The Big Interview: Dr William Shanahan
FEATURE - 9TH AUGUST 2017
Dr William Shanahan, psychiatrist and medical director of Nightingale Hospital, on why more people should seek help if they are struggling with their mental health, and why they shouldn’t fear what will happen if they do
“The stigma attached to mental illness is still one of the major barriers we have to cross,” says Dr William Shanahan, psychiatrist and medical director of Nightingale Hospital. “It is preventing a great many people who are in need of help from coming forward. This stigma lies behind a great many misconceptions—not only about the nature of mental illness itself, but also the circumstances under which a person may require help and what happens when they do.”
For many, mental health treatment remains a mysterious and intimidating area of healthcare—our response to which is still rooted in visions of the dark Victorian asylum. While it is clear that things have moved on in recent years, there are still people who feel they need help but who lack the confidence to seek it. While Dr Shanahan understands that engaging with his profession can seem like a huge leap of faith, he believes the benefits of taking it can be enormous—and the experience need not be a frightening one.
“Above all, our job is to listen; to give the patient space to talk and for us to take a thorough history,” he explains. “From there we can assess the person’s symptoms and make a diagnosis. Psychiatrists are trained doctors, so part of our job is to determine whether symptoms are the result of a physical illness, a combination of physical and mental ailments, or strictly psychiatric. It could be that there is an underlying neurological problem which can be rectified through surgery, or there may be a hormonal problem, in which case we will call in an endocrinologist. Once we have all the relevant information, we then design an appropriate treatment path. Taking a proper history is critical—without one, you don’t have a firm basis for diagnosis. The problem with a lot of people who are not trained psychiatrists is that they don’t know how to take the kind of history you need to make the right decisions.”
This leads us to a point that Dr Shanahan feels particularly strongly about: those people who lack the proper training and accreditations but who set themselves up as therapists. “These are people who are often told ‘you are such a good listener’ or ‘I always feel better after talking to you’. Based on this, they put up a plate somewhere saying ‘therapist’, and start taking patients. They don’t understand how to take a proper history, so they focus on a tiny part of the person’s life. They tend to relate the patient’s problems to areas they have personal experience within, but when someone comes in with something different, they don’t know what to do. This is what makes amateur therapists very dangerous people. Also, without training, they have little knowledge of or access to the wide array of clinical tools available to the professional. I have had to spend time—sometimes a considerable amount of it—unravelling the damage that has been done by amateur therapists.”
At Nightingale Hospital, the core staff are a group of well-trained psychiatrists, psychologists, psychotherapists and clinical nurses. Their medical training means that psychiatrists can prescribe medication if necessary. The psychologists may not have had medical training (though some have), but are highly trained in assessing and treating mental health conditions using evidence-based psychological therapies. They tend to focus on a particular area, such as phobias, depression or eating disorders.
Dr William Shanahan
Some who have studied psychology and are trained doctors decide to become psychotherapists, taking a psychoanalytical approach. Dr Shanahan believes this multi-faceted approach is better for the patient, as it increases the options available when designing their treatment path. “The patient will see the psychiatrist and may also see a psychologist as part of their treatment, if there’s a need for more focused work on phobias, for example.”
A major part of this approach is to ask how clear a picture the patient has of their mental health status. This may seem obvious, but few people take the time to take a critical look at their feelings—most wouldn’t know how to. Dr Shanahan suggests thinking about your mood in terms of short term (weather) and long term (climate) feelings. For example, during a sunny day a cloud might come by and block out the sun so you can feel a bit darkened and low, but the cloud dissipates and you feel sunny again. If it is always cloudy, and the person feels like they hardly ever see the sun, it is very hard for the weather (how they feel on a day-to-day basis) to improve. Suddenly a person can find themselves in a situation where things are always dark and getting darker, until their mental state deteriorates to the point that a mood disorder develops.
“A mood disorder can present itself in many different forms, such as anxiety, obsessions, compulsions, panic attacks, phobias, or depressive illnesses,” Dr Shanahan explains. “You may begin to struggle to get out of bed in the morning because you are feeling so low, or develop insomnia and cannot sleep. Whatever it is, the main point is that there has been a change of behaviour. Part of our job is to establish what the person feels is ‘normal’ for them now, and what ‘normal’ was in the past. We try to unravel a complex knot of symptoms and feelings, to get to the core of what is going on. I take the patient through a series of questions to find out why they are here today—why not a week ago, or a year ago? What is happening now that has brought them to this place? That’s why taking a history is so important: there can be any number of things that have brought them to my door.”
Many patients arrive because they cannot get to the bottom of a physical symptom, such as a headache. They might initially go to the GP, but as the symptom persists, the investigation may escalate to scans and a neurological consultation, and suddenly the patient is worrying if it is a brain tumour. They are convinced there is something wrong, but nothing is found. The doctor may then consider whether anxiety or depression is playing a role. “At that point, the doctor will send them to us. We then establish whether they are suffering from a mental illness which the mind has been expressing as something physical, and look to help them realise that the pain is linked to a mood disorder,” the psychiatrist explains. “We can reassure them by telling them they don’t have multiple sclerosis or a brain tumour; the dizzy spells and headaches are due to their anxiety.”
Dr Shanahan also believes that the profession is getting better at diagnosing complex disorders, finding more nuanced treatments and using more effective and better-targeted medications.
“Depending on the seriousness of the condition, within an hour I may be able to help a patient realise that it is not as bad as they think. Their worry is actually the bigger issue,” Dr Shanahan tells me. “In fact, often they don’t need any treatment, they just need to play some sports, lose some weight or put plans in place to get a proper night’s sleep. I have had patients leave one session saying, ‘thank god, that’s great’ and never needing to see me again. Or I might think that they could do with an extra bit of support—perhaps some counselling, such as cognitive behavioural therapy (CBT), to restructure their ways of thinking. This is a valuable piece of therapy which may cure a neurosis a person has struggled with for many years, in several weeks.”
Dr Shanahan stresses the need to be careful about leading the public to expect medication for a mental health problem. It may, in fact, be better for them to talk, perhaps undergoing some family therapy with their spouses or partners rather than reaching for medication. “This is especially important if alcohol or drugs are a factor, because the best first step is to get that out of the picture. In fact, in cases of depression, the best anti-depressant you can prescribe is to stop drinking,” he tells me. “If someone with depression is prescribed medication and the doctor has missed the fact that they have an alcohol addiction, the patient is effectively taking several drugs when the best course of action would have been to remove the problem in one go. It goes back to the importance of taking a good history.”
There are times when it is not an easy fix, when the person the psychiatrist is treating is seriously ill, and treatments needs to be escalated. If a patient arrives saying they are so depressed they have been contemplating suicide—which is something most psychiatrists face during their career—it is a very different situation. If the person has a stable support network, anti-depressants may be prescribed to bring things under control quickly, alongside talking therapy. But the therapist must be sure of the patient’s ability to stick to the regime. For example, if drink is a major issue, can they be trusted to drink less, or will they continue to drink heavily alongside the medication? This is particularly worrying, as combining alcohol with some anti-depressant medication can be seriously toxic.
“If the person is psychotic, I may introduce an anti-psychotic medication, but the best option may be to bring them into hospital for treatment. That way, highly trained nurses and therapists can watch them 24 hours a day and they will be much safer. It sounds drastic, but this approach can save patients years of misery,” the doctor explains, as a sombre look flashes across his brow.
“As psychiatrists, we also have the power to invoke the Mental Health Act and detain people against their will. This is what we call ‘sectioning’. We don’t take this decision lightly, as it means we are depriving a person of their freedom. It is only ever done if a member of the team is worried that the patient poses a risk to themselves and other people.”
‘Psychotic’ is a loaded word, beloved of journalists and screen writers, but what does it actually mean? It relates, says Dr Shanahan, to a patient losing touch with reality. “A psychotic patient might hear voices talking about them, putting thoughts into their head, and making them think or do things. The important thing is that they have no insight into their condition; they believe these voices are real,” he explains. “But with therapy and medication, you can teach them about their condition. They may not stop hearing voices initially, but we can give them some understanding that their mind is playing tricks on them, and this gives them some measure of control. That way, if things begin to deteriorate and the voices get worse, they can let somebody know and appropriate action can be taken.”
According to Dr Shanahan, while the public perception is that psychotic patients are always dangerous, this is not the case. The reality is they often feel isolated from the rest of us, are worried and frightened by the voices and usually desperate for some kind of help. Often a person suffering from psychotic tendencies will sit thinking and worrying quietly for hours. But help is available to lead them out of this desolate place—it is just a case of getting it to them.
The most dramatic treatment available to Dr Shanahan and his colleagues is electroconvulsive therapy (ECT). To most, this conjures up images of a rats’ nest of wires connected to the skull of a patient who is strapped down and twitching as electrical currents flow through their brain. But while there is no escaping that this is a major procedure, reserved for people who are seriously ill, the reality bears no relation to the horrors lurking in the public imagination.
“ECT is only used when all other treatments have failed. It has a lot of bad press—mainly as a dramatic device in movies—but it can be a life-saving treatment. I have seen it make huge improvements in women suffering from deep post-natal depression. I have seen mothers who were very distressed, back at home with their families feeling well and able to cope. I have seen it save months of misery and reunite families. It is also very good for people with deep depression—those who feel their life is worthless and really do not want to live anymore,” the doctor explains.
When using ECT, an anaesthetist is called in to assess the patient and if they are fit to undergo a general anaesthetic, that is the last they will know about the process. “While asleep, we put pads on both sides of the head and introduce a gentle electrical current across the brain. This causes a movement of the ions in the brain, which changes the way the targeted brain cells function. It sounds very dramatic, but this is what anti-depressant drugs do too. The difference is that what can take months with anti-depressant medication, ECT does much more quickly. You may need several sessions to get completely well, but there is no doubt it can be a hugely effective treatment.”
Thankfully, however, ETC is a long way down the mental health treatment path and very few people will ever travel that far. And Dr Shanahan thinks it could be even fewer if we saw a change in society’s attitude to mental illness.
“If I had a silver bullet, I would use it to make people far less fearful of psychiatry—in fact, less fearful of mental health therapy as a whole,”
Dr Shanahan says earnestly. “I would ask people to recognise that things can start getting on top of any one of us at times. The loss of a loved one, break-up of a relationship or the loss of a job, sometimes a combination of these circumstances, can cause waves of emotions a person might begin to struggle with. But that is okay; we were not born with a giant ‘S’ on our chest; none of us is Superman. There will always be some illnesses that require more in-depth treatment. But if we can remove the stigma surrounding seeking help and get more people doing so early on, it will increase the chance that the first visit people make to someone like me, will be the only one they need.”