Human givens in primary care

Community psychiatric nurse Liz Potts describes her experience as one of the few primary care professionals in Coventry using the human givens approach.

WHEN I was training to specialise as a mental health nurse, my fellow students and I assumed our role was very different from that of clinical psychologists. We did the caring and supporting. Psychologists, we believed, did 'something else', something mysterious. They had skills in their toolboxes that were superior to anything we could offer to people in distress. We felt somewhat the same about psychotherapists and counsellors.

Psychiatric nurses aren't fully trained in any particular psychotherapy. We learn a bit of this and a bit of that: some listening and counselling skills and some elements of cognitive-behavioural therapy (CBT) and so on. The cognitive approach made the most sense to me but it didn't seem to have all the answers — and neither did I, when patients said to me, "But, if it is my thoughts that are making me anxious, how come I wake up suddenly at night in a sweat of panic?" It felt as if we were trying to fit people's behaviour into neat boxes and had to ignore or discard anything that stopped the lid from closing.

Then I went to a seminar on the human givens approach and, from the broadness of its base, it seemed to answer so many more questions — it felt like a ray of sunshine. Here, through the concept of essential human needs and innate resources, was a simple explanation of what it is to be human and an approach to helping people that was brief and focused on their skills and abilities, enabling them to engage in their lives. I also realised just how damaging some psychological approaches can be to people suffering from depression, if they embed the depression (by getting sufferers to 'explore' it more deeply) instead of helping lift it.

By that time, I had taken a job as a community psychiatric nurse (CPN), working within a primary care team for Coventry Primary Care Trust. Unusually, I work at a GP surgery, sharing an office with health visitors, district nurses and occupational therapists. (Normally, CPNs work from within community mental health teams based, for instance, in mental health resources centres.) My proximity to the seven GPs at the practice, and to my colleagues in other disciplines, means that, obliquely, I have been able to increase awareness of the effectiveness of the human givens approach.

For instance, shortly after I joined, one of the GPs asked if I felt up to seeing a young girl who had been traumatised by a rape a year previously, or whether he should refer her to a psychologist at the hospital. I had just attended a Human Givens College workshop on how to treat post-traumatic stress disorder quickly and safely with the rewind technique, so I agreed to take her on myself. Jenny was 16. She had seemed to cope with the awful event that had happened to her until six months afterwards, when the young man responsible was arrested and she had to give evidence in court. The memories and associated fear came flooding back; her behaviour at school deteriorated dramatically and she started drinking, in order to cope with her emotions.

When I assessed her, to her surprise, I focused on her resources, rather than on what was 'wrong' with her. Previously, she had been confident and outgoing, enjoyed school and going dancing. Now she had lost all of her confidence and her friends, was unhappy and habitually binge drinking. The rewind technique had an instant effect. When I saw her two weeks later, the intrusive memories had all stopped and she had re-established contact with some friends. I worked at relaxing her and helped her to identify and imagine achieving what she wanted to do in her life. The third time I saw her, she was completely back to her old, bubbly self. That really convinced me that I could help people put something awful behind them and get on with their lives. It wasn't some long-drawn-out process that only psychologists or 'highly trained' psychotherapists or counsellors could do.

When the NICE (National Institute for Clinical Excellence) guidelines for treating PTSD were published, the GPs had little idea what to make of them. They have no time to spend struggling to get to grips with treatments like CBT and EMDR (eye movement desensitisation and reprocessing) — which weren’t even defined in the short version of the guide produced for GPs. Contrary to the belief of psychologists and perhaps psychiatrists, GPs are not necessarily well versed even now in what CBT is all about. Having learned from me a little about the human givens approach, and seen how successfully I have been treating people, they feel confident in referring patients suffering from PTSD to me instead of, as per the NICE recommendation, committing them to a lengthy waiting list for CBT. Because I am on the premises and communication is so easy, I can usually make space to see their patient within a week, if necessary.

