The Model Is Broken

I had an interesting conversation with a friend this week who had no idea how the current mental health system works in the UK. Inspired by that, here's a post on why the model we have for both physical and mental healthcare is only right part of the time.

If you've never been exposed to the UK mental health system, it makes sense that you might think it works similarly to the system we have in place for physical healthcare - and, in some ways, you'd be right. And, as always, in some ways you'd be really wrong. Part of the issue is that we as a society are very firm believers in the biomedical model of healthcare, which looks something like this:

You have a symptom, usually one that is obvious to you and others. You see a doctor. The doctor runs some tests, and tells you that you have illness X, and that the severity of your symptom matches the severity of the illness at this point. You are given some medicine, which you take every day. The symptom goes away, and you no longer have illness X.

The biomedical model works well some of the time. It's helpful for chest infections (mostly), or other things where a course of antibiotics clears the issue right up. It's even helpful for some cancers, where you get pretty clear symptoms and you can be cured with chemotherapy or radiotherapy. But for a lot of things it doesn't work so well, and whilst there are too many reasons for that to pour into a blog post, I'm going to look at a couple of them.

If this is your model of the world, it makes sense that you would apply it to mental health. There's a couple of clear reasons that this doesn't work:

• ​You have a symptom, usually one that is obvious to you or others - with mental health difficulties, they can happen very rapidly and obviously, or they can come upon you by stealth. Often, the first time some of my patients hear the word "depression" is when they're sitting opposite me and I broach the subject - and often they've been depressed for many years. 
• You see a doctor - this can depend on whether you've noticed that you are unwell, or whether other people have encouraged you to seek help - or not to seek help. The biomedical model is great, but it ignores social context completely. If you live in a family where mental illness is seen as a weakness (and yes, that still happens), you're not going to see a doctor.
• The doctor runs some tests, and tells you that you have illness X - mental health is often harder to unpick than a simple diagnosis. You might have mixed anxiety and depression, OCD that's masquerading as psychosis, PTSD or C-PTSD that looks like a personality disorder to some clinicians...it's a real minefield and obviously, the more complicated it is, the harder it is to get a clear diagnosis. That then has implications for treatment.
• You are given some medicine - you might be given antidepressants, or anti-anxiety drugs, or both. They might help, or they might make you feel much worse. All medications have side effects, whether you're taking antibiotics for a UTI or anti-epileptic medication that's also licensed for chronic pain. Sometimes medications work fantastically, and sometimes they don't.
• The symptom goes away, and you no longer have illness X - this works if illness X is caused by some kind of imbalance in your body, or by a broken bone. But what if you're depressed because you have no money to heat your home, or you're anxious because you don't know how you're going to pay for your child's school uniform next month? What if you have C-PTSD because horrible things have happened to you? Therapy can help a lot with trauma, but it doesn't take it away completely, and neither therapy or medication can remove the social and economic inequalities in the current system.

The reality is that we have a partially complete model that was never really designed to cope with anything but the most basic of illnesses. Looking at things from a purely biomedical viewpoint ignores the social, structural, economic, environmental and psychological health of human beings, all of which are really important. Add to that a system that can't cope with demand, and you have year-long waiting lists for treatments within a mental health context that may or may not come with a cap on the amount you can access. Whilst we probably wouldn't put a limit on the number of years that a diabetic person could access insulin for, we're quite happy to put a limit on the number of sessions of psychological therapy that a person can have. And as you might have gathered, the very idea of that fills me with rage.

The idea that there must be a cap on psychological therapy, especially in primary mental health services, minimises the importance of mental health. Yes services are stretched, but making someone wait six months to access six sessions of therapy and then go back on a waiting list is only compounding the problem. We need to trust clinicians and trust patients - if we're doing a good job, both parties in the relationship will know when therapy should end, and it will give you a chance to do that work within a more trusting relationship. If someone knows you're only going to help them for about three months, there's no real reason for them to invest in the relationship (and therefore the work).

​This is the same for chronic physical health conditions. One of the conversations I have repeatedly with my colleagues is the sense of helplessness some of us have when people want to see us again three or four years after we've done some work with them. We don't have any new strategies for managing chronic pain, and it can feel like a failure on the part of the patient (they're not coping) and on the part of the clinician (we haven't fixed them). But when you have a chronic condition, there is no "fix," and sometimes people need a little bit more help. To put them back on a six month waiting list, or to deny them access to a service, feels impractical and wrong.

​I feel like I've done enough ranting for one post! In a later post, I'll put a few ideas down about how I think we can change things. If you've got any that you want me to include, let me know in the comments.