Psychiatry Reflections: Interview with Nigel Evans
Nigel Evans is a recently retired NHS psychiatrist from South Wales.
Since his retirement he has dedicated his time to painting. His paiting 'King of the World at Last' was featured in the first issue of VAINE.
We decided to catch up with him again for our 3rd edition (2021) to talk about his experience of working in the field of Mental Health.
What is your experience of Mental Health in your professional life?
Working as a psychiatrist places you in a very privileged and unique position as you find yourself trusted with the most private details of an individual’s life and psyche.
By the nature of the work you are witness to people experiencing profound and disturbing emotions, frightening perceptions and distressing thoughts which influence their behaviours and social relationships.
To witness someone struggling with severe depression or a disturbing psychosis is emotionally challenging but is tempered by the knowledge that as a psychiatrist there are things you and the wider team can do to help.
It takes time at the beginning of your training to slowly find your own way to manage your emotional reaction to such experiences. This is done by a process of peer support and supervision by senior colleagues and is an ongoing reflective learning experience throughout your working life.
Having positive supportive relationships helps inside and outside of work. I’ve found it essential to have interests outside of medicine - music, film, mountains to name a few – as this allows you to switch attention from the stresses and strains of work and recuperate.
One of the great stressors for psychiatric staff is when a patient dies by suicide. Mental health staff will have known some service users for many years so it can be particularly difficult if the doctor has known the patient and their family for a long time.
How do psychiatrists deal with the responsibility of determining the right care for someone who is in poor mental health?
In my experience psychiatrists tend to be on the more empathic, open minded and socially liberal end of personality attributes so find themselves in something of a paradoxical position at times when, in order to ensure treatment is given, an individual is deprived of their liberty via the Mental Health Act and admitted to hospital.
Detention in hospital is not a situation that psychiatrists would wish to happen and we endeavour to manage most situations outside of hospital and it is worth remembering that the number of people treated in hospital is very much a tiny minority of people with mental health problems.
Admission to hospital can be a frightening and traumatic experience so should be avoided where possible.
We work through a principle of intervention in the least restrictive manner and in the best interest of the patient.
Our professional bodies have become more attuned to supporting staff and help is more available than it was when I was in training.
How do you feel the provision of mental health services compare to other fields of medicine?
During the Covid pandemic there has been much written in the medical press about the concept of “moral distress” amongst health staff where decisions about patients’ care are being made so far outside of the normal practice due to severe resource constraints and workload pressures that clinicians are struggling with consequences of the decisions they are forced to make.
I think a case can be made that psychiatrists have felt some of this for many years, albeit at a less intense level.
Mental health services have been severely underfunded for many years in a way that would be totally unacceptable for other branches of medicine.
Patients continue to be admitted in some places to old, barely fit for purpose buildings which would not be tolerated in general medicine.
Staffing levels are often minimally adequate both in hospital and in the community. Access to psychological therapies is still too limited. The provision of good quality, timely rehabilitation services remains too inaccessible.
There is often limited access to meaningful psychosocial care in the community and limited supported housing projects to facilitate timely discharge from hospital.
It has been difficult at times to watch patients’ wellbeing suffer due to the lack of access to services that would help them.
There are also strong correlations between social adversity, social inequality and poor health, so there are many factors outside the control of psychiatric staff that have major detrimental effects on service users’ wellbeing, that can only be addressed at a societal and political level.
How have things changed in your field throughout your career?
A big change in practice since I started in psychiatry has been a slow reduction in hospital beds and the development of services to prevent admission to hospital via home treatment and crisis interventions teams.
This has helped to change the focus of treatment from hospital to the community but inpatient services became somewhat neglected in the process and patients’ experience suffered as a result.
Other specialist services have also developed and whilst this allows a development of expertise, it can present the service user with a seemingly unfathomable organisation which is difficult to navigate and at times difficult to access.
In recent years, service users, their families and allies have become more proactive in demanding change to services and this helps to influence decision making, but there is still a long way to go.
How has the patient/doctor relationship changed over that time?
The greater involvement of service users in their care is one of the biggest changes I have seen during my time as a doctor. When I started to work in 1989 the practice of medicine was much more paternalistic, whereby the doctor would be seen as an expert decision maker and patients’ views on treatment canvassed less.
There has been a shift to working more collaboratively with service users in that treatment options are considered taking into account the values and views of the patient.
This is especially true of longstanding conditions where the patient develops a deep understanding of a health problem through their lived experience.
There are tensions here at times, especially in mental health, where an individual’s capacity to discuss treatment may fluctuate. The aim here is to formulate plans during periods of wellness regarding how to manage future episodes should they occur.
What is your perspective on the way mental health issues are treated and understood in the UK and other Western cultures? Do you think it is overly-medicalised?
There are a variety of service user-led groups and allied health professionals that are critical of psychiatry as it is commonly practiced believing it to have medicalised aspects of human experience for which solutions should be sought in other spheres.
It is difficult as a general adult psychiatrist to accept these arguments fully but we need to find some common ground from which to maintain constructive dialogue.
We are neither just our biology or just our social construct but some complicated interaction of genes, biology, early life experience, social environment, exposure to substances, interpersonal relationships and current life circumstance.
