There is no doubt that extending the right of choice when it comes to mental health is an important step towards parity of esteem with physical health.
Involving people as much as possible in decision-making to find the way of working that’s most helpful to them is critical. For many people accessing mental health services, their ability to choose has already been compromised. People do not choose to be mentally unwell; they do not choose to live with the negative consequences of mental illness.
For some, the notion of control and choice may be central to the illness itself. Enabling choice and control in the recovery process can help with engagement and potentially with outcomes.
If there is one thing we can be sure of, it is that we are fundamentally different from one another in many complex ways. What works for one may not work for another. To secure best outcomes, different interventions may be required. Sometimes, the most appropriate treatment for a particular individual may not be the one that has the greatest evidence base.
What do we even mean by ‘best’ outcome? Surely this is, in part, determined by individual values?
Being symptom-free may be the holy grail for some but not for others. ‘Best’ is what is best for that particular individual at that particular time. Offering treatments which have been shown to result in positive outcomes for many is good practice and should absolutely remain central to the provision of health care.
However, reliance on such evidence-based approaches should not stifle innovation.
There is no reason why other therapies cannot measure outcomes just as well as interventions such as CBT, which lend themselves more readily to empirical study.
It is crucial that we find new ways of working and demonstrating impact. This means we need to do different things, ask different questions and use different methodologies than we are used to.
Maybe we need to pay more attention to asking what people want rather than telling them what they need, largely based on what is available.
Asking what helps – and crucially what doesn’t – seems obvious, so why don’t we always do it? Maybe, our fear of not being able to accommodate those preferences stops us asking. If the gap between what people want and what they can realistically have is too wide, the notion of choice is somewhat redundant.
We know that to have choice, there needs to be options – real options – to choose from. There are clearly benefits to having a wide skill set under one roof. However, this does not mean that we have to offer everything to everyone. We do need to know what we are good at, and continue to do that well, while addressing any local gaps in provision either through investment in new services or via partnerships with other providers.
Perhaps the key word here is ‘local’. Digital offers are extremely helpful in this respect as, by and large, geography does not restrict access. The challenge for services offering more traditional (face to face) interventions is to provide choice through good services that can be easily accessed.
Children and young people in particular tend to experience systems and rules in all aspects of their life which reduce their ability to choose and sometimes create unhelpful power imbalances with teachers, parents and other adults.
If any of my three children were to require specialist support, I could envisage one responding better to a CAMHS offer (particularly if this meant time off school!); one opting for a schools-based intervention (particularly in a group setting involving friends and peers) and one preferring a digital offer (particularly an anonymous one that did not have to involve me!).
I would absolutely want them to have control and choice over this to improve their experience, engagement and ultimately outcome. That’s before even thinking about the intervention itself.
And let’s not forget the importance of the therapeutic relationship in improving outcomes within mental health. The notion of having evidenced-based therapists as opposed evidence-based therapies, and being able to have choice over this, is an interesting one.
Surely transparency is at the heart of making choice work well for all. This includes transparency about the services available, the outcomes they offer, the experience people have when using them and the different ways in which care can be delivered: at home, in schools, through technology, as
well as in traditional care settings.
We need to be creative in working out what will work and for whom. And do this collaboratively with those and for those who use our services.
Dr Lynne Green, Clinical Director, XenZone