Communication and collaboration in the treatment of mental disorders

One of the initial obstacles for service users and professionals alike is disclosure. The potential service user must take a leap past that sense of shame, perceived weakness and the idea that they are simply malingering (Byrne, 2000). Health professionals may meet resistance in their attempts to detect disorders, and may need to diagnose without direct disclosure from the patient (Allen, Fursland, Watson, & Byrne, 2011). In recent years, campaigns to promote awareness of mental health have taken strides in breaking down some of these barriers of shame or denial, yet there are still more steps to take both in staff attitudes and patient understanding.

So why the reluctance to seek help? The stigma of mental disorders is still prevalent; in a study of voice-hearers, it was noted that those who heard disembodied voices were unwilling to disclose this to others for fear of being labelled ‘schizophrenic’ or ‘dangerous’ (Beavan, Read, & Cartwright, 2011). Others simply do not want to be unwell, or fear being considered a time-waster. Some service users may be simply unable to properly assess their own mental well-being. There is also the worry that a mental disorder could be a blot on the record in terms of potential employment: certainly among employers, studies have shown that more awareness of mental disorders is needed (Biggs, Hovey, Tyson, & Macdonald, 2010).

The language of mental illness is also ingrained in most of us by the time we reach adulthood. Madness in media over the past three centuries seems to fall into two broad categories: danger, and entertainment. In Jane Eyre, Rochester's first wife Bertha Mason is described as a wild animal: “… the lunatic sprung and grappled his throat viciously, and laid her teeth to his cheek.”(Bronte, 1864). John Carpenter's horror film Halloween, has Michael Myers escape from a mental institution to wreak revenge on his home town. In real life, media reporting of mentally ill offenders tends to operate around a vernacular of ‘maniac’, ‘evil’, or ‘psycho’, particularly in the tabloid newspapers. For example, a man suffering from paranoid schizophrenia who fatally stabbed musician Jonathan Zito on a tube platform in 1992, was described by the Sun newspaper as an ‘18-stone crazed killer’ when it was revealed in 2009 that he was to be downgraded to a medium secure unit. (Marsh, July 29, 2009).

In terms of entertainment, there are the eighteenth century days of the Bethlem Royal Hospital, or ‘Bedlam’ where visitors could pay two pence to make ‘sport and diversion of the miserable inhabitants’ (Harris, 2003). Nowadays, when a celebrity has a public breakdown, such as Britney Spears(Hilton, 2011), or struggles with addiction, such as Lindsay Lohan (Stapleton, 2010), photographs from the courthouse, the ambulance or the hospital are beamed straight to us via a plethora of entertainment channels and websites. With the world online 24/7 via Twitter and Facebook, gossip like this will be global in seconds. No wonder, then, that service users can be so reticent in coming forward.

There may also be a significant discrepancy between what the patient believes to be mental illness and what the doctor considers to be mental illness(Prior, Wood, Lewis, & Pill, 2003). Allen (2011) cites the statistic that 50% of adults with anorexia nervosa, and between 50 – 90% of adults with bulimia nervosa may not seek treatment. Another problem, discussed in a previous issue of this journal, is that health professionals themselves are likely to delay seeking help, avoid disclosure and attempt self-treatment (Brooks, Chalder, & Gerada, 2011). In O'Donaghue's study of patient attitudes to involuntary admission, it was found that the number of patients who considered admission necessary post-treatment was fewer than those who considered it necessary when they were first admitted. 43% of patients interviewed were re-admitted within a year, half of them involuntarily(O'Donaghue et al., 2011).

Faced with these issues of disclosure and understanding, it seems that communication and language are stumbling blocks to be got over if patients and professionals are to collaborate upon both diagnosis and treatment. This editorial considers aspects of the collaborative process between service user and professional – where it works, how it can help, and where improvements are needed.

It is interesting to contrast two papers featured in the previous issue of this journal – one evaluating lack of collaboration, and one evaluating what might be considered extreme collaboration. In the study of a focus group made up of service users diagnosed with personality disorders, (Rogers & Dunne, 2011), the users were asked questions about their inpatient experience. From this discussion, it was found that the majority of the service users in the group felt that staff found them a drain on resources and not really ‘unwell’ compared to patients diagnosed with disorders such as schizophrenia. Also, there tended to be a lack of collaboration in their own care: the language used when offered ‘voluntary’ admission as an alternative to sectioning implied a lack of control and choice over their situation. Rogers suggested that staff training in personality disorders, as well as dealing seriously with patient feedback and complaints would improve communication channels between staff and patients.

One the other side, is the study which looks at the positive (and controversial) effects of collaboration via Positive Risk Taking (Birch, Cole, Hunt, Edwards, & Reaney, 2011). This study evaluated self-harm incidents in women living in three women's units over a period of six years. Self-harm is an activity with roots in childhood physical, sexual and emotional abuse, separation and/or loss, and the quality of childhood attachments. Those who self-harm also report feelings of intense isolation and emptiness(Gratz, 2003). Birch's study recognised patients' need for security, collaboration and control; therefore the women were encouraged not to self-harm, but not stopped from doing so (for example by confiscating sharp household implements). Women who accessed this service were asked to take responsibility for their engagement with staff and with treatment. Living on a unit, they were also expected to live and work within the group, taking part in household tasks and decision-making about the running of the unit, about their own medication and writing their care plans. Over a six year period Birch noted that the frequency of self-harm incidences dropped.

One interesting aspect of this study was that the women observed were encouraged to live and function as a group, and this social aspect may have helped reducing feelings of isolation and alienation and thereby also reducing the need to self-harm. We can also see, in a study of adolescent patients suffering from anorexia nervosa, their attitudes to compulsory treatment were directly related to their relationships with parents and health professionals - that is, the majority considered decisions founded on trust and goodwill of more importance than freedom of choice(Tan, Stewart, Fitzpatrick, & Hope, 2010).

At a time when the funding of mental health services is under scrutiny and threat of government cuts, methods of collaboration and communication with service users is even more important. Payment by results is being rolled out to healthcare services, and the needs of each patient in terms of social, physical as well as mental well-being will need to be assessed, considered and fed into payment schemes (Mason, Goddard, Myers, & Verzulli, 2011). The increasing cases of disorders such as depression will also put greater strain on the economy (Lee, 2011). This study also looked at incidences of depression among specific racial groups. Lee considered that immigrant people were able to overcome isolation barriers by using social networks to integrate and that foreign-born people who did not marry were at greater risk of experiencing major depression than those who did have partners. Preventative action, in this case facilitating social networking among communities, could be looked at as a way to halt the possibility of developing depression and thus reduce strain on government resources.

Mental disorders can be exacerbated by feelings of shame, isolation and a seeming lack of control over mind and spirit. By collaborating and communicating effectively with service users, it may be possible to improve diagnosis, treatment and recovery. The client, by collaborating in their own treatment and care stands a better chance of retaining an element of control over their disorder. If collaboration is not possible, then communication and trust are essential in underpinning decisions taken on behalf of the client. Finally, encouraging social collaboration among peers could be effective in terms of prevention, funding, reducing feelings of isolation and promoting recovery.