As a community psychiatric nurse, part of my work is to administer depot injections of antipsychotic medication to those prescribed them and monitor the effects and side effects of medication that patients are taking. I work alongside psychiatrists and secondary mental health services, when my patients are under their care, and I will accompany patients to appointments to support them, if this is their choice. I feel that it is unfortunate that psychiatry is still so firmly rooted within a medical model, with medication the first line of treatment, and I am happy to help patients' voices be heard, if their wish is to reduce their medication. Patients' expectation is often of a 'magic pill' that will cure all their troubles. When one medication fails, another may be tried, or added to the first, resulting in the polypharmacy that appears to me to be fairly commonplace within mental health services.

Unhelpful labels

Psychiatrists and psychologists all too often seem to try and fit people into categories dictated by the diagnostic criteria used within mental health services, so that people often end up with distressing labels such as 'schizophrenic' or 'personality disorder'. One woman, whom I had been helping with anxiety and depression, was shocked and understandably distressed when she was given a prescription by a psychiatrist in the outpatients' department, on which was written a diagnosis of 'borderline personality disorder' and 'adjustment disorder'. These diagnoses had never been mentioned to her in her two years of contact with the mental health service! The 'label', I discovered, had been applied by a junior doctor during her initial two-week inpatient admission, when she had not been cooperative with the nursing staff. I know from my own experience of working on a psychiatric ward that patients deemed 'difficult' often end up with this label — and it colours other professionals' views of them thereafter. Therefore, as I didn't, in my own professional opinion, think the diagnosis was warranted, I wrote to my patient's consultant psychiatrist to say so and attended her next appointment with her. The upshot was that he agreed to 'work with' the diagnosis of anxiety and depression, instead of borderline personality disorder, but refused to overturn or change the previous diagnosis because it had been agreed by a consultant psychiatrist senior to himself who, as far as I am aware, had not actually met the patient!

Whereas the human givens approach starts from the perspective of the person, their emotional needs and resources, this simple understanding is missing in so much of psychological medicine, particularly in the way that services are run. For instance, the first time people go to a hospital outpatients' appointment, the psychiatrist may spend up to an hour taking a thorough history. Patients feel heard and, therefore, hopeful. When the psychiatrist prescribes a drug, they often assume that it will cure their troubles. They return for their next appointment, expecting the same amount of time and attention but are sometimes shocked to find that, at best, they receive a 10-minute review of their medication. Very often, each time they go to an appointment they see a different doctor, which again can be very distressing.

The case of Rosalind, a woman in her early 50s, also illustrates how the way a service is organised can feel as though it lacks human understanding. She was referred to me by one of my GP colleagues because she had chronic anxiety and depression. Seven years previously, when living in a different area, she had been referred to the psychological services team, to see a psychologist. Before her appointment, she was sent a lengthy and complicated questionnaire, which she was expected to complete by herself and return. She found the task horribly daunting, and anxiety inducing, but just about managed to make herself do it. On arrival at the assessment, she discovered that she was expected to complete another questionnaire, the prospect of which, this time, threw her into a panic, and she refused to do it. Her case was closed, as far as the psychological services team was concerned.

Working with Rosalind

By the time I met Rosalind to offer her ongoing support, she was on high doses of a variety of different psychiatric medications because, over the intervening years of no progress, it had been continually upped; she is very damaged by all she has been through. I spent a long time engaging with her and she revealed to me that she believed the root of all her problems was that, for all her married life, her husband had been cross-dressing. This was something she had never felt able to come to terms with and they had kept this secret from everyone they knew. She thought of herself as a victim, who had been weighed down and oppressed by this secret for all these years. I helped her reframe her idea of herself as victim by exploring with her the choices she had made; the reasons why she had stayed in her marriage and why she and her husband had chosen to keep their secret.

Rosalind had taken early retirement about six years previously, due to her problems with anxiety, and she had not yet come to terms with her loss of status and independence. She felt very angry and let down by the mental health services but she has gradually started to trust me, and this led to my being able to work with her to set some small goals. She had once loved walking and gardening, but a knee problem had curtailed such physical activities, so we worked to help her recall and rediscover the enthusiasms she used to have for other more sedentary activities. As a result, she took up tapestry again. With the help of her GP, we are also working on gradually reducing the medication she is on.

About a quarter of the patients I work with are chronic sufferers from mental ill health. Unlike those who actively choose to seek help, many of these are people who have spent 20 or 30 years shuffling around within the mental health services, dulled by hefty doses of psychiatric drugs. Some are not motivated to make changes in their lives. They identify with their diagnosis — it is what defines them and grounds them — and they would be frightened to move on. However, I'll always try to say or suggest something that might open minds to different possibilities, without threatening their status quo.