Treatment and support should take into account all of these factors and ignoring any one of these does service users a disservice.
How do you think society in general can come to a greater understanding of mental health? Or remove taboos?
Stigma remains a significant issue despite lots of work to examine and understand its origins and effect change. Attitudes are slowly changing over time thanks in part to campaigns such as Time to Change. Their website is a useful resource for people to look at and become involved with.
Participation in education and policy development has an important part to play in changing attitudes. Positive role models have an important part to play to demonstrate that most people recover well and to instil hope.
Ultimately mental health services are made up of individuals who reflect the values and views of the society in which they reside, therefore measures to educate people properly, promote respect for each other despite our different beliefs and values, and reduce inequality and exclusion within wider society are essential.
Unfortunately we appear to be living in a very polarised society at the moment, exacerbated by a toxic social media environment and a refusal by some to recognise deep historical injustice and its ramifications in our current lives.
Sadly some of those people are in positions of power and attempt to harness this division to maintain their position. Populist governments around the world also have the worst records on protecting their populations from deaths from coronavirus.
Speaking of Covid, how do you think the lockdowns have affected people’s mental health?
Exactly how the coronavirus pandemic has affected the nations’ mental health is uncertain.
I am worried about the effect of the absence from school for many children, not only on their educational attainment but on their social and emotional development so we could be storing up very significant problems for a generation of children.
There is some evidence of an increase in reports of self-harm and eating disorders in children and adolescents. Deaths due to alcohol also increased in the UK last spring.
Overall the pandemic has exacerbated and highlighted the significant social inequalities in the UK and is likely to make them worse given the disproportionate effects of the pandemic on health as already highlighted.
We have certainly not all been in this together, as the deaths of BAME people have demonstrated, meanwhile in the current UK Cabinet 65% went to fee paying schools (the national average for below 16 is 7% and 16-18 is 18%). I think righteous anger is the only sane response in these circumstances.
What role does art play in mental health issues?
How the arts relate to mental health depends on how the question is framed.
There is good evidence that participation in creative activities promotes improvement and recovery from a variety of anxiety, depression and trauma based problems probably through such factors as social inclusion, promotion of autonomy, installation of hope, boosting confidence and self esteem through purposeful pleasurable activity, and the pre-processing of formerly chaotic and disorganised thoughts and feelings into a more coherent understandable experience.
The relationship between the artist, their art and their mental health is very complicated with a lot of the discussion focused on retrospective analysis of notable individuals’ biographies.
Are all arts the same? If there is a consistency of psychological profile for novelists, is this the same for poets, painters, jazz musicians, concert pianists, composers or mime artists? Are there some common factors for all creative artists? How to explain great artists of seeming psychological equanimity?
Prospective studies tend to be small in number, focus on specific groups and rely on self-selection or self-reporting which makes it hard to eliminate bias and to generalise any findings.
How has your own artistic practice helped you in your own life?
I have always enjoyed music in various forms, I read as regularly as my concentration allows, I avidly watched films as a younger person with a tendency to the macabre and weird and still do, I have enjoyed theatre and visual art more as I have got older.
My work has always required pretty intense interpersonal contact, high emotional expression and lots of talking. I think that non-verbal art forms help to declutter the mind of the incessant chatter and emotional arousal experienced at work.
I’ve started to paint in recent years, which again bypasses verbal expression, although I’ve found that some thought about composition before you start makes for a better outcome.
It’s been an interesting experience choosing what to paint, then seeing what comes out at the end of the process, whilst reflecting on the relationship between the object painted to myself as a painter and my emotional response to the finished work.
In addition, there is the very act of laying down the paint which has a pleasurable physicality to it whilst attempting to learn various techniques in the process.
What are the most important things that people should do to look after their mental health?
With respect to good mental health it is difficult to generalise a prescription to suit all, as an individual’s risk varies with their family history, their biological inheritance, early life experience and current life circumstances so specific risk assessment would be needed for specific circumstances.
One thing that has impressed me during the length of my career is the resilience and fortitude of many of our patients who have had difficult experiences, sometimes living with distressing symptoms for prolonged periods whilst continuing to live in difficult circumstances.
However, there are general measures to maintain wellbeing. We know that good supportive relationships are generally protective and promote recovery. Living life will always throw up stresses and strains, being able to recognise this is a starting point and I would recommend that people find ways to identify problems, attempt to remedy them where possible and find ways to manage stress at an early point in a non-harmful way.
Most people do most of these things adequately most of the time of course. Exercise is good for most mental health issues and improves physical wellbeing. Use alcohol sensibly. Find satisfying and purposeful occupation - some of which may include getting involved in movements to effect positive societal change.
Seeking help sooner rather than later when needed also helps. I suspect that may sound rather banal but the basics of looking after yourself probably are not that complicated. The difficulty is putting it into practice whilst navigating a path through an uncertain world, especially if battling poverty, difficult life experiences and later life discrimination at which point it is probably easier said than done alone but better if supported and sustained by positive relationships.
Inerview with Nigel Evans, VAINE Magazine (Issue 03: Mental Health), 2021
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