Recognizing Dr. Nikki Scheiner’s expertise in psychology and her commitment to advancing mental health care, this piece explores her work in Functional Neurological Disorder (FND) treatment, the challenges within public and private healthcare systems, and the need for a patient-centered approach. Her insights shed light on the complexities of mental health care accessibility and the importance of reforming treatment models for sustainable, high-quality patient outcomes.
The Industrialization of Mental Health Care and Its Impact on Patient Treatment
Most of us are familiar with the question as to whether medicine is a science or an art. As a Consultant psychologist who has worked both in the National Health Service (NHS) and in Private Practice in the U.K., I often ask myself if the more appropriate question is whether medicine is an industry or a profession. This question is particularly apposite when considering the provision of mental health treatment.
Mental health has long been the poor relation in healthcare in the UK, despite the Royal College of Psychiatrists’ ongoing campaign for ‘parity of esteem’. Go to your local hospital Accident & Emergency with a broken leg and (admittedly, after a wait of some hours), you are guaranteed to receive treatment; if you go with a ‘broken’ mind, you could be facing a delay of well over a year before receiving appropriate care. Who fares better: the individual on crutches or the person whose condition leaves them emotionally and psychologically disabled and immobile, unable to face the world? What criteria are we applying to assess ‘worthiness for treatment’?
Until we prioritize care above economics, the only two groups of patients who will receive comprehensive care and treatment are those who are treated pro bono and those who self-fund
Paradoxically, even within mental health there is a lack of parity. Treatment provision for Functional Neurological Disorder (FND) - my own specialty - is unequal across the NHS, with some mental health Trusts lacking capacity to offer anything beyond a single session assessment. The disorder, which sits at the intersection of Neurology and Psychiatry, is characterized by physical and neurological symptoms which inhibit an individual’s ability to carry out their daily activities. By the time that patients get to see a specialist, many have endured the indignity of being told that because there is no or insufficient explanatory structural pathophysiology, their symptoms are ’all in their head.’ Diagnostic uncertainty and a lack of respect compound their distress - which has been described as comparable to that endured by patients with a severe and enduring mental illness.
Inspired by the pioneering work of Mark Hallett in the U.S., and Alan Carlson and Jon Stone in Edinburgh, I wrote a group protocol for treatment of FND patients in an NHS out-patient setting. It was a 12 week programme (3 hours a week), based upon principles of cognitive behaviour therapy (CBT), Compassionbased therapy, Acceptance & Commitment Therapy and Mindfulness. I delivered it together with an Assistant Psychologist, knowing that, when needed, I could call upon the support of my Psychiatry colleagues in our Liaison Psychiatry service. The aims of the treatment were to help patients modify unhelpful beliefs about their condition, suspend their expectations and learn to train their attention away from their symptoms.
Our results were pleasingly good but could have been even better had we had the basic resources to supply a comprehensive service. Despite robust evidence that patients with neurological movement disorders frequently recover faster with physiotherapy, this service was beyond our budget. The patients’ needs were secondary to the Trust’s targets. It seemed that the National Health Service was becoming the National Health Industry.
Fast forward the years and I have left the NHS behind. I continue to believe strongly in nationalized medicine, but struggle with its priorities. Psychologists continue to face the impossible choice of either offering partial treatment to a large number of patients or treating fewer people but ensuring that they are well and resilient upon discharge. In the former case, it is inevitable that people will relapse and need to be readmitted - rather like the person who fails to complete a course of antibiotics and subsequently becomes more unwell. Mental health patients, prematurely discharged, are given the unglamorous moniker of ‘revolving door patients.’ In the latter case, targets are missed. Bore responsibility for not meeting targets. Clearly, the economic model is incompatible with, or unreconcilable with, the care model.
Naively, I thought that working in private practice would be far simpler. My ethical principles are clear: I work with patients to empower them. Once they have gained all that I can offer, we agree that our work together is complete. People ‘drop in’ for a psychological review if they wish; others return a few years later to tackle a different problem. I now understand that this model is the privilege of very few patients.
Insured patients with Functional Neurological Disorder all too often face many of the same restrictions of those who rely on the NHS. Their belief that having medical insurance equals immediate access to treatment is frequently dashed. First, they may have to convince their insurance company that FND is a ‘real’ condition, a hurdle that invariably causes delays, and sometimes perpetuates the stigma of being told that the condition is just ‘in your head’. Secondly, there is only a small pool of specialists. Thirdly, many of these providers have chosen not to continue to work with AXA PPP health or BUPA because of these companies’ extremely low remuneration policies. And fourthly, sessions for FND are often limited in number. This lack of consensus, emblematic of an industrial approach to medical care, is frustrating for both patients and treatment providers - and unsustainable.
We need a fresh look at how as a civilized society we think about mental health. Until we prioritize care above economics, the only two groups of patients who will receive comprehensive care and treatment are those who are treated pro bono and those who self-fund. Everyone else falls through the cracks in the market-place of Late Capitalism.
