The Institute of Mental Health

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!
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Dr Rex Haigh
http://greenshrink.blogspot.co.uk/
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The Institute of Mental Health

Dr Rex Haigh ~ Has CBT killed the human spirit?

The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we're up against, originally posted on 17 June 2012 entitled 'Has CBT killed the human spirit?'.
Much as psychoanalysis set the cultural tone for our understanding and conduct of relationships for most of the twentieth century, cognitive behavioural therapy (CBT) has been leading us into a much less forgiving place for the last twenty years or so.

[caption id="attachment_404" align="aligncenter" width="300"] CBT Circle


In the world of psychotherapy, CBT has numerous siblings and cousins: most with three letter abbreviations to make a multiflavoured soup of ‘alphabetti spaghetti therapies’. Two flavours of the month are Dialectical Behaviour Therapy (DBT)  and Menatlisation Based Therapy (MBT). DBT, with its trendy 'mindfulness' plus new age and hippy edge, give its authoritarianism a warm fuzzy feeling; mentalisation has considerable weight of respectability afforded to it by years of attachment research in the experimental psychology departments of prominent universities – and charismatic professors with superstar status to market it. There are many other manualised and packaged 'new therapies', easily findable with your favourite search engine. But my overwhelming feeling is that they are all missing the point, and engaged in a pointless horse race with celebrity status prizes for the academics who reduce the interventions to dumbed-down therapy cookbooks, and then make sure everybody is following the recipes with multivariate statistical analyses backed up by powerful regulators like NICE. To me, this all seems like a very elaborate, somewhat sinister and ruthlessly inexorable way of taking the essential human qualities of the therapeutic relationship out of the picture.

[caption id="attachment_405" align="aligncenter" width="300"] Mandala



It feels like these ways of working are all fashions of the moment – holding onto the coat tails of …of what? That is the big puzzle. All sorts of vaguely pejorative words and phrases get bandied about by malcontents like myself – without understanding the precise definitions – such as reductionism, materialism, biogenic dogmatism, logical positivism, determinism, behaviourism, scientism, alienating modernity, market managerialism. The best one I’ve seen lately is instrumental rationality: "A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end".

At its root, at least from where I stand at the moment, seems to be the need for certainty – and the fear of chaos that would ensue were we not able to measure, predict and control everything in our working lives. It is interesting indeed that complexity – what we have to deal with on multiple levels in our work every day – is only a step away from chaos, and indeed ‘creative chaos’ is an important ingredient of therapeutic communities, and perhaps all group therapies. Along with ‘therapeutic ordinariness’ and Keats’ Negative Capability (being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason) we seem to be in the world of the romantic poets, postmodernists, and idealists – dealing with moral philosophy, semiotics and aesthetics. Truth and love and beauty, maybe, rather than rigour and technique and effectiveness.

I would maintain anywhere that we need all of both sets of values in the world of the complex and often chaotic systems that determine human development, and we confront daily in psychotherapeutic work. We need multivariate regressions, p-values and confidence intervals for instrumental reasons – but they should be our tools rather than our purpose. Perhaps complexity and chaos theories could provide a conceptual, and even mathematical, bridge between these two worlds.

After an ill-tempered social meeting with two senior colleagues, and months of fighting the ‘corporate machine’ in my day job I think these considerations have wider relevance – in academia, public policy and health service management. What links them may be the impossibility of allowing any human being working in these systems to trust another – an no longer allowing people to hold that uncertainty, rather than algorithms and risk registers.

Universities are now run by financial considerations where the security of grant income subordinates everything else: they have to ‘play it safe’. We end up with students mounting legal challenges when they do not agree with the results when their work is marked, and researchers who produce numerous programmes, projects and papers with very little real value – and only need to show that their strategy does not cause any risk to the projected income stream.

In public policy, it is utterly unacceptable for anybody in the civil service to admit any failing – however small – that might reflect ill on their political masters. When we have a colossal failing – such as the absence of anything that is genuinely psychotherapeutic in the statutory structures of the whole of a country’s mental health system – then the conspiracy of silence is utterly deafening…

In the corporate world of NHS Foundation Trusts, a similarly sanitised version of reality is all that is allowed to be released for public consumption. When everybody knows that real cuts are being made, it cannot be spoken – even in letters to medical colleagues. Presumably it would be a ‘reputation risk’ for the truth to be acknowledged.

But this ugly truth – of the way we are so often not allowed to relate to each other as human beings any more – might even go to the core of the current global malaise. I met an economics undergraduate the other day, and he was explaining to me the depth of mathematical and statistical techniques that he is struggling to learn. The bursting of ‘debt bubble’, from which we are all now suffering, was built on sophisticated algorithms which allowed financial risk to be packaged and sold at lightning speed, with no intervening human thought about sustainability, or feeling that something morally wrong was being done. Is it not this chicanery, and the political systems which underpin it, that need to be exposed and dismantled?

The answer, I hope, is in the philosophy of greencare. Not particularly in the details of therapeutic horticulture, animal assisted interventions or care farming, but in the better use of land, air, soil, water, sunshine and each other for our mental health; the realisation that we need to live sustainably in a finite world; that mental health care is not scalable like an industrial process; and that it’s only relationships between each other that really matter.

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Dr Rex Haigh FRCPsych
www.greenshrink.blogspot.com
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