The D-Word

Why do mental health services fear dependency?

If you have ever been a user of mental health services, you will probably have noticed that most of them are time limited. In fact, it can sometimes feel like even as you are beginning your journey with the service, you’re already having to think about the end. And the end will come, whether you are ready for it or not.

There are, of course, several practical reasons for this. Time limited services are usually run by the statutory sector or by cash-strapped charities. These services have a mandate – a duty, even – to help as many people as they possibly can. There is an economic need, too, to help people move forward and become productive, contributing citizens again after a crisis.

But what becomes of those who need more?

All too often, I hear the idea of open-ended services being criticised because of the “D-word” – dependency. “We don’t want to create dependency”. “Dependency is unhealthy”. It makes us uncomfortable, particularly when we talk about adults.

The idea of trusting people with a mental health condition to decide for themselves how long they need a service or an intervention seems to be quite alien. I will admit that it was for me before I came to work at LSLCS, where I began to see not only the harm that can be done by our mistrust of the “D-word”, as well as the health inequalities it creates. Before I came to LSLCS, I had, as my American friends would say, ‘drunk the Kool-Aid’ about dependency and in a previous job I had even advocated for more time-limited provision rather than an open-ended approach because of the beliefs I had unconsciously absorbed about “the D-word” during my career, from family, peers, and my own use of services.

It became impossible for me not to notice that it is rarely services that charge at the point of use that also use this anti-dependency language. If you are fortunate enough to be able to afford private care or therapy, it is generally accepted that you can access that service for as long as you need to. But all too often, people with histories of trauma and abuse who often need help from services are also financially disadvantaged because poor mental health affects your ability to work, earn, and reach your potential. There may be no choice to pay for a service that allows you to go for as long as you genuinely need to. So I wonder if there is a darker reason behind mental health providers’ fear of dependency and assertions that it is “unhealthy” or “not therapeutic” – is it more that we as a society simply don’t want to pay what it really costs to help people recover, whatever that looks like for them?

Are we hiding behind an uncomfortable truth?

Is there an alternative to time-limited provision – and what might that look like?

In the person-centred philosophy that we live and breathe at LSLCS, however, we believe that not only can people be trusted to decide for themselves how long they need to use our services for, but that ‘dependency’ is not a scary word. After all, as human beings, we are dependent on a lot of things. We are dependent on the air that we breathe, the water that we drink, the food that we eat, for our very survival. In our modern society, however, where the individual reigns supreme and total self-reliance is prized above all other qualities, we tend to forget about all the things we remain dependent on, including the Earth itself.

If a child experiences adversity and inconsistency in their lives, particularly in terms of their caregivers’ emotional availability to them, it affects their ability to trust and to form the bonds with others that are necessary for emotional wellbeing in adulthood. For some, the first time they will really get to work on this is during mental health treatment and recovery. What a lot of people struggling really need, for the first time in their lives, is to be able to be dependent in a way they were never allowed to be as children – and a mental health service, staffed by empathetic, caring, self-aware individuals, might be their best chance of that.

What we are effectively saying when we offer only time-limited provision is “You’ll move on when we’re ready, not when you are” which can often mirror the damaging experiences people seeking help may have already had. And if that person’s health doesn’t work to the service’s set timescale, we effectively send the message that the person is wrong for not fitting in with it, provoking yet more feelings of guilt, alienation, and self-doubt in those who do not thrive within that model.

It is important to bear in mind that time limited provision is not always bad and it works for many people, especially those who may use mental health services once in their lives to overcome a one-off issue or crisis. This conviction that time-limited mental health services should always do the job for everyone, however, could be preventing us as a society from considering alternatives and examining our beliefs and prejudices around mental health, which is what we really need to do if we are to build a compassionate, effective, and just system.

Liz Smith