Wednesday, 26 April 2017

Three psychologists tell the critical psychiatrists

…and all of them were white and male, and middle class and middle-aged, and 'academic' if you want to add those to the charge sheet.

But this was the annual one-day conference of the Critical Psychiatry Network – a mainly UK-based online group of several hundred psychiatrists. It is held in the School of Sociology and Social Policy at Nottingham University – and a few dozen of the members make it to the conference; this year’s title was ‘Recovery in a Time of Austerity’. And that is indeed what we talked about – although a couple of programme changes needed to be made: Tim Kendal, our Grand Vizier of English Mental Health, had to cancel because of the civil service ‘purdah’ now an election has been called. Just like the clean air act going through parliament. Julie Repper, leading light of the national recovery college razzamatazz, was replaced by an even bigger cheese in the world of ImROC, Mike Shepherd, now retired from his role there. But a good time was had by all – even if the speakers did end up all being white male psychologists. Three kings bearing gifts, maybe.

In which case the first on, Dave Harper from UEL, was the King of the land of rational discourse. He spoke softly and with authority on his subject of ‘Responding to the challenges of austerity, recovery and neoliberalism’ – weaving a web of facts that made it hard to disagree that inequality is the pump that we need to take the handle off. But his critique included subtler points, such as the likely psychological impacts of inequality (from the ‘Psychologists for Social Change’ group) and authentic ‘recovery’ being in danger of being only understood in an individual context and dyadic conversations – and missing the whole ‘the personal is the political’ point. All good stuff: no nonsense, but no fireworks. I particularly liked his BPS daleks screaming ‘formulate’ rather than ‘exterminate’ (ref RitB) though I was a bit troubled by his black polo sweater. It gave me flashbacks to the same kit as worn by Davros, as we used to call the architect of IAPT and all the ghastliness that has followed it. See other blogs for more details…

Next was the King of Recovery Colleges, or at least ImROC – Geoff Shepherd. He gave his talk with the air and authority of a big beast on a day off (although he explained to us that he now has every day off, at least insomuch as that he is retired from his previous commanding role). But he gave a fishy history of ‘recovery’, and he told us it was going to be fishy – because there are so many invisible and inaccessible fish in the sea of facts that incompleteness was inevitable. He did start by going back to The Retreat – but with only scant reference to therapeutic communities, which have been espousing, disseminating and celebrating the same ideas for centuries, not just a few years. Although his delivery was a bit like that of a tired expert, he did have a cracking analogy for the end – which really nailed the problem for me better than his generous welter of words: the poor troubled man, who is carrying us, is exhausted and clapped out despite us doing all we can to help him. Except, that is to get off his back. Geoff really does believe in the stuff – even though he’s clearly an expert.

After lunch, the finale from the King of Recovery Evidence – Mike Slade, the home candidate from Nottingham’s Institute of Mental Health, talking about ‘Recovery – commandeered but rescuable?’. He wasn’t quite political enough to call it ‘colonised’ – and he was keener on lists and declarations of new paradigms, than he was on any deeper analysis of how that commandeering is linked to something bigger, smellier and more rotten than his neatly constructed powerpoints could show. one interesting proposal he made was to pay doubly-qualified clinicians more - those who have lived experience, as well as a professional qualification. And he muttered something like 'you just wait and see' under his breath when a few of the audience didn't quite believe him. But to be fair, I think he had the most fire in his belly of the three – perhaps through youthful exuberance (well, compared to some of us) in the role of a globetrotting messiah of recovery. I suppose what unnerved me is how slavishly he adhered to the hierarchy of evidence in his arguments and conclusions – and although they did seem watertight by the positivistic standards we have all been encouraged to worship, only one type of evidence was worth even considering. I have seen that in other people with fire in their bellies, in the PD world, and it’s not always a Good Thing.

Overall, I felt a bit less at home there than at similar sized and similar format conferences in the therapeutic community, personality disorder and greencare worlds. It is as if those other areas are not just critical of mainstream practice, but are actually doing something different. A different sense of informality, openness and responsibility? Maybe that’s just a problem for psychiatrists – and we need psychologists to tell us. 

Friday, 7 April 2017

NICE idea from Gothenburg

I was expecting to arrