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In Brad Pitt’s recent Oscar-nominated film ‘Moneyball’, Jonah Hill plays Peter Brand a young Yale economics graduate who brings a radical approach to scouting baseball players, based on ‘Sabermetrics’ (derived from the acronym ‘SABR’, which stands for the Society for American Baseball Research). Brand’s approach is to almost exclusively use players’ batting statistics to determine performance and selection rather than relying on the team’s scouts and intuition. It worked and in this true story the Oakland A’s went on to win an unprecedented 20 consecutive games in 2002, setting the American League record.

Of course no health organisation would rate its clinical performance on data alone, would it? Actually some might if a) there were the data and b) they told you something about outcome. Avedis Donabedian, the original guru of healthcare quality, in his classic 1966 paper Evaluating the Quality of Medical Care¹ argued that “outcomes, by and large, remain the ultimate validation of the effectiveness and quality of medical care". The trouble has been the lack of available UK data regarding local healthcare outcomes and hence performance, both within organisations (ie for clinicians) and outside (for the public). Internal audit data have traditionally been used by clinicians for monitoring standards but few data have been available systematically to allow the comparative analysis of clinical performance by clinicians or hospitals. However the game-changer came in 2001 following the publication by the independent Dr Foster Intelligence website² of mortality rates for general hospitals. Now, comparing a range of routine outcome data has become commonplace for most disease groups, exemplified par excellence in Muir Gray’s NHS Atlas of Variation³ where differences in practice (outcome), such as amputation rates by area of the country, can be readily compared.

But what about mental health? Curiously most available mental health patient data are focussed on measured activity and processes rather than outcomes. There is no equivalent Dr Foster appraisal for mental health trusts. This might reflect the difficulty in determining what a ‘good’ outcome is (other than suicide being clearly the worst outcome); for example, is a good outcome symptom reduction or good quality of life or a combination? Nevertheless the lack of outcome data in mental health, for those commissioning services if not the clinicians and the public, is surprising given the societal burden of mental disorder, never mind the financial cost especially say in forensic settings (1% of the NHS budget being swallowed up by medium secure psychiatric care).

So what should mental health organisations do? As the business meme goes ‘better information leads to better decisions’ although providing feedback on outcome and hence performance to clinicians has been on the agenda, for example as one of the US Institute of Medicine’s “top six global health challenges”, for over a decade⁴. One healthcare provider, Kaiser Permanente in the US, grabbed the opportunity to feed back clinical data through an elaborate informatics approach for its staff although apparently almost bankrupted itself in the development process. Kaiser clinicians having access to and control of data to monitor their performance is now central to optimising their quality patient care and its supreme organisational efficiency.

All this might improve in Englandtoo with the publication of the newest NHS Outcomes Framework⁵ where a range of agreed indicators will be used to help measure outcomes. However some of this is predicated on the timely availability of accurate data while noting that in mental health settings the most important outcomes might be the least easy to measure. But that is where patients come in to help with a greater emphasis on so-called Patient-Related Outcome Measures (PROMs). Interestingly maybe patients have known ‘what good looks like’ all along. Last month Imperial College published analyses of patients’ ratings of general hospitals from the NHS Choices website since 2008⁶ and sure enough the better-rated hospitals tend to have lower death and re-admission rates and hospitals rated the cleanest have lower MRSA rates.

So, what is a busy clinician to make of it all? Comparisons of services are potentially scary, an “an atmosphere of pressure” according to the government’s transparency tsar Tim Kelsey (and former Dr Foster founder). However most clinicians think they are doing a good job but often lack the resources or the clinical data to prove it but will they welcome the opportunity (‘pressure’) to have their stats poured over as they come out to bat?

Posted by: Dr John Milton Consultant Forensic Psychiatrist & Forensic Research Lead Rampton Hospital Nottinghamshire Healthcare NHS Trust E: This email address is being protected from spambots. You need JavaScript enabled to view it. References ¹ Donabedian A (1966) Evaluating the Quality of Medical Care Available via the Milbank Quarterly (2005) http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2005.00397.x/abstract  ² Dr Foster Intelligence http://drfosterintelligence.co.uk/ ³ NHS Atlas of Variation http://www.rightcare.nhs.uk/index.php/atlas/atlas-of-variation-2011/ ⁴ Institute of Medicine of the National Academies: Crossing the Quality Chasm: A New Health System for the 21st Century http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx ⁵NHS Outcomes Framework 2012-13 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131700 ⁶ Greaves F et al (2012) Associations Between Web-Based Patient Ratings and Objective Measures of Hospital Quality Arch Intern Med 172: 435-436 doi:10.1001/archinternmed.2011.1675

Therapeutic communities recently celebrated 40 years since the birth of the Association of Therapeutic Communities (ATC) with round table discussions held last month at the University of Nottingham.  The focus for the event was ‘Re-birth in a time of austerity,’ specifically reflecting on the past 40 years and discussing what the future may hold for TCs when the ATC is re-launched in a new guise later this year.

The day covered several topics including leadership and charisma, research, management and organisation, publishing, staffing and education.  Yet the big question on everyone’s mind was the future of TCs.  As Nick Manning recently noted in his post, TCs have not made the impact that they perhaps could have done.   With the closure of some TCs, the threat of closure for others and the continual challenges for NHS TCs, the future is looking uncertain at best.

During the celebratory event, the point was made near the end of the day that it is unlikely that TCs will ever truly fade away.  Much like the performing arts and theatre, which continuously face hardships and funding crises, TCs will simply keep forming and reforming.  I tend to agree with this argument, not least because TCs are about people and the quality of relationships.

Therapeutic communities aim to provide a safe environment whereby troubling relational patterns can be explored, often reprising the dynamics found in family relationships (Jones 1976).  By using a variety of therapeutic approaches, an unhelpful social reality can be challenged, reconstructed and ultimately transformed.  TCs employ interpretive techniques from both staff and user community members to help the latter learn a healthier way of relating in their own social world.  Thus social interactions and relationships are at the core of the therapeutic work that occurs within TCs.

Middleton et al (2011) argue that supportive relationships during a therapeutic programme are valued most by service users and are the most influential in terms of recovery.  Qualities such as feeling ‘safe’, ‘understood’ and ‘accepted’ are of paramount importance to people receiving care.  Incidentally, these are also some of the core principles upon which TCs are based (Haigh 1999).

