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Psychiatric care – Threat or opportunity?

Jonna Södervall-Väyrynen is a trauma psychotherapist who wants to take part in societal discussion about important topics and raise trauma awareness among professionals and in general.

25 April 2018

In her doctoral thesis in psychology Pirjo Lehtovuori examined the significance of personal attributes of a psychotherapist in terms of successful outcome of psychotherapy. Differences in psychotherapists often influence the experienced benefit of psychotherapy. Evaluating the attributes of psychotherapists is a practice that should spread across the field of social and health sector. Educational background of the caregiver obviously matters but their personality factors influence the way they use their professional know-how in the care relationship. In mental health work the ability of the caregiver to empathize and detach are determining factors in the way the patient experiences they have been treated and cared for. Traumatization happening inside the care system is a taboo waiting to be shattered.

A friend of mine is a student of social studies. She asked me to help with an assignment about mental health work. The assignment was to first read all of the related Käypä hoito –recommendations and then write an essay about how to face a patient of two different mental health disorders such as anxiety. I asked how long should the essay be. More than one page, she said. My friend stated that either she has completely misinterpreted the assignment or then mental health work is so complex that she is unable to understand it. After an inspirational conversation I urged my friend to turn in an essay that is less than one page basically saying: “A person with anxiety disorder should be faced like any other person. They are greeted in a polite matter, asked to come in and to tell what’s on their mind. The therapist should be willing to listen and to sincerely hear the answer.”

At what point did helping people turn into rocket science? Was it when everything was to be listed in care recommendations? Or when someone calculated that more efficiency and savings are needed? When evidence based care became the goal?

How can we turn a greeting and a kind smile in to an evidence based practice? Exactly. There are a lot of elements in helping others that can’t be written down to recommendations. Everything that goes on between two individuals in a care relationship can never be examined in a way that would make it qualify as a medical recommendation.

Care recommendations make good servants but poor masters. They are summaries composed by experts about how to diagnose and treat specific disorders. Anyone doing care work should remember that official recommendations can never replace their own expert assessment of what are the best diagnosis, treatment and rehabilitation for an individual patient. Taking into account how inadequately disorders caused by a severe trauma are considered in the diagnostic systems, we are facing a structural problem. How to get suitable treatment to something that doesn’t even exist in the diagnostic system? Hopefully this will change in the near future.

Another difficulty is the requirement for evidence-based care. I don’t mean that the health care field should be Wild West where anything disguised as care is acceptable. I mean that care practice based on stern clinical experience should be as valuable as for example the ones that make scientific research easy because of their simplicity (such as structure care models based on manuals). I have noticed that these days person being treated has to fit into some specific cost efficient method to make a good patient. But how on earth would it even be possible to create structured methods where one size fits every patient and one cure treats all illnesses? That’s starting to sound supernatural.

Photograph by Seija Hirstiö, Heartwaves design Seija is one of the writers in the book Five Survivors, a Hundred Lives – Stories about Trauma and Dissociation

Are human individuality and uniqueness just empty words in quality manuals? It is a scientific fact that the consequences of being traumatized have certain similarities. This gives the caregiver a sound theory base to achieve both quality and efficiency in their work. However the caregiver shouldn’t be under an illusion that they always know best or can exclusively define what is right for each patient. Self-determination of each patient must be respected. If we truly want to take the uniqueness and individuality of people into consideration we must come to the conclusion that it’s impossible to create a method that suits everyone. A while ago online therapy sessions were recommended in a health care district publication. It was seen as an especially beneficial method since it eliminates “unnecessary empathy from the care relationship.” This proves that the values of modern psychiatry have hardened. This will not result in high quality care or even the desired long term cost efficiency.

One of the features that make psychiatry a special field in medicine is that safe high-quality care ensues in an equal relationship. It’s likely that a surgeon has better knowledge of his field of expertise than an average patient. This isn’t necessarily the case in psychiatry and the caregiver must be able to tolerate it. The role of the therapist in trauma psychotherapy treatment is to help the patients heal themselves. This point of view pushes the caregiver off from their pedestal into an equal collaborative relationship where the caregiver doesn’t posses higher form of knowledge of how the patient should pace their journey to personal healing. Sure the caregiver provides different points of view and options, even challenges while bringing their professional expertise in to the service of the patient’s personal process. It’s not trendy in the modern world to give patients some peace and space to grow while considering their individuality and uniqueness. But when humanity is swept aside, caretaking can turn into abuse in an instant.

I told about my friend doing social studies. She has been pondering whether she can do this job. This is crucially important. The deep core of professionalism is to know your boundaries. Caretaker is the wild card that can make the carefully build evidence-based house of cards collapse. If I should list the most important qualities of a caregiver I would put the strong ability to self-reflect on top of the list. In theories about early interaction the parent’s ability to reflect is seen as central to forming a relationship. It’s the same thing in a care relationship. The caregivers should dare to regularly ask themselves “Can I do this job?” and then truly listen to and hear their own answer. Everyone can’t do everything and that’s ok. This job is for those who can do it. The most important thing is to acknowledge how I as a caregiver affect the other person. This way the care is safe for the patient. Safety is the foundation of successful trauma treatment. In care systems people are traumatized because of so-called care. It should be possible to have a reflective conversation about the matter.

Someone reading this might think who am I to say anything about the abilities of caregivers. I am in no way special. I am just as imperfect and flawed as we human usually are. I work hard every day to be safe for the people I treat and interact with. Avoidance and silence are typical for a trauma phenomenon. But they don’t advance development of good care practices or sense of security for patients. Then again dealing with shame and talking about it acts as an antidote to avoidance and silence. That enables us to deal with patients’ personal experiences about the care they have received and guide modern psychiatry towards safe practices.

#traumapsychotherapy #psychologicalsafety

This blog post was originally published in Finnish in the registered association of trauma and dissociation Disso ry website.


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