Sunday 25 August 2019

Making sense of Majella's outburst about trying to find a psychiatrist

Like housing, mental health services are cursed by a shortage of supply, but it's a complicated situation

RANT: Majella O’Donnell complained about her friend’s search for a psychiatrist, and many people agreed with her stance. Photo: Andres Poveda
RANT: Majella O’Donnell complained about her friend’s search for a psychiatrist, and many people agreed with her stance. Photo: Andres Poveda
Donal Lynch

Donal Lynch

Are psychiatrists the new landlords? To listen to Majella O'Donnell last week you would have thought they were. Her description of her friend's search for a psychiatrist had many parallels with the stories from the ongoing housing crisis: A desperate punter at the end of her tether, a whole class of (presumably wealthy) individuals dispassionately benefiting from the shortage of supply - the friend was told she'd have to wait until February to be seen - and an overall system that seems hopelessly skewed against the ordinary person earning an ordinary wage. €300 an hour was the rate Majella's friend was quoted.

It was probably the expletive in Majella's "rant" that woke us up (no wonder Daniel reportedly hides in the wardrobe during arguments, you couldn't help thinking) but many people seemed to agree that she had a point. "How dare anyone charge that kind of money to help another human being who is in a desperate situation," she wrote. "That sort of fee CANNOT be justified!!"

Is she right? There would have been the option to go public and in an emergency you can present yourself at A&E where you will be seen by a psychiatrist. The problem seems to be with those people for whom care is pressing but not life-and-death urgent. I phoned the office of a psychologist on behalf of a friend of mine two weeks ago and, similarly to Majella, was told that there would be 14 weeks of a wait and that a GP referral was a cast-iron prerequisite. The self-assessed (and patently obvious) level of urgency, and the fact that my friend doesn't have a GP, was neither here nor there. The friend has since been hospitalised, a massively expensive and disrupting process that could potentially have been avoided had she been treated on an outpatient basis. How can we remotely say we're taking mental health seriously when vulnerable, distressed people have to go through this expensive, lengthy rigmarole to get seen?

Even for those who do get seen there is something slightly unnerving about the conventions of psychiatric treatment. The so-called 'therapist's hour' (45-50 minutes) invariably leaves a bad taste in the mouth. It seems slightly bizarre that someone in acute distress gets this amount of time, after which the psychiatrist cannot be contacted for virtually any reason until the next appointment. Psychiatrists must be professionally compassionate but sometimes the professionalism seems to override the compassion.

The money does slightly stick in the craw, as my father would say, too. I once saw a psychologist who talked to me about the importance of life goals. "For instance, one of my life goals is to pay off the house in Cornwall quickly," he helpfully shared. I couldn't help but think: "Yeah, that's what I'm helping you do." But maybe that's just my internal rage. There's probably a pill for that.

Those kind of resentments partly spring from the very personal relationship one has to establish with a therapist. And it's probably unfair on the therapist. Part of taking mental health seriously is accepting that it is no less important than our physical health. If you were getting surgery done you'd be more concerned at the skill of the surgeon than that they truly cared for you. Nobody would express surprise if seeing, say, an oncologist privately set you back €300 an hour. Depending on the field of medicine it could be substantially more than that. A six-week wait would seem quite short when compared to some of the waiting lists for consultants in our hospitals. Yet there seems to be an expectation that mental health professionals should kind of fill the lacuna left by the parish priests of yore. We think that they should work for free or out of the goodness of their hearts. We think they should be as accessible as vote-hungry TDs holding front room clinics.

Are these fair expectations?

A psychiatrist, like any consultant, is paid commensurate with the fact that there aren't many of them (just as their aren't many country music superstars) and because, in many cases, they're making life and death decisions. They also have to give over a good portion of their youth to the long, hard slog of studying and training. There's five or six years in medical school for starters. Then comes a further 18-month internship to cover basic medical and surgical training. At that point they have to decide what kind of specialisation they want to go into. From there, they've another four-year training course, with another barrage of exams and a demanding training scheme. They have to apply for a higher psychiatry scheme where they do some work experience, research and teaching before they can become a consultant. At the end of all of that they still have people bitching about their fees, guilt-tripping them about their lack of compassion, and expecting them to accept cases based on amateur referrals at the drop of a hat. It's little wonder that in the past many medical students didn't even consider psychiatry as a career path.

A senior Irish psychiatrist pointed out to me this week that even now a majority of Irish students who do decide to specialise in the area go abroad because the terms and conditions of employment are so much better in other countries.

This is a particular problem in psychiatry because the nuances of language and culture are important in assessment. Somebody might say they're depressed when what they actually mean is that they're sad, but it's up to the doctor to decide where one ends and the other begins.

Part of the problem is undoubtedly that those other, more plentiful purveyors of talk therapy - psychotherapists - have yet to achieve proper regulation and oversight. Most of them still get their qualifications from private commercial bodies, which hardly inspires confidence. Majella wrote that her friend had been to her GP and had been prescribed antidepressants. She went on Claire Byrne Live and said that her friend was also exploring the option of psychotherapy. This is sometimes a confusing road to go down. There is still a whiff of 'wild west' around mental health services in this country. That needs to be addressed but in the meantime there probably isn't much to be gained by making psychiatrists into scapegoats.

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