saving. But recovery is best maintained where it is supported by friends, and family and community, and when patients can live safely in their neighbourhoods, and where the right to a shared experience of life is cherished.
Recovery is sustained when we can stay healthy, when we can laugh as often as possible, when we can take care of ourselves and ideally take care of someone else as well, and, most of all, when we can be kind to ourselves and to each other. Recovery becomes apparent once we have learned to tame the anxiety of our unconscious mind and choose instead to adapt to life in a more connected and hopeful way.
It seems that once we locate our mind we begin to understand it. The room is a space for the mind and a metaphor for the mind at the same time. Most of us will never find ourselves on a psychiatrist’s couch and yet our lives would be perilous if we did not make space for our mental health. In this space, we can hold up a mirror and acknowledge our search for meaning.
By going to the room, life becomes more resourceful and rewarding. In showing up there, we show up for life.
Prof. Jim Lucey is a psychiatrist and medical director of St Patrick’s Mental Health Service in Dublin. This extract was taken from his book In My Room published by Gill & MacMillan.