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This will be my last blog post as arts coordinator for the Institute. It is a time for reflection and anticipation as I prepare to leave the IMH, say my farewells, and prepare for my new position at University of the Arts-London College of Fashion.

I thought I'd take the opportunity to share a few highlights.

1- 'My big baby' [caption id="attachment_1364" align="aligncenter" width="300"] House for a Gordian Knot, Ekkehard Altenburger

The huge sculpture 'house for a Gordian knot' that sits outside the the IMH headquarters is perhaps my biggest (and heaviest) legacy. I have joked about 'taking it with me' but the fact is, the 6 tonne giant is going nowhere and I relish the fact that it will still be standing proud, as a beacon of hope and positivity about mental health for many hundreds of years to come. I wonder what the now ultra-modern jubilee campus will look like then?

The project itself was akin to a roller-coaster ride which included floods, tantrums and budgetary constraints (I mention no names here for fear of reprisals!). The 18 month saga however was well worth it when I see the magnificent result glowing proudly in front of the IMH. The sculpture has attracted nicknames like 'the grub' and 'the meteor' and visitors regularly stop to look and pose for photos. It is a tangible reminder of the power of art to stimulate emotion and debate as well as to enhance the environment. Working with the talented sculptor Ekkehard Altenburger was a real joy due to his vision, tenacity and professionalism. Particular thanks also go to Nick Manning, Gerry Carton, Saul Tendler, Maxine Clift, Mike Cooke, and Richard Wigginton for their support throughout the project. It was very much a team effort.

I will miss seeing my 'big baby' each day on my way into work; it never fails to lift my mood and reminds me of the importance of art in my life. Access to art and creative activities is essential to my health and wellbeing. I hope that I have used my role as arts coordinator to facilitate those opportunities for others.

2- 'Art in the Asylum' The exhibition 'art in the asylum' at the Djanogly Gallery (6 Sept-3 Nov 2013) was very much a labour of love. The project took some 4.5 years from the original idea to the opening of the exhibition. Many times I almost gave up as various setbacks stalled and threatened the project. For those who didn’t see it, the exhibition charted the diagnostic and therapeutic use of art in British asylums from 1832 to 1970. It also addressed the critical role that asylum art played in art history with the creation of art brut and later outsider art, which is now a highly marketable commodity with commercial fairs annually in Paris and NYC. All the effort paid off as around 10,000 people attended the exhibition and its associated events and reviews were glowing. Many people gave remarkable feedback about the impact and significance of the exhibition e.g. ‘superb and thought-provoking’, ‘mentally incredible’, ‘staggering art’, ‘very moved by amazing artwork’, ‘provocative and thoughtful’. Visitors travelled from far and wide, even braving the tram works (!) to get there. The earliest work from the 1800s from Crichton Royal Institution in Dumfries attracted much attention and a number of visitors travelled all the way from Scotland to see it. It had never been exhibited before outside Scotland and it demonstrated the historical importance of Scottish mental health care so it was a real coup to have it.

I am pleased to report that, due to popular demand, I am currently preparing a text about the exhibition which should be ready later this year or early 2015. It is not an exaggeration to state that the exhibition was transformative for me as it developed my creative and curatorial skills and moved me into an artistic realm where I feel very much at home. An especially huge thanks goes to my co-curator Esra Plumer and to Neil Walker at the Djanogly Gallery for their creativity and commitment in realising 'art in the asylum' and to the lenders of the some 130 works included, without which there would have been no exhibition.

3- the IMH exhibitionsWhat began on a very small scale to raise awareness of mental health issues and to encourage service users to submit artwork for exhibition in the building, have now become nationally recognised exhibitions with a large number of submissions coming from all over the UK. It was my mission to fill the IMH with art and I must say I have almost succeeded. Highlights include the 'pugs in space' launch at the 2012 foundation lunch complete with performance art 'human canapé' and 4 pug dogs running loose amongst the suited delegates. Another unforgettable moment was when a service user cried tears of joy as she embraced me and expressed gratitude for giving her the opportunity to show her art in the IMH. I am especially proud of the work I have done at Rampton Hospital, working with a particularly vulnerable population; running art workshops, facilitating submission of work for exhibition, and attending patient events to give feedback on their artwork and to give out awards for artistic achievement. It is clear that for this group of people who have limited access to creative opportunities and community engagement, art can be a powerful route to recovery. As one said to me, 'I am an artist now, not a patient'. Many thanks to Giovanni Grassi at the Acorns unit for his tireless work in assisting me with activities at Rampton and to Mike Harris for his support.

I feel like I could go on and on but I won't. As this brief missive hopefully conveys, I have really enjoyed my role as arts coordinator. It had been personally and professionally enriching and I hope that I have left a healthy legacy for the new IMH arts team of Gary Winship and Elvira Perez to move forward. I know that the future of arts activities at IMH is in good hands with them.

It is satisfying that art is now embedded in the culture of the IMH. My work hasn't been without its detractors and it can be hard to justify expenditure on art in the age of austerity. I would argue that it is a small price to pay for the enrichment that art provides with its power to stimulate, decorate and in some cases agitate. Long may it continue.

Victoria Tischler

17 year-old Benjamin Braud has Tourette Syndrome (known as ‘tics’ or ‘TS’). He chose to spend a week long work experience placement at the University of Nottingham, specifically with researchers from the division of Psychology, based at the Institute of Mental Health. After he’d finished his experience we asked him how he got on…

How did you come to have your work experience at the University of Nottingham?

I came to the University of Nottingham because I wanted to see the variety of choices and skills they offered. In fact, when I contacted the research team (who I already knew because I’d volunteered to help them with Tourette Syndrome research in the past) they allowed me to spend a week with them, which I’m grateful for.

Were you already involved in research at the University of Nottingham?

Yes, I’ve done many exercises and relaxations on TS which were part of research studies that students were doing. Also, I’ve done a few MRI scans which enabled the researches to have a closer and detailed look at my brain.

Were you in a particular team or department?

I was involved in the department of Psychology where I helped Jane Fowlie, Dr Ruth Wadman, Amelia Draper and research students. I also went to the Institute of Mental Health, where the MRI scans were being done. It was extremely interesting and fascinating to take part in the research. I would be happy to do it again.

Why did you choose this work experience placement?

Since I have been helping the research teams with their study into TS, I wanted to see the other sides of their job, which in fact were quite interesting. It was great to find out about the other studies and opportunities they are involved in.

What did you hope to achieve from this work experience placement?

This work experience has given me a variety of skills. It has been extraordinary, fun and most all fascinating. I’d hoped to gain more knowledge to allow me to have a clearer idea of how to get on the path to my future career – which I did.

Can you give us an idea of the kind of things you did – any duties or things you were asked to do?

The activities I participated in were always interesting! I did research activities (games/simulations), learnt about new research studies, and I even learnt about Psychopaths! I also learnt about how research is conducted and learnt more detail on how Tourette Syndrome occurs with the human brain with Professor Georgina Jackson and Dr Elena Nixon. However, there is so much to talk about as it has been a great journey!

What do you feel you gained from the experience?

This experience has given me skills which I can develop, mainly confidence and communication skills because meeting new people has boosted my confidence. Plus everyone was friendly - the environment was great! There are plenty more skills which I have developed but the main one would be new knowledge about the outside world, which has enabled me to be more confident about myself.

Would you have any advice for anyone about to go on work experience?

My first thoughts were that they would treat me like a lab rat, however; I was wrong because the people have been kind, honest and friendly, which was great. The only advice I would give is just be yourself and look smart on your first day as it will give the people a good impression about you and what you are like. Also, don’t be afraid to ask any questions - I learnt a lot.

What are your future career plans/goals?

Before I went to work experience I wanted to go to University. But now I feel like I want to do an apprenticeship. Even though the University of Nottingham offers science based studies, I would prefer to do an apprenticeship in a lab in the same type of research, but maybe in a different disorder. Perhaps help with TS. But, nevertheless, this work experience has given me a lot of options and choices.

A friend of mine recently made me smile, as we were discussing recent pieces of work I have done for the Care Quality Commission (CQC).  Her comment was ‘Blimey you’ve gone over to the dark side’.  This is the reputation the CQC has; however, although I have only been on three inspections I have learnt so much. My role has been to chat to service users and ask how they feel they have been treated.  I don’t just ask the questions about this, and I use the following as prompts: is the service ‘safe, well led, caring, effective and responsive’.  It’s a skill that I am still mastering to use the way people feel about the care below.

It has certainly been an eye opener. As a patient of many areas of health in Nottingham how lucky I feel my treatment has in the most part been very good. A hospital I went to had buildings that looked like Anderson shelters. The recovery room at the hospital was at the top of a steep corridor, so there was a pulley system almost like a ski lift to take the trolleys up.

I have spoken to many patients who have had many different health issues and feelings. The one I remember more than anything was an elderly lady who was wheelchair bound. She was in a nursing home in Nottinghamshire. She was in the lounge watching the French open and had an incredible smile on her face so I couldn’t resist talking to her. It turned out she had played tennis nationally. Previously I had found older people difficult to relate to, but this lady was so happy talking about tennis. I don’t want to make it look easy to go into a service, and sometimes inspections can make it difficult for staff.  As many of you will have seen on the television about mistreatment of patients, it’s the CQC’s role to make sure this doesn’t happen. Some of the inspections have discovered bad practice; this is often from learnt behaviour by new staff coming in and being incorrectly trained.

