The Institute of Mental Health

Dr Hugh Middleton ~ Some thoughts on the origins of mental illnesses...

Some thoughts on the origins of mental illnesses...

One of the things debated and discussed in blogs such as this, and in a lot of other places, is the nature of “mental illness”. Is it biochemistry? Is it genes? Is it the result of stress? Does it exist at all? Is it a construction arising from oppressive political influences? Take your pick and follow the trail that leads from it.

This is all very interesting and entertaining for those of us who enjoy debate and discussion, but it can leave the distressed, anxious or confused person who is seeking help somewhat lost. Do I need medication? Have I got faulty genes? Should I seek a less stressful situation? Am I making all this up? Is it someone else’s fault? Perhaps it is just as well the British Journal of Psychiatry has recently published a special supplement which offers clarification.

Before you go rushing off to find this Holy Grail, let me explain. The January 2013 edition of BJPsych. includes a short supplement of some nine papers edited by Swaran Singh and Max Birchwood which is entitled “Youth mental health: appropriate service response to emerging evidence”. What is notable about this is not so much what each of these papers says, directly, but how what they say, collectively, can be interpreted as a meta-message of much wider application and interest.

It is significant that the authors are all established mental health research professionals with a recognised track record of publications in mainstream medical journals, grants-winning success and senior academic posts. Their research is respected and influences practice and practitioners, and as a result it is of interest to look closely at what they are saying. It might be different from what is expected, or even from what they intend.

In essence there are three messages which interweave. The first is led by Peter Jones, Professor of Psychiatry at the University of Cambridge, England. His first sentence reads “Adult mental health disorders begin in adolescence.” 1 The substance of his paper, which follows this assertion, is careful and convincing evidence from clinical studies, clinical epidemiology, secondary analysis of birth cohort data and cross-sectional surveys which support it. If conventional definitions are accepted, that 50% population will experience a DSM-IV mental health disorder during their lifetime, then a staggering half of these disorders will have begun by the age of 14. This ranges from 11 as the age when half of all anxiety disorders might have begun to 30 for the same assessment of mood disorders. Jones’ paper is a clear and authoritative summary of empirical, positivist data. They inescapably identify what we call mental illnesses, as difficulties which have their origins in adolescence. He chooses to associate these findings with what is known about human brain development through childhood, puberty and adolescence but there is no evidential or epistemological justification for privileging this causative connection over explanations based upon emotional wellbeing and appropriate parental nurture. Jones’ statement, “Adult mental health disorders begin in adolescence.” is firmly supported by data. It doesn’t point to earlier developmental stages, and by adolescence he means the period that extends into early adult life. It is not a re-statement of psychodynamic dogma. In fact there is something intuitively obvious about it.
A second message is that there is value in attempting to do something about this, proactively, and preventatively. Patrick McGorry illustrates some of the benefits from such approaches, bemoans the scale of challenges of doing so, champions “early intervention” as a more realistic institutional approach, but at the same time draws attention to the inescapably harmful labelling that comes with this2. In contrast Paul Stallard and Rhiannon Buck describe how it is quite realistic to include a resilience-promoting programme in the school curriculum and reduce the risk of “depression”3. It seems to work. In another paper Andrew Chanen and Louise McCutcheon discuss ways in which earlier intervention amongst younger, more vulnerable individuals might mitigate the development of distressing patterns of interaction which are conventionally known as Borderline Personality Disorder4.

The third message is that we don’t listen to these first two messages. The core theme of the supplement is that current Irish, UK and Australian services are poorly matched to what the editors describe as young people’s needs. In particular the clear evidence that most so-called mental health difficulties apart from dementia begin in adolescence or early adulthood is not matched by services that focus upon this period. Instead, conventional child and adolescent mental health services provide for young people to the age of eighteen. After this, professional input is provided by the same service and with the same approach and philosophy as that providing for older adults to the age of sixty five. Several papers draw attention to the consequences of discontinuity, as young people receiving professional mental health input transfer from child and adolescent services to adult services at eighteen, right in the middle of the period of vulnerability Jones and others identify. Inevitably recommendations about how things might be done differently have to be constrained by reluctances to change, but also by the fact that in the UK, in Australia and in most other countries an individual’s legal status changes as they reach the age of eighteen. This is important.

It is important because growth and maturation are, by definition, progressive processes. Becoming an adult is not something that suddenly happens on a particular day. These papers are also important because they draw attention to the fact that a very large proportion of what is conventionally called “mental illness” begins during the time when children are changing into adults … during a time when their identities are forming and when they are still vulnerable to influences beyond closer family ties and, during adolescence, increasingly exposed to them.

Most of us navigate this period safely and successfully, though I guess few would look back on it as a trouble free time. What Jones reminds us is that the cost for those who don’t can be very high. From many points of view “mental illness” is a self-fulfilling prophecy; disabling medication, sick role, stigmatisation and reduced ambitions and expectations are all so easy to fall into, and very difficult to escape.

Locating the origin of many “mental health difficulties” in adolescence also forces a review of what they are. The prevailing “illness” model identifies them as something alien that has afflicted the individual from outside, rather like an infecting parasite, or as something that has assaulted them such as an injury or the development of a malignant growth. If most actually begin during a time of vulnerability, then rather than identifying the condition itself as the problem, it would seem more appropriate to focus upon the vulnerability. It isn’t a big step, then, from identifying vulnerable young people as tomorrow’s psychiatric patients, to recognising that much might be done by being available to and responding accordingly. I am not advocating widespread methylphenidate for ADHD, or any of the other misguided misapprehensions which contribute to the growing number of medicalised young people. They have already been damaged by diagnosis. For all of us who can recall anything of it … or indeed observe it amongst our own family and friends, what makes for a successful adolescence and what hinders it? Acceptance, rather than pathologising? Respect and encouragement rather than criticism? Consistency?

Adolescence might be uncomfortable to observe or to experience, but it isn’t an obscure mystery. I wonder if we are giving it the attention it deserves? Perhaps what we call mental health problems really are largely due to the fact that not everyone gets the love and support they need when they are growing up. It’s a no brainer but an awfully difficult one to really get hold of ... even harder to correct or prevent, yet if this is where the facts point us, shouldn’t we follow?

References:
1. Jones, P.B. (2013) Adult mental health disorders and their age at onset. British Journal of Psychiatry 202, s5 – s10.
2. McGorry, P. (2013) Prevention, innovation and implementation science in mental health: the next wave of reform. British Journal of Psychiatry 202, s3 – s4.
3. Stallard, P. & Buck R. (2013) Preventing depression and promoting resilience: feasibility study of a school-based cognitive-behavioural intervention. British Journal of Psychiatry 202, s18 – s23.
4. Chanen, A.M. & McCutcheon. L (2013) Prevention and early intervention for borderline personality disorder: current status and recent evidence. British Journal of Psychiatry 202, s24 – s29.

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Sasha Scambler ~ "Loneliness, conflation and ideology" (from the Cost Of Living blog)

Sasha Scambler ~ "Loneliness, conflation and ideology" (from the Cost Of Living blog)

Sasha Scambler is a medical sociologist based at King’s College London. Her main research interests are disability and long term conditions, inequality, social theory and old age.

These excerpts are re-posted from the Cost Of Living blog. Please access and read the full and original post via the Cost Of Living site: http://www.cost-ofliving.net/loneliness-conflation-and-ideology/.

“1 in 10 over 65s are 'chronically lonely' ”.

“The term loneliness is used as if there is a shared understanding of what it means”.

“The consensus view is that loneliness results from a deficiency in a person’s social relationships”.

“The danger is that conflating loneliness with social isolation and exclusion and then seeking to address these problems through targeted, often individualised, interventions fails to address the wider structural issues such as ideology and the relationship between individualism and society”.
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Upcoming local event regarding anti-psychiatry legacies

Anti-Psychiatry and Its Legacies @ Nottingham Contemporary

Tuesday 12th and Wednesday 13th February 6-9pm

Programme of screenings and discussions in the context of the exhibition Piero Gilardi, Collaborative Effects.

Piero Gilardi’s work with marginalized communities, including those confined to mental hospitals, was influenced by Italian psychiatrist Franco Basaglia (1924-80). Alongside Michel Foucault, R.D. Laing, Felix Guattari and Thomas Szasz, Basaglia contributed to the diverse foundations of the anti-psychiatry movement; he argued that all asylums should be replaced by open therapeutic communities, a controversial position which provoked both mental health reform and inspired socially-activist approaches to artistic practice.

Over two evenings, a programme of screenings and discussions focuses on different national contexts involved in the development of Anti-Psychiatry and questions its status as an interdisciplinary critical legacy bridging philosophy with creative and clinical practice.

Tuesday 12 February, 6 – 9pm

Free, The Space at Nottingham Contemporary

6pm Dora Garcia The Deviant Majority, From Basaglia to Brazil (2010, 34’)

Garcia’s film forms part of her ongoing investigation of the political potential of marginal positions. It is structured around encounters with three organisations: Accademia della Follia (Academy of Madness), the Trieste Psychiatric Hospital’s theatre company; Carmen Roll, a former member of the German Socialist Patients’ Collective; and the Freaked on the Scene Theatre of the Oppressed, Rio de Janeiro.

7pm Panel Discussion

With contributions from John Foot, Professor of Modern Italian History, UCL. Foot is currently leading a project focused on Basaglia and the closure of mental asylums in Italy. David Reggio, Kingston University/Universidade Comunitária da Região de Chapecó. Reggio has worked within institutional psychiatry at the renowned La Borde clinic and with the anti-psychiatry movement in Brazil. Howard Caygill, Professor Of Modern European Philosophy, Kingston University. Caygill’s research interests include philosophy and psychiatry as well as contemporary European philosophy, ethics and theories of resistance.

Wednesday 13 February, 6 – 9pm

Free, The Space at Nottingham Contemporary

6pm Screening: Luke Fowler, Bogman Palmjaguar (2007, 30’)

The subject of Fowler’s film is a trained conservationist and certified paranoid schizophrenic who is fighting a legal battle against this diagnosis. Featuring discussions with psychiatrist Leon Redler (a former colleague of R.D. Laing), this is a film about the injustices of contemporary psychiatric practice and also a portrait of the Flow Country, a remote area of rare blanket bog and wetland in Northern Scotland.

7pm Panel discussion

With contributions from Duncan Double, Consultant psychiatrist Norfolk & Suffolk NHS Foundation Trust and founding member of The UK Critical Psychiatry Network, a platform for debate, discussion, lobbying and publication to critique the contemporary psychiatric system. Alastair Morgan, Senior Lecturer in Mental Health, Sheffield Hallam University. Morgan’s perspective encompasses critical theory and clinical practice, having worked as a qualified nurse in community adult mental health with marginalized and excluded groups. Angela Woods, Durham University. An inter-disciplinary medical humanities researcher and author of The Sublime Object of Psychiatry: Schizophrenia in Clinical and Cultural Theory.

