The Trouble with Doctors: Part Two - Breaking the GP Barrier

So to summarise the discussion downblog: despite most having had no mental health training whatsoever, GPs are the 'ongoing physicians' for the majority of those living with mental illness. What this means in practice is that the 75% of those suffering with mental illness (half the UK population, incidentally) receive no treatment as a direct result of having been 'bounced back' from access to this treatment by GPs who misunderstand their symptoms. For those who do access treatment at GP level, it is often the case that only the symptoms present at the time of their visit are treated, and then often with inappropriate drugs. So, as happened to me, a bipolar patient might present with symptoms of depression which are treated with an anti-depressant. This induces mania. The patient does not seek help whilst manic as they do not believe that anything is wrong, and very often no intervention is made from other channels (family, friends etc.). So the wider problem goes either misdiagnosed or undiagnosed entirely. The patient then returns to the GP when in, say, a mixed state. The GP interprets this as depression and anxiety, prescribes more anti-depressants along with highly addictive tranquillisers and the cycle begins again, except this time there's the problem of nascent drug dependency to contend with as well. At no point is the patient referred on to a specialist, which would break this cycle. In addition to the ignorance of many GPs, one of the most powerful forces keeping this cycle going is, in my experience and that of many of my peers, the inability of the patient to communicate the extent of their condition. This can be down to a number of factors, for example the catatonia induced by depression, the racing thoughts and self-loathing which come with mixed states and obstruct your ability to articulate yourself; or the shame and self-deception to which you are subject during periods of relative clarity. So whilst the medical profession umms and aahs over whether or not to actually train general practitioners in this fairly important area of medicine, what can we do from our side to overcome this problem of communication and access the treatment we need? It is in this spirit that I present the first of a series of points which helped me along the way to just that. It is not intended to be instructional – if anything it's a wish-list of things I wish I had been told at age 16 – but I do hope it will provide some practical tips on navigating the murky machinations of the mental health system, and a few cheap laughs along the way.

1. Honesty. It's pretty hard to be honest with yourself about what your brain does, and what it induces you to do, when you suffer from a serious mental illness. As I touched on in Part One, not only have you got all that no-fuss-please-we're-British-ness flying around, you also probably don't want to admit to yourself just how weird this shit can get. In addition to all the scary moods, thoughts and voices, chances are you've probably acted on them at some point; done some pretty socially unacceptable things, and some things you're so ashamed of you can barely believe it was you who did them. If you've ever experienced psychosis, you also almost definitely did not believe that your visions and voices were symptoms of mental illness at the time. In retrospect, for a long time I was stuck in limbo somewhere between ignorance of my condition and knowledge that something was awry but lacking the capability and will to stare it in the face. As anyone who has experienced this curious state will know, it is not for nothing that 'limbo' is another word for 'purgatory'. I wanted desperately to be better, but that would have necessitated admitting I was crazy, and I really wanted not to be crazy. Equally, I wanted a diagnosis that would confirm my suspicion that something was indeed rotten in the state of 19, but I was terrified to ask for it, in case my condition and the behaviour to which it gave rise turned out to be simply the result of a series of unsavoury character flaws. 

For me it was a slow journey from this seething mass of contradictions to finally achieving a diagnosis which made sense to me and (so far, fingers crossed) effective treatment for it. The one factor present in every single leap forward, however, has been an increased capacity for honesty with myself and others about my condition and its effects. I believe that the single most helpful thing anyone could have done when I first became seriously ill was to have encouraged me to acknowledge the exact nature of my symptoms and reassure me that, rather than making me a spectacular failure of a human, they simply meant that I had a condition which was manageable. I recently went with my sister, S, to an open meeting of her eating disorder support group where this was the central theme. Overeaters Anonymous (don't be fooled by the name – the group supports all those dealing with compulsive eating, so anorexia, bulimia and compulsive overeating are all represented) is, like its Narcotics and Alcoholics namesakes, a 12-step programme. As such, it is pretty prescriptive in its methods and there are certain elements of the programme which I find difficult to swallow, not least the rule that participants must acknowledge the existence of a 'higher power' and relinquish control of their addiction to it. However, the programme does involve levels of self-interrogation and contingent bravery for which I wholeheartedly salute its members. Step Four, for example, consists of making of a 'moral inventory' in which participants must list all their 'flaws' and all the 'wrongs' they have ever done to anyone as a result of their addiction (in this case an addiction to food and compulsive behaviours around it). In Step 5, they must use this to admit to their higher power, to themselves and to another human being the exact nature of their 'wrongs'. Here again, although I am somewhat uncomfortable with the term 'wrongs' in the context of a severe mental illness, the overall process – that of investigating, exhaustively, all of the symptoms and effects of one's condition – was remarkably similar to the process which eventually helped me to break down the barrier to effective treatment. Before making an appointment to see the GP, I wrote down over a period of weeks (enough time to work myself up to seeing them, and to take plenty of breathers from what was a pretty horrible task, frankly) exactly what my immediate and historical symptoms and episodes were, warts and all, even and especially the stuff I really wanted to bury. This way, I had a 'cue sheet' for when the going got tough, and one which I could always give to the doctor to read if I couldn't face saying certain things aloud. Also, when it came to writing my letter of self- referral, already having something on paper made doing this under pressure a lot easier and reduced the risk of my wimping out and not putting the really shit bits in as simply copying it out made me detatch from the process of writing. Prior to doing this, I also went through what I had written with D. This was crucial – like the members of OA I had the pleasure to meet, I had spent years in fear of what I think and do when ill, and of the fact that these things could very well make me a fundamentally bad person. For the OA members and for me, the experience of someone you love and respect knowing your darkest thoughts and deeds – and consequently really knowing you rather than the sanitised version you are struggling to project – and accepting you anyway brought about an almost immediate shift in thinking. For me, if such a wonderful person had heard and understood all the things I thought were terrible about me, and responded with 'that explains a lot. Now I understand , and can actually help you rather than worrying that my girlfriend was kidnapped and replaced by a neurotic doppelganger. Still love you. Do you want hug and some of my pie?' then maybe I could start to consider the formerly ludicrous possibility that I was not quite so rubbish as I had always imagined.