So if you hear that the CQC is coming please don’t look at them as the dark side, I haven’t seen Darth Vader yet, they are there to help, and stop bad practice.  Services that have been inspected will be able to blow away the dark side and help bring about a lighter side for those unfortunately are being treated in many ways by the NHS.

I realise this isn’t going to happen overnight but we need to keep walking towards the light and be happy that the dark side is very slowly becoming that bit lighter.

Peter walks into the staffroom carrying a signed sports tabard and a box of matches. He sits down heavily on the chair beside the fridge, closes his eyes briefly and sighs.
‘What’s the matter?’ asks the person sitting next to him.
‘Well… you know Billy Jones, big boy, cross-eyed, year Eight, Dad’s in prison for arson…’ but the bell goes before Peter can finish the story of his run in with an unpleasant pupil. Within a year, Peter will have left the teaching profession.
On January 31st, 2014, Sir Michael Wilshaw Chief Inspector of Schools, speaking at the North of England education conference in Nottingham, commented on the national scandal of four out of ten teachers leaving the profession within five years of completing their training. One suggestion is that these departing teachers simply lack resilience. A few years ago, The Teacher Development Agency was asked by the Dept. of Education and Skills (DfES) to identify psychometric tests which will weed out ‘less resilient’ personalities from groups of prospective students before they start their teacher training courses. After a bumpy ride, these tests came into existence in September 2012. The DfES hopes that money will not, therefore, be wasted on training people who will never have the personality to survive in a classroom. But what is resilience? How will these tests measure resilience and, most importantly, how have government agencies decided that ‘resilience’ (or perhaps only the appearance of being resilient) has become a necessary – perhaps the most necessary - part of the repertoire of some one who wishes to teach?

From Selye’s GAS in 1955 to Meichenbaum’s Stress Inoculation Training in 1975, and on to Marmot in 1991, ‘workplace stress’ has been a central topic in psychology research for decades - and then came Seligman and this new thing called ‘happiness’ or, as in his latest book ‘the ability to flourish even under duress’. This attractively upbeat focus on resilience i.e. ‘the ability to flourish under duress’, rather than stress, has grown out of the Positive Psychology movement, which had its coming out ceremony in 1998. Martin Seligman, a professor at the University of Pennsylvania, advocated at that year’s annual meeting of the American Psychological Association that mental illness should not be the sole preoccupation of his discipline. In 1975, Seligman had published the results of research which showcased the development of the concept of ‘learned helplessness’. Having gained evidence that he could replicate the inaction and hopelessness of human depression in animal participants, Seligman took his research in the opposite direction, and explored the possibility that interventions by psychologists using cognitive behavioural therapy (CBT) could promote optimism, wellbeing and resilience in human subjects.

Over the last 20 years, positive psychology has gained credence through further research by social scientists, neuroscientists and economists, and the importance given to its’ emphasis on the measurement of ‘happiness’ has been willingly embraced by politicians on both sides of the Atlantic. David Cameron’s two million pound plan to measure the nation’s happiness got under way in April 2012. The Office of National Statistics had its first four happiness questions in that year’s annual Integrated Household Survey which was sent out to 200,000 British homes. In the United States, the US army isn’t just measuring the levels of ‘happiness’ amongst its troops; it is attempting to promote well being by investing 125 million dollars in a 5 year programme involving 800,000 soldiers, which involves teaching soldiers ‘emotional resilience’ at Seligman’s department at the University of Pennsylvania. Fostering resilience in pupils has become a by word in education, too. For many student teachers in the United States and in Britain, ‘creating the resilient pupil’ is part of the course programme. In many schools, fostering resilience in pupils is part of the pastoral agenda. So perhaps it was inevitable that academic research would turn to the examination of resilience in teachers themselves. For example, in 2007 and 2008 Cardiff University’s Work Environment Research Centre reported on a longitudinal study into work related stress which included teachers in its participant sample and in Cambridge the Well Being Institute studies the development of well being in schools.

But there is a need to define the sources and the mechanisms of resilient behaviour before we can incorporate resilience training into any pre-vocational assessment or CPD programme. This has been the focus of a series of seminars entitled ‘The Resilient Teacher’ which have recently been based in the Education Department of the University of Nottingham. The central questions of the debate have been ‘what is resilience?’ and ‘can it be usefully fostered in teachers?’ These ESRC funded series of seminars, led by Christopher Day, Anne Edwards, Amanda Griffiths and Qing Gu have been examining the wide ranging body of contemporary research into ‘resilience’ in teachers. The focus of the first tranche of seminars, stretching from May 2010 to January 2011, was to seek a definition of ‘resilience’.

Rather than seek a theoretical definition, Dr. Nigel Hunt, who contributed to these seminars, showed us how his work focused on gathering empirical evidence by observing how individual people became ‘able to cope’ and able to ‘function normally’ after living through a traumatic event. He has led research which gathered the responses of participants in Iraq and China to the appalling experiences they had of, respectively, war and earthquake. The results of his research suggest that the development of resilience can be tracked and supported by narration. After a traumatic event an individual goes through a series of changes in how they narrate their experience. At first narrating their experience is harrowing. Some obvious and measurable indicators of this distress are that the participants’ blood pressure rises, their heart rate increases, they tremble. They display all the reactions of high arousal – the ‘fight or flight’ stress response – they are re-experiencing the event. But as they repeat their explanations they gradually incorporate these experiences into a narrative which they can safely repeat without distress. Dr. Hunt’s premise is that this alteration of the effect of the narrative on the narrator, which can only happen after a number of repetitions, may be at the root of the development of resilience. The question for those in dismay at the exodus of teachers from the workforce is - could Dr Hunt’s finding be usefully applied to teaching?

This simple need to tell the story of a stressful event can be seen, or heard, in our workplaces every day. Professions where employees deal directly with the public incorporate mentoring into the cycle of the working month. Social workers have to undertake one hour of informal discussion about work with a person of their own choice each month. Police officers also have a formal ‘talking’ programme. Mental health workers have both formal and informal mentoring as part of their work pattern. These words are taken from an interview that was given to me by a senior health worker I will name Cara :

'Each week I attend a team- wide case conference involving around 20 staff where information about each patient is shared between psychologists, nurses and the off-ward support staff. Once a month I attend a debriefing session where I can discuss in confidence any concerns I have about my client base which is about 25 patients. Once a month I can choose any colleague and book an hour with them to discuss, again in private, wider issues about the job. I know that this support structure helps to keep me sane. Maybe in one way it works because it shows that there is a recognition by the policy makers above us that staff require support - the service we provide is so personal and so unique to each patient – and it’s hard to explain to what you do to anyone outside the profession.’
Dr Hunt introduced his contribution to the seminar series by saying that at first he could not see how his work with the traumatised victims of war and natural disasters could be related to ordinary members of the teaching profession. As he explored the experiences of teachers he realised that there were similar patterns of incidents and response at play. If time to talk were given precedence – if teachers actually had ‘time to talk’ at school as part of the weekly timetable then would they, could they become a ‘more resilient’ workforce? What he had observed in trauma victims was the dynamic process of resilience being built. The current psychometric tests available for ITT to measure resilience are static. They can only offer a snapshot of a state of mind. The interrelational quality of the conversation which Peter was about to have in the staff room that day is harder to measure but could provide invaluable information on how to promote ‘resilience’ within the teaching profession on how to promote resilience in any profession. Far more useful information than the blurred snapshot of a prospective employee’s mental state offered by psychometric testing and far more useful than waiting to patch up those who fall by the wayside by offering them ten sessions of CBT.

Fiona Birkbeck
PhD Research Student
Department of Education
University of Nottingham
This email address is being protected from spambots. You need JavaScript enabled to view it.
Day, Christopher et al (2011) Beyond survival: teachers and resilience. Nottingham: University of Nottingham.
Hunt, N. C. (2010) Memory War and Trauma. Cambridge. Cambridge University Press
Marmot, M. G.; Davey Smith, G.; Stansfield, S.; et al. (1991). Health Inequalities among British civil servants: the Whitehall II study. Lancet 337 (8754): 1387–1393.
Meichenbaum, D. M., & Cameron, R. (1983). Stress inoculation training: Toward a general paradigm for training coping skills. In D. Meichenbaum and M.E. Jaremko’s (Eds.) Stress Reduction and Prevention New York. Plenum
Seligman, M.E.P. and Maier, S.F. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology, 74, 1–9.
Seligman, Martin E. P. (2011) Flourish: A Visionary New Understanding of Happiness and Wellbeing. New York. Free Press
Selye, H. (1956) The Stress of Life. New York . McGraw-Hill

In March 2014 the national media ran stories on the subject of ADHD based on interviews with a US academic. This article outlines the response from the Institute of Mental Health's CANDAL centre of excellence.

The Observer (30.03.14) headlined an article: Children's hyperactivity 'is not a real disease', says US expert. It reported an interview with Dr Bruce D Perry, Senior Fellow of the Child Trauma Academy in Houston, Texas.

Dr Perry is visiting Britain to meet cabinet members Ian Duncan Smith and Jeremy Hunt, as well as addressing the influential Early Intervention Foundation, chaired by Labour MP Graham Allen. Dr Perry is, to his credit, a prominent advocate of the idea that the way we treat children has profound effects on the way their brains develop physically, and that this has far-reaching consequences for their lifetime mental health. We entirely agree.

However, there are many things about the Observer’s report of its interview with Dr Perry that we find worrying, particularly the Observer’s rhetorical headline, and the potential impact of Dr Perry’s reported views on public understanding of and policy towards ADHD.

Dr Perry rightly says that ADHD describes a broad set of symptoms, and that many of us “at any given time" would fit “at least a couple” of the symptoms of ADHD. But this entirely misses the point that for a clinical diagnosis of ADHD, symptoms of inattention, hyperactivity and impulsivity must be severe, persistent and impairing. These difficulties present challenges that are all too real, and the role played by childhood trauma does not make them less so.

The NICE ADHD Guideline carefully reviewed evidence from numerous clinical trials and concluded that while behavioural interventions should be offered first to milder cases, pharmacological intervention is the most effective treatment for severe ADHD. As the Observer rightly notes, prescription rates for ADHD drugs in the UK have risen sharply in recent years. However, far from the rise being a scandal, it reflects a welcome trend towards greater access to care for children with ADHD, and prescription rates in the UK (in contrast to many parts of the US) remain well below the estimated prevalence of the condition.

Nonetheless there is legitimate cause for concern over long-term use of any drug during childhood. Dr Perry raises two concerns.

Firstly, he is reported as claiming that the evidence suggests there are no long term benefits of psychostimulants. Dr Perry may be referring to the rigorous Multi-modal Treatment study of ADHD (MTA)^1,2. While results after 14 months of randomly allocated treatment showed clearly that carefully crafted medication treatment was more effective than state-of-the-art psychosocial treatment alone, or routine community care. However, naturalistic follow-up of the MTA sample after random treatment allocation ended at 14 months found that differences between the treatment groups diminished over timeand that serious functional impairments often remained^3,4. Importantly, the results showed that treatment benefits were only maintained while carefully crafted medication was maintained. The implication is not that medication doesn’t work in the long term, but rather that effective treatment needs to be maintained for benefits to persist. This is similar to the management of other long term conditions such as hypertension and diabetes – where benefits are only persist if the treatment is given.

Secondly, Dr Perry reportedly argues that psychostimulants raise reward thresholds. But substantial evidence ^5–8 indicates that raised reward thresholds are typical of untreated ADHD , a dysfunction attributable to an underlying deficit in the dopamine system, and that methylphenidate, which increases the amount of dopamine at brain synapses, actually lowers those thresholds, helping children to engage and concentrate better on less immediately rewarding activities such as school work, and be less distracted by the immediate stimulus or buzz provided bycomputer games, mobile phones and social media. 

Dr Perry states that we should be cautious about medication “particularly when the research shows you that other interventions are equally effective and over time more effective and have none of the adverse effects. For me it's a no-brainer.”  Of course if this were true he’d be right, as no one should medicate children if other interventions that are safer and just as affective are available.  But research does not show that other (behavioural) interventions are “equally effective” for ADHD – indeed a recent study⁹ showed that even what evidence there was for the effectiveness of non-pharmacological interventions for ADHD largely disappeared when the children’s behaviour was rated by observers who did not know whether the child had received the intervention. Although politically unpalatable, it appears that the evidence for the effectiveness of existing behavioural interventions for ADHD has been oversold.

At CANDAL we are committed to developing and evaluating novel cognitive and behavioural therapies of exactly the kind that Dr Perry advocates, aimed at breaking the negative cycle of dysregulation, but clearly much more work needs to be done to make them effective.

We entirely agree with Graham Allen that “if you can diminish adverse childhood experience, then we eliminate a lot of the causes of dysfunction.”  We applaud Graham Allen’s efforts to focus public attention and government resources on “evidence-based programmes” that will help improve children’s mental health and reduce the “costly and damaging social problems”that can result from conditions such as ADHD.

Children with ADHD and their families in the U.K. deserve betterpublic understanding of the complex, multifactorial nature of this disabling condition and access to better treatments, not sensationalist and stigmatising headlines that suggest that these children and young people do not have a “real” condition.

 

Signed:

Professor David Daley (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Professor Cris Glazebrook (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Professor Chris Hollis (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Professor Georgina Jackson (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Dr Elizabeth Liddle (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Professor Peter Liddle (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Professor Kapil Sayal (This email address is being protected from spambots. You need JavaScript enabled to view it.)

 

Members of CANDAL Centre for ADHD and Neurodevelopmental Disorders Across the Lifetime, Institute of Mental Health, University of Nottingham.

 

References

1. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch. Gen. Psychiatry56, 1073–1086 (1999).
2. Conners, C. K. et al. Multimodal treatment of ADHD in the MTA: An alternative outcome analysis. J. Am. Acad. Child Adolesc. Psychiatry40, 159–167 (2001).
3. Molina, B. S. G. et al. The MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study. J. Am. Acad. Child Adolesc. Psychiatry48, 484–500 (2009).
4. MTA Cooperative Group. National Institute of Mental Health Multimodal Treatment Study of ADHD Follow-up: 24-Month Outcomes of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Pediatrics113, 754–761 (2004).
5. Rubia, K. et al. Methylphenidate normalises activation and functional connectivity deficits in attention and motivation networks in medication-naive children with ADHD during a rewarded continuous performance task. Neuropharmacology57, 640–52 (2009).
6. Johansen, E. B. et al. Origins of altered reinforcement effects in ADHD. Behav. Brain Funct.5, (2009).
7. Liddle, E. B. et al. Task-related default mode network modulation and inhibitory control in ADHD: effects of motivation and methylphenidate. J. Child Psychol. Psychiatry52, 761–771 (2011).
8. Groom, M. J. et al. Effects of Motivation and Medication on Electrophysiological Markers of Response Inhibition in Children with Attention-Deficit/Hyperactivity Disorder. Biol. Psychiatry67, 624–631 (2010).
9. Sonuga-Barke, E. J. S. et al. Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments. Am. J. Psychiatry170, 275–289 (2013).

This is a guest blog from Nell Munro, originally posted on the Mental Health and Capacity Law blog here. Dr Munro has also written an excellent (and extremely popular) EasyRead version of this blog, found here.
Connor Sparrowhawk died in an assessment and treatment centre in Oxford in July 2013 after suffering an epileptic seizure whilst he took a bath. Connor had been diagnosed as having epilepsy for two years, was receiving medication for his condition and there were many signs in the weeks preceding his death that his seizure activity might have increased.

An independent report commissioned by Southern Healthcare NHS Trust which runs the centre where Connor was a patient has just been published. It has found that Connor’s death could have been prevented if staff had recognised that his epilepsy created risks around taking baths and conducted a proper risk assessment.

This post is not about the report. Instead it is a reflection about the current state of the law on the liabilities of state institutions responsible for detaining people who subsequently die in their care.
Has the Trust violated Connor’s right to life under Art 2 ECHR?

There are two aspects to this question:

Did Southern Healthcare owe an operational duty under Art 2 ECHR to Connor?

AND
At the time of his death did Southern Healthcare know of a real and immediate risk to Connor’s life which they could have taken reasonable steps to avert?

The answer to the first question must be yes. Connor’s legal status at the time of his death was that of an informal patient. His admission history had been chequered, he had been admitted as an informal patient, later detained under the Mental Health Act and then discharged from MHA detention although an assessment completed at the point of his discharge from detention concluded that he lacked capacity to make decisions regarding admission. A standard authorisation for his detention had been sought under Schedule A1 MCA but this had been refused so there were no formal controls in place regarding his detention status. However, after the unanimous Supreme Court decision in Rabone v Pennine Care NHS Trust  it is clear that the approach to be taken to deciding the question of operational duty under Art 2 ECHR is one of substance not form. Connor lacked the capacity to make decisions about his admission and he was on a locked unit. He was manifestly deprived of his liberty and under the control of the state. As such he could not have protected his own right to life and it was the state’s duty to do so instead.

The content of the report only tell us that Southern Healthcare staff could have prevented Connor’s death which is not the same as saying the death was predictable. Liability under Art 2 ECHR does not arise simply because the state has taken on the care of someone who has an illness and subsequently dies. Nor does it arise because the state has taken on the care of an individual within a well-organised healthcare system but one rogue professional acts negligently.

The starting point remains the infamous ‘Osman’ test – that the state can only be liable if it knew or ought to have known of a real and immediate risk to the individual’s life and had failed to do all that could reasonably be expected of them to avert that risk.

The fact of Connor’s de facto detention is not decisive although it is persuasive. His family would also need to demonstrate that the risk of death was ‘real’ in this sense meaning serious or significant and ‘immediate’ which has been glossed as meaning ‘present and continuing’. Threats of suicide 18 days prior to a suicide were held in Renolde v France to have been adequate evidence that a risk was immediate. Repeated warnings by family members that an individual is showing signs of seizure activity would seem to fall into a similar category.

The fact that the risks posed by Connor’s epilepsy were not known to staff are a matter of evidence, but ignorance is irrelevantif it is found that the staff should have known about the risks.