The events are free - but we recommend booking online in advance:

To register for Part I, Tuesday 12th February: http://ncantipsychfullevening1.eventbrite.com/#

To register for Part II, Wednesday 12th February: http://ncantipsychfullevening2.eventbrite.com/#

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Charley Baker ~ A new collection of narrative around self harm

Myself and Claire Shortland were on Radio Derby on Monday 22nd January talking,
amongst other things, about a new collection of narrative around self harm that
is being co-edited by myself, Clare Shaw and the late Francis Biley. The link is
below and can be listed to for a few more days. We are on at 2 hours
14 minutes into the show, and there's David Bowie in the middle of the interview
too!

http://www.bbc.co.uk/programmes/p0137r8j

Charley Baker
Lecturer in Mental Health
University of Nottingham
EMAIL: This email address is being protected from spambots. You need JavaScript enabled to view it.
WEBSITES: www.madnessandliterature.org / www.healthhumanities.org

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Paul Glasziou: Most innovations are not advances: innovation + evaluation = progress

Editor's note: this blog was originally posted here on the BMJ's blogsite.

Innovation is currently fashionable. But new is not necessarily better [1]. Progress rests in sifting out the effective innovations. Edison clearly understood this process: when he developed the light bulb, he tried and discarded thousands of possible filaments. Without testing and recording each option, he may have gone on a random walk and left us in the dark. But persistence despite failures paid off. When a reporter asked him about his lack of success he replied: “Young man, why would I feel like a failure? And why would I ever give up? I now know definitively over 9,000 ways that an electric light bulb will not work. Success is almost in my grasp!”

Medical innovation appears to be similar—many failed attempts, but progress through testing and recording these. A recent systematic review found that proposed new treatments are about as likely to be worse as to be better than the current standard. Djulbegovic and colleagues [2] examined 743 trials from four cohorts of registered studies where they could get all the results—published or not (avoiding the positive spin of publication bias). For survival the average advantage was a relative improvement of just 5%, whereas for the primary endpoint it was a relative improvement of 9%. However, there was a wide spread around this small advance: sometimes new treatments could be much worse. The key lesson is to have humility about our innovations, and to put them to rigorous testing. We can then progress by finding the occasional incremental advance, and the even rarer breakthrough.

The history of chemotherapy for childhood leukaemia illustrates this process well. In the 1940′s in Boston, the pathologist Sidney Farber thought folate might arrest the development of childhood leukaemia. However, the children he treated appeared to get worse, not better. Failure? Only temporarily. Reversing this idea suggested anti-folate drugs (such as methotrexate) might work, which did lead to some remissions, but which were only short lasting. However, that a drug might treat cancer was a paradigm shift that was then honed by trials of different doses, durations, combinations, etc. Most showed no improvement, but some did, so that over three decades of experimentation survival went from 0% to over 80%.

So innovation is vital, but must go hand-in-hand with careful evaluation. Most of the improvements are sufficiently small that only rigorous testing will reliabily detect them.  Without testing we end up, as with managerial re-disorganisation, in a random walk that may go nowhere.

References:
1. Evans I, Thornton H, Chalmers I, Glasziou P (2011). Chapter 1: New—but is it better? Testing Treatments. London: Pinter and Martin. Freely downloadable pdf at www.testingtreatments.org
2. Djulbegovic B, Kumar A, Glasziou PP, Perera R, Reljic T, Dent L, Raftery J, Johansen M, Di Tanna GL, Miladinovic B, Soares HP, Vist GE, Chalmers I. New treatments compared to established treatments in randomized trials. Cochrane Database Syst Rev. 2012 Oct 17;10:MR000024.
3. Spain P, Kadan-Lottick N (2010). Observations of unprecedented remissions following novel treatment for acute leukemia in children in 1948. JLL Bulletin: Commentaries on the history of treatment evaluation (www.jameslindlibrary.org).

Paul Glasziou is professor of evidence based medicine at Bond University and a part time general practitioner.

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Charley Baker ~ Celebrating Positive Experiences of Health and Healthcare

Originally posted in the International Health Humanities Network blog on 10 January 2013. Forgive me for the personal preamble to this blog post - but I want to contextualise what will follow.

I was recently admitted to hospital for planned surgery, at the Queen Elizabeth Woolwich which comes under South London NHS Trust in the UK. I have a chronic health condition which has required many surgical procedures over the past 12 years. Prior to this operation, I had spent many months in a huge amount of pain. This had a great impact on my day to day life. Having worked in the NHS for many years, I now educate nurses as a lecturer. As with most healthcare professionals, I struggle immensely with being a patient, finding it anxiety provoking, and an experience I am not comfortable with - I border on phobic with hospital admissions. Hence, I was very, very frightened about this procedure, necessitating a longer stay and with greater complication potential than my previous surgeries.

I need not have worried. Every single member of staff who cared for me, from domestic staff through to the nurses who were on duty during my admission and the medical staff, was outstanding. The nursing care was without fault - the nurses were compassionate, caring, had extremely good communication skills and demonstrated excellent clinical competence in terms of their pre and post operative care. Similarly, during the arranging months, I had much contact with administrative staff across both sites. All of these staff members were fantastic - polite, organised, supportive and calming at a time when I was struggling from a physical perspective and anxious about the procedure itself and the longer term implications of this. These staff are all a credit to the Trust, and were absolutely without fault in every communication I had with them. They really did go above and beyond their remit in helping us.

The particular Trust that I was admitted to is undergoing a well-publicised and very challenging time - as indeed are most NHS services in the age of austerity. Is spite of this, the care I received was fantastic.

Which got me to thinking the following - what was it about my care (aside from the physical benefits that have resulted) that meant I had such a positive experience? How does this relate to the IHHN's core philosophy - 'Bringing the Human Back into Health'? What could people take away from hearing about this? And how could I thank the staff, en masse, aside from the letter I wrote?

HUMANITY….At every stage, I felt like I was treated as a human being, as Charley Baker, who has anxieties and aspirations, a life outside of the hospital setting and the condition, rather than as a number, a patient, a mere body to be mended.

COMPASSION….The staff demonstrated genuine warmth and caring – the nurse who admitted me took the trouble to sit with me and put an arm around my shoulders when reassuring me about what was to come. This was a welcome tactile intervention in an otherwise coldly clinical environment.

COMMUNICATION….The nursing and care staff did not appear to be too busy to listen, though I have no doubt that they were incredibly busy. Procedures were explained in full to me, and to my husband, and we were given ample time to ask questions. My Consultant Surgeon excels in this area, as did every member of nursing and care staff. This made a huge difference. I also witnessed the care they provided for the other women in my bay of five – and it mirrored mine in positivity.

CONTINUITY....I have been under the care of Mr L. for many years, despite relocating to Derbyshire six years ago. On discussion with Mr L. and with family, we decided to keep my care at the London-based hospital. This continuity of care is vital in any long term condition.

COMPETENCE….I have every faith in my consultant’s competence – and the care staff carried out every intervention and procedure competently, kindly and swiftly. One issue with educating nurses is that inevitably I scrutinise procedures and results - a little knowledge is a dangerous thing! But I did not need to have worried.

These are simple things, and things which I am sure I do not need to preach about to healthcare professionals at all levels. But they are things that can be hard to achieve in a time when staff numbers are being reduced, the drive for economic efficiency is at the forefront of developments, and when the caring professionals – in particular, nurses – are facing what seems to be a barrage of criticism at times in the press.

I wanted to write this blog post to celebrate the care I received, to thank the care teams involved, and to add my own small contribution towards buffering the seemingly relentless negativity that can surround issues such as these. I wrote to thank the hospital and the Trust, and also contacted them prior to writing this blog. As one of their communications officers said, while many people do experience good care, these are not the stories that make headline news, or are often acknowledged at a wider level. I’m glad to be in a position to celebrate the contributions that staff are making, in spite of incredibly challenging times. Thank you to them all.

Posted by: Charley BakerLecturer in Mental Health University of Nottingham School of Nursing, Midwifery & Physiotherapy

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Sean Duggan ~ A decade of austerity should spur on fundamental care reform

Sean Duggan ~ A decade of austerity should spur on fundamental care reform
Originally posted in the HSJ blog Leadership in Mental Health, 17 December 2012 and re-posted in the Centre for Mental Health blog on 3 January 2013.
[caption id="attachment_755" align="alignleft" width="105"] From Leadership in Mental Health.
Sean Duggan is chief executive at the Centre for Mental Health.


This month the NHS has been reminded from all directions of the scale of the financial challenge it faces. While much of the focus of debate about the NHS continues to be the structural changes that are now taking shape, the bigger question remains how the health and care system is going to cope with the financial pressure it faces in the coming years.

At the beginning of December, the chancellor’s autumn statement announced the government’s intention to continue to maintain health spending up to 2015/16 while most other departments are likely to continue to experience real terms reductions in their funding.

'We have heard a lot about integration but too often it has been two dimensional'

But a report by the Nuffield Trust the same week warned that the NHS could face a “funding gap” of up to £54 billion by 2012/22 without real terms funding increases.

In the shorter term, it warned, the NHS faces the prospect of cutting services or reducing the quality of care by 2014/15 as the prospect of making continued productivity gains begins to tail off − in other words, many of the more painless methods of saving money are going to be exhausted.

Artificial divides
The challenges facing the NHS are to some extent much less acute than those of many other public services. Local authority budgets, the police and welfare spending are all falling much more rapidly. But taken together with social care, the NHS and its partners face the longer term trend of steadily rising demand as the population ages and chronic illness and disability take up an ever larger proportion of its funding.

Whether the scale of the “Nicholson challenge” is £15 billion or £54 billion, the implications for the health and care system remain much the same. Small-scale, one-off efficiency savings are not going to do the trick. The entire system has to reform itself, not so much structurally as in the way it supports people’s health, wellbeing and independence.

Artificial divides, be they between health and social care, physical and mental health, or primary and secondary care, need to be dismantled.

We have heard a lot about integration this year but too often it has been two dimensional and focused on only part of the picture. From the perspective of the service user, any form of dis-integration is unhelpful and sometimes disastrous.

Stark choices
One of the biggest forms of dis-integration in our system continues to be that between physical and mental health support. Yet this year the Centre for Mental Health reported clear evidence that up to 10 per cent of the NHS budget is spent on the extra costs of treating long-term physical illness caused by the coexistence of mental health problems.

‘A decade of austerity may in the end spur on some long overdue fundamental changes’

From having liaison psychiatry teams in general hospitals to better collaborative care arrangements in the community, much of this cost could be saved.

The first clinical commissioning groups to be authorised will begin to face some stark choices in the way they spend their money next year. Most are already grappling with these dilemmas as they consider how to cut costs.

Perhaps uniquely among public service commissioners, they do not have to make dramatic immediate cuts to their spending. They have the opportunity − the necessity in fact − to take their time; to reform patterns of service provision and established ways of working; to shape health services on a different footing.

A decade of austerity may in the end spur on some long overdue fundamental changes to our health and care system. To do otherwise is to risk the health and wellbeing of every one of us in the years to come.

http://www.hsj.co.uk
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Bree Hernandez ~ An Alarming Trend on College Campuses Around the Nation

Understanding teen stress, anxiety, and depression has been a major focus at the Institute of Mental Health blog this year. Today’s article, by American higher education expert Bree Hernandez, takes a closer look at how university students -- particularly those studying at the graduate level -- are impacted. Bree has made a career out of discussing the benefits of graduate education, and she is quite knowledgeable about student issues both in and outside of the classroom.

Mental Health Problems Continue to Plague Higher Education
Psychologists have increasingly noted that mental health issues among college students have been on the rise for more than a decade. While the entire college-level population is generally perceived to be at higher risk for depression, anxiety and other conditions than other adolescent or adult communities, recent data shows that occurrences are especially high among graduate students.

In 2010, the American Psychological Association (APA) reported that mental illness among college students had risen dramatically within the previous 10 years. Based on a survey of more than 3,200 American university students, 96 percent of students who visited their campus clinic for psychological treatment were diagnosed with at least one mental disorder. While cases of average depression remained the same (“relatively mild”), rates of severe depression rose seven percentage points between 1998 and 2009. Furthermore, doctors noted a steady rise in the number of students using medication to combat their mental issues. In 1998, 11 percent of students took medication for depression, anxiety, mood disorders and ADHD, among other conditions; in 2009, that number reached 24 percent. There is reason to believe it is still on the rise.

Margarita Tartakovsky, Associate Editor of PsychCentral, recently noted that graduate students are at the greatest risk of suicide. Based on a study conducted at Berkeley University, nearly half of all graduate student respondents suffered from an emotional or stress-related disorder that affected them on a daily basis. The demanding nature of graduate-level coursework – which is typically taught within a less structured environment than undergraduate studies – plays a crucial role in the mental health of grad students, Tartakovsky found. When coupled with the stress of accruing massive student debt in order to receive a master’s degree, the deck often seems stacked against the student. While 52 percent of stressed out graduate students considered receiving help from mental health assistance services, only 27 percent actually followed through.

To mitigate the negative consequences of mental health issues, many of today’s campuses provide accommodations to affected students. According to a report by the University of Washington, these accommodations may be made in regard to classroom policy (preferential seating, early availability of textbooks and syllabi), course examinations (extended time, assistive computer software) or assignments (relaxed deadlines, substitution). However, some of these accommodations may actually be doing students a disservice by customizing the academic experience to fit their specific needs. According to a report by the Jed Foundation, institutes of higher education should not “fundamentally alter” courses in order to accommodate students with mental health issues, nor should the schools incur an “undue burden” (logistical or financial) to make accommodations.

There is also a question of fairness, argues a recent report from a professor at the College of New Rochelle. “Accommodations allow students equal opportunity to participate in all aspects of college life,” the report states, “but should not provide unfair advantage over other students or fundamentally alter the nature of courses.”

Many experts today are touting low-impact strategies that students can employ as an alternative to campus-wide accommodations for individuals with mental health issues. Studies have shown that many first-year students enter university studies with pre-existing mental health conditions which have not yet been addressed, and seeking professional help prior to arriving on campus could mitigate some of the problems related to these conditions. And because many of these mental disorders are stress-related, health experts urge students to regularly exercise, get eight hours of sleep every night and refrain from frequent drinking or recreational drug abuse. And according to Psychology Today contributor Julie Hersh, all students can play a role in fighting mental health issues on campus by forming committees and support groups for affected individuals.

Students who suffer from mental health issues should not exclusively rely on counselor treatment or campus-wide accommodations in order to succeed in college. By practicing low-impact strategies like those listed above, affected men and women stand the greatest chance of completing their courses and earning a degree in spite of a debilitating mental disorder.
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Dr Rex Haigh ~ TCTC: born 22/10/12, Windsor, England

Dr Rex Haigh ~ TCTC: born 22/10/12, Windsor, England
The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we're up against, originally posted on 24 October 2012.

'The Windsor Conference' started in the 1970s, set in the right royal setting of Cumberland Lodge, in the gated community of extreme privilege of Windsor Great Park. Every autumn, the grand old founding fathers of the British TC movement all came to play here, every year, until 2010. With friends and colleagues from overseas, mostly the Netherlands at first; later Italians and currently Greek therapists, together with a smattering of like-minded clinicians, researchers and TC leaders from Switzerland, Germany, New Zealand, Australia, USA, India and Africa, they came along to an unbroken sequence of annual community meetings, and much besides, until last year.

[caption id="attachment_709" align="aligncenter" width="297"] Cumberland Lodge (rear)


What happened last year? Well, the organisation of ATC decided that it was time for a change – the most prominent reasons were that the 3-night conference, for up to 100 people in its heyday, had become too expensive for many, inaccessible to new delegates, and somewhat anachronistic and unrealistic in its expectation that all delegates must stay throughout the four leisurely days. There was a general feeling of it having become somewhat repetitive and perhaps ‘stuck’. It was therefore moved to a large and pleasant Quaker Meeting House in Birmingham in September 2011, but the membership soon made it clear that they wanted Windsor back!

So, for the 2012 event, a new three day/two night format was introduced, which had a theme of INTEGRITY – with a different sub-theme each day and various guest speakers. Delegates were able to come for one, two or three days – and were made welcome with goody bags, a very professionally produced programme, and daily large and small discussion groups.
 
 
INTRODUCING INTEGRITY
The first day was called ‘Introducing Integrity’ and it was built around the ending of two longstanding TC organisations, The Association of Therapeutic Communities (ATC – for adult TCs) and Charterhouse Group (CHG – for children’s TCs), and the merger to form a single new body ‘The Consortium of Therapeutic Communities’ (TCTC – for all types of TC).
On the shoulders of giants:
Nick Manning and Colwyn Trevarthan (front)
Rex Haigh and Gary Winship (rear)

Gary Winship – a longstanding champion of the movement – gave a spirited and funny précis of ATC’s forty years which he called ‘a cross between a love letter and a eulogy’. He peppered his talk with lively character vignettes of some of the main characters over the years, and criticised ATC for not having enough managerial ‘savvy’, and for being rather patriarchal in its choice of leaders; he acknowledged the organisation’s adaptability and relentless adherence to a radical political position, through the thick and thin of social psychiatry, Thatcherism, regulation and governance, to neoliberal economics. Richard Rollinson, with many years of CHG history, told of missed opportunities to come together sooner – and the different but oh-so parallel history of personalities and conflict, trials and tribulations in the history of the childrens’ TC organisation.

After saying goodbye to the old organisations, and a typically wonderful Cumberland Lodge lunch, the main topic for decision about the new organisation was introduced: what sort of organisation do we want TCTC to be? (TCTC2B??) Was it to have ‘more of the same’ (called the narrow focus), or was it to look to expand and cover new territory – particularly including the wider use of TC principles in different ways and settings? Almost a reprise of David Clarke’s ‘TC Proper v TC Approach’, or the more recent ‘Community of Communities’ and ‘Enabling Environments’ projects. The eight small groups, variously scattered throughout the lodge, thought about it and described a clear consensus: think wide. After having done most of the thinking, the inaugural AGM was mostly a formality; perhaps most interesting for electing six new board members, several of whom are ex-TC members.

The hour-long large group at the end of the day – now called a ‘community meeting’ – was reflective and open, if a little constipated. As its conductor, I was determined not to make any plunging interpretations and to positively nurture it as a warm and welcoming space. Indeed, nobody tried intimidating tactics of ‘Nobel Prize thinking’ (as originally described by Lionel Kreeger) – and  the Greek delegates seemed particularly appreciative of the simple opportunity to be together. When somebody thoughtfully asked them if they wanted any space at the conference to be in a Greek-speaking small group, they said that they could do that at home!  It’s widely acknowledged that being in a large group (this one was between 60 and 75) can be a weird emotional experience; I would add that it is even weirder to be conducting one.

PROMOTING INTEGRITY
The second day had three seriously impressive external speakers. The first was Professor Colwyn Trevarthan, from Edinburgh: the distinguished academic who introduced the concept of ‘primary intersubectivity’ (which impressed me first when I heard of it in my Cambridge social psychology days, and still does). With a title of ‘The Social Brain: The Healing Power of Emotions’, he put on a dazzling performance to demonstrate experimentally what we all feel and know clinically: that there is a lot more to relationships, and how important they are, than  transmitter neurochemistry, or detailed scans (even though discoveries such as mirror neurones support this), or indeed the multitude of clinical questionnaires and ‘instruments’ that we routinely use could ever meaningfully measure.

A few gems – often of linguistic precision as much as empirical fact - which caught my attention, amidst the array of sparkling jewellery:
  • “a project made propositional by their collaboration” (musical analysis of infant movements)
  • secondary intersubjectivity – from about 9 months – includes understanding the intention of the other; “sense of shared dynamic intentionality” (catch up, mentalisation!)
  • primary complex emotions = PRIDE and SHAME
  • elemental need for playfulness / fun / imagination / creativity
  • ‘Empathy’ is philologically the wrong word: sympathy is better, and mirror neurones would be more accurately described as ‘sympathy neurones’
  • ‘being human’ is more limbic and subcortical than it is cerebral…
Mark Johnson was next with a powerful service user account, ‘Reclaiming Integrity after a Destructive Childhood’. Mark is a Guardian columnist and author of the very successful book ‘Wasted’, who founded the charity and social enterprise ‘User Voice’.
After lunch, we had Leonie Cowen giving us a refreshingly clear and radical view of how commissioning should be done. If only it was!

A panel discussion to explore the detail of the issues, followed by small groups, gave ample time and space to give the ideas due reflection and digestion. ‘Fringe sessions’ followed – and Fiona and I took about a dozen delegates for a walk to the copper horse, after explaining what greencare is  and showing some pictures of our project, yurt and all, at Iver Environment Centre. Unfortunately the gate was locked just shy of the copper horse itself, because it’s rutting season for the deer – but there’s greencare for you. And of course, in the leisurely old days of the Windsor conference, a whole afternoon would be set aside for walks in the park; later to be timetabled as ‘professional networking’ to avert the gaze of sharp-eyed study leave funders. No such luxury any more – unless we repackage it as ‘greencare’!