In determining where money should be spent however, funding commissioners are interested in value for money and whether or not a treatment is effective.  Whilst there is research to demonstrate the effectiveness for specific therapeutic approaches such as cognitive behavioural therapy, Pilgrim et al (2009) writes that is the quality of relationships that ‘consistently predicts outcome, independent of the espoused model or condition being treated’ (244).  This is good news for TCs who place such a high value on helping individuals establish a healthier sense of self-identity and social relationships.  Yet it is hard to justify value for money when the relational approach favoured by TCs does not lend itself easily to the operationalised frameworks required by healthcare commissioners and funding bodies (Morant and Manning 2005).  There are no simple solutions to these funding challenges facing TCs.

The future for TCs may look uncertain.   However, the importance of relationships in the human experience will never be diminished.  As individuals and relationships are at the heart of TCs, perhaps, in some form or another, they will never truly fade away.   So the question then remains, what will the next 40 years bring?

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

Jones, M. (1976). Maturation of the Therapeutic Community: an organic approach to
health and mental health. New York: Human Sciences Press.

Morant, N. and Manning, N. (2005). Principles and Practices in Therapeutic
Community Research. Therapeutic Communities, 26(3), 227-243.

Middleton, H., Shaw, R., Collier, R., Purser, A. and Ferguson, B. (2011). The Dodo
Bird Verdict and the Elephant in the Room: a service-user led investigation of
crisis resolution and home treatment. Health Sociology Review, 20(2), 147-156.

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), 235-254.

Institutional (e.g. prison) settings and mental health: Goffman revisited? According to Goffman (1961), upon entrance to total institutions (prisons, asylums, monasteries, army camps, etc.) inmates may begin ‘a series of abasements, degradations, humiliations, and profanations of self’ (p. 24). Inmates’ conception of self ‘is systematically, if often unintentionally, mortified’ (p. 24). The processes of admission to an institution mark ‘a leaving off’ (p. 27) from the ‘conception of himself made possible by certain stable social arrangements in his home world’ (p. 24) and ‘a taking on’ (p. 27) of ‘activity whose symbolic implications are incompatible with his conceptions of self’ (p. 31). However, is consideration and/or utilisation of this — albeit seminal — institutionalisation work of Goffman (1961) apt today? (N.B. You are warmly invited to note your comments below this post).

In relation to the prison milieu, it is argued ‘social integration may play a different role for persons incarcerated in total institutions than among the general population due to unique prison conditions’ (Lindquist 2000:431). For example, Schmid and Jones (1993) found inmates’ ‘prison careers’ (p. 439) to be creative processes ‘through which inmates must invent or learn a repertoire of adaptation tactics’ (p. 439). ‘A person who is incarcerated for the first time becomes a “prisoner” but does not automatically acquire a meaningful status within the prison world’ (p. 439, double quotation marks in original); this suggests individuals move from free society with its (either prescribed or imagined) statuses to the prison setting with its absence of meaningful ascribed statuses. Incarceration experiences are, therefore, somewhat subjective and fashioned by individual prisoners. It is reported the prisoner population shares ‘the experience of being pulled in psychologically different directions’ (p. 443). Notably, assimilation into the penal environment remains salient here — in the 1990s.

To return to the broader application of Goffman’s work, more recently — in 2011 — Mac Suibhne (a Senior Registrar at St Brigid’s Hospital, Ardee, Ireland) concluded: ‘Goffman’s key role was in humanising patients and drawing attention to the patterns of interaction that dehumanised them’ (p. 1). Arguably, this notion of de/humanisation of patients/persons in institutional settings appears somewhat perennial — as a pertinent academic, clinical, political, etc. topic (e.g. http://news.bbc.co.uk/1/hi/health/8101325.stm or the BBC1 Panorama programme Undercover Care: The Abuse Exposed (May 31st, 2011). Thus, perhaps renewed attention to Goffman's mid-twentieth century work is appropriate for health and social care academics, clinicians, etc. today?

Goffman, E. (1961) Asylums: Essays on the social situation of mental patients and other inmates, London: Penguin Books

Lindquist, C. (2000) ‘Social integration and mental wellbeing among jail inmates’, Sociological Forum, vol. 15, no. 3, pp. 431–456.

Mac Suibhne, S. (2011) ‘Erving Goffman’s Asylums 50 years on’, The British Journal of Psychiatry, vol. 198, pp. 1–2.

Schmid, T. and Jones, R. (1993) ‘Ambivalent actions: prison adaptation strategies of first-time, short-term inmates’, Journal of Contemporary Ethnography, vol. 24, no. 4, pp. 439–463.

As a disclaimer, I should probably declare that this is a cross-posting, from the entry I wrote on the Law School's mental health and capacity blog last month; as far as I know, we have little shared readership, however, and I wouldn't want to deprive you here...

Last month, a research team across the Universities of Bristol and Bradford and the Mental Health Foundation released their report into best interests decision-making under the Mental Capacity Act 2005 (MCA).  The MCA allows for (among other things) decisions to be made for an individual when that person is found to lack the capacity to make the decision for herself.  If the individual is found to lack capacity, then a decision can be made on her behalf in her ‘best interests’.  The research team looked at a great deal of aspects around this decision-making process, but I was particularly interested in their findings regarding the first step: determining capacity.

The lack of mental capacity is the cornerstone of the Act; it is the ‘gateway’ step, and without a finding of a lack of capacity, health and social care professionals are not able to intervene.  And yet, given that it has such an important role in the legislation – and a potentially intrusive one in an individual’s life – ‘capacity’ and how to assess it is a surprisingly mercurial concept.  The MCA provides that capacity should be tested through four factors, whether the individual is able to:

-          understand information
-          retain it
-          use and weigh it,
-          and communicate their decision.

This test is primarily one of cognitive function; the quality of the decision reached by the individual should not be of issue, but rather the process by which they get there.  In section 1 of the Act, which outlines the principles underlying the legislation, it is quite clearly declared that 'a person is not to be treated as unable to make a decision merely because he makes an unwise decision’.

On paper, this sounds relatively simple – essentially, try not to be too judgmental about people’s decisions, and observe instead their cognitive functioning ability.  What the report reveals, however, is making the distinction between an unwise decision, and one which results from a lack of capacity, is difficult for health and social care practitioners, and what seems to be happening in many cases is those individuals who have specific disabilities or histories are being assumed to lack capacity, when they make what appears to be an unwise decision.  Another result of this research has been the discovery of what the team call a ‘concertina effect’, where capacity decisions are being made simultaneously with decisions about what action is in the individual’s best interests.  They suggest that often, a decision has already been made about what course of action should be taken, and therefore a finding of a lack of capacity had to be found in order to implement it.