Finally the fact that small measures could avert the risk weighs strongly in favour of finding a substantive breach. The reason the test in Osman v UK is typically described as a high threshold to reach is political rather than legal. Neither the UK not the Strasbourg court wants human rights law to become the vehicle for extending the liability of public authorities to cover liability for the actions of criminals or individual incompetent professionals. Such an approach could subvert the ends of justice. But systemic failures are different. Here there is a policy argument in favour of using human rights law as the tool to force healthcare providers to prioritise patient safety or the police to maximise the safety of detainees. This is reasonable provided the changes in practice this requires are those which are included in the definition of good healthcare – like assessing the risk of drowning if someone with epilepsy has a bath unsupervised.

The decision in Rabone has made it easier for these substantive claims to be taken, notwithstanding Lord Dyson’s emphasis on the language in Osman and Van Colle that the test of ‘real and immediate’ risk was significantly higher than that employed in the common law of negligence.

In the case of people detained by the state the threshold set for establishing a real and immediate risk is only notionally different from the very low threshold set for foreseeability in tort. It is not clear from the facts of the decided cases that the two areas of law actually operate differently. I cannot identify any decided cases which did not meet the requirements for ‘present and continuing’ risk under Art 2 but which would still give rise to a successful action in negligence (because the test for foreseeability in tort is lower than the test of immediate harm) and sadly the issue is unlikely to be tested. Deaths in state detention tend to involve people who do not leave dependants (in the narrow sense defined by the Fatal Accidents Act 1976) and the damages that can be recovered for their death under an action in tort will be small so in practice actions are always taken using the Human Rights Act with small additional claims made for the costs arising from the individual’s death.

Taking an action for a substantive violation under the Human Rights Act may not be what the family want to do.
The state also has an obligation to investigate all deaths which arise when a person is under state responsibility. In England and Wales the primary mechanism for achieving this is via the coroner’s inquest.  Recent caselaw has held that investigations such as the one published today are not essential for meeting the requirements of Art 2 although publishing them is still good practice.

I get the very strong impression that when an individual dies in the care of the state the responsible authorities are deeply conflicted about how to meet their investigative duty under Art 2 in a way which also meets the needs of the family and how to avoid admitting liability for failing to meet positive duties under Art 2. If I was advising a healthcare provider I could not tell them how to do both.

The issue is not damages. The quantum awarded for actions taken under the Human Rights Act are typically small, and pragmatic legal advice on any borderline case would be to suggest the authority apologise and settle an action as early as possible to avoid legal costs and the costs of staff time involved in giving evidence. A bigger issue is reputational harm. The current uncertainty about what actions may give rise to liability after Rabone means that honestly acknowledging poor care for an in-patient who lacked capacity may be tantamount to acknowledging liability for their death and a violation of their right to life. This raises the stakes considerably.

At the same time families have consistently demonstrated their need to understand what happened to their loved one. The facts of Powell v UK describe a nearly 10 year long battle by a couple desperate to establish the facts concerning the medical decision-making prior to the death of their 10 year old son who died as a result of medical negligence. In the subsequent caselaw concerning deaths in prison, police custody and most recently in mental health services families have made it clear that they need to understand the circumstances which lead up to their loved ones death as soon as possible after the death. Waiting to know fuels fear, anger and the plausible belief that the provider must have something to hide and that others may be in danger. All of this at a time when the family are grieving.

Can anything be done to improve this?

Two things could possibly improve it. One is emphasising that establishing how a death occurred is distinct from the question of fault. This distinction is actually made in coroner’s practice, but is confused at the level of some of the leading judgments on how coroner’s inquests serve the purpose of Art 2.
Current caselaw on the function of the inquest has emphasised that its role in meeting the state’s investigative duties under Art 2 ECHR are ‘parasitic’ on the state’s positive duties under Art 2. In other words the investigative duty exists to serve the positive duty, and it is primarily necessary to perform the investigative duty in circumstances when we think the positive duty may have been compromised (Middleton and R(Smith) v Deputy Coroner for Oxfordshire). The situation is subtly different where the death occurs outside detention. In Takoushis it was argued that the investigative duty still arose when the person died outside custody, but here the policy reasons for it (based on close analysis of ECtHR caselaw) were different. The object was to ensure that whether by empowering family members to take a civil action or by holding an inquest the legal system must ensure that all deaths which might be attributable to negligence can be investigated. The judgment in Takoushis found that the English legal system met this requirement. So the current position in English law does not support the view that when the operative duty under Art 2 is engaged investigations into the death should be an end in themselves.

But the behaviour of families does not suggest they need to know how the death occurred only or mainly because they need to know if the death was unlawful. They need to know for a wide range of reasons which our legal system does not currently address.

Another question that arises is whether we need a procedure which falls between inquests held under the Coroner and Justice Act 2009 and the root cause analysis internal investigations conducted under the current guidance on serious incident investigations. The objects of the inquest are to serve the needs of the community and in most cases to meet the formal requirements of an independent investigation required to satisfy the investigative duty under Art 2. And the objects of the internal investigation are to ensure healthcare providers identify dangerous practices and potential improvements for the future. But neither procedure is adequately oriented to meet the needs of bereaved families.

I don’t have a good conclusion for this blogpost. But Connor Sparrowhawk’s mother does. It is a blogpost called Imagine.

This is a reblog from the blog of the Menninger Clinic, and the complete post can be found here - the below is just a taster!

"I deliberately chose a tendentious title for this essay – misleadingly metaphorical rather than literal – to highlight, as one of my recent posts outlines, my alarm stemming from reading research on stigma.

With many others, I had assumed that treating psychiatric disorders as “a disease like any other” (i.e., like any other general medical condition) would ameliorate stigma. This biological perspective reflects a longstanding trend away from moralizing toward medicalizing mental illness – in Karl Menninger’s words, transforming “sin” into “sickness.”

Research on attitudes toward mental illness
In believing that we would thereby ameliorate stigma, we were wrong. My previous post was inspired by Erlend Kvaale and colleagues’ synthesis of extensive research that yielded surprising findings. Although construing mental illnesses as brain disorders decreases blame of the mentally ill person, it does not reduce stigma (i.e., social distancing). Moreover, this reframing can be harmful: It increases pessimism about prognosis, and it also risks increasing perceived dangerousness."

The Mental Capacity Act 2005 provides a framework for making a decision for an individual who is found to lack capacity to make it him or herself.  Where an individual lacks capacity to make a decision, a decision must then be made in their best interests under s.4 of the Act.  Section 4(6) provides that, when making a decision in someone else's best interests, account must be taken of any past or present wishes or feelings, beliefs or values that would have influenced their decision, and any other factors they would have been likely to have taken into account if they had capacity.

Since the MCA came into force (and indeed, prior to the MCA as well), it has long been a subject of debate as to the weight that an individual’s wishes and beliefs carry in this process.  Munby J (as he then was) gave two judgments in the years just after the MCA came into force which dealt with this factor, the first being Re MM; Local Authority X v MM (by the Official Solicitor) and KM [2007] EWHC 2003 (Fam), at paras [121]-[124], the second being ITW  v Z & Ors [2009] EWHC 2525 (Fam), which restates Re MM and adds several elements.  Re MM noted that P’s wishes and feelings should always be a significant factors, but were not necessarily determinative.  He pointed to the need to consider the degree of P’s capacity when expressing wishes and feelings, and the impact of not giving effect to them.  ITW v Z and others added the caution that the relevance of wishes and feelings will be case by case, and that additional factors to consider are the strength and consistency of those views over time, how rational, sensible, responsible and pragmatic the views were, and the possibility of actually implementing the action necessary to respect the views.

Munby J was, in that case, specifically dealing with P’s current wishes, when he/she lacks capacity, but those factors are equally applicable to thinking about the relevance of past wishes and beliefs; in particular, where someone has made a strong statement refusing a particular treatment, and subsequently loses capacity, what weight should that statement be given?

Sections 24-26 of the MCA outline the process of ‘advance decisions’ – these are decisions which are binding on medical professionals with regards to refusal of treatment where the issue arises once P has lost capacity.  For advance decisions to be binding on professionals, they must be ‘valid and applicable’ to the circumstances, and must be signed by both P (or P’s representative) and a witness – any other written statement is simply something to be taken into account as part of s.4(6).

However, a recent decision in the Court of Protection, published a few weeks ago, suggests that spoken statement can have a similar effect as advance decisions, although presumably they are not legally binding in the same way.

Newcastle Upon Tyne Hospital Trust v LM [2014] EWHC 454 (COP) centred on the time-honoured issue in medical law of the giving of blood products to Jehovah’s Witnesses.  LM had been admitted to hospital in early February, suffering from a duodenal ulcer, which was causing dangerously low haemoglobin levels.  During the next few days, LM met with several medical professionals to discuss her treatment options, and she was very clear that she did not wish to accept blood products.  She was also seen by a psychiatrist, due to her presenting with confusion on arrival, and a history of depression and schizophrenia.  She was found by the psychiatrist to be well, and the physical medical professionals she spoke with felt that she understood the implications of refusing blood products and had capacity to make the decision.

Subsequently, LM’s condition deteriorated significantly, she required intubation, ventilation and sedation, and clearly lacked capacity to make any further decisions.  Her anaemia became profound and life-threatening, and it was clear that a blood transfusion was really her only hope of survival, but that even then, her condition may not have improved.  In addition to her statements during the preceding days, the clinical team had been aided by information from members of LM’s congregation, who affirmed the strength of her belief, and her views on the issues of blood products, which had been consistent since the 1970s.  The medical team decided that her decision to refuse blood products should be respected, and sought a judgment from the Court of Protection affirming this decision, given its life-threatening nature.

Mr Justice Jackson, handing down his judgment sadly after LM had passed away, agreed with the decisions made by the medical staff.  He considered that LM’s decision was ‘valid and applicable’, and it was correct to respect it.  He considered carefully the issue of her capacity at the time the decision was made, and the long-held and consistent nature of her belief on the issue, and concluded that her refusal of consent ‘was applicable to her later more serious condition.  There was no difference in kind and I am satisfied that she intended her decision to be effective in the circumstances that subsequently arose’ (para 21).
This is not a decision being made within the framework of s.4(6), but rather a clear spoken refusal of consent being treated with the same respect as a written, valid advance decision.  Although not clear from the judgment, one presumes that such spoken words are not binding on professionals in the same way as a valid advance decision under ss. 24-26 of the MCA are, but it does give much more weight to such clearly stated advance statements.  This is to be applauded – LM was making a decision about the specific treatment relevant to her condition with capacity, and very close to the time when the treatment actually needed to be given.  Further, there was clear evidence that this decision was not being taken on a ‘whim’, but a long-held belief; why should it not have been respected, simply because it was not written in a specific format?

However, Jackson J does note that, had there not been such a clear, valid and applicable decision, and the issue had to be decided under best interests, he 'would have granted the declaration sought on the basis that to order a transfusion would not have been in her best interests.  Applying s.4(6) in relation to the specific issue of blood transfusion, her wishes and feelings and her long-standing beliefs and values carried determinative weight.  It is also of relevance that a transfusion might not have been effective to save her life' (para 23, emphasis added).

We are now in a position where, when refusal of consent stems from clearly stated and long-held beliefs, it seems to have a ‘determinative weight’ when considering best interests.  Further, where that refusal is made clearly, with capacity, with regards to specific treatment, it will be treated like a valid advance decision.  However, there are still some questions; Jackson J adds in the point that it is ‘also of relevance that a transfusion might not have been effective to save her life’, but we are left wondering what the decision of the court might have been had it been a more certainly life-saving procedure.  There is also the issue that this is an issue of religious conviction – would a long-held belief founded on other grounds be given the same respect?

I teach tort law to first year law students, and coincidentally last week our tutorial was on trespass and issues of consent and capacity, and even more coincidentally, the problem question we dealt with concerned the refusal of consent for a blood transfusion.  However, the woman in the problem question was refusing the transfusion due to a fear of contracting CJD, despite the negligible risk of this happening.  When we were discussing ‘Grace’s’ refusal of consent for the blood transfusion (claiming, somewhat dramatically, ‘I’d rather die than contract CJD!’), my classes were often split as to what they thought the doctors should do with regards to respecting that statement once Grace lost consciousness and the giving of a transfusion became a matter of life or death.

Some felt that such a clear decision should be respected, while others questioned the validity of this decision, as they were concerned she did not truly understand the risk.  We explored the issue a little more, and considered the circumstances where such a statement might be respected – perhaps she had been a vet during the 1990s and seen many cows suffering with BSE, perhaps she had been a research scientist.  I asked what if she had simply developed something of an obsession, and done a lot of research, and decided that death was better than the risk, however small, of living with and dying from CJD.  On this, the classes were often split again, and I certainly would be interested in the view of a court.  Would a deeply held belief such as this be respected, or would it be considered, in the words of Munby J in ITW v Z and others as not ‘rational, sensible, responsible or pragmatic’?  That is a difficult question to answer, and certainly raises questions about the prioritisation of religious belief over others.

Amanda Keeling
PhD Research Student
School of Law, University of Nottingham
This email address is being protected from spambots. You need JavaScript enabled to view it.

“History admits no rules, only outcomes. What precipitates outcomes? Vicious acts and virtuous acts. What precipitates acts? Belief’.
David Mitchell. Cloud Atlas [2004]. Chapter: ‘The Pacific Journal of Adam Ewing’
The book ‘Cloud Atlas’ consists of six‘ interrelated’ stories that take the reader from the remote South Pacific in the nineteenth century to a distant, post-apocalyptic future. Eventually the reader ends where they started. Each story contains a document, movie or tradition that also appears in a previous story. It shows how history not only repeats itself, but also connects to people in all time periods and places.

On the 18^th February 2014, Norman Lamb, Care and Support Minister, launched the ‘Crisis Care Concordat’ (https://www.gov.uk/government/news/better-care-for-mental-health-crisis) - signed by more than 20 national organisations - in a bid to drive up the standards of care people should expect if they suffer a mental health crisis, specifying how emergency services ought to respond.

Norman Lamb proclaimed the concordat would ensure “Better care for people in mental health crises will not only help those living through their darkest hours to recover – it can also save lives’. 
The Confederation Mental Health Network chief executive, Stephen Dalton, applauded this statement, but emphasised the need for mental health to be treated on a par with physical, or "…all the will, awareness and training in the world won't translate into real improvements."
The concordat follows the policy directive launched in January 2014 by the Deputy Prime Minister, Nick Clegg, ‘Closing the Gap: Priorities for Essential Changes in Mental Health’.  Closing the Gap outlines 25 areas for health and care services to take action to make a difference to the lives of people with mental health conditions, and builds on the Government’s policy launched by Norman Lamb last March, which aims to make mental health services more effective and accessible, and to be funded and planned in an equal fashion to physical health services.  Seemingly we are not short of guidance, policy and ministerial commitment to the task of bringing our mental health services out of crisis, emphasising again the long-standing policy focus of delivering services in the community and of being responsive to individuals needs particularly at time of crisis.

News stories continue to provide insights as to how bad the situation has become in many parts of the country with:
- Bed shortages,
- People being held in police cells due to the lack of a bed or having to be placed in a hospital considerable distances from their home, friends and family
- The demise of multi-disciplinary teams, particularly noting the withdrawal of social workers, the ‘tearing up’ of joint working agreements between health and local authorities and in some areas cuts by local authorities in the number of social work, and support service posts and the closure of community mental health facilities

Last week’s blog by Dr. Nic Hendey ‘Realistic Recovery Model – Rhetoric or Reality’, questioned whether our mental, physical, and social care services are really integrated, operating in tandem and equal, and gave an insightful testimony that they are not!

With Local Authorities around the country announcing their budgets for 2014/15 meaning further cuts to welfare care, it’s all a bit gloomy.  Or is it?  Writing in the Guardian last Friday, Nigel Edwards, a Senior Fellow at the King’s Fund, argues that the quality of care for patients at home or in the community is becoming more of a reality.  Yet to achieve this requires an investment in staff and services.  He argues that government initiatives have failed, too concerned with structure and ownership than the actual operation of services.  Our most important task now, he states, is to ‘reduce the complexity of services’.  However, his call for services to ‘find ways to increase their reach’  seems hollow given the current reality for many Local Authorities and voluntary sector services.

Karl Marx commented that history repeats itself, firstly as ‘tragedy’ and secondly as ‘farce’.  Will history be kinder to our mental health services of today?  It is worth remembering that 2014 is the not the first time we have deemed our mental health services inadequate and outmoded.  In July, 1960 Enoch Powell became Health Minister in Harold McMillan’s conservative government.  He set about the immense task of reforming the nations then antiquated hospital services, including the ‘Mental Hospitals’ - or ‘Asylums’ as they were frequently referred to.  At the Conservative party conference in March 1961, Powell slammed these institutions. He spoke of the need for the transition to community based care, the horrors of the asylums, the implications of the changes due and the services and finances he envisaged were needed to facilitate this.  A ten year plan for change to mental health services was drawn up with a view to assessing the needs of the mid and long-term future, and the changes that would need to take place to accommodate those needs.  His speech set the wheels turning for ‘community care’.

Powell expressed the need for ruthlessness in preparing these provisions, and to reduce the number of mental health beds by 50%. This was related to the advances that had been made in the preceding years to his speech, not just in terms of treatment but also in the legislation that had been passed - the Mental Health Act 1959, much of which still remains evident in the Mental Health Act 1983, even after the amendments introduced in 2007.

Then, as now, a change of attitude was needed.   Services themselves were to form the identity of mental healthcare, rather than the buildings, and as such, the buildings and operational framework would be dismantled.  Still to this day we see much of the type of services that Powell envisaged being put in place as important.  The environment suitable for mental health treatment in the future would be in wings of general hospitals, which would assist in the deinstitutionalisation of mental healthcare.

Then, as now, there was a need to forget the money spent to improve institutionalised services, and to rather consider the benefits of the changes to be made in order to provide something ‘different and better’.  Local Authorities needed to work with medical staff in hospitals in order to develop community services, and that they must take responsibility for those in their care.  In essence, it was no longer acceptable to place somebody in a hospital and have no further involvement in his or her care; teamwork would be required.

The rest of the story, as they say, is history, and many readers of this blog will recall what happened in the years after Enoch Powell’s ‘Water Towers’ speech.  Part 2 of this blog will look at whether the development of ‘community care’ did subsequently become a tragedy of history and, if we take Marx’s analysis at face value, a farce is to follow?

Robert J. Nisbet.
He also blogs at http://donquixote.me/Contact: This email address is being protected from spambots. You need JavaScript enabled to view it.Tweet: @NisbetRock

In addition to the post by Dr Hendey, we wanted to draw your attention to this post by Dr Tom Insel, Director of the National Institute of Mental Health.  Dr Insel's post follows his attendance at the Word Economic Forum in Davos, where global mental health was a hot topic.   As a taster, here is the first paragraph - for the full post, please visit the NIMH's official blog here. Just returning from the World Economic Forum (WEF) in Davos, Switzerland. While media reports covered speeches from some of the 40 heads of state attending or skewered the over-the-top parties of the rich and famous associated with this annual meeting, they missed a remarkable story: this was the year that mental health became a hot topic at the WEF. There were over 20 sessions on health, many of them focused on mental illness, dementia, or mindfulness. Philip Campbell, editor-in-chief of Nature, moderated a session on the “Mental Health Imperative.” An unprecedented health summit began with the Prime Minister of Norway declaring that mental health was her leading health care priority. And celebrities from Goldie Hawn to Arianna Huffington argued for the need to focus on mental health. One Davos regular compared mental health in 2014 to AIDS in 1994, when the WEF declared the need for a global focus on an emerging, heavily stigmatized, frequently misunderstood disorder...

We are pleased to welcome a post by our newest editor, Robert Nisbet.
The Beryl Institute defines the patient experience 'as the sum of all interactions, shaped by an organisations culture, that influence patient perceptions across the continuum of care'. Through a number of benchmarking reports and research projects the Institute demonstrates that actions by most organisations are primarily tactical, which pose challenges to achieving true systemic impact and lasting change. This highlights the need for organisations to think more strategically about their patient experience goals and to let this strategy influence their business objectives and decisions on how clinical care should be delivered.

Thinking through some of the challenges of effective patient engagement in their care and treatment, I quickly drifted into the memory banks of my childhood and in particular family Sunday lunch times. Silence was strictly observed at the table to ensure that the BBC’s Light Programme ‘Family Favourites’ (best remembered by its later name ‘Two-Way Family Favourites’) was not interrupted, as it crackled from a Bakelite wireless that sat like some shrine on the sideboard.

Silence, though, could be interrupted if a Flanders and Swann song was played, to enable us to accompany the well-acclaimed duo. Their songs of the '60s were linked by contemporary social commentary; 'a witty and educated diversion' as Kenneth Tynan, critic for the Observer, commented.  Flanders and Swann's concerts toured first with ‘At a Drop of a Hat’ and, on return to the UK after their European and American tour, ‘At the Drop of Another Hat'.

To prevent any further drift into my recall of the '60s, the Flanders and Swann song ‘The Gas Man Cometh’ is a timeless piece of insightful commentary into the habits and culture of many organisations and services. Flanders (with Swann nodding his agreement), fresh back from across the pond, would press upon their audience their observations that 'wandering around things have come to a pretty underpass here in England while we've been away. It's small wonder to us that satire squats, hoof in mouth, under every bush'. The purpose of satire is to strip of the veneer of comforting illusion and cosy half-truth, and as Flanders and Swann practiced ‘to put it back again’. Of their ‘respectable songs for responsible people’, 'The Gas Man Cometh’ is best known for providing a ballad of unending domestic upheaval.

[youtube http://www.youtube.com/watch?v=zyeMFSzPgGc]

Recognising that my reworking of the songs lyrics are no match for the talents of Flanders and Swann, I hope that they still convey the same style of satire that duo applied to situations of everyday life; in this case the challenges faced by the NHS. Moreover, I hope that I do not offend any individual whose profession or ‘craft’ is referenced below. If you wish to sing or play along, click here.

The Health Professional Cometh'Twas on a Monday morning
The GP came to call;
The medication wasn’t working – I couldn’t go out at all.
He tore of all my clothes
To try and find a vein,
And I had to call a Nurse in to put them back again.
Oh, it all makes work for the NHS to do!
'Twas on a Tuesday morning
The Nurse came 'round;
She pulled and she stretched and she said, "Look what I've found!
Your joints are far too tight but I'll put it all to rights." Then picking up a leg [pop] put my knee right out.
Oh it all makes work for the NHS to do!
'Twas on a Wednesday morning, the osteopath came round.
He called me Mr. Nesbit, which isn't quite my name.
He couldn’t reach the knee without sitting on by back, so I called the physio in.
Oh it all makes work for the NHS to do!
'Twas on the Thursday morning the physio came along.
With her lotions and braces and her merry...phy-sio song,
She popped my knee back in…it took no time at all,
But I had to get a psychiatrist in to come and assess my needs.
Oh it all makes work for the NHS to do!
'Twas on a Friday morning the psychiatrist made a start.
With questions and theories he covered all my past.
Every nook and every cranny,
But I found when he was gone.
He'd made so depressed that I lost the will to live.
Oh it all makes work for the NHS to do!
On Saturday and Sunday they do no work at all...but alas I sat in A&E.
So, ‘Twas on the Monday morning that the GP came to call.

If we are to engage the patient with a better experience of their healthcare this requires a radical transformation in the way healthcare institutions and professionals serve their patients. Likewise, we need to assist patients (if the circumstances permit) to recognise and take responsibility for being active participants in also changing their ‘role’. Noting that professionals, and their family members, are not immune at times from having to be ‘patients’ themselves.

The necessary change is being spurred by recent legislation coupled with an overwhelming entourage of policies, guidance, commissioning and payment models designed to reduce costs while improving outcomes. These efforts centre on the idea that improved communication and engagement equals a better patient experience and real cost savings. The work of the IMH alongside a wide and informed network of research and evidence-based practice is playing a crucial and influential part not only in the debate but in the ‘making it happen’ zone.

But!

Organisational cultures, professional comfort zones, the long tradition of patient ‘passivity’ and the ‘fairy tale’ belief that the NHS will always be there, sets an incredible challenge. Cuts, reconfigurations, mergers and acquisitions in health and social care services are providing, and will continue to provide for some time, regular items for the news media.  Is there sufficient time to achieve what we know can make vital difference to how we plan and deliver services or will the 'Gasman still cometh' until there is no one to answer their knock on the door?

If by reading this article you have become a little disheartened – then cheer yourself by watching another rendition of the ‘The Gasman Cometh’ (new page)!

Robert J. Nisbet.
Robert is a member of the IMH and by ‘trade’ a social worker. He worked in post-sixties Britain in a variety of mental health services, and these days he provides programme management support for the East Midlands Adult Safeguarding Board.
He blogs at http://donquixote.me/
Contact: This email address is being protected from spambots. You need JavaScript enabled to view it.
Tweet: @NisbetRock

In addition to Robert's post above, we also have a re-blog from the Centre for Mental Health's Policy Officer, Helena Brice.  The original post, and the rest of the Centre's blog, can be found here.
Recently government published an action plan: ‘Closing the gap: Priorities for essential change in mental health’, building on the 2011 strategy paper ‘No Health without Mental Health’, which set out how to improve the mental health and wellbeing. The strategy aimed to put mental health on a par with physical health (parity of esteem) and to tackle negative outcomes. Lots of positive work has happened since the strategy was published, but there is a lot more still to do and hopefully this action plan will spur the relevant bodies back into action.There are key roles for all government departments as well as local authorities. The Health and Social Care Act 2012 enshrined parity of esteem in law and that esteem is now in the action plan. The Welfare Reform Act 2012 also has had major implications for people with mental health problems.

‘Closing the gap’ lists 25 areas where people can expect to see, and experience, the fastest changes. These fall under the following five headlines:

1. Increasing access to mental health services.
2. Improving the quality of mental health services.
3. Integrating physical and mental health care.
4. Starting early to promote mental wellbeing and prevent mental health problems.
5. Improving the quality of life of people with mental health problems.

1.   Increasing access to mental health services
People have to wait too long for treatment but access to services is a very important step towards recovery. We therefore fully support the commitment to introduce clear standards for access and waiting times by 2015 but they need to apply to children and young people as well as adults. To monitor that this is taking effect in child and adolescent mental health services (CAMHS), the government must collect the appropriate data.

As the Bradley Commission’s first briefing paper explored, Black and minority ethnic (BME) communities are still a group less likely to access mental health services and, when they do, it’s often through less mainstream routes, such as community organisations or liaison and diversion services. It is fantastic to see in the action plan that the government is committed to working with the Race Equality Foundation and other stakeholders to understand why BME communities find it so hard to access services.

2.   Improving the quality of mental health services
Quality of mental health services is a huge issue; unlike in physical health services the friends and family test has not been in place. This means that mental health services have not been under the same obligation as physical health services to improve. Information about public attitudes to the quality of services has not been collected and services can’t find out what works and what doesn’t work. We welcome that from the end of December 2014, the friends and family test will be used in all mental health care settings including for children and young people.

3. Integrating physical and mental health care
If the health care system is going to become more efficient, it is vital that mental health and physical health are integrated. Although there was a clear objective in the strategy that more people with mental health problems would have good physical health, this has still not been realised.

If mental health and physical health are better integrated it will have a number of positive outcomes, not only leading to better health but also to savings for the NHS. A great example of such integration is psychiatric liaison services. They provide mental health care to people being treated for physical health conditions in general hospitals and were found by the Centre to save an average hospital £5 million a year. Centre research has also calculated that between 12% and 18% of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – this equates to roughly £10 billion in England each year.

Accordingly, it is very good to see that the government has asked Health Education England to develop training programmes for healthcare employers on mental health problems and how they may affect their staff.

4.   Starting early to promote mental wellbeing and prevent mental health problems
The government has acknowledged that half of people with lifetime mental health problems first experience symptoms by the age of 14. One in ten children aged between 5 and 16 has a mental health problem, the most common of which is conduct disorder. At its most severe, conduct disorder affects 5% of children but many more will suffer from early behavioural problems that will have serious consequences. If these early behavioural problems are not dealt with, the children affected are twice as likely to leave school with no qualifications, three times more likely to become a teenage parent, six times more likely to die before age 30 and 20 times more likely to end up in prison.

The action plan commits to support schools to identify mental health problems sooner. This is very encouraging, but more needs to be done.

Too often teachers don’t know the symptoms of mental health problems in children and, if they do, are not sure where to refer them. The Centre recently published a series of tailored briefings aimed at different professionals that may come in to contact with children who have the signs of conduct disorder. One of them is specifically for those working in schools.

We know that targeted parenting programmes are effective and cost effective, for severe behavioural problems. The cost of these interventions is more than covered by subsequent savings in public spending. Parenting programmes need to be easily accessible to those parents who need it, but we know that this is not currently the case.

5.   Improving the quality of life of people with mental health problems
Mental health lags behind many other conditions on the information front. Cancer has a long established National Cancer Intelligence Network and there is also a Child and Maternal Health Intelligence Network. Public Health England and NHS England are currently establishing the Mental Health Intelligence Network (MHIN). This network will bring together comprehensive information about mental health and wellbeing to provide a greater insight into common mental health problems, how they vary with age, and what the make-up of different areas is in relation to mental health problems.

The information will help health and wellbeing boards and clinical commissioning groups commission the most appropriate services for their areas. It will also help better inform the government of what works. Practical and substantive change cannot be made without this information.

In recent years there has been a central government cut back on collection of data, hopefully the MHIN will help buck this trend. It is encouraging to see that the government is pushing for greater information sharing. Integration can only truly happen if the information is shared, however we must make sure that the correct information is shared. Information is vital to drive change and to influence policy.

Why this document is good
This paper re-asserts who in the health and social care world are responsible for what in mental health. It is brilliant news that the government is planning on measuring their progress against the priority activities described in the document and that they will report back next year. This means that we should be able to see where improvements are really being made and where work stills need to be done.

Helena Brice
Policy Officer, Centre for Mental Health
http://www.centreformentalhealth.org.uk/

David Smith's blog = "My take on the world, life, mental health and charity in the UK".

David is Director of Development at The Retreat in York (http://www.theretreatyork.ork.uk @theretreatyork).

On January the 21st David posted a reflection re. "Closing the Gap".

Please find below the link to this blog.

David has given us his permission to use this on our IMH blog.

http://davidsmith3012.wordpress.com/2014/01/21/36/

 

On Monday, 20^th January 2014 our deputy Prime Minister Nick Clegg addressed a conference where he advocated that change is necessary to improve mental health care. Initially, I was delighted to finally witness a vital area of health being brought to public attention. It has been well documented that at least one in four people will experience a mental health problem at some point in their lives. This staggering statistic illustrates a domain that deserves priority but more importantly requires attention urgently.

But before I could even gather my thoughts on his grand speech, I was bombarded with articles, comments and tweets, all of which appraised his views on the current problem of mental health and aims to overcome these.  I, however, remain sceptical of his grand remarks and perhaps agree to some extent with Paul Jenkins, who wrote in the Independent ‘while the government is saying all the right things, the reality on the ground simply does not match up to the rhetoric’.  Of course, as Jenkins argues this is greatly worrying for several reasons and I will discuss a couple based on my interests, knowledge and experiences.

My overarching concern with Clegg’s speech is the over simplicity given to the nature of mental health.  He identifies that ‘we’ are still not comfortable talking about mental health and this issue of hiding as well as being ashamed of mental illnesses is old-fashioned. Whilst arguing against stereotypes he falls into his own trap. Is this merely old-fashioned? And for whom are these views old-fashioned? It may be the case for some groups that the hiding of mental health issues is a very real problem and cannot just be dismissed as ‘old-fashioned’ and outmoded. For example, my research data, which is exploring understandings and management of mental health problems amongst the Gujarati community in Leicester, suggests this notion of hiding, being ashamed and uncomfortable is far from old-fashioned but a lived reality, deep-rooted in culture. It is not as simple as talking about mental health to remove stigma, but rather understanding where these opinions arise from and how they can be overcome from communities’ perspective; what a sociologist might refer to as a ‘bottom up approach’. It is far too easy for politicians to make grand claims that they think serve the majority but by doing so not only do they neglect the growing population of ethnic communities, but are on the road for further complications and obstacles. I may then - and have been many times - been asked what the solution is. Although I am at a stage where I do not have a definitive answer, I can firmly argue that services provided in the UK need to be more person-centred to accommodate for the multifaceted nature of mental illnesses.

The document ‘Closing the gap: priorities for essential change in mental health outlines 25 areas for health and care services in support of the governments’ priority policy of ‘making mental health services more effective and accessible’.  One change the document presents, and Nick Clegg reminded us of, is the prospect of allowing people with mental health difficulties more choice and control concerning their care. As Jenkins rightly argues we have seen a 2% cut in mental health spending whilst mental illnesses are on the increase.  How can improvements and more choice be provided if both services and funding are not available? Once again, an assumption is made that if more choice and control is given this will be a positive change regarding mental health services. Legislation geared towards greater autonomy does not always mean this is being preached on the ground. What about communities who face cultural and social barriers regarding their healthcare? I am not arguing that these steps should not be strongly considered, but that a central element is lacking, of understanding the complexity surrounding mental health and how we are able to manage it. Nick Clegg talks the truth about current issues of stigma and people being uncomfortable talking and responding to mental health and it is far too easy to call this ignorance. I agree it is key that we all work together (health, education, employment, justice and welfare); in a way where assumptions are not easily drawn and institutions closely work alongside our communities.

Therefore, Mr Clegg, I agree there has been an attitude to mental health which is just plain wrong and thank you for bringing these critical issues to the public domain. But as Jenkins argues ‘words simply aren’t enough’, and may I add too naively simple and broad. If we want to improve mental health care we need to see a detailed venture not only financially but how the government specifically sets out to bring mental health out of the shadows; that with greater understanding.

Rupal Patel PhD Research Student, Department of Sociology and Social Policy This email address is being protected from spambots. You need JavaScript enabled to view it.

Re-post: Prof. Paul Crawford ~ "Mental Health and informal care: Maybe now, finally, we can start polishing our hidden gems"

The appointment of Lord Victor Adebowale as chair of the Parity of Esteem Board should bring some urgent focus to mental health; but it's only a start, as Prof. Crawford explains in this exclusive editorial (for www.nhsManagers.net/) looking at the significant paradigm shifts which are really required:

http://www.nhsmanagers.net/guest-editorials/mental-health-and-informal-care-maybe-now-finally-we-can-start-polishing-our-hidden-gems/

This week's IMH blog update is a re-post from: "Changing Minds, Changing Lives: Mental Health and Learning Disabilities in the UK" - this is the blog of the Mental Health Foundation and the Foundation for People with Learning Disabilities. The post's author Toby is Head of Development and Later Life at the Mental Health Foundation. He leads on work in mental health in later life and dementia, as well as being involved with mental capacity. Toby's post debates stigma, mental health, culture, language, and sport. The concepts of celebrity, gender, and the media are also tackled. You can access this blog via: http://www.changingmindschanginglives.com/2013/12/some-thoughts-on-stigma/

Over the past decade, the employment of peer support workers (PSWs) within mental health services has taken off. The distinctive element of peer support is that it draws on personal lived experience of emotional distress to support others going through similar experience.  However, peer support is not just about sharing lived experience of mental health problems; it can also be about mutual experiences of trauma, education, culture, shared age group, sexuality and life experiences. It is about drawing on all of our roles and strengths to promote and provide whatever support a person requires to help them move closer to their ambitions.

The ability to harness one’s own lived experience and combine this with positive communication and listening skills is at the core of peer support. As a peer support training team, these are the skills that we hope to harness and develop through training for potential Peer Support Workers. With this ambition, so far we have trained over 400 students to become PSWs across the country. Reaching this milestone has been a roller coaster for us and along the way we have learnt a huge amount, not only about what is helpful in delivering training and supporting organisations, but about the incredible strength and inspiring journeys of all the people we have trained.

In 2009, our training team had no idea of the snowball effect they were about to witness surrounding recovery and peer support training. We developed our PSW training module at a time when Peer Support activity was relatively new within the UK but the importance of peer support is gradually becoming more recognised within mental health services.

As we have continued to facilitate PSW training, we have become aware of other areas where specific training might benefit the workforce. We have begun to offer additional training courses based on the emerging needs of organisations, current trends in policy and specific requests from organisations/service user groups. These new projects have now become equally as important as our core PSW training. All the courses which we have expanded to offer are advertised in our new prospectus.

Alongside our advertised courses we have had the opportunity to design bespoke courses and consultancy packages for particular service areas where peer support roles are tailored for a new client group. One such example is our delivery of a bespoke course for Child and Adolescent Mental Health Services (CAMHS) to support the use of PSWs in helping people transition to adult services. During this project, the training team offered bespoke Peer Support Training to the prospective PSWs as well as training to prepare staff teams, help in developing an implementation strategy, and support in discussions with commissioners to explain the importance of peer support work in this specific role. This was provided using a firm base of recovery values and appreciative enquiry meaning that consultancy was supportive, strengths-based and non-directive.