Large group, and a splendid dinner – hijacked as a magnificent birthday party by the Bard of East Anglia. Then there was drinking, and dancing, and more. I was long in bed by then.

DEMONSTRATING INTEGRITY
We all now know so well that is does not matter a jot what good work we do, if we cannot suitably demonstrate what we do, and justify it with the sort of evidence required by the prevailing demands of the superordinate system. So – enter the TCTC research group, ably chaired by Susan Williams and presided over by Nick Manning.

They presented two streams of thought about outcomes: individual questionnaires so we can all be measuring what matters, and doing it in a way that facilitates comparison; and environment questionnaires to measure that elusive ‘atmosphere’ which is so easy to smell, but so hard to define.

The two questionnaires which came top of their Delphi exercise were:
  • CORE (34 items for well-being, symptoms, relations and risk)
  • Euroqol EQ-5D (5 items for quality of life are almost meaningless taken individually, but are very significant to health economists and QALY calculations)
So these are now going to be recommended to Community of Communities to be included in the basic service standards. Others also mentioned included the Recovery Star, HoNOS, GHQ and its derivatives, and the social functioning questionnaire.

None of the environment questionnaires examined were quite up to scratch – too old and whiskery; too long; too complicated; or not particularly relevant for TCs. The committee is therefore going to design a new one, with help by piloting it in volunteer communities. Watch this space…

Equally significant, in that ‘deep and thick’ way that only rigorous ethnography or phenomenology can do, were some of the research presentations about PhD work under way. In fact, there are currently three qualitative studies under way at Nottingham’s Institute of Mental Health – which can only serve to enrich and expand the academic base for the field.

After lunch, the demonstration of integrity took a different turn – and we all assembled in the elegant drawing room for we knew not quite what. We first heard the story of Simon Clarke, told by himself – from a hopeless and chaotic existence, through Christ Church Deal TC (CCD), to a productive high-level academic career. The next was Jonathan Walker, from an equally troubled background through CCD to a very successful career as a Liverpool campaigner and street musician: we enjoyed two lyrical and moving songs. Finally, Matthew Shipton told us of his own similar trajectory from squalor and disarray to rediscovering his own musical aptitude. Then he lifted the lid on the grand piano and simply blew everybody’s socks off (as they say) with a twenty minute rendition of an exquisitely complex Chopin rendition. Being about conflict and its resolution, he prefaced it – but so much more besides.

Bedazzled, we collected tea and wandered into our final small group sessions, before the final presentation: a presentation from a modern-day progressive catholic foundation school in Leamington Spa, called MAL-HER-JUS-TED. It was led by a passionate and forceful teacher from Chicago (echoes of the Boys Republic?), and described how they gathered information from ex-residents of young people’s TCs as part of the Lottery-funded ‘looking after other people’s children’ project run by Craig Fees at the Planned Environment Therapy Trust (PETT) in Gloucestershire.

With just half an hour’s quiet and reflective large group to finish, most seemed appreciative of being with each other – and their various contributions.

[caption id="attachment_711" align="aligncenter" width="300"]The logo of the new combined organisation The logo of the new combined organisation


Back next year, dates booked already. By then we’ll see if this new organisation is on the tracks we hope - to say and do something really significant…

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Dr Rex Haigh FRCPsych
www.greenshrink.blogspot.com
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A manifesto for social science research in the field of mental health - Nick Manning


Today we have a blog post from IMH Director Professor Nick Manning, with, as an introduction, some questions to think about and a link to a lecture by Professor Nikolas Rose.  Together, this post and lecture provide a 'sociological' view of mental health, and hopefully will provide some food for thought over the Christmas break.
Visiting this link will take you to a 'mediasite' presentation by Professor Nikolas Rose, entitled 'What is mental health today?'.  Please note that viewing this video may require additional plugins on your web browser.  If you are prompted to install Microsoft Silverlight, it is safe to do so, and you will need to restart your browser for the changes to take effect.  Other lectures by Professor Rose can be found here.
Some questions to think about when watching the video, and while reading Professor Manning's post, which follows:

1. Is there an epidemic of mental disorder?
2. Does the path to understanding mental disorder lie through the brain?
3. What is the role of diagnosis and diagnostic manuals?
4. Should we seek early diagnosis of those at risk of future mental pathology?
5. What is the place of patients, users, survivors, consumers in the mental health system?

Professor Manning's Post
Over the last 20 years a number of critical issues have challenged the mental health field in two areas.

First, the evidence for and effectiveness of treatment has been criticised for:
  • the integrity and relevance of research (pharma company trials, for example on the effectiveness of SSRIs and atypical anti-psychotics);
  • promissory claims by genetics and biological psychiatry research, which have not revealed hoped-for breakthroughs;
  • the extent of the evidence base (RCTs, NICE, complex interventions, which have not offered strong support for singular interventions);
  • the effectiveness of new technologies (CBT, DSPD are being challenged, and the latter investment has been wound up after 10 years and £0.25 billion)
Second, there has been criticism of the care and treatment practice, such as
  • the quality of care (murders by Christopher Clunis, Michael Stone, Richard King; care home scandals such as Winterbourne View; public enquiries such as the death of David Rocky Bennett);
  • the development of European and UK mental health legislation (risk prediction is weak and hence compulsory treatment and legal advice are contested).
The pattern here is for research based on an aetiology and pathology of mental illness in terms of biological processes and structures to have made limited progress. A recent UK Medical Research Council review of mental health research in the UK concludes that “the research questions in this field have been relatively intractable” (MRC, 2010).  Genetic markers have been elusive, neuroscience has yet to show clear directions for diagnosis and treatment, psychological treatments and effective drugs have been disappointing.  Yet the biomedical model has retained its dominance, despite the limitations of pharmaceutical, genetic, neuroscientific and psychologically based interventions.

By contrast there is a body of work from social science in relation to epidemiology and therapy, which demonstrates clearly the working of social processes in the distribution and care of mental illness. For example there has been growing evidence for the last 50 years that mental illness rates are related to the social inequalities of race, gender, age, migration, and unemployment (Pilgrim and Rogers, 2009). Part of this pattern is a selection effect caused by prejudice and stigma, for which the social theory of labelling, developed in the 1960s, provides evidence and explanation (see Scheff, 1999 for a summary). But part of this is direct causation mediated through stress (see Wilkinson and Pickett 2010 for a summary). In terms of therapy there is social science evidence about the damage poor treatment environments can do (Goffman, 1991, et seq), and the consequences of social isolation under community care. There is also evidence about the way in which those treatment environments can be positive and therapeutic (Lees, 2004), and about the potential for building better supportive personal and social networks (Spencer and Pahl, 2006).

At the same time there has been a growing burden of mental distress.  Bloom, et al (2011, p.26) estimate that mental disorder is the leading global cause of all disability-adjusted life-years. Suicide is second only to traffic accidents as the cause of death among those aged 15–35 years (WHO, 2005). 75% of prisoners in the UK have a diagnosable mental disorder, with rates of psychosis in excess of 20 times the national average. Mental health problems account for 35–45% of absenteeism from work, at a cost to Europe of €136.3 billion in 2007 (ECNP, 2009; OECD, 2012). Overall costs of mental disorder in the UK have grown from £77.4 billion in 2003, to £105.2 billion in 2009 (CMH, 2010).

Such a combination of growing need and perceived problems with the effectiveness of existing healthcare is fertile ground for innovation. The response from the biomedical research community has been to repeat the pattern from 30 years ago, and make a renewed emphasis on building more biomedical and neuroscience capacity on the basis of familiar promises and prospects. For example the MRC (2010) review notes that there is “low research capacity” in the field.

However an alternative approach originating in the USA in the 1990s has grown rapidly and vocally to fill the gap. This approach is based on the concept of ‘recovery’. Recovery means the right to a life that has meaning and satisfaction as defined by the person themselves, even if their mental health problems cannot be eradicated. Recovery originated as a grass-roots movement in the USA (Davidson, Rakfeldt and Strauss, 2010). It has spread with enormous energy throughout the English-speaking world (US, NZ, Aus, UK), and is under serious discussion in Europe (Samele, 2012; WHO, 2005). It is increasingly supported by professional, third sector and activist movements, and has very recently appeared in both the latest UK Department of Health policy No health without mental health (2011) and the US Federal government’s Substance Abuse and Mental Health Administration policy (SAMHSA, 2011). For example SAMHSA defines recovery in four parts:
  • health - managing one’s disease(s) and living in a healthy way;
  • home - a stable and safe place to live;
  • purpose - meaningful daily activities, such as work, with the independence and resources to participate in society;
  • community - relationships and social networks for support, friendship, love, and hope.
The emergence of recovery originated as a social movement by those experiencing mental health difficulties, but it has since been adopted by mental health professionals, and more latterly incorporated into the policy framework of government health and social care departments. Although the SAMHSA definition is typical of the field, weaker meanings of recovery have been promoted by different professional groups as a way of accommodating their existing activities and interests, such that there are now three definitions or types of recovery used within the mental health field, ranging from weak to strong:
  • as a reduction of medical symptoms (recovery RI), frequently stressed by medical staff.
  • as the complete redefinition of the meaning of mental disorder, and the instillation of hope for a better life (recovery RIII), increasingly used by service users and their representatives.
  • as rehabilitation, mainly employment (recovery RII), often used by nursing and social care staff.
Relevance of social science
Social science has a long tradition of work in the field of mental health. The earliest work analysed the aetiology of mental illness in relation to major social patterns such as urbanisation and social inequality. At that time most mental health sufferers were placed in large hospitals, and these institutions also furnished a rich source of sociological data about the structures and dynamics of large organisations. Fundamental developments in interactionist sociology on identity, group life, power negotiations, and grounded theory were made by Goffman, Strauss and others. Labelling theory and stigmatization, developed in the work of Scheff (1999) and others, founded a research tradition that was subsequently applied to the sociology of crime, youth culture, and race. Much of this crossed to the UK to inform studies of organisations, deviancy, work, and the professions, but despite an interdisciplinary interest in resilience, wellbeing and happiness, there has been far less social science research in the mental health field in the last 20 years.

In other related areas there have been major new research avenues explored, such as the sociology of physical health and illness, and the sociology of the body.  Medical sociology is by far the biggest sub-field of any in sociology, and yet almost none of its work focusses on mental health. For example studies of doctor – patient interactions, the nature of diagnostic practices and meanings, and the anthropology of symptoms, have made major advances in our understanding, yet little of this work has crossed over into the mental health field. Some examples would be Kleinman’s (2011) work on the somatisation of human suffering, and the way in which anthropology alerts us to the cultural relativity of biomedical concepts, and Busfield’s (2011) recent argument that the diagnosis of mental illness is becoming over-extended. Of closer relevance to recovery is Crossley's (2006) research into oppositional movements by service users and the way these are structured in common with pressure groups and political movements.

However these examples are notable exceptions in relatively quiet field. An important task therefore is to gather data on the way in which all three different definitions of recovery are used and promoted in the ‘recovery society’.  We need a detailed examination of the way in which this term has developed, the way it is being widely introduced in practice, the experiences of mental health service users, and the methodological issues involved in gathering and assessing data about it.  We should bring social science back into this field by the careful and critical investigation of recovery which is based centrally on a social aetiology, and the novel use of powerful social technologies, for example: Pahl’s work on friendship, personal communities and ‘social convoys’ (Pahl, 2000; Spencer and Pahl, 2006); Hacking’s analyses of ‘making up people’ and the ‘looping effects’ of mental disorder categories (Hacking, 2007); and research on ‘successful’ lives of both the profoundly impaired and the rich (Pascall and Hendey, 2001; Pahl, 1995).

There is today an unprecedented opportunity to re-think the nature of mental disorder, its health and social care, the experiences of those struggling with it, and the application of these findings to wider areas of long-term health conditions.

References
Bloom, D.E., et al (2011) The Global Economic Burden of Non-communicable Diseases. Geneva: WEF

Busfield, J. (2011) Mental Illness Cambridge: Polity Press.

CMH (Centre for Mental Health) (2010) The economic and social costs of mental health in 2009/10
Crossley, N. (2006) Contesting Psychiatry: Social movements in mental health London: Routledge
Davidson, L., Rakfeldt, J and Strauss, J. (2010) The roots of the recovery movement in psychiatry Wiley

DH (UK Department of Health) (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages Gateway Ref 14679, HMGov

ECNP (European College of Neuropsychopharmacology) (2009) 22nd Congress, 12 Sept, Istanbul

Goffman, E. (1991) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates Penguin.

Hacking, I. (2007) ‘Kinds of people: moving targets’ Proceedings of the British Academy 151, pp. 285-318

Kleinman, A. (2011) 'Four social theories for global health' The Lancet 375, 9725, pp 1518-1519

Lees, J., Manning, N., Menzies, D. and Morant, N. (2004) A Culture of Enquiry: research evidence and the therapeutic community, Jessica Kingsley Publishers

MRC (Medical Research Council) (2010) Review of Mental Health Research London: MRC

OECD (2012) Sick on the Job? Myths and Realities about Mental Health and Work.  Paris:OECD

Pahl, R.E (1995) After Success. Fin-de-Siècle Anxiety and IdentityCambridge: Polity Press

Pahl, R.E. (2000) On Friendship Cambridge: Polity Press

Pascall, G. and Hendey, N. (2001) Disability and Transition to Adulthood: Achieving independent living Brighton/York: Pavilion/Joseph Rowntree Foundation

Pilgrim, D. and Rogers, A. (2009) Sociology of Mental health and Illness Buckingham: Open University.

SAMHSA (US Federal Substance Abuse and Mental Health Administration) (2011) at  http://www.samhsa.gov/newsroom/advisories/1112223420.aspx
Samele, C. (2012)  European Profile of Prevention and Promotion of Mental Health (EuropPoPP/MH), Brussels: EU Executive Agency for Health and Consumers.

Scheff, T.J. (1999) Being Mentally Ill, A Sociological Theory New York: Aldine de Gruyter

Spencer, L. and Pahl, R. (2006) Rethinking Friendship Princeton University Press

WHO (2005) Mental health: facing the challenges, building solutions. Copenhagen: WHO

Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why Equality is Better for Everyone Penguin.

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Professor Ruth McDonald ~ Paying for Performance in the NHS – is it good for our health?

In the olden days, we used to trust public servants to do their best for the people they served. Nowadays things are a little different, especially in the NHS. Policy makers are increasingly resorting to ‘Pay for Performance’ (PfP) in an effort to drive up the quality of care delivered to patients. The Commissioning for Quality and Innovation Payment Framework, or CQUIN as it is known, makes a proportion of income conditional on the achievement of quality improvement and innovation goals. This was increased from 0.5 to 1.5% in the second year of the scheme and this year the percentage was increased to 2.5%. David Nicholson, the NHS Chief Executive said recently that he wants to see this rise to 4 or 5%, presumably due to fears that the 2.5% isn’t having the desired effect.

The question asked by a lot of people is ‘do PfP schemes work’? But this is the wrong question, since it fails to recognise that these initiatives are all different. What we need to do is to look at the features of the individual schemes – how they are designed and implemented and in what context – and assess impact to work out how and to what extent a scheme works.

Our recent evaluation of the Advancing Quality (AQ) scheme in the NHS North West found that it saved almost 900 lives. The bonus payments were a drop in the ocean compared with CQUIN, which suggests that whilst it’s helpful to offer carrots, there are other motives afoot here. Perhaps NHS staff are only too ready, willing and able to improve services, but what they need sometimes is a little help. In this case, help took a number of forms including standardised data definitions and bespoke software. But aside from these technical aspects, collaborative events brought together staff from all 24 participating organisations to share their learning and work through common problems. In addition to shared learning, the development of this AQ ‘community’ appears to have been really important in providing emotional support for what has been (make no bones about it!) a gruelling and often uphill struggle for the staff involved. As our study shows, ‘PfP’ can produce desired results, yet  what motivated the front line NHS staff in our study was not ‘rational’ calculation of efforts versus rewards, but an ability and desire to  work together in a supported way, to do what they all felt was the right thing for patients. AQ has now broadened its scope to include all of the mental health Trusts in the region so we’re watching with interest to see if the initial success can be replicated as the programme expands.

Much of the thinking on incentives has traditionally been dominated by economists who take a rather one dimensional view of human beings. And economic rationality has often been seen as contrary to emotion. But an obsession with finding the magic percentage which proves to be a tipping point is the wrong way to go here (David Nicholson, please take note). What’s needed is for policy makers and evaluators to begin to adopt a less impoverished view of human behaviour - recognising the importance of emotion in improvement initiatives would be a good place to start.

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Professor Ruth McDonald
Chair in Health Innovation and Learning
Business School
University of Nottingham
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Dr Richard Gipps ~ Neurotic Theories of Neurosis

This week, the IMH Blog is pleased to introduce blogger Dr Richard Gipps, Charted Clinical Psychologist.  Richard's blog, Philosophical Perspectives in Clinical Psychology, covers a range of topics including philosophical issues in psychology, psychotherapy and psychopathology, and engaging clients 'with genuine and fruitful solicitude'.  We encourage you to have a read and check out other posts from his site. 
The post below, entitled 'Neurotic theories of neurosis' was originally posted on 10 November 2012. 
Here's a hunch: That our theories of neurosis are sometimes rather radically constrained by the ways in which neurosis neurotically invites us to understand it, and by the ways in which we neurotically respond to the invitation.

Here's a rather simple example to get us going: Geoff says he is 'falling apart', struggling to 'hold himself together', is worried he is going to 'lose control'. Ah right, so must we think that the healthy person is one who manages to hold himself together, who is in control of his feelings? But isn't just this precisely the hubristic idea at the heart of neurotic disorder: that we ought to be managing our feelings, actively holding ourselves together? The idea that this is what mental health amounts to is, it seems to me, clearly absurd - and yet it is all too easy to start thinking this way when we heed the invitation to understand neurosis in a neurotic manner.

What do we have to do with here? In truth it is actually the neurotic person (i.e., admittedly, pretty much all of us some of the time) who tries to keep 'in control', who is managing not to 'fall apart'. For when all really is going well for us we surely aren't best described as in the business of 'remaining in control' or 'keeping it together'.  That instead is what we do when we are beset by an inner conflict but manage not to show it.

[caption id="attachment_676" align="alignleft" width="199"] Jonathan Lear


When we are not neurotic we are not beset by an inner conflict; and so, because we are integrated, we have no need for control. When instead I am relaxedly myself then there is no need for me to manage anything inwardly. When all is going well we don't have to do with, say, ego and id and superego in tension with one another (cf Jonathan Lear on Love and its Place in Nature). We aren't trying to control unacceptable urges. The patient may come to the doctor because they want help with 'managing their feelings'; the doctor's job, however, is to point out the patient's hidden premise: that feelings need to be managed - to point out that this hidden premise is precisely what is causing the argument not to go through.

Or consider anxious depression. We are often enough encouraged to try to manage our depression, to look after ourselves. In an anxious depression I lose trust that my life will work out as I hope. I become hopeless. My life, one could say, becomes a predicament. But it surely isn't that, when things are going well for me, it is because I am managing my feelings better, that I am finding reasons to be cheerful, that I am running on hope.

When I am not anxiously depressed I am instead not focused on my own emotional processes, not anxiously thrown back on myself. Instead of thinking 'how today shall I manage my depression' I might instead think 'and how today shall I live, what can I do to live today in the best (most integral, moral, helpful, meaningful) way I know how?' 'What responsibilities to others and to myself do I have the opportunity to discharge?' Depression throws us out of our lives and back in on ourselves. It may seem to be merely inviting us to understand it as a condition - but what is really happening is that we are being invited to understand ourselves as beings who are conditioned. It invokes a passive, causal, language in which the subject is a being now beset by their own feelings, bodies, thoughts, circumstances. The language of agency and genuine subjectivity goes missing. Depression invites us to suppose that what we need to do is to 'manage our minds', a challenge which is best left unheeded by anyone who still aspires to genuine subjectivity. (Buber: 'So long as the heaven of Thou is spread out over me, the winds of causality cower at my heels, and the whirlpool of fate stays its course.')

[caption id="attachment_677" align="alignright" width="222"] Martin Buber


Just as neurosis invites us to understand it neurotically, thereby sucking us in to the neurotic predicament, psychosis invites us to understand it psychotically. We see this in certain theories of 'made' thought, feeling and action. ...'Ah, what these phenomena (e.g. thought insertion) reveal is that my everyday self-ascriptions of thoughts and feelings actually have a hidden dual character - such that I recognise the thoughts yet must also attribute them to my self.'... But, honestly, can you imagine a more psychotic conception of our allegedly healthy first person aptitudes? Normal thoughts and feelings suddenly become, on this theory, states that obtain in me and which I must recognise for what they are, and recognise as a product of my own psyche. Having a thought suddenly psychotically implicates me in having some kind of inner entity present to my mind. This theory of mind psychotically splits the thinker apart from the thought.

