Patients and bloggers often complain about their GPs’ lack of understanding of mental health, so I was interested to come across an article recently that suggests some ways in which the work of GPs (primary care) could be better aligned with mental health care.
The complaints about GPs are not always entirely justified. Some GPs seem to their patients to have an unsympathetic manner when in fact they are performing their primary care role perfectly well. On the other hand, some GPs appear sympathetic and reassuring while at the same time making poor choices about medication and referral. It takes all sorts.
The article, What would an ideal mental health service for primary care look like? (PDF) looks forward to the near future when GPs will be much more involved in commissioning community and hospital treatment (secondary care) services in the NHS.
When the article was written, the organizations that are planned to commission NHS secondary care were to be called “GP commissioning consortia” but the name has since been changed to Clinical Commissioning Groups (CCGs) to reflect the involvement of other professionals in addition to GPs.
One of the article’s key messages — the only message, really — is that:
In order to commission an ideal mental health service for primary care, GP commissioners should challenge accepted distinctions and divisions.
I think that’s putting it a little too strongly. Certainly, the point of creating CCGs is that clinicians are very likely to do things differently from, and better than, the NHS bureaucrats who are in charge of commissioning secondary care at present, but it’s not clear to me that challenging accepted distinctions is really part of the commissioning role, and the article doesn’t elaborate the point.
Anyway, the ten distinctions and divisions that allegedly should be challenged do make interesting reading. The divisions are between:
- mental health clinics and the GP surgery
- short GP consultations and extended mental health ones
- mental and physical illness
- severe and enduring mental illness and other difficulties
- the individual and the family
- the mental, social and economic domains
- all the different mental health disciplines and ideologies
- neighbouring localities or boroughs
- offering a diagnosis and treatment, and having a therapeutic conversation
- the patient’s voice and the doctor’s decision making
The end. The article doesn’t suggest any new distinctions and divisions to replace the ones in the list. That makes it a bit obvious that the whole idea is utter nonsense. If there were to be no distinctions at all between all these things, then the whole field of mental health would become a huge pile of mush, impossible to manage or even to discuss intelligently.
Looking at one of the ten in more detail, the division between severe and enduring mental illness and other difficulties, the article makes a blatant factual error:
There may not be DSM-IV labels for people struggling with complex social and family problems, existential crises, longterm loss of confidence, permanent lack of direction or intractable self-absorption…
In DSM-IV, Axis IV covers external psychosocial stressors, although the axis is admittedly rarely used, and other symptoms like self-absorbtion are certainly covered by axes I and II. (Axis III, by the way covers physical conditions that have a psychological effect, another of the ten distinctions.)
Regardless of this error, the final assertion is just silly:
An ideal mental health service would recognise the scale of difficulties experienced by people without a severe and enduring diagnosis and would make adequate provision for them.
Trying to treat all of life’s difficulties as mental health problems would just clog the system with people who have difficulties, i.e. absolutely everyone. People with specific, curable, mental illnesses would easily be forgotten in the crush.
Indeed, this has happened to some extent in the NHS’s IAPT services, which have encouraged people to seek treatment for perfectly normal mild, short-term feelings of depression and anxiety, and as a result find it hard to deliver successful treatment to patients with more severe disorders.
Grains of truth
There are some grains of truth, though, in the proposals. For example, the ground-breaking Open Dialogue approach to psychotherapy that I described almost exactly a year ago in Grass does to some extent challenge the distinction between the individual and the family.
And the distinction between the patient’s voice and the doctor’s decision making has been breaking down for a long time, challenged by NICE guidelines and the NHS Constitution:
Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment.
So, while the idea as a whole is nonsense, the article nevertheless makes an interesting read because of the way it juxtaposes sound ideas with drivel. The author certainly knows how to tell a good story.
The author, John Launer, originally graduated in English before training in medicine. He is now a big noise in the training of doctors, and a prolific writer. His writings help make the case that doctors should have a scientific background, it seems to me.
One of his favourite notions, mentioned a couple of times in the article, is the importance of narrative in medicine. A 1999 paper of his in the BMJ (British Medical Journal) describes the approach in mental health, using three brief case studies: A narrative approach to mental health in general practice (PDF)
Again, the overall gist of the article is nonsense:
The success of “talking cures” depends on their ability to give coherence to the client’s experience of physical or mental illness and to enable the construction of a narrative of healing or coping
That’s like saying the success of flying in aeroplanes depends on your ability to describe how aeroplanes fly. It’s just not true. The passengers don’t need to know how the wings work. Even the pilot doesn’t really need to know how the wings work. And, like the more recent article, this one didn’t elaborate the point.
Talking cures may sometimes provide a coherent narrative, just as some passengers may know how the wings work, but it is neither necessary nor sufficient. Far from supporting narrative, the three case studies actually undermine it.
In the first, Helen’s story, an elderly woman regularly talks to her GP about her difficulties over the last ten years. The narrative we are offered is that the GP’s role is to make sense of the story of Helen’s life:
…not just as listening to Helen, nor just as formulating diagnoses, but to see it as asking questions which explore a better story…
However, another narrative might be that the GP is creating dependency here, getting a vulnerable patient hooked on pointless exploration of her past. Helen’s psychological problems are no more than a competent counsellor should have been able to help her deal with in a matter of weeks, and at only 70 Helen could have moved on and built a new life for herself.
In Rustem’s story, the GP imagines that Rustem might be suicidal because of his many problems of social isolation, physical health and addiction. Yet there is no evidence whatsoever that Rustem really is suicidal. It’s just a story the GP made up.
In addition to all his other problems, Rustem now has a GP whose actions are guided as much by the GP’s own imaginary fears as by the tragic reality of Rustem’s life. It’s hard to see how that can possibly help, and the article doesn’t elaborate the point.
Sheryl’s story, finally, is of a child whose behaviour causes problems. The child’s mother would like a referral to a specialist who might be able to help her child, but the GP imposes a narrative in which the idea that a specialist might be able to help is no more than the mother’s “impulsive optimism” and he only reluctantly agrees.
Distinctions and divisions
GPs like this, who blur the accepted distinctions and divisions between the reality of a patient’s difficulties and the GP’s own imaginary narrative can be a menace. They’re the ones who won’t order the right tests, who resist making referrals, and who refuse to prescribe what consultants recommend for their patients.
As a teller of stories, John Launer has had a successful career. But some of his stories are tall tales, full of superstition and imagination. They’re great to read, but you’d be very silly to believe in them. Among the GPs who do believe in them are the ones patients and bloggers complain about, the ones who seem to be on a different planet, unable to align their thinking with what mental illness is about because in their heads they are telling themselves a different story.