Brenda's story

Brenda is 60 and has chronic, active psychosis. She has fixed delusions, such as that her water is being poisoned, and has fantastical, complex beliefs in different godlike creatures and the signs they send her. She lives alone and, although well supported by her daughters, is clearly lonely — largely because she resists people's efforts to help, even when the effects are beneficial. For instance, her support worker took her to a local painting group, which she enjoyed enormously, but she didn't want to go again. I have built up rapport with her and it seems that having someone she can trust, and to whom she can tell the strange things that make up her private world, is a comfort to her. (Her daughters refuse to listen to her 'madness'.) So I listen to her and, when she describes some delusion that causes her panic, I'll normalise it at a physical level by saying, "It must be frightening, feeling that way. What I find really helpful when I'm fearful is doing something called 7/11 breathing." I'll then demonstrate how to breathe in to the count of 7 and out to the count of 11, and how it calms down a thudding heart. She seems to find such interventions helpful.

Moving on

Sometimes, however, I am thrilled to be able to play a part in helping someone really move on with their life and it is the human givens approach that has given me the skills to do this. Bob is only 50 but has had chronic anxiety for the past 13 years. At that time, he had suffered a mental breakdown, largely arising from overwork, and had ended up in a psychiatric hospital. His experience there had so traumatised him that he was terrified of ever going in there again. He didn't dare do anything that might challenge and overwhelm him and, as a consequence, had become virtually an agoraphobic. At the time I was asked to see him, he had managed to collect his wife from work in the car, for the first time in all those years. Usually, he didn't dare, because he feared he would have a panic attack if he was kept waiting.

I congratulated him on what a huge step he had achieved in collecting his wife and the fact that he had achieved that without any help — stressing that he clearly had the inner resources and the motivation to move forward in his life. I worked with him over a period of six months, during which time I used the rewind technique to deal with the hospital trauma, gave him techniques for relaxing himself and helped him set goals and believe in his ability to achieve them. The biggest one was to take a holiday with the family in a caravan — he had not been on a holiday in 13 years. He achieved it; he and the family thoroughly enjoyed themselves, and he now has the motivation to set even bigger goals. He is even thinking of returning to some kind of employment, something he was unable to contemplate when I first saw him.

Gradually, my CPN colleagues are becoming more aware of what I can do. When I meet with them to discuss our caseloads, I talk through how I've helped people and what techniques I've used. Currently, I am planning to introduce a needs assessment with clients — to scale how well, or poorly, their needs for connection, status, attention, safety, privacy, and meaning, etc are being met — and, in due course, I'll share that idea, and its impact on patients, with my colleagues. I have planned a lunchtime training session at the surgery to talk about the human givens approach and teach some helpful skills. This session will be for the GPs and other primary care colleagues — health visitors, occupational therapists and district nurses — and may well lead on to other sessions for colleagues in different primary care teams, and maybe the community mental health teams in the city.

My primary care colleagues will come to me for advice if they have any concerns about a patient's mental health. The health visitors will ask me to see a new mum on their list, if they suspect post-natal depression, and the district nurses and occupational therapists, if one of their elderly patients seems to be getting depressed.

However, as the only person in Coventry that I know of using the human givens approach, I do feel professionally quite lonely, in some respects. So I hugely value being a member of the Association of Human Givens Practitioners in the NHS, which is centred at Milton Keynes. We come from all different specialities but what we have in common is the need to manage NHS bureaucracy, and to find 'quiet' ways to pursue and introduce new approaches within it. I hope, for instance, that the positive feedback I receive from patients and the speed and effectiveness of my work will continue attracting the interest and curiosity of my colleagues, and show them that things can often be better done differently. Just as I used to think that psychologists and psychotherapists must be so much better trained and equipped than I to deal effectively with human misery, so do many GPs and other health professionals still believe that particular myth — and, like most myths, it is powerful and pervasive. We must patiently keep working and wait while the wellspring of change fills slowly, drip by drip.

This article first appeared in "An Idea in Practice" 2007