Or consider schizophrenic delusion. Here we have, I would submit, a radical failure of what the analyst's call 'symbolism' - the capacity to find the mot juste to voice, give tractable form to, the feelingful inner life. Instead of the expressive and integrative life of symbol formation the patient offers us a descriptive and explanatory discourse concerning something that is happening to them: this narrative is the crystallisation of the delusion, the patch over the rent in the ego. But then, to make matters worse, the psychologist offers us a theory of delusion as a matter of a subject coming to mistaken explanations about what is going on for them - as if having an explanation here was just fine, it just being the content of the explanation in question which is the problem. (The psychologist, after all, is likely to imagine that we are positioned in the world as sense makers - beings puzzled by their surroundings engaged in their own individual projects of figuring them out. Funny how such an innocent-sounding idea can end up obliterating so much of what is important in being human - such as being someone sensitive to senses and meanings that are already there, sensitive in virtue of their being-in-the-world rather than because of any cognitive endeavours undertaken.)

Or consider PTSD. We are so often invited to think that the problem is as the patient describes: that the problem is that they are having traumatic memories which 'intrude' on their consciousness, memories that are not under their control. (Let me be clear: this indeed is a good description for what is experienced: the question concerns what the goodness of the description consists in.) It is as if we are being invited to choose between a conception of memory as happening to us and a conception of it as actively undertaken. But neither of these are normally the case. Rather I, the subject, am of a piece with the flow of my memory which is not (apart from rarely) engaged in in any kind of willed manner. Speaking for myself, I seem to spend a fair bit of my day quite happily in a state of associative daydream; this it seems to me is entirely normal and perfectly healthy. And during this time I quite often recall some of the deeply shocking or upsetting things that have happened to me or to those I love. I do not 'will' those memories, since I very rarely, basically never, will any of my memories. The traumas of my life are condensation nuclei around which associative chains cluster; sometimes I must shake myself out of these, but they pass quickly in any case, and this is just normal memory doing its normal thing. A neurotically ill mind, however, may be dissociated from its own memories, unable to bear their affective charge, and the memories will now appear as intrusions, as thrust upon them. It may be these memory intrusions for which they seek help. Now it's bad enough if I start to construe my memories as ego-alien, to feel them as thrust on me - but now imagine that a cognitive psychologist came along to theorise the whole issue with an mechanised and entified view of memory as a matter of having inner states or processes going on inside us. Or some other mechanistic psychologist (NLP anyone?) suggests that the way forward is in substituting certain 'cognitions' for others. Where would be then? (Well: we'd be where we too often find ourselves.)

When we are neurotic it is hard for us to escape, since our every framing thought of the escape route is constructed out of the fabric of the neurotic trap. As if that wasn't bad enough, it is also all too easy for the clinician to now start to theorise the project of not being neurotic in a neurotic way, to try to help the patient 'manage their mind'. To use a rather ACT-ish metaphor: the patient asks the clinician to help him find ways to quell or avoid what he takes to be the monster threatening to break down the door of the room in which the patient is hunkered down. Now we clinicians know perfectly well that if the patient were to find the courage to open, rather than push against, this door, the alleged monster would then saunter in and out by himself and in the process shrink down to a much more tolerable size. The patient could also come to see that the monster was nothing but himself. Well, I say we know this perfectly well. But then again, when we theorise, or practice in an overly theory-driven way, it is something which it seems to me is all too easy to forget.

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Dr Richard Gipps
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Dr Simon Clarke ~ Living in Glass-Walled Asylums: The Schizophrenia Commission Report

Last week the Schizophrenia Commission, headed by the mental health charity Rethink, released its report into the current state of care in the UK for people diagnosed with Schizophrenia. It made predictably depressing reading. Amongst other things, employment rates for people diagnosed with schizophrenia are less than 7%. The life expectancy rates are 15-20 years lower than the general population due to physical health-related problems. These health problems are often associated with weight gain, side-effects from powerful anti-psychotic medications. A huge proportion - 87% - of service users report experiences of stigma and discrimination, whilst the cost of schizophrenia to the economy was estimated at around £11.8 billion.

Perhaps even more depressing was report’s findings into the current state of mental healthcare in the UK for people diagnosed with schizophrenia. Mainstream psychiatric care was described as “a broken and demoralised system that does not deliver the quality of treatment that is needed”, in which service users “feel shuttled from one team to another as if on a factory production line”. Inpatient wards are often “frightening places where the overwhelmed nurses are unable to provide basic care and support” and in some cases “so anti-therapeutic that when people relapse and are in need of a period of care and respite, they are unwilling to be admitted voluntarily”. Too often, “medication is prioritised at the expense of the psychological interventions and social rehabilitation” and genuine service innovations like Early Intervention is Psychosis (EIP) teams are “vulnerable to service cuts”. The net result of all this is that psychiatric care “adds greatly to their distress and worsens the outcomes for what can already be a devastating illness”.

As someone who has experienced psychosis, been sectioned, diagnosed with schizophrenia, spent time in an alternative therapeutic community, qualified as a clinical psychologist and worked for two years in an EIP service in London, I can relate to much of this. I found my inpatient stays traumatic and demoralizing. As a result of medication I put on four stone of weight in 6 months. I used cannabis to cope, which of course led to more long-term problems. Thankfully I was helped by an alternative therapeutic community; the love and kindness showed by people in the community helped repair some of the damage from my experience as a psychiatric service user. Supportive but challenging relationships were key, as in fact they always are (Pilgrim et al., 2009).

So before we become self-satisfied with smug complacency about having better attitudes towards severe mental illness than wider society, perhaps we should get our own, crisis, house in order. Attitudes amongst mental health staff can still reflect negative, and inaccurate, expectations of people diagnosed with schizophrenia; in one study for example (Nordt et al., 2006), psychiatrists’ attitudes were more negative than the general population. Health professionals with past or present experience of mental health difficulties are often less likely to disclose their problems to colleagues than people outside the health service (Hinshaw, 2008).

When I was working at a large, well-known mental health research institution a senior colleague once told me, “you only got the job because of your psychiatric history, not because you are a good researcher”. When, whilst working at another NHS Trust, a confused visitor looking for an A & E department was told by a receptionist, “No, no love you’ve got it wrong; this is not a real hospital, this is a hospital for mental people”. The receptionist helpfully added a circular motion beside his head to illustrate what he meant by ‘mental’, just in case the flummoxed visitor (and, presumably, the patients and carers waiting in reception) didn’t understand.

Those in glass houses…

Posted by: Dr Simon Clarke Clinical Research Psychologist Nottinghamshire Healthcare NHS Trust

References: The Schizophrenia Commission Report (2012): http://www.schizophreniacommission.org.uk/the-report/.

Hinshaw, S.P. (2008) Breaking the Silence: Mental Health Professionals Disclose Their Personal and Family Experiences of Mental Illness. New York: Oxford University Press.

Nordt, C., Rossler, W. & Lauber, C. (2006) Attitudes of Mental Health Professionals Toward People With Schizophrenia and Major Depression. Schizophrenia Bulletin 32(4): 709–714.

Pilgrim, D., Rogers, A. and Bentall, R. (2009) The Centrality of Personal Relationships in the Creation and Amelioration Mental Health Problems: the current interdisciplinary case. Health: an interdisciplinary journal for the social study of health, illness and medicine 13(2): pp.235-254.

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Debbie Butler ~ Work, mental health, and general health

Ever had a re-occurring health problem making time off work an ever increasing problem? Add on top of that a mental health difficulty, and what do you get? In my case very anxious and an enormous feeling of guilt: ‘If I don’t go to work they will think I am pulling a fast one’.

My physical health has been poor these last four years with numerous leg operations. For those of you who have known me for a while you will have grown close to my moon boot, crutches, and plaster. I have seen research showing that those individuals with mental health problems and are employed have a better attendance than those without mental illness. Within my circle of friends I have seen that a lot and am very proud of those that keep themselves in work under self-pressure to keep going. Work is difficult for us all at times, we all have things happening outside of work which can impact on our attendance, but if you add mental health problems to the equation then stress can be exacerbated.

I would be interested in hearing from anyone who may have done research in this area or is contemplating doing so. I do know there is still a lot of stigma around employing people like me. I have the Personality Disorder label and do find some days hard but that shouldn’t stop me going to work. We all have bad days. I don’t give up easily and would advocate work as a real and useful distraction. I remember my first coping strategy when I realised I needed to evade violent and intrusive thoughts was to put the kettle on.  I do it as second nature now, as well as coming to work. I have a great bunch of friends and colleagues in the Institute of Mental Health and look forward to coming to work each day. Instead of sitting on the sofa as I did for ten years doing nothing. Over the last few months I have felt like going back to that sofa but you know I would miss the life I have now with all my friends and colleagues and to be honest I can now go on holidays; for example, I love to go cruising.

Don’t forget, if you need a forum to take research ideas to, let me know at the MHRN and we will get some service users and carers together to help you.

I look forward to seeing you when I get back from my operation.

Posted by:
Debbie Butler
Patient and Public Involvement Officer
NIHR Mental Health Research Network
East Midlands Hub
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Jenelle Clarke ~ Change in Action at the TCTC Annual Conference

[caption id="attachment_638" align="aligncenter" width="300"] Cumberland Lodge (Windsor Great Park)


The Consortium for Therapeutic Communities (TCTC) hosted its first annual conference last month, 22-24 October 2012.  Held at the beautiful and scenic Cumberland Lodge within Windsor Park, it was an opportunity for those interested and/or working in therapeutic communities (TCs) to come together.  The conference itself has been running for several years, organised by the 40-year old Association of Therapeutic Communities (ATC).  Significantly, this was the first year that the newly formed TCTC, which took over from the ATC earlier this year, hosted the event.   This year’s conference theme was ‘Delivering Integrity’.*

I am relatively new to the TC world and this was my first time attending the conference.   This was like no other conference I had attended.  It was not just that each day started and ended with a community meeting (60+ individuals sitting in a circle, talking and reflecting as a group on the days’ events), the Greek dancing, the multiple cheerful toasts at dinner, or that at times the conference resembled a type of family reunion; it was more the atmosphere and purpose of this conference that set it apart.

On the first day, members of the TCTC (formerly members of the ATC and Charter House Group) had the opportunity to vote for the first TCTC board of directors.  This was no small thing – it was not only saying goodbye to 40 years of the ATC, it was asking the question, what do we want next?  Conference delegates had the task of discussing the future direction of TCs, what type of organisations/communities TCs should include (or perhaps more importantly, exclude), what the ‘mission’ should be, building a solid research evidence base, lobbying and advocating for community approaches within mental health / education / social care, and how the TCTC should go about all of this.  There was much discussion and debate; however despite the variety of voices in the room, it was clear that the current direction of TCs has to change to become more proactive, rather than reactive, to changes in government policy and funding.  For some, this sparked feelings of loss at having to let go of the old.  For others, especially those of us who are new to the TC world, it felt rather exciting and optimistic.

Having ushered in TCTC and started the conversation as to the future of TCs, Day 2 of the conference moved on to explore ‘Promoting Integrity’.   To that end, presentations included a keynote address from Professor Colwyn Trevarthen titled ‘The Social Brain: The Healing Power of Emotions’; a talk by Mark Johnson, ‘Reclaiming Integrity after a Destructive Childhood’; and Leonie Cowen, ‘Integrity in Commissioning: Ensuring Needs are Met’.

[caption id="attachment_639" align="alignleft" width="258"] Drawing Room - where 3 stories of personal change were given (Day 3)


Day 3 of the Conference, which specifically looked at ‘Demonstrating Integrity’, included a presentation from the TCTC Research and Development Group, research paper presentations, life stories of personal change, and a presentation and video on the MAL-HER-JUST-ED project (for more info about this project, please see the Performance and Workshops section on the Therapeutic Living with Other People’s Children website).

At the final community meeting of the conference, the feeling in the room still held one of excitement and of hope for the future of TCs.  Whether that can be translated and then sustained in terms of real life policy and funding challenges remains to be seen.  However I am an optimist, and as an American my faith in the optimist approach was restored in last week’s US presidential elections.

[caption id="attachment_641" align="alignright" width="289"] President Obama


Just like Obama managed to pull off a re-election win during trying times in American (and world) history, I would like to believe that TCs too will find a way through the funding cuts, the individualist and at times isolationist approach to mental health and social care.  But, as with Obama, there is real work to be done as the challenges and oppositions we face will be with us for some time.  And will likely get worse.  So the question remains, despite all of this, what will 40 more years of TCs bring?

(*NB: Rex Haigh also wrote a blog post about the TCTC Conference: TCTC: born 22/10/12, Windsor, England.  As a regular conference attendee for many years, he provides a much more in-depth perspective about all these changes and talks more fully about the presentations and speakers.  I highly recommend it!)

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
E: This email address is being protected from spambots. You need JavaScript enabled to view it.



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Dr Hugh Middleton ~ Mental health care: working together to reach full potential

Dr Hugh Middleton (Consultant Psychiatrist Nottinghamshire Healthcare NHS Trust and the University of Nottingham’s School of Sociology and Social Policy) writes on how research is identifying success stories and offering new strategies for collaboration: To précis, mental health professionals need to work together if they are to fulfil their potential and deliver the best possible patient care, a new report has revealed (ref. below).

Hospital soap operas, everyday experience and what we hear about the “state of the NHS” all draw attention to strife between those who “do” health care and those who manage them, so it is good to see publication of some fresh research that tries to rise above this. October 10th saw publication of the final report from a three-year investigation of multi-disciplinary team working in mental health. Numerous investigators were involved, including Dr Hugh Middleton and other participating organisations (e.g. Nottinghamshire Healthcare NHS Trust).

Healthcare professionals must work together as effective teams if they are to provide the best possible patient care. This is important for mental health services where quality includes consistency and a reassuring sense of being known and understood. Providing these and at the same time working in shifts, so that the service is available beyond office hours, is difficult without great team processes.

Previous research shows that many multi-professional teams fail to perform to their full potential, as they are not clear about their objectives, disagree about goals, their leadership and how to work together; or they find themselves trying unsuccessfully to meet the conflicting demands of senior managers from different disciplines. The Healthcare Commission has discovered that as many as half of all NHS staff may work in dysfunctional teams, which can jeopardise patient care and undermine staff well-being.

The overall aim of this research was to explore such issues in more focused detail amongst teams providing NHS mental health services. A variety of settings were investigated. Service users, their families and friends, a range of mental health practitioners and service managers were all consulted in the course of developing a novel measure of community mental health team effectiveness. Some 1500 practitioners from 120 teams took part in a survey which estimated how effective such teams were, and reported upon what it was like to work in them.

There were strong associations between team effectiveness, measured on a scale which reflects service users’ views of good and bad practice, and the quality of team working. This was assessed using the Aston Team Performance Inventory, a well-established measure of team working. Particular success in providing good quality mental healthcare was found amongst teams that had a clear sense of purpose, welcomed participation in creative problem solving and were well led in a style that encouraged reflective practice.

Alongside this survey the investigators also observed a number of team meetings and interviewed 114 service staff, 31 service users and 13 users’ informal carers. This qualitative research enabled enquiry into the interactions that lie behind numbers derived from the survey. In terms of what matters to service users it revealed disparities between what they find important, such as relationship, flexibility, availability, consistency and understanding, and requirements of the organisational settings from which care is provided.

Of service users, in the words of one community mental health team manager:

“… they don’t really want to see the paperwork and they don’t really want to see the risk assessment, don’t really want to see the care plan, sometimes they’ll talk to us about the care plan but they don’t want copies of it … a care plan doesn’t mean anything to them in that sort of sense but I think we do keep trying to engage with them … “ In relation to creativity, in the words of a support worker:

“So there may be some patients who would really, really benefit from you say taking them for a day at the seaside, because that was what they remembered their parents doing for them when they were little and that would mean so much for them to do that. We obviously can’t do that, and time is probably our most valuable resource really” These are readily dismissed as intuitive and predictable findings. Perhaps unsurprisingly they relate good clinical mental health outcomes to team creativity, task focus, participation, supportive leadership and interest in true relationship. On the other hand they are also timely and novel. They identify clear relationships between organisational determinants of the practitioner’s context and well-being, and the outcome of their clinical activities. It will require further studies to establish whether such interactions are also present in healthcare settings that are possibly less dependent upon practitioners carrying out “emotional work”, but an element of that is present in all health care settings. What this research demonstrates is that the success with which “emotional work” is conducted, in part reflects the practitioner’s emotional well-being and that is in the hands of those who manage and commission health care. There are connections between the management of health services and the service user’s experience which are not simply reflections of business efficiency, but provide the creative commissioner or manager with more sophisticated opportunities to influence real outcomes.

Reference:  West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; 2012.

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Dr Rex Haigh ~ The World Psychiatric Association International Congress 2012 Conference

Whilst attending the World Psychiatric Association International Congress 2012 Conference (held 17-21 October), Rex Haigh, an NHS consultant psychiatrist, wrote a blog post for every day of the conference.   With a packed conference schedule of activities from 6:30am to 11pm, Rex reported on the variety of presentations, themes and discussions that emerged over the five days.   To highlight the conference, we have selected one post to reblog in full, covering the presentation from Rex's team and a variety of poster and speaker presentations from Day 2: More than 17 (just).

We would highly recommend checking out the rest of his posts as it appears to be an excellent conference with thought provoking themes arising.  To access all of the conference daily posts, please see the following on Rex’s blog:

The Yerkes-Dodson Test (Day 1)
(Day 2 is posted below)

Ulysses or Lithium? (Day 3)
Wheeling, Dealing and Scheming (Day 4)
The Kindergarten of Democracy (Day 5)
 
Featured Post by Dr Rex Haigh: More than 17 (just) 
Arriving for breakfast at 0632, I was surprised (and very pleased) to see I was
the last one there. We ate rather silently and nervously, and got the metro to
arrive in our presentation room just after 7am. We put up our display posters
either side of the stage, and leaflets on all the seats; we adjusted Yousuf’s
powerpoints a few more times,and finally handed it over to the technicians.
Then we waited…


Although there were only 3 attendees there on the dot of 0800 (our official starting time), somebody did say that lots more were outside the congress centre, just arriving – so we waited a few minutes before starting.

Soon there were 17 and by the end we had about 30, though there was some coming and going. The talks went pretty well exactly to time and to plan, and are available on the LLE website www.livinglearningexperience.com.  Afterwards, we breathed a sigh of relief and had the freedom to enjoy the rest of the congress.

[caption id="attachment_581" align="alignnone" width="300"] Nearly 17 by now


C B Nemeroff (USA) gave the first plenary lecture – on Neurobiology of Child Abuse and Neglect – and gave a dazzling exposition of the genetic, neuroimaging and pharmacological bases of adult consequences of childhood trauma and abuse, and how the people with histories of maltreatment had different brains. Although he seemed to deliberately avoid the PD label, it was almost a return to the days of ‘endogenous v reactive’ depression – except over a life course, rather than weeks or months. Quite reassuring to those of us who fear being eclipsed by the biomedical juggernaut driven by the economics of the pharmaceutical industry.

Then to the posters – hundred of them from all over the world; interestingly all of those from latin countries bearing a prominent ‘no conflict of interest’ declaration, none of which would have suggested any such suspicions. Is this an international version of the UK ‘health and safety’ culture, used to destroy trust and spread persecutory anxiety? And next to the poster, a display of restraint cages through the years, and straitjackets exhibited like a fashion display. Was this deliberate irony?

[caption id="attachment_582" align="alignnone" width="300"] Bed shortage?


[caption id="attachment_583" align="alignnone" width="300"] C&R?


[caption id="attachment_584" align="alignnone" width="300"] PICU?


[caption id="attachment_585" align="alignnone" width="300"] Straitjacket couture?


Next to a heart-warmingly reassuring session by Czech psychiatrists and therapists from The International Centre for Integrated Psychotherapy (Knobloch). Heart-warming because it was human-scale and clinical, reassuring because it is a TC by any other name. Although they only briefly referred to TCs, I asked if they recognised the British TC tradition, with Maxwell Jones and all, as their work seemed so familiar: and indeed they did. Somehow, we should be making friends with groups like this.

Towards the end of the afternoon, were workshops. The title of ‘Innovation in Psychotherapy Education’ was catchy enough to attract me, but for some reason, my heckles were soon raised once there. It was a sharply commercial presentation of an elegant and well constructed Moodle website for training in basic psychotherapy – not unlike KUF in its design, but lacking the radical ‘relational’ edge that I think is essential in any therapeutic engagement. A sales pitch, I suppose, when I was looking for realttitude change, I suppose – tackling ‘us & them-ness’ – ever seeking that dear old ‘quality of relationship’ again.  After an initial altercation which Yousuf and I had with the presenter – about the viability of hard evidence-based rules for all psychotherapies – I meekly shut up and watched nigh on a dozen video clips of very self-assured therapists teaching how to do CBT…

The final session was much more cheering, though. Professor R S Murthy was being presented with a special prize. The purpose, structure and committee for this prize was explained at great length before the ceremonial exchange of gifts and flowers and the lecture could begin. Professor Murthy is recently retired Dean of the NIMHANS – ‘the Maudsley of the Subcontinent’ in Bangalore – and I explained to him before the talk about our link with ASV and the intention to do an LLE there in the next year or two. Maybe we should do a second one for NIMANHS residents! But he was great – talking our language like few others did here.
Here’s the points from two of my favourite slides of his. This one gave seven criticisms of the current ways of psychiatric thinking and practice:

1.       Medicalisation of suffering
2.       Vague diagnosis
3.       Mainly pharmacological interventions
4.       Doubtful outcomes
5.       Insensitivity to local customs and practices
6.       Loss of personal context
7.       Psychiatric imperialism


And this one gave three points for the ‘paradigm change’ that’s needed for world mental health to improve:
  • Recognition of the central role of people and families
  • Information and interventions for them
  • Professional development to share this
Back for a celebratory meal of stroganoff with dumplings and Czech beer at a cosy little restaurant just near the hotel. But rock on Professor Murthy – you’re my main man!
Posted by:
Dr Rex Haigh
http://greenshrink.blogspot.co.uk/
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Helen Smith ~ Changing the approach to self-harm in young people

In 2006, The Mental Health Foundation reported that 1 in 12 young people self-harm. This year, YoungMinds, a mental health and emotional wellbeing charity dedicated to children and young people, have been working in conjunction with Cello PLC’s ‘Talking Taboos’ campaign to conduct extensive research into self-harm in young people. The published report entitled, ‘Talking Self-Harm’, detailed that inpatient admissions over the last year alone have risen by 10% in under young people under the age of 25. It is likely however, that numerous young people coping with self-harm remain undetected for a number of reasons addressed below, and therefore these statistics are likely to underestimate those affected.

‘Talking Self-Harm’ details that two thirds of teachers, parents and young people who took part in the research feel more uncomfortable talking about self-harm than other issues such as eating disorders, drug use, smoking, bullying and binge drinking. They would additionally be concerned that they would say the wrong thing if a young person who self-harmed turned to them. Whilst young people reportedly feel most comfortable approaching the internet for help regarding self-harm, this may be detrimental as the information available online is variable and can present dismissive attitudes rather than supportive attitudes. 50% of young people included in the research acknowledge that they should in fact be approaching parents and GPs for help instead of the internet, however only 10% said they would feel comfortable doing this.

Regarding groups in a position to offer help to a young person affected by self-harm, parents typically reported that they would perceive self-harm in a young person as failure as a parent, and a third of parents would not seek help with a health care professional.  Almost half of the GPs reported that they did not really understand young people who self-harm, whilst a third were concerned about what language to use when consulting with a young person about self-harm. Teachers reported feeling ‘helpless’ on the issue and the majority expressed that they would like clear practical advice and materials to help young people address self-harm. All groups reportedly have trouble empathising with young people who self-harm.

These points highlight serious weaknesses in the social support network and the professional help that should be available to young people who self-harm and furthermore exposes the need for us all to talk more about this sensitive topic so that we can more readily support those who need it. It is not surprising that nearly 4 out of 5 young people who completed the research said they don’t know where to turn to for advice about self-harm. It is apparent that although most people acknowledge the seriousness of self-harm, too many feel they are not in a position to offer appropriate help and support. The report calls for increased awareness and handling of self-harm in young people if we are to break down the barriers and stigma that currently prevent people from seeking and receiving the help and support they need.

Posted by:
Helen Smith
PhD Student (Division of Psychiatry)
Institute of Mental Health

Resources
The Mental Health Foundation ‘Truth Hurts’ report is freely available at:
http://www.mentalhealth.org.uk/content/assets/PDF/publications/truth_hurts.pdf?view=Standard
The YoungMinds and Cello PLC’s Talking Taboos ‘Talking Self-Harm’ report is freely available at:
http://www.cellogroup.com/pdfs/talking_self_harm.pdf
A BBC interview with a woman coping with self-harm is available at:
http://www.bbc.co.uk/news/health-20039008
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Chloe Hill ~ An internship at the Institute of Mental Health

Chloe Hill ~ An internship at the Institute of Mental Health
I wrote a post for this blog a couple of weeks ago based on ‘Society’s perception of “perfection”’, so as I’m now coming to the end of my Internship here at the Institute of Mental Health I thought I’d write a little bit about my experience here and how influential it has been on my decisions for the future.

When I left Ecclesbourne Sixth Form (Derbyshire) in July, I really didn’t have much of an idea what I wanted to do with my gap year, let alone my whole future career. I thought I wanted to do something related to Psychology and perhaps Criminology, but wasn’t exactly sure what. I wrote to the IMH hoping for a little work experience to give me an insight into the world of psychologists and psychiatrists, so I was extremely pleased when I was invited for an interview and offered an Internship.

Whilst here as an Intern, I’ve had the opportunity to gain an insight into the Institute and its work via attending seminars, workshops, and hearing the stories of some really fascinating people. The experience that has affected me the most has to be a workshop I attended entitled “Understanding Personality Disorder” with the Mental Health Research Network. We were first addressed by a therapist, who explained personality disorders in a way which I particularly found useful having had little previous experience in this field of healthcare. However, it was meeting the service users themselves that influenced my decision to consider Clinical Psychology as my future. Their stories of how their lives had been turned upside down by their personality disorders were quite poignant and moving, but it was the gratitude they expressed for people who actually listened and understood them that influenced me – particularly the benefits and outcomes created with help from these understanding relationships. I have also attended meetings with Learning Disability Paediatricians regarding current studies with autistic children, and the PPI (Patient and Public Involvement) Forum which consists of relevant individuals, including service users, who wish to be involved in the research process.

So what have I learnt from it all? Aside from the fact that I don’t think I’m ready to be getting up at 6 am for a job for the rest of my life yet!, I’ve decided to apply for a Psychology degree at University with the intention of studying a Masters in Development Psychology afterwards, which will hopefully help me on my way to undertaking a Doctorate in Clinical Psychology. For the rest of my gap year I’ve organised a voluntary placement at a local Special Needs School, and work experience in a clinical environment. Ideally, I’d love to be a Clinical Psychologist with children and adolescents, working with them during and after difficult times and events.

So a final thank you and goodbye to the Institute of Mental Health; I don’t know what I’d have done without you! My time here has been truly inspirational.
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Neil Chadborn ~ How might community organising relate to health or social research?

How might community organising relate to health or social research? #nottinghamcitizens
Neil Chadborn, Collaboration for Leadership and Applied Health Research and Care @nchadborn
On 17th October I joined a delegation from School of Sociology Social Policy to attend the first major public meeting of Nottingham Citizens.

170 people, representing 34 organisations, met at Nottingham Trent University to discuss how an alliance of organisations from ‘civil society’ might lobby the candidates for the first elected Police Commissioner, to improve the safety of the city.

We heard from the Rector of St. Nicks Church, Steve Silvester, about how the project has developed in Nottingham over the previous two years. During this time the group has raised £100k of community funds, held 1000 meetings and trained over 120 community leaders. The idea is to build a network of faith communities, schools, unions and charities to act on common concerns for the city.

Nottingham Citizens see the election of the new Police Commissioner as an opportunity to get the voices and concerns of the people of Nottingham heard in a powerful way. Four key concerns of Nottingham residents were described by personal testimonies of horrific incidents in the city. These issues have been researched, for example by mapping and surveying. Based on the personal stories and the research, action plans have been drafted to put to the Police Commissioner as the ‘Asks’ of Nottingham Citizens. Our objective for the evening was to vote on priorities (or veto) these concerns. We decided within our organisations our priorities, and the overall result was as follows:

1)      Safer Young People – following the story from a young girl who had been traumatised by a man approaching her on her way to school. This is a too frequent occurrence across the city and Nottingham Citizens have mapped routes to school and are asking for a greater police presence on these routes.

2)      Sensible Stop and Search – a young black man gave an account of being racially abused and physically assaulted during a police stop and search, being put in a van without being charged and without being read his rights at arrest. Nottingham Citizens are asking the Police Commissioner to ensure that receipts are given for every stop and search (and also stop and account), to ensure greater accountability.

3)      Safer City Centre – we heard an account, read by a friend, of a female student who, because she didn’t have enough money for a bus fare, had difficulty getting home after a night out and was attacked and raped in Forest Recreation Ground. Nottingham Citizens are asking for the police to move their operations centre to within the Rec itself. We are also asking that more support is given to Police Community Support Officers who are now on patrol until 1am.

4)      CitySafe Cabs – an Asian taxi driver told us about an incident when he was held at knifepoint within his taxi and forced to drive around the city, whilst also being racially abused. He managed to escape and fled his taxi (his livelihood) in fear of his life. His family have lived in fear during the investigation and conviction of the man, and continue to live in fear as he has been seen on their home estate after being released from prison. Nottingham Citizens are asking for match-funding to enable installation of CCTV in taxis.

How does Nottingham Citizens relate to the University? Firstly they are asking for our support on a personal level – if you feel strongly about any of these stories, please come with us to an Accountability Assembly with the future Police Commissioners (Mon 12th November, 18:15) where we will ask for action on these issues (email for more details: This email address is being protected from spambots. You need JavaScript enabled to view it.). In future we could raise concerns from within the university community.

From my public health perspective, action on all of the above has benefits for health and wellbeing for the people of the city. Obviously, if the number of violent attacks can be reduced, that can have huge impacts in avoiding the physical injury as well as mental trauma to individuals and families. Furthermore improving city safety can have an important impact on resident’s perception of risks. For people who may have been leaving in fear of these risks (sometimes emphasised by the press) knowing that the city is taking action could alleviate stress and hence benefit mental wellbeing. However actually taking part in Nottingham Citizens could be beneficial; Prof Sir Michael Marmot (and colleagues at University College London) has shown, in a series of studies on stress and health, that having a sense of control in day-to-day life can improve health and wellbeing.

The second question we are considering, is how departments and centres within the University may relate to Nottingham Citizens. Could Sociology, or various research centres including my own (Collaboration for Leadership and Applied Research in Health and Care) offer support or research for particular projects? In turn this could be an effective way for us to disseminate findings from relevant research to a local audience.

Thirdly can we ‘open up’ our departments to the city communities, whether from a student perspective – widening participation, or from engaging the public in our research processes and outputs, seminars for example.

Fourthly can we learn from their approach of ‘community organising’ to inform our engagement processes. Several of our members are engaging with Nottingham Citizens in order to learn more about the approach. We are also considering inviting their organisers to hold training sessions for our research staff. Maybe this could also be useful for students and teaching staff. This is an ongoing debate within our departments and centre – please feel free to join the debate (possibly on twitter: @nchadborn or @clahrc_ndl or @uniofnottingham or search for #nottinghamcitizens).

http://www.citizensuk.org/chapters/nottingham-citizens/
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