The current changes in medicine are trickling down and showing up everywhere. In psychiatry and mental health, we are not immune.
One of the ways our clinics are changing now is that the approach to initial assessment, triage, and acceptance for treatment is a moving target once again. Basically, anyone can walk through any door and ask for help. He will then be screened by a clinician, then his story will be told in a treatment team meeting designed to decide who would benefit from the mental health center’s services and who would best be served by referral out to another entity, such as the Department of Disabilities and Special Needs or their own family physician.
Once the determination is made that the services of the center are right for that particular patient, then he is assigned to a therapist and treatment begins. It goes for ten sessions or twenty sessions or longer, depending on presenting symptoms, diagnosis and the desires and goals of the person seeking help.
Unless it doesn’t.
Sometimes, after six sessions or worse yet, six months, the patient is told that she will have to switch to another therapist or counselor in the middle of the process. This is most likely not something that she will have chosen to do herself, especially if she has developed a rapport with her counselor and feels that she is making good progress towards her goals.
It is happening more and more because we simply have too many patients and too few providers and need to cover too many bases. A therapist who normally does play therapy with five year olds may have to pick up the slack and see adults with bipolar disorder. A psychiatrist who loves seeing adult patients with chronic illnesses such as bipolar disorder and schizophrenia (raising hand) may find himself a de facto child psychiatrist for a clinic of five hundred patients because his predecessor retired or moved or died. These mandated changes may come from an immediate supervisor or straight from the top.
If we as therapists and counselors and doctors think this is stressful, imagine what our patients must be feeling.
They have already told their story, in great detail and with great emoted pain, to one person. Now, they have to tell it again? To start all over? They have finally summoned the courage to talk about sexual abuse that occurred twenty years ago, and now they have to re-live that trauma to re-tell the story to another therapist?
If you’ve been there as a patient, you know how hard it is to do this. You feel lost for a while, adrift, until you re-tether yourself to another port in the ongoing storm. If you’re a doctor or counselor or therapist, you know how hard it is to pick up therapy in the middle of the course, to review what someone else has already done and try to build on it, instead of crafting the original plan yourself and going forward together.
In medicine generally, and in mental health specifically, trust is important. Continuity is crucial. Knowing that the person who is trying to help you knows your own individual story, your little secrets, your hopes and fears, is the keystone in the overarching plan for excellent care.
Disrupting this process at the whim of bureaucrats, legislators and bean counters may be good management, but it is not good medicine.