Funder by the Department of Human Services Auspiced by Our Community

BREAKING UP WITH YOUR DOCTOR

We hear so often of people diagnosed with 'mental illness' who either 'lose their services' and are upset by this, or are really scared that they will lose their service if they dare to show any improvement in their mental health.

Many of us have experienced this ourselves. We may know that everything is not OK for us (and we suspect the clinicians know this too), yet we are being told we have improved to a point where we can cope on our own. The tendency is for us to either:

Shame and guilt are often the mainstays of the lives of people diagnosed with 'mental illness' - shame that we have achieved too little in our lives; guilt that we are still dependent on others (sometimes our parents).

The judgmental language of 'high functioning' and 'low functioning' labels are too often used as a tool to regulate client flow through a services.

It seems ridiculous that mental health services would seek to protect their throughput figures and hence funding in such a way that they augment the burden of shame and guilt for consumers. However this often happens in the terminating of therapeutic relationships.

Of course, sometimes this difficult event is handled well by clinicians. But in too many cases:


The role of services in creating dependency

When we look at the language of psychiatry we see why we get caught up with services and sometimes find it difficult to 'move on'. Terms like 'co-operative' and 'compliant', are juxtaposed continually against terms like 'non-compliant', 'difficult' and 'manipulative'.

To be a 'good patient' in the eyes of the system, we often have to acquiesce to the expectations of the system and those who serve it. It's good to do as you're told, look after the clinicians and second-guess what they want you to do and say.

However, when 'they' decide it is time for you to 'move on', all of these 'behaviours' that were considered attributes get inverted - they become signals of dependence.

This is very hard to understand for many and it is made harder because we are so used to taking on the guilt load. Many of us just assume we have done something wrong.


When there's no choice

Choice to terminate a particular relationship is much more difficult if we have no say in whether we are locked up or 'treated' at all, as is the case with people who are being 'treated' under the Mental Health Act.

Choice is also impacted by scarcity - choice is very uncommon for people receiving 'treatment' by Public Mental Health Services and Community Health Services, for example, because these services are so stretched. Bad luck if you and the therapist don't get on. Bad luck if you have a forbidden diagnosis. Bad luck if you didn't impress the 'Intake Team'.

People in rural and regional areas are another group who have little choice when it comes to selecting and moving on from therapists/clinicians, simply because there are so few alternatives and rarely affordable ones.


When it's the clinician's choice

Most of the clinical groups that provide therapy, case management or support, particularly over long periods, learn protocols for bringing therapeutic relationships to an end. They know it is hard - often for both parties - but they are the ones who must shoulder the responsibility.

These protocols are supposed to make the 'termination' (great word!) gradual so that we can get used to the idea of not having this support in our lives. This process happens over quite a long period, with frequency of visits being reduced and a lot of discussion about 'where to next'.

Unfortunately there are two major problems:

  1. Public services often can't afford the time for clinicians to participate in this transition process properly;
  2. Some clinicians are transparent and badly skilled and we can see straight through their 'finale performance'. This leaves some of us feeling demeaned and manipulated which indeed we often are.

If you feel undermined it's OK to be cross. Many of us have experienced the same thing. However, don't cling on past the point of dignity. Leave abruptly if this feels like a good way to get your power back, and find other consumers for support, at least in the short term.


When it's our choice

Some of us blast out of public services as soon as we are no longer retained under the Mental Health Act. We realise the damage that has been done by being incarcerated and having so very little control over our lives and bodies.

Many of us hate the medical drugs we have been forced to take , think the Diagnostic and Statistical Manual is a fraud and that medicalising our personalities is unethical, and we have no problems at all steering clear of all medical interventions in the future - if we can. The fact that 'mental illness' is the only illness where one can be forced by law to endure unwanted treatment is a great motivation for escape.

Sometimes, particularly in the case of private psychiatrists, psychologists and counsellors, it is left to us to decide when it's time to end the therapeutic relationship. This presents a whole new set of challenges.

Surprisingly perhaps, people with some choice can get almost as trapped as people with no choice.

After what can be years of 'therapy' it can be hard for some of us to trust our own judgment, especially if it runs contrary to that of the 'therapist' we have learnt to rely on.

This is a particular trap if we are purchasing 'therapy' in the private therapy market. It is very easy to forget that psychiatrists, clinical psychologists and counsellors are running businesses.

Some of us may even start to take responsibility for looking after the therapist. We start to believe we must stay. These strange dynamics can capture us.

Power and control issues are inevitable. Some of us work hard at being a 'good' patient/client. This can also make initiating leaving hard.

We can also lose power when decisions that we make are pathologised by the other person in the room. It is more difficult to make independent decisions to leave under these circumstances.

Larger social institutions that govern community behaviour also influence us. Gender and cultural issues sometimes render women silent; levels of education, social class and homophobia on the part of the clinician, for example, all affect the decisions we make.

What moves we make in such circumstances will depend on whether we get mad and whether we get silenced.


When it's time to move on

Here are a few things you can do when you know that it's time to finish a therapeutic relationship but you're having trouble moving on.

Reconceptualise your relationship to 'mental illness' and therapy

If we start to see our emotional distress as having a positive side - life-changing 'break-throughs' rather than simply negative 'break-downs' - we increase our capacity to make informed choices.

We are no longer beholden to the therapist - we are paying for them to provide a service (even if that's through Medicare). It's a business transaction.

Thinking of our therapy sessions this way can give some of us the confidence to speak up.

Seek stories from others

This is when support and advocacy groups really come into their own.

Seek out and speak to your group and other friends who have terminated therapeutic relationships successfully.

Ask them key questions about what they did and how it went. How long did it take? What was the reaction of the therapist? What did they create in its place? Where else did they look for support? Did they find any websites that helped?

Surprisingly most doctors and psychotherapists know almost nothing about support groups and advocacy groups, even those in close proximity to their practice. This is a product of the limitations of their training.

It is also true that many private clinicians are concerned about support groups on the web. Some of this is well founded and some is not wanting to let go of their power.

Bring a friend along

If we have an Advance Directive, our clinicians will hopefully be aware that there will be times when we want someone to come with us to an appointment (there might be a bit more resistance if we spring it on them).

It's important that we bring along the person we want to bring, not the person we think the therapist might want or expect us to bring.


Ending a harmful therapeutic relationship

Sometimes it is the patient who knows that a relationship must end. Obviously this includes instances (thankfully rare) where there have been gross illegal acts such as rape or assault by clinicians. However, harm is not always so obvious.

Other causes of harmful relationships might include: