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Returning to a Relational Approach in Psychiatry

The relational dimension of care has been core to our profession since its inception. Highlighted by Jaspers over a hundred years ago was the dialogical aspect of treatment; the relationships that we cultivate with our patients. This was seen as central to the art of psychiatry. Empathy was the gateway through which all phenomenology could be truly understood and it was only through a subsequent relationship, built on that empathy, that deeper levels of change and recovery became possible.

There has also been an equally important technical aspect from the outset too. Since the latter half of the last century this has been pharmacotherapy. Good psychiatry always stood upon both these pillars.

In recent years, however, the relational pillar has atrophied.

I have been a Consultant Psychiatrist for nearly 20 years and in this time, I have worked across a range of different services from crisis/home treatment to rehabilitation to in-patient to Psychiatric Intensive Care Units (PICU) and I currently work in a community recovery team in North East London. I have also been increasingly engaged with the Royal College of Psychiatrists in recent years; sitting on the College Council as well as Special Interest Group, Regional and Faculty Executive Committees. This has given me a national vantage, which has brought into view a consistent story around our services and how they have been resourced and organised over the years.

If we trace our current crisis to its origins, it began with the closure of asylums. While this was an essential, progressive step in the evolution and modernisation of mental health services, it was also combined with an unprecedented cull in staffing. It was expected that, without the asylums, there would no longer be any need for such large numbers of clinicians. As a result, local health authorities were able to cut over 20% of their total staff budgets within the first year alone, according to the King’s Fund. Indeed, for the Secretary of State at the time — Enoch Powell — a reduction in the financial burden of mental health services was a key driver from the start.

This drastic reduction in staffing meant that the baby had effectively been thrown out with the bathwater from day one of de-institutionalisation. And this has continued to be the trajectory for most of the intervening years. For example, between 2010 and 2015, mental health Trusts faced cuts equivalent to £598 million a year, every year. The number of trained psychiatric nurses in this period also dropped from just over 41,000 to less than 37,000.

All of this has been further compounded by the short-term thinking that has mostly pervaded policy and service development since then — focusing largely on ever more rapid throughput and briefer episodes of care — all of which almost completely ignores the therapeutic value of deep and lasting relationships.

Policymakers started visualising mental health services as if they were some sort of conveyor belt. An increasingly fragmented system started to move patients from one team to another, leaving the therapeutic relationship as little more than an afterthought. Even NHS England today describes the current system as one in which “we have a team for everything and a place for no one”, with far too many teams, too many boundaries for patients to navigate and multiple cracks in the system that patients can all too easily fall between.

The evidence has been pointing to the harm that these developments have the potential to cause for over 30 years now. It was back in 1993 that Arlene and Gunderson did a study in which they showed that the therapeutic relationships forged in the early months of treatment have a lasting impact on outcomes in the long term. Those who had experienced deeper therapeutic relationships were more likely to have fully engaged in treatment and thus demonstrated an overall reduction in symptom levels. A few years later in 1996, Krupnik et al published a study that showed the positive impact therapeutic relationships have on outcomes regardless of the modality of treatment they are otherwise receiving, whether that be pharmacotherapy or psychotherapy.

In 2008, McCabe and Priebe took it one step further, looking at a range of psychiatric services and concluded that across a variety of mental health care settings, the quality of the therapeutic relationship can actually predict the outcome.

It is the secret resource that we all have access to, yet it is one that has depleted over time as our hollowed-out services moved increasingly towards an exclusive focus on crisis and risk management.

I believe, however, that it is possible to turn this tide.

The pandemic has put the scarcity of the nation’s mental health provision into sharp focus. Late in 2021, Chris Whitty gave a speech to Medical Directors of Mental Health Trusts explaining how, having examined the impacts of COVID, he believed that mental health services now needed to be a key focus going forward. It was like the tide coming out so far that, for the first time, we were able to see the state of things on the seabed and mental health services fared among the worst. He argued for higher prioritisation of mental health services and better resources. This however, given the decade of talk around “parity of esteem” before it, is not the first time we have heard such language. Nevertheless, today we are at least presented with an opportunity. And if we don’t grasp it now, we will lose it.

We need to make the case for the prioritisation of therapeutic relationships once more. To truly deliver better outcomes for patients we need to spend more time with them. The increase in resources needs to also be combined with a reduction in bureaucracy, not an increase in it, which is often the case with new investment. More targets, more KPIs and more boxes to tick will surely only result in more time with computers over patients. This needs to be guarded against at all costs.

The Royal College of Psychiatrists needs to form alliances with other professional bodies as well as third sector and service user networks to lead a commission for compassionate care, in which we work together to locate and highlight best practice across the country and, through this process, make a compelling case for the increased investment we need.

A return to a more relational approach also means a shift in culture. Embedding and prioritising listening skills into our training will be key. Clinicians of all backgrounds need to become experts in creating safe spaces that help build a sense of trust. This is essential if we want to make our services more trauma-informed.

It is only through a single-minded determination to rebuild our resources and the skills we need, that I believe we can both reconnect to our roots and re-emerge into a new era. One in which meaningful relationships work hand in hand with new technologies to maximise hope and improve outcomes for many more of the men, women and children who seek our help.


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