This year, the team has also been thrilled to have been invited to present their work at national conferences. Presentations have included to the 25^th World Hearing Voices Congress in Cardiff and the first Narrative Future for Healthcare conference in London. We have used these conferences as a way of sharing our experiences of what works as trainers. Regular presenting has helped the team to become aware of the level of practical understanding and knowledge which we have developed over 5 years. We have been able to present on themes of peer support, story sharing and disclosure, and co-production to name a few. These opportunities have enabled us not only to share our experiences but also to continue learning from a wide range of audiences, co-facilitators and other conference speakers.

Peer support has always been hugely important not only to us as trainers but to us as people in recovery too. There have been times for all of us when the support of a peer has provided us with the understanding and strength we have needed to take our next few steps. As a team this has made us incredibly passionate about recovery and peer support. We hope that in training we pass this passion onto others to spur them on in their individually inspiring paths of recovery.

Emma Watson
Institute of Mental Health (Nottingham)

Tread softly because you tread on my dreams
W.B. Yeats

Schizophrenia is never being able to trust your senses: we see things which ‘are not there’; we hear what no one else does. We therefore live precariously, with a terrific amount of uncertainty and confusion for long periods of time. This is also an experience particular to individuals.

The Open Dialogue approach gives due recognition to this and seeks to tentatively explore exactly what is happening in the lives of individual clients and to find ways forward which grow out of current predicaments, evolving solutions to expressed difficulties and weighing each tread-fall with care and attention.

This is done through the medium of ongoing exploratory treatment meetings which are convened with all the people connected in the social network of the client in attendance and contributing from their perspectives, with as many meetings as it takes to evolve and become the solution and resolution of the difficulties expressed and experienced, finding a way forward launched from the dialogue taking place. This open and thorough dialogue finds a language to best express the realities of life from client-perspectives, exploring these towards outcomes which everyone present can approve and give consent to.

This is a true and meaningful discernment of what is happening in the life of the client. The care taken in achieving this accuracy is well-rewarded in rendering complex issues accessible to practical solutions and removing scope for mis-understanding and discord later; maybe this process of ascertaing the facts will not have to be visited and revisited again, having uncovered the truth at first onset.

No one jumps to conclusions or imposes stock remedies or solutions, because it is better not to have answers than to apply the wrong ones. When the whole topic is explored with everyone present and conferring, the way forward can become much clearer, with all possibilities explored and only the feasible solutions ruled in. Any sense of compulsion is banished from the proceedings and the approach is sensitive, commensurate and quite beautiful in its simplicity. Why would it not work!

So instead of discounting and disregarding the words of people with schizophrenia, these have taken centre-stage. Open Dialogue practitioners are listening carefully and non-judgmentally to the narratives of people with first-onset schizophrenia in a quest to ascertain appropriate care and treatment - without naming it. Is this a Revolution? What do we all think of this?

Rodney Yates
Open Dialogue Nottingham
http://www.facebook.com/nottinghamopendialogue
http://hypoconcer.ning.com
December 2013

This post, 'Are our mental health services in crisis?', originally appeared on The Fabian Society on 5 November 2013 and is re-posted with permission from the author. There is an increased demand for mental health services in Britain, but we are failing some of our most unwell and vulnerable people.

Last week, the Health and Social Care Information Centre published its annual report into the use of the Mental Health Act. In 2012/13, for the first time, the number of people detained under the Mental Health Act crossed 50,000 (a 4 per cent increase on 2011/12, continuing a rising trend).

The NHS bed crisis And yet since 2008, bed numbers for the mentally ill have been cut by 36 per cent. In the last year alone, 1,700 beds were cut, representing a 10 per cent reduction in bed numbers.  This massive reduction in the capacity to care for our most unwell has led to the stories that have emerged in recent weeks of people having to be admitted 200 miles away from home and; tragically, those who have killed themselves while awaiting a bed.

In August 2013, the Health Select Committee reported that Approved Mental Health Practitioners were having to detain people under the Mental Health Act, illegally, in order to secure a bed as it was almost impossible to admit people who agreed to come into hospital.

In my own practice, I’ve heard of several days in the last few months when there has been no NHS bed left in the country. The system has been stretched beyond breaking and it’s perhaps no surprise that the average city inpatient ward is a place seething with anger, threats and chaos. Small wonder that in these environments, demoralised and overworked staff are reduced to focusing on immediate risk reduction with the unwell, rather than supporting their recovery in a therapeutic environment.

In October Dr Martin Baggaley, the medical director of the South London and Maudsley Trust and one of the leading psychiatrists in the country said that mental health services in England are in a state of crisis. The Care Minister, Norman Lamb, acknowledged that there are problems, but still there is a lack of action.

How did things get so bad for mental health services in Britain, and what underlies our inability to act?

Suicide rates and austerity Suicide rates are an indicator of the strengths and weaknesses of the system. Falling year by year since 1997, they started to rise again after 2009. The Office for National Statistics reported that 2011 saw a further ‘significant’ rise in suicide numbers, 6045 people took their own lives that year.

The idea that a nation’s mental health will inevitably suffer as a consequence of the economic recession is flawed. Both Iceland and Greece suffered with the collapse of their economies. However, Iceland rejected bailouts – with austerity strings attached, invested in health and social care, and its population has not suffered a change in health status. On the other hand, Greece’s austerity drive has led to a worsening of a host of health indicators including a 30 per cent increase in suicides.

Based on some economic indicators, the Coalition is claiming success for austerity-based policies. But viewed from a health perspective, there is little to be joyous about.

A perfect storm Within the health service, the conditions of the ‘Nicholson Challenge’ for the NHS to find £20 billion savings by 2015 and the first disinvestment in mental health services for working age adults since 2001 (according to the Department of Health’s National Survey of Mental Health Investment) have contributed to the current crisis. Other factors include cuts to Local Authority budgets that have led to social workers being ‘redeployed’ away from mental health teams into more traditional social worker roles and cuts to voluntary sector funding that has led to the closure of many of the programmes that supported severely unwell people to find purpose in their lives.

It’s within this ‘perfect storm’ that services are cutting, slicing and re-disorganising to meet cost improvement challenges.  Hidden behind politically correct jargon of ‘treatment at home’ and ‘care in the community’ beds are being cut to meet the financial pressures.

The Health Select Committee report raised the alarm that it was more than just anecdotal evidence that suggested illegal detentions. People are killing themselves while awaiting a bed. If this was happening to people with heart disease or cancer, there would be an outrage. Why is it taking so long for any action to be taken?

Private concerns Perhaps the answer lies in the dramatic increase (32 per cent) in the number of admissions of the mentally ill to private sector beds, which is a consequence of the NHS bed crisis.

In October, the Health Service Journal reported that these admissions often cost £3000 a week in the private sector. A spokesperson for Cygnet Healthcare, a private provider, has even said in an interview reported in Community Care that the reduction in NHS beds has been one of the main drivers for a 30 per cent increase in the number of service users it had supported in 2011/2013.

These beds are often not local to the patient. At a time when someone is most unwell creating distances from family and friends is the opposite of what many people need. Similarly, the loss of the continuity of care between the NHS community team and the inpatient private provider will extend the duration of an admission and worsen therapeutic engagement.

This is the opposite of high-quality care. Whereas community mental health teams support patients as much as they can to try an avoid unnecessary admissions and there is often a discussion between the inpatient and community teams of the local NHS service about the need and expected outcome of an admission – what are the incentives that operate within the private sector and will this make clinical care better in the long term? Is this economically effective?

There are also concerns about transparency. The Health and Social Care Information Centre raises concerns that although the independent sector are now looking after a quarter of inpatients, some of the major providers are not providing required information (the mental health minimum data set) for monitoring.

We’ve been fighting a battle to keep the NHS public, and yet a portion of the NHS that supports the most vulnerable is being dismantled in this crisis. Conservative politician, Oliver Letwin, said in 2004, within 5 years of a Tory government there would be no NHS. I can’t help but wonder if the dramatic privatisation of the care of the mentally ill is more than an unintended consequence.

Stigma and discrimination The stigma and discrimination that people with mental illness continue to face partly explains the lack of action. According to YouGov research in early October, the mentally ill are widely seen as the most discriminated group in Britain. Attitudes have hardened towards the mentally ill, and the narrative of deserving and undeserving poor has hit this group hard.

This is despite £21 million lottery and DH funded anti-stigma campaign led by leading mental health charities. Stigma can be a difficult concept to understand, but the fact that this is a group of people with relatively less power and that attracts little public sympathy has allowed this crisis to continue.

The road ahead There is much that needs to be done. We must galvanise public support; research into the impact of privatisation on care pathways and audit the costs; and develop a workable plan to reverse or at least halt further bed closures until capacity for community support can be expanded and its safety and effectiveness demonstrated. And this needs strong leadership – both clinical and political.

Encouragingly, at Labour party conference this year Ed Miliband showed that he gets it. He described mental illness as a one nation problem – but one that we don’t talk about, that’s been swept under the carpet and how that needed to change.

In an excellent speech on mental health and illness to the Royal College of Psychiatrists last year, Miliband announced setting up a Labour Mental Health Taskforce. Now is the time for that taskforce to act.

Arun Chopra Consultant Psychiatrist @arun_chopra