Endings in mental health treatment

This week I’ve been thinking about the endings of connections in mental health services. I’ve experienced one ending last week which didn’t go well and will be having a further ending this week. In mental health care relationships are often built between patients and professionals. As a patient you may see someone regularly and may be disclosing your innermost thoughts, feelings, emotions or past traumas. They may be by your side during the most difficult times. If you’ve been seeing someone regularly for a long time you may also get to know them as a person, they may share their own struggles at times. If you have become quite isolated a health care professional might be the only person you see once a week. A healthcare professional may have done things for you, attended horrendous appointments that you couldn’t go to alone, advocated on your behalf, answered a call from you when you’ve been distressed and wanting to give up. They may have saved your life.

There is a guilt in feeling attached to a health care professional, it’s frowned upon to become too attached. We do need to move on at some stage, but someone shouldn’t feel guilty about finding that hard, if you’ve been supported by someone it’s not unusual to feel a sense of attachment. A health care professional may see lots of people and may have lots of endings, so may be more used to managing their emotions around this, for a patient however this won’t be the case. I’m autistic, so change is particularly difficult and I feel someone’s abilities to cope with change should be carefully thought about when leading up to an ending. There are many issues that aren’t specific to me, for example someone may have had few or no supportive, positive relationships in their life, their relationship with the health care professional may be the first one they’ve ever had. I can’t imagine how hard it would be when it came to an end if that was my experience.

One of the best endings I had with a health care professional was simply meeting for a hot drink as an ending and talking about our interests, rather than treatment. When they moved on they sent me a really kind email highlighting the positives about me and expressing that I had also taught them things too. I’ve had a few psychiatric hospital admission endings too, for one admission all of the night staff wrote post it notes of kindness and pushed them under my door and on a different admission my key worker, a health care assistant wrote me a letter.

An ending is important to me too and I like to be able to express that. This may not be the case for everyone, as everyone is different. For some people they may want to end things with as little fuss as possible. For me, I like to give someone something. I will usually paint a card, with a note of thanks expressing how someone has helped me and positives I have noticed about them. I am coming to the end of individual therapy this week. Prior to each therapy session I’ve been practising mindful photography on my way to each appointment. I’d saved all the photos on my computer and have made a photo book for the therapist with photography exercises or examples of how photography helps me. I hope that it helps them with their own mental health. I have also had experiences of endings with other patients. When you spend a long time in hospital, particularly eating disorder hospitals where you have 6 meals a day with people, plus groups, you really get to know people well. They become your support, companions, constant sources of encouragement and kindness. When you leave hospital you may never see them again. In one admission I bought everyone a bird pin badge from the RSPB and made them a card explaining why I had chosen a badge and what their support and relationship meant to me. I’ve received lovely gifts and cards from others which I still look over when I am struggling. I recall an admission to an acute psychiatric ward, there was little joy in people’s days there. On my leave from the ward I bought hot chocolate, marshmallows and cream and made drinks for the other patients as a goodbye. I still remember the peaceful hour we spent together talking and drinking them.

I feel I can’t end this blog without describing a difficult ending I had this week. I will begin by saying that I know that the person involved wouldn’t have wanted to have upset me. I know that they probably didn’t have time to think it through as they would have been juggling 101 more important things. It was hard for me though as I’d known them for 2.5 ish years. The appointment started late, it felt rushed, I had to meet the new person supporting me at the same appointment. I’d stayed up late the night before working on something for the ending. I was distressed by the late start, distressed by them forgetting something important that we had agreed the week before. It didn’t feel like a therapeutic ending. In an ideal world I’d have liked for them to recognise that and reschedule a short meeting to focus on the ending only, but this isn’t an ideal world and as it wasn’t offered I am using this blog to educate and reflect. I felt too embarrassed and guilty to express that it was a difficult way to end 2.5 years of working together. I felt I couldn’t express my needs, as they would consider it to be overly needy. I hadn’t really recognised that the ending would be hard, perhaps they could have considered that?

If you are a professional approaching an ending with a patient I would consider the following:

  • Talk and plan with the patient how best to come to an end. Give them notice of an ending in advance if you can. Even if a patient has requested an ending appreciate that it could still be difficult for them.
  • Written words can mean so much and can have a lasting effect. Consider writing something for your patient, highlighting their progress, their positive attributes or what you have learnt from them.
  • Don’t try and cram multiple things into an ending appointment.
  • Leave your patient with tools which could support their recovery ,if appropriate. Some have suggested a kindness jar of positive statements. I’ve given people pebbles in the past which I’ve picked up on the beach. A gift doesn’t have to cost anything.
  • It’s okay to send a patient a letter or an email of thanks after an ending appointment.

This blog ends with the photos I took on my way to therapy which have gone into my gift for my therapist.

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