2. Enlist the troops. Basically, this is the creation of the 'support network' that all mental health professionals will advise you to have. Whether it's the one person you initially told about your intention to seek help, a dedicated support group (this comes highly recommended if you are worried about involving friends or family too closely), or a group of close friends, get yourself a mini-army who will support you through the following steps: they will be the people to have your back in appointments when necessary, to speak on your behalf when you find it too difficult, and to keep you on-track during the whole process.

3. Setting Objectives. Ridiculously, my City sales training (yeah yeah yeah, I was a recruitment consultant for lawyers, I lasted six months ie. the point at which hypomania and the novelty of playing Mad Men dress-up had simultaneously begun to wane, please laugh) probably played a big part in helping me communicate with my GP. Much like an actor is taught to 'know their motivation' for a scene, you must set an objective for every single sales call and meeting you enter into. In most cases the objective will be a small step towards a larger goal which seems scary and unachievable on its own. For example 'today I will get this person to send me their CV' with the overall goal being 'I will manage to persuade both them and the client that they are the best person for the job even though they are massively underqualified, have zero experience and a patchy work history and don't want to work for them anyway thereby securing a hefty commission cheque and not getting sacked'. Once this principle was transferreed to my October visit to the GP, my objective became 'today I will get my GP to refer me for further treatment' with the overall, big scary goal being 'I will get better, stop self-harming, stabilise my mood, hold down a job, engage in further study, manage and enjoy a functional relationship, and avoid completely self-destructing every 6 months.'

4. Objection handling. This dark art is one of the first things any sales trainer worth their salt will drill into their trembling recruits. In the legal recruitment world, objection handling is the practice of trying to get someone to stay on the phone to you after you've called them in the middle of a really important Lawyer meeting and tried to sell them an imaginary job (in the hope that they'll go for it so you can tell them it's unfortunately now off the market but do they want to interview for this one instead except it's totally a waste of their time but it does help you hit your targets) and they have – entirely justifiably – told you to fuck off. There's a little acronym for doing this, LAARC (not to be confued with LARPS, or indeed 'having a lark' which it is emphatically not) which goes:

Listen (carefully to the objection), eg. 'I don't want another job. My job is a nice job and in case you hadn't noticed we are in fact in the middle of the biggest global recession for 80 years you ridiculous parasite'

Acknowledge (their concern) eg. 'I appreciate that you are content in your current role'

Assess (the root of the concern)eg. 'I can understand that you are reluctant to look into the market right now given the current economic climate'

Respond (by offering a lovely solution. There is always a lovely solution, even and especially if it is an outrageous lie) 'But you're obviously also very career-conscious and I'm sure you wouldn't want to miss out on the ideal role so why don't you come in for a chat (during which we'll ply you with coffee, biscuits and smarm, convince you that your current firm is about to take a nose-dive and that your career hangs in the balance unless you apply for this shiny shiny job Right Now) and we can let you know as and when interesting things come up.

Confirm (your course of action) 'So what I'll do is I'll book you in for a meeting with myself and my colleague tomorrow at 8am'

Translate this to a GP situation and you get something like this:

L: 'You don't look too depressed and you're not manic. Here, have this Cytalopram, it will take the edge off.

A: 'I appreciate that my full range of symptoms might not be immediately obvious'.

A: 'I can understand that you want to treat the symptoms of depression'

R: 'I am not manic at the moment, and when I am I do not believe anything is wrong but I have had several episodes (hand over cue sheet if necessary). I am currently coming out of a very severe depressive episode (indicate on cue sheet if necessary) which is why I have been able to get myself here at all. Anti-depressants have not helped in the past as they induce mania, so I would rather not take Cytalopram'.

C: What I do want is a long-term solution that will enable me to live with my condition. I would like to be referred to a psychiatrist, please.

Repeat as necessary, with help from the troops if needed. In the process, you will more than likely demonstrate a much greater knowledge of your condition, needs, and the mental health system itself than your GP, and they will agree to refer you.

So hoorah! Objective achieved! GP Barrier broken! At this point, however you will need to arm yourself for the next step: achieving a correct diagnosis and a programme of treatment that works for you. In Part Three, we'll look at the strange science that is mental health diagnostics and the fabled guinea-pig approach that many psychiatrists seem to take to drug treatment. Until then, good luck, and happy barrier-breaking!