These two findings put together put a rather worrying light on practice around mental capacity issues.  The MCA was supposed to institute a functional test of cognitive ability, rather than a status test whereby an individual with a specific diagnosis is presumed to lack capacity by virtue of that diagnosis, or an ‘outcome’ test, where those decisions which are ‘unwise’ are deemed to be incapacitous; the thrust of this is that we should not question someone’s capacity merely on the basis they have an intellectual or cognitive disability, and are making what we perceive to be a silly decision.  What the findings of the study suggest is that the ‘status’ and ‘outcome’ approaches seem to be alive and well in practitioners practice, and that there is no space for the making of unwise decisions when you have an intellectual or cognitive disability.

All of this should be more concerning when we consider the massive leap which Article 12 of the UN Convention on the Rights of People with Disabilities (CRPD) presents in our thinking about mental capacity.  Article 12 declares that everyone; has the right to enjoyment of legal capacity, and that the State must provide adequate supports to enable that capacity to be exercised.  The MCA itself is a relatively progressive piece of legislation and should be praised, but it has to be questioned what good it is if, regardless of the letter, even the spirit of the law does not appear to be followed in many cases.  If such attitudes still persist, almost five years since the MCA came into force, then what hope does the rather more dramatic ‘paradigm shift’ of the CRPD have for changing fundamentally the way we treat people with different levels of intellectual and cognitive functioning?

I recall back in 2002, a local prominent GP telling me “I’ve worked in NHS for over 25 years and seen 15+ reorganisations and not one of those had any impact on my practice”

Of course they hadn’t   - he hadn’t let it. He hadn’t `owned’ nor engaged in the reforms.  The advent of practice based commissioning (pbc) with devolved GP budgets promised change and GPs began to get interested, but there was frustration because of the differences between their local concerns and commissioning by a PCT delivering  for a wider population.

Advent of CCGs did re-enthuse some local GPs who found themselves as clinical leads, able to directly redesign pathways and negotiate with providers in contracting.  It could also be argued that some degree of `tribalism’ emerged.  GPs feeling that have been regarded for years by consultants as not quite having their status and here was a chance to demonstrate who really had power in the NHS – especially in face of a 45% reduction in commissioning managers. For others, it was an opportunity to make real change for their communities.  Tear down the traditional structures and let a thousand flowers bloom said Mao during the Cultural Revolution (though Conservatives prefer `creative destruction’).  Early indications are that GP engagement is having a positive impact in some areas.

However, it has rapidly become clear that the `Maoist’ promise of the reforms is already beginning to take a decidedly centralist/ managerialist turn. The lack of checks and balances on the role of the NHSNCB (National Commissioning Board) and the promise of increased performance management around nationally set criteria and area wide Health and Wellbeing Board targets brings with it the realisation that CCGs won’t have the envisaged freedoms.  The `thousand flowers’ must all be the same otherwise there would be a `post code lottery’, something the NCB would not countenance. There are also significant concerns over governance within the commissioning structure and how CCGs can quality assure increasing numbers of providers under AQP with less managerial resources. Privatisation of commissioning support does not increase resource and brings with it other concerns. There is already talk in DH on the `optimum size’ of a CCG (and it’s not too far off the size of the early PCTs) so concerns about loss of `local focus’.

There is also realisation that this may be a `divide and rule’ of doctors to bring in the Governments own  `cultural revolution’ around a privatisation agenda. GPs may be being `set up’ to take the blame for this, rationing and other failures in the NHS as it is forced to do more with less resource, and against rising patient expectations – ironically, perhaps, fuelled by the CCGs own community engagement activities. These reforms are happening on `Their Watch’ and GPs are very aware of that.

There is enthusiasm for clinical commissioning –  GPs like it and I personally believe it is the way forward – but these are not the right reforms to facilitate it. They have not been fully thought through.  In some areas I’m sure CCGs will succeed brilliantly and be able to bring some local flavour despite having to with adhere to National and regional commissioning agendas. In other areas they will fail badly and there is little governance provision for failure other than forced merger with another CCG.  The risk is that enough failures would discredit the use of clinicians in commissioning for a decade to come.

Posted by: Ian Shaw

Campling et al. (2004) argue we are all constructions of our environment and of each other, developing our identities, learning patterns of communicating, and our social responses in the context of our social environment. ‘The quality of our physical environment can be health giving or health destroying’ (Howard 2004:69).

Johnson and Haigh (2011) review the Royal College of Psychiatrists’s latest initiative, the Enabling Environments (EE) project. This novel 21^st century approach can be considered a development of the preceding therapeutic environment treatment methodology and the therapeutic community movement; the principles of EE represent an adaption of these values and standards in reference to contemporary society and the current nature of mental health (Johnson and Haigh, 2011). The EE system intentionally identifies features in any given setting that foster a sense of connected belonging for the involved social actors ‘and suggests a process by which these principles can then be customised for specific settings’ (Johnson and Haigh 2011:17).

Two new concepts from the EE initiative are noteworthy here: the psychologically informed environment (PIE) and the psychologically informed planned environment (PIPE). To summarise, both of these approaches strive for greater psychological awareness of a setting, humane and enlightened treatment, enhanced wellbeing for all involved, plus reflective practice and shared action learning in the staff team (Johnson and Haigh, 2011). The PIPE scheme is designed for high security or high risk settings (e.g. Her Majesty’s Prison Service).

It is argued, by Johnson and Haigh (2011), that the EE initiative signals a new approach to social psychiatry and has implications for both public mental health and social policy in the UK: ‘the enabling environment approach is as broad as it is ambitious’ (p. 22).

To relate these debates to my own area of interest (i.e. prison mental health): Johnson and Haigh (2011) detail nine core elements to the provision of EE; four of these are important in relation to the prison setting: ‘a positively enabling environment would be one in which the nature and the quality of relationships between participants or members would be recognised and highly valued ... where engagement and purposeful activity is encouraged ... where power or authority is clearly accountable and open to discussion ... where behaviour, even when potentially disruptive, is seen as meaningful, as a communication to be understood’ (pp. 19–20, ellipses denote removed sections).

These four ideals are poignant as a) the importance of quality relationships between those with differing social roles in the prison setting is not always considered critically, b) the quantity of worthwhile activities provided for prisoners is (in some prisons) arguably diminutive, c) the power relations in a prison (e.g. between wing staff and prisoners) are not often debateable, and d) disruptive behaviour often results in sanctions in the prison environment and perhaps insufficient attention is devoted to understanding underlying causes of socially deviant actions in the setting.

The EE vocabulary of shared values is the basis for the practical application of the approach; this is problematic in the prison setting, as the underlying goals of the NHS and HMPS are somewhat dissimilar (e.g. care versus containment). Thus, to conclude, the EE initiative serves to highlight the worthy prisoner versus patient issue in prison establishments.

Click here to see Nick Manning's post.

References:

Campling, P., Davies, S., and Farquharson, G. (2004) (Eds) From toxic institutions to therapeutic environments: residential settings in mental health services, London: Gaskell.

Johnson, R. and Haigh, R. (2011) ‘Social psychiatry and social policy for the 21^st century: new concepts for new need – the Enabling Environments initiative’, Mental Health and Social Inclusion, vol. 15, no. 1, pp. 17–23.

Howard, T. (2004) ‘The physical environment and use of space’, in P. Campling, S. Davies, and G. Farquharson (2004) (Eds) From toxic institutions to therapeutic environments: residential settings in mental health services, London: Gaskell, pp. 69–78.

As part of my role as the Institute's arts co-ordinator I have taken on the weighty task of commissioning an artwork to mark the opening of our new headquarters in May 2012. How do you represent mental health in a sculpture? This will be the task of an artist who will work with mental health service users, a local artist, and healthcare students over the summer. This series of blog posts will chart the sculpture's progress, from the background to the project, through its design, and finally its installation right outside the entrance to our new building. Not to forget the grand unveiling in November! You'll be getting updates from me and also mental health servicer users, students and the sculptor. Oh, and there'll be lots of pictures of course!

Art in the Institute: With the generous support of Nick Manning and Gerry Carton, since 2009 the Institute has been hosting successful art exhibitions in partnership with City Arts (http://www.city-arts.org.uk/). The exhibitions have added colour and interest to the Institute offices and more importantly have created opportunities for staff, students and people with mental health difficulties to display and sell their artwork. The exhibitions have proved popular with staff and visitors (see PDF: review_identity) even though some of the work included is challenging, see Vince Law's 'This is what you did to my head 2' part of current 'diversity exhibition'.


Many an interesting conversation has been overheard in the corridors about the work on display.

I am a strong advocate for the therapeutic usefulness of art for people who experience mental distress and the exhibitions help to promote social inclusion by giving people who may feel marginalised the opportunity to display their work. We have an opening for each exhibition to which we invite artists and staff.


We offer awards, here are Nick (IMH Director) and I giving an award to  artist Anthony Gariff in front of his work. 


A guest judge helps me with this task, for the current 'diversity' exhibition it was the talented artist and doctor Ian Williams (http://graphicmedicine.org/).

Exhibiting has a positive impact on artists taking part see for example http://jennamichellepinkartist.tumblr.com/post/12563841079/city-arts-exhibition. 

For me, one particularly memorable encounter was with an artist who approached me at an exhibition opening. She has obsessive compulsive disorder and anxiety and has a long history of involvement with mental health services. She was accompanied by a carer and she held out her trembling hand towards me. Fighting back tears she thanked me, telling me how much it meant to her to have the opportunity to show her art on the Institute's walls and for staff to be able to view her work.

It seemed natural to plan a special artwork to mark the opening of our impressive new headquarters. The hardest part thus far has been fundraising, not straightforward in these tough economic times. Yet, ably assisted by Tim Harris, an arts and culture consultant www.timharrisconsultancy.co.uk. I have raised an impressive £32 K for the project. An advert (see PDF: IMH sculpture advert copy) to find the right sculptor was sent out at the beginning of February. Since then we have responded to requests for further information from almost 200 artists from far and wide, even from the USA! Thanks to Tim and Phil Wain for helping with this. A small group including university and Institute staff, a curator, an artist, a service user, and a medical student will gather soon to shortlist 3 artists. They will create maquettes (models) to go on display online and in the Inst offices for you to comment on and choose your favourite. I will be visiting Rampton hospital soon to consult with patients there about the project, giving them a chance to have some input into the sculpture design. What do you think the sculpture should look like? Let me know. More soon. Victoria.

It started going wrong at the LibDem spring conference last year. There was criticism of the Health reforms and Nick Clegg had to back track. In interview Shirley Williams said that neither Clegg nor Cameron (neither renowned for their work ethic) had read the Health Bill before signing it – they had relied on a verbal briefing by Lansley. The Royal colleges and the Unions were beginning to mount a resistance and the famous pause listen and reflect took place.

The Health Select Committee said that the Govt. had `lost control of the policy agenda’.

In April Cameron decided that Lansley needed time to get the professionals `on board’ and policymaking was `outsourced’ to the Future Forum.  Lansley was effectively told to agree to whatever the Future forum came up with. This needed a climb down by Cameron and saw him lose some face, but he expected that it would be worth it when he could deliver the reforms.

This, in part, explains Cameron’s anger this year when he found that, not only had the pause not got the professional `on board’ with the reforms but that there was now significantly more bodies opposed to the reforms than there were before! It was this that led a No.10 spokesperson to say that the Health Secretary `should be taken out and shot’.

The NHS has never been out of the front pages since and Government is having to make policy in the full glare of the public spotlight. Usually a policy issue will burn in the public gaze for a week or month and then get relegated to the political sections of the newspapers and the public slowly forgets . These reforms have been in the front pages for at least a year.  It’s etched in their memory and it will still be in their memory at the next election. Cameron and Lansley has made the NHS toxic for the Conservatives yet again. Now everything that happens in the NHS will be blamed on the reforms and if the Govt try to spend their way out by injecting large amounts of cash into the NHS to make the reforms work – critics will point to how expensive they have been.

Lansley must have felt pleased when he decreed that 45% of Commissioner Management costs would have to be cut, demonstrating his zeal in cutting back bureaucracy. However, with more and more concessions and changes having to be made to the Bill and more risks apparent it seems that the reforms are likely to create more bureaucracy not less. As I write the National Commissioning Board announced that they will be organised into 3 layers – National, Regional and Local (read DH, SHA and PCT) and you can add to that the CCGs as well as the Health and Wellbeing Boards, etc.

Whether this reform is passed or not, Lansley will be reliant on NHS managers and professionals to try and sort out the mess and make the system work.

Posted by Prof. Ian Shaw
University of Nottingham, Professor of Health Policy

What is meant by patient and public involvement in mental health research?  I recently found out that organised activists had successfully recruited women with breast cancer to a key study, overcoming the barriers that researchers alone had faced.  I know that campaigns are sometimes successful in obtaining access to drugs through NICE.  But ‘mental health’ is a label attached to an enormously diverse group of people.  There are two issues that trouble me.

Firstly, I’ve always been perplexed that people with mental health problems are lumped together as one interest group.  It is often led by people with bipolar disorder, whose experience is to say the least different from that of people with chronic depression, while the stigma attaching to a diagnosis like for instance schizophrenia is of a different order.  Within these diagnostic groups, people differ in important ways: ethnicity, age, education, income and gender, all of which have implications for the impact of a mental illness.  Most mental health PPI privileges the voice of the educated, middle-aged, White population. As long as PPI is left to the researchers and other established groups, this bias is likely to be perpetuated.  In times of hardship the most vulnerable are at the cutting edge - shouldn’t we be prioritising the perspective of the most disadvantaged sectors?  

Secondly, I see patients ultimately as the consumers of research.  The analogy that I find most apt is that of a customer ‘building’ a house in which to live.  The customers know how it should look and feel, they know what they want it to represent for them. They choose a number of features, like the size of the rooms, the location of the front door, the type of roofing material.  But they employ professional, architects, planners, builders, electricians and plumbers to build the house.  Since I’ve spent decades trying to improve my own research skills,  I can’t help but see the lead researchers, interviewers, methodologists, statisticians, health economists and administrators as the professionals in the research enterprise.  It is not safe or efficient for most service users to take their places.

Patients should commission research as they would engage with the architect to build a house and control how the budget is spent, but they don’t need to ‘get involved’ in the technicalities.  Giving more power to patients means giving them the research commissioning budget.  The pressure on researchers from funders to devote more and more of our limited research resources to ‘involving’ service users is a distraction from the fundamental fact that meaningful patient involvement would mean giving service users greater control of how the money is spent – and that would mean the DH yielding some of its power to patients. 

Posted by:
Professor Justine Schneider
Professor of Mental Health and Social Care
University of Nottingham

Welcome to the launch of the Institute of Mental Health (IMH) Blog!  This blog is affiliated with the Institute of Mental Health (University of Nottingham and Nottinghamshire Healthcare NHS Trust).

Our aim is to capture the variety of interest and expertise that is reflected in the Institute’s diverse membership body by bringing together a range of different disciplines and interests groups collaborating to discuss pertinent issues within mental health.  The blog seeks to incorporate the four aims of the IMH by promoting current research, inviting discussions regarding innovative practice, providing a forum of information and education, and encouraging feedback and discussion on best practice.  Posts are written by a wide variety of those interested in mental health, including mental health professionals, academics, clinicians, service users, carers, researchers, students, etc.

To get the blog started, we are pleased to launch with six posts from within the Institute:

• Professor Nick Manning, Director, Institute of Mental Health: “plus ça change, plus c’est la même chose” 
• Dr Hugh Middleton, Clinical Associate Professor and Honorary Consultant Psychiatrist: “Illnesses like any other”. The challenge of a multi-disciplinary approach to mental health 
• Dr John Milton, Consultant Forensic Psychiatrist & Forensic Research Lead (Rampton Hospital): ‘Doing the right thing’ 
• Professor Eddie Kane, Director, Centre for Health & Justice, IMH, and Melanie Jordan, Centre for Health & Justice: The IMH’s new Centre for Health & Justice — its raison d’être 
• Professor Ruth McDonald, Chair in Health Innovation and Learning: 'The Apple Diet - it may be good for your health, but don't swallow it whole'
• Professor Justine Schneider, Professor of Mental Health and Social Care: What is Meant by Patient and Public Involvement in Mental Health Research?

We encourage you to respond to a post or leave us comment, and hope that you will join the discussions.  In addition, we welcome posts on any mental health related topic of your choice, including responses to previous posts, news and events/publications you would like to promote.  For further information please email a member of the IMH Blog Team.

All posts and comments are moderated prior to being published on the blog to ensure that entries adhere to IMH and University of Nottingham guidelines.  Whilst you do not need to have a WordPress account to leave a comment, please note that all comments must be relevant to the IMH blog and be accompanied by a valid email address (which will not be published.)

We look forward to hearing from you!

All the best,

The IMH Blog Team
Jenelle Clarke, ESRC PhD Student (Sociology) (This email address is being protected from spambots. You need JavaScript enabled to view it.)
Melanie Jordan, NIHR CLAHRC-NDL (This email address is being protected from spambots. You need JavaScript enabled to view it.)
Amanda Keeling, ESRC PhD Student (Law) (This email address is being protected from spambots. You need JavaScript enabled to view it.)

(For reference, please see Dr Hugh Middleton's post, “Illnesses like any other”. The challenge of a multi-disciplinary approach to mental health.)

Hugh Middleton raises some admirable and poignant questions here, particularly in relation to the responses of young doctors regarding mental health as a strand of their medical training. I find the ‘Marmite-like properties’ of psychiatry (as a discipline to teach) to be a marvellous simile. Consequently, I am left pondering if this characteristic of mental illness is relevant also for the general population (e.g. the other readers of Hugh’s Jan., 2012 Observer edition). My own area of interest is prison mental health and the volatility alongside importance of political and public opinion is remarkably salient. Thus, I wonder if mental illness is a topic — for the public — that either commands attention, devotion, and concern or perhaps at other times a certain amount of distrust, inattention, and insensitivity; to précis (albeit oversimplified), a love versus hate relationship. Although, clearly, this rumination renders the public a unified social group with an absence of dissident opinions; whereas, this is of course not the case. To continue, as a (medical sociology) researcher, and not a clinician/psychiatrist, I find it a captivating and engaging pleasure to ‘revel in the mess’ that is the quagmire of mental health and illness policy, practice, research, and development. However, the aforementioned position of some doctors (as highlighted by Hugh) is understandable, as they are required to accept responsibility for these patients and their mental health; whereas, a researcher’s accountabilities in legal- and health-based terms are, relatively, diminutive. Thus, perhaps is it easier for academics to embrace Hugh’s notion of swimming in the ‘messy swamp’ that is psychiatry and its related endeavours. Notwithstanding this call to support yet recognise mental health research as a convoluted pursuit — remembering the ‘uncertainties of diagnosis, the absence of confirmatory laboratory findings and conflicting theoretical frameworks’ — there is perhaps (regrettably) also scope to consider how such studies align with the current age of austerity and the requirements for research to produce overt outcomes and demonstrable impacts. Nevertheless, if we accept ‘mental illness as an impending tsunami of disability’, continued research and development in the field of mental health is most certainly a requirement; moreover, neglect would, arguably, display myopic tendencies. After all (as noted by Hugh), ‘happiness, despair and confusion are everyone’s business’ and not just the concern of the portion of our population (approx. half, I’m told, but surely not?!?) who love to spread Marmite on their toast.

Posted by: Melanie Jordan NIHR CLAHRC-NDL Nottinghamshire Healthcare NHS Trust & University of Nottingham Institute for Mental Health E: This email address is being protected from spambots. You need JavaScript enabled to view it.

(For reference, please see Prof. Nick Manning's post,  “plus ça change, plus c’est la même chose”.)

Nick Manning’s post regarding the ‘routinisation of charisma’ within therapeutic communities is a timely reflection as the ATC prepares to celebrate 40 years next week.   With a scheduled round table discussion about the history of TCs, the issues he raises here will most likely be in the forefront of everyone’s mind.

Therapeutic communities have certainly gone through many transformations over the years.  Their popularity depends on who you ask; even more so for their relevance as a therapeutic intervention (current or historical!).   Some people will even express surprise when they hear that my doctoral study is exploring social processes within TCs – they thought TCs had long since faded away.

With a patchy research history (though better in recent years) and a habit of opposing dominant therapeutic interventions, Nick rightly says that TCs are today a ‘minor strategy in those areas where they are not a threat’.  As a social movement, TCs have struggled to maintain their edge and pushing ‘through a ‘paradigm shift’ in the field’ has yet to occur.

Understanding the rise and fall of social movements is certainly pertinent.  As an American, I need only look to across the pond for a recent example of charisma that has failed to change the world as so many of us (naively?) hoped.  Though instead of 40 years, it took less than 4 for the ‘revolutionary zeal’  of Obama’s ‘Yes We Can!’ to morph into several reasons why ‘No We Can’t’.  But perhaps even more important to understanding why things like this happen, is asking what happens next?

The question facing TCs as it celebrates 40 years of the ATC is crucial.  Ultimately as we reflect, we will all be wondering the same thing: what will the next 40 years bring?  Will TCs continue to be on the ‘fringe’ within mental health, or is there a viable alternative? Are we doomed to repeat endless cycles of ‘charisma and routinisation’, or can we produce something that genuinely stands the test of time?

Only time will truly tell.  But just as President Obama will be getting my vote again this November, I certainly hope that TCs will contribute significant research and ideas about therapeutic practice to the field over many years to come.   

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

Last November the Institute of Mental Health celebrated its 5th birthday. A month earlier the death of Steve Jobs, the man who took Apple from a small start-up enterprise to the world’s most valuable company dominated media headlines and popular attention. Jobs wasn’t universally popular (an interviewee quoted in Adam Lashinsky’s recent book ‘Inside Apple’ suggests googling ‘Steve Jobs’ and ‘asshole’ will produce a lot of hits and he’s not kidding!). And the secrets of Apple’s success are... well secrets. Jobs was notoriously secretive about the inside workings of Apple. Harvard Business School’s Davds Yoffie had open access to Apple for 6 months in the early 1990s before Jobs returned to head the company he’d founded. The resulting Apple case study, used as part of numerous MBA and Exec Ed programmes has been rewritten 5 times since its 1992 incarnation. But these rewrites contain no new information about what happens inside Apple, as Jobs denied Yoffie access, when he was back at the helm.

We do know a lot about Apple from outsiders and past employees, as well as from what Jobs himself said publicly. Importantly, Jobs was keen to retain the energy and flexibility of a small start-up company, despite Apple’s growth and was highly critical of anything that smacked of ‘bureaucracy’ (apparently ‘committee’ was a dirty word at Apple).

So what does all of this have to do with the IMH? Well, the Institute has gone from a small ‘start up’ to a multi million pound enterprise in a few years. The challenge of retaining the energy and enthusiasm associated with small ventures is an ever present one. For all its negative connotations ‘bureaucracy’ isn’t entirely a bad thing, as Max Weber pointed out (if you need some convincing, Paul du Gay’s in Praise of Bureaucracy is a great place to start). Yet although, transparent structures and processes, which are independent of individuals (however charismatic) may be desirable, as Robert K. Merton observed many years ago, an emphasis on conformity and adherence to rules, can result in rules becoming an end in themselves. The task for the IMH is to maintain structures and processes which ensure good stewardship of resources and systematic approaches to doing business (even though, at times, these may constrain individuals), whilst at the same time guarding against conformity as an end in itself. The sort of ‘goal displacement’ Merton identified would threaten spontaneity and (calculated) risk taking which appear to be key factors contributing to the success of IMH to date.

As an ex-NHS bureaucrat and an idiosyncratic social science academic, half of my brain can see the advantages of bureaucracy, but the other half would rather I was left alone to do as I like!  Before I suggest that IMH ‘stay hungry, stay foolish’ – Jobs’ mantra gleaned from the Whole Earth Catalogue, reflecting, amongst other things, his dislike and distrust of management ‘wisdom’ from Business Schools and the MBAs they peddle- I should probably acknowledge that Tim Cook, the man chosen by the Board as Jobs’ successor at Apple has an MBA and appears to be feel right at home with spreadsheets, rules and policies. I’d be the last person to suggest that IMH uncritically adopt ‘wisdom’ from Business School academics, but maybe the emphasis for the future should be on staying hungry. In a world where research is adding to knowledge every day, perhaps we should leave the staying foolish to others!   

Posted by:
Professor Ruth McDonald
Chair in Health Innovation and Learning
Business School
University of Nottingham

The intentions of this blog post are threefold: 1.) To introduce the IMH’s new Centre for Health & Justice; 2.) To overview the Centre for Health & Justice’s creation and its objectives; 3.) To seek bloggers’ development suggestions in relation to the Centre for Health & Justice’s goals.

In preceding years, the question of how best to deliver healthcare in both the justice environment and in secure healthcare settings (alongside considering the balance of investment between these two sectors) has been a topic of policy and service delivery debate. The new Centre for Health & Justice at the IMH aims to research and examine these issues further.

The Centre for Health & Justice intends to review how healthcare is fashioned (i.e. commissioned, provided, managed, and practised) across aspects of the UK’s Criminal Justice System. Recently, there have been a number of policy initiatives that have redrawn boundaries and moved budgetary and service responsibilities between and within health and justice agencies — aiming to improve the outcomes for people who are detained at various levels of secure provision across both systems. Significant financial investments have been made as a result of these policy alterations; the Dangerous and Severe Personality Disorder programme is one notable example. Significant further change regarding health and justice in this country is afoot; the Centre for Health & Justice’s research output intends to impact these amendments.

Whilst there is evidence that some of these past and new initiatives have or could improve delivery (both directly and indirectly) this evidence is drawn from disparate strands of research rather than a coherent, planned, and multi-disciplinary programme. The dimensions of ethics, law, education, criminology, social policy, environmental design and security, organisational design, and economics (as important examples) feature little in the currently published material. These dimensions, as well as clinically focussed and practically designed research, should provide the fundamental evidence base on which the new generation of health and justice services are built. Where these disciplines are part of the debate it is usually in a compartmentalised way and the different literatures and perspectives rarely cross-fertilise each other to form a base for new service initiatives, rounded evaluations, or policy evolution. However, these disciplines, literatures, and perspectives often represent stand-alone, well-developed bodies of knowledge that could — if brought together — form a powerful multi-layered framework to help shape and evaluate policy and service development. Such an integrative approach would better reflect the reality of the complex delivery and policy frameworks that form the often confused experience of those who are detained in the systems — and to a great extent the staff who work in them. The Centre for Health & Justice embraces intentionally a broad range of academic, practical, and clinical approaches and disciplines.

The development of the Centre for Health & Justice represents a natural response to the current trend towards the development of a more integrated policy and delivery approach to offender health. The Centre for Health & Justice brings together a multi-disciplinary, national, and international R&D and teaching capacity focussed on improving both the understanding and provision of health interventions for offenders, particularly those who experience mental illness/es.

Posted by: Prof. Eddie Kane, Director, Centre for Health & Justice, IMH Melanie Jordan, Centre for Health & Justice, IMH

We all like people to do what we want. There are ways to achieve this, usually involving metaphorical sticks or carrots. Government is starting to think about nudging the science around choice (if there is such a thing). However what we are usually talking about in healthcare is ‘compliance’, usually defined as a willingness to follow a course of treatment but in effect meaning whether patients take the medicine prescribed by physicians. In the good old days, doctors prescribed the right pills and model patients took them. Then it emerged that actually as patients we only ever take our medicine correctly about half the time. Even worse, we now know that about only half the clinicians prescribe the right drugs. So an intervention with a capacity to reduce symptoms say by 60% only achieves about 15%.

Previously the only focus was on how to improve patients’ compliance with treatment. This is crucial in some areas of mental health, like psychotic illness, where insight can be sufficiently impaired that compliance with treatment is reduced. However the flip-side is to focus on ensuring clinician, not patient, compliance. This isn’t always easy. Take hand-washing, a known ‘intervention’ to reduce infection and iatrogenic complications within hospital. Despite being a low-cost preventative strategy, accessible to all clinicians, getting successful clinician compliance has been problematic. Notwithstanding high-profile campaigns, clinicians will over-estimate their compliance with hand-washing when covertly observed. This has led to novel strategies to improve hand-washing such as publically shaming under-compliant clinicians, the use of ward computer screensavers depicting bacterial Petri dish growth or best of all getting patients to ask their clinician personally if they have washed their hands.

Healthcare organisations are wrestling with areas of clinician ‘compliance’ in other ways. Take two examples. First, there is a debate is about finding the balance between algorithmic approaches to treatment, usually based on evidence, such as Maps of Medicine or NICE guidelines, with the specific clinical approach required for a particular patient with their specific presentation. This is a challenge in some areas of mental health where evidence about interventions can be scanty or the outcome data are insufficiently rich to evaluate. Most of us can usually make a case for exempting (not complying with) some part of a patient’s treatment from a standard algorithm or pathway, based on our wider experience, although with limited subsequent performance data to determine whether it is a good decision. This needs to change.

Second, clinicians are suffering from policy and procedure compliance overload. A recent BMJ article, whose author is a (ahem) Human Factors Consultant, noted how the clinical management of an elderly patient admitted with a broken hip would include 75 clinical and trust guidelines and policies. Think about how many emails clinicians might get a week helpfully updating them on changes to policy and procedures. Sending the emails doesn’t ensure compliance. If we want clinicians to do the right thing so that patients can have the right thing, simplifying the system (rather than shaming) might help.

Posted by: Dr John Milton Consultant Forensic Psychiatrist & Forensic Research Lead Rampton Hospital Nottinghamshire Healthcare NHS Trust E: This email address is being protected from spambots. You need JavaScript enabled to view it.

This week’s Observer (29/1/12) carries at least three articles concerning mental health issues. One refers to the growth of brain cells from stem cells, themselves derived from skin samples of people with schizophrenia and bipolar depression with an eye to testing new drug treatments for these conditions. Another discusses political debate over definitions of happiness as ideological differences play out around these distinctions. Emphasising how compelling the media find the study of happiness, the Observer also treated me to a free copy of Tal ben-Shar’s 192 page book on the subject. The third was an outline of statistics and expressions of concern about suicide amongst children in penal custody.

Years experience of teaching psychiatry to medical students have made its Marmite-like properties clear … they either love it or they hate it, and year on year more fall into the latter category. Despite figures which present mental illness as an impending tsunami of disability; one in four of the population will suffer, single most common reason for sickness-related benefits, predicted greatest cause of disability world-wide by 2030, huge numbers of American adolescents taking psychiatric medication, more than forty two million NHS prescriptions for antidepressants in 2010/11, and rising, few want to do it. Despite initiative after initiative, psychiatry remains close to the bottom amongst medical students’ and newly qualified doctors’ career choices.

Those that don’t like it find it messy. One recent survey from New South Walesreported that students find psychiatry “low prestige”, that its treatments are ineffective and that it lacks scientific foundation¹. Those that do like it also find it messy, but revel in the mess. A parallel Canadian survey reported that students interested in psychiatry had an educational background in the arts and a strong social orientation². The uncertainties of diagnosis, the absence of confirmatory laboratory findings and conflicting theoretical frameworks which range from the neurobiological through cognitive behavioural to psychoanalytic and the socially constructed make psychiatry feel like a messy swamp. Not a comfortable place for the aspiring doctor wanting to practice the appliance of science.    

Swamps are only a problem if you want to farm, to build a house or to drive a road across them. If you are a botanist, a bird watcher or an entomologist they are a delight, which brings us back to the Observer. It reminds us that for the wider world, mental health and illness are not just the narrow concern of specialists. Happiness, despair and confusion are everyone’s business and most people’s experience at one time or another. Attempting to shoe-horn the vagaries of human experience into the conceptually narrow confines of “illness” isn’t working and won’t prove sufficient. Of course there may yet be therapeutic gains to win from neuroscience but the same is also true for other disciplines that contribute to the study of human difficulties and how we respond to them; law, nursing, philosophy, politics, psychology, social sciences and more. If those in the field are to match wider expectations of their teaching, their practice and their research, then we have to rise to the challenge, and acknowledge that what are about is indeed a truly pluralistic enterprise.

Unfortunately one person’s pluralism can be another person’s tribal conflict. Mental health services and mental health research remain firmly hierarchic, with the medically qualified psychiatrist at the top of the tree, and with that comes a whole herd of “elephants in the room”. Certainly the most able should lead, but is that synonymous with a medical qualification? Even if it is, is the pluralism necessary to do the task justice achieved by the training currently undertaken by the medical psychiatrist? Perhaps what is most striking amongst medical students encountering psychiatry for the first time is their struggle with the credibility of “these are just illnesses like any other”. However else they might be described, on the whole medical students are bright young people. Is the honest insight of the young trying to say something we find difficult to hear?

Hugh Middleton, January 29^th 2012.

1.Mahli, G.S., Coulston, C.M., Parker, G.B., Cashman, E., Walter, G., Lampe, L.A.and Vollmer-Conna, U. (2011). Who picks psychiatry? Perceptions, preferences and personality of medical students. Australian and New Zealand Journal of Psychiatry. 45 861 – 870. 2. Gowans, M.C., Glazier, L., Wright, B.J., Brenneis, F.R. and Scott, I.M. (2009). Choosing a career in psychiatry: Factors associated with a career interest in psychiatry amongst Canadian medical students on entry to medical school. Canadian Journal of Psychiatry 54 557 – 564.

Posted by: Dr. Hugh Middleton, Clinical Associate Professor, University of Nottingham School of Sociology and Social Policy. Honorary Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust.

 (An epigram by Jean-Baptiste Alphonse Karr in the January 1849 issue of his journal Les Guêpes (“The Wasps”).

2012 is 40 years since I first became involved with research in the mental health field as a graduate social science student visiting Henderson Hospital in Surrey as a potential fieldwork site for a study of ‘therapeutic communities’. It is also 40 years since the association of therapeutic communities (ATC) was set up on the initiative of Dr Stuart Whiteley, Medical Director at Henderson. My research question was whether TCs could be better understood as a scientific invention, applying social science as a medical intervention, or as a social movement for change, seeking to influence the balance of power in the mental health field.

That was a period of flux in mental health research. A social understanding of mental health issues was taken seriously by the powerhouse of research and influence in the field – the Institute of Psychiatry. Professors Wing and Brown were looking at social processes in the mental hospital and in the community, with solid research methods and results. But these studies were focussed on the negative effects of the social environment within which patients found themselves. The TC by contrast was promoting the use of social effects as a positive intervention in the pursuit of therapeutic change: characterised by anthropologist Robert Rapoport as the use of ‘democracy, communalism, reality confrontation and permissiveness’.

Such a culture was at odds with a model of specific medical or psychological interventions, not easily reducible to discrete technical processes. Indeed those who used this approach threatened the conventional distribution of power – patients themselves were conceptualised as part of the potential therapeutic armoury, and the personal qualities of staff, especially younger staff with lesser qualifications, were elevated to at least equal if not greater significance than conventionally trained medical and psychological staff. Not surprisingly this approach has never been well tolerated by the dominant players in the mental health field.

TCs have continued to survive as a minor strategy in those areas where they are not a threat – for personality disorder, a condition which has been shunned by a majority of psychiatrists as untreatable; in prisons, and secure facilities, where they have been tolerated as useful in the support of security (relational security); for group psychotherapy, one of a range of non-medical and ‘fringe’ interventions in the field. They have been branded by commentators from the evidence based medicine position as an ‘evidence free zone’ because they have not been seen to produce the right kind of randomised controlled trials (actually they have, but that is another story about the politicisation of evidence).

It is ironic to observe a new effort to harness a social technology, entering the field 40 years later with very similar reactions. ‘Recovery’ has a set of values very similar to the original therapeutic community, and seeks to develop positive social interventions celebrating the mutual support that patients can give to each other, and downgrading the utility and even the focus of conventional medical and psychological interventions. The reactions in the field have been remarkably familiar – those under threat have objected that this raises the spectre of poorly managed risk, and of patients posing a threat in the community.  Others (in the Institute of Psychiatry) are trying to reduce it to a conventional medical or psychological intervention, proposing to run randomised controlled trials of factors such as ‘hope’. 

36 years ago I published an early paper that forecast the fate of the TC, using two sociological sub-fields focussed on social movements, and on scientific innovation: as a social movement it would follow a pattern identified by Max Weber 50 years before as the ‘routinisation of charisma’ – the slow loss of revolutionary zeal, and the institutionalisation of technique over social values; as a scientific innovation it would be rejected unless it could assemble impeccable evidence of its effectiveness, and force through a ‘paradigm shift’ in the field.  This has proved quite accurate. As a sociologist, I would expect recovery to suffer the same fate as the TC: it will lose its impetus for social change, and become routinised, and/or it will fail to lock down a paradigm shift in the mental heath field.  If I live to be a hundred, I shall just have another 36 years to find out.

Posted by: Professor Nick Manning Director, Institute of Mental Health University of Nottingham NottsHC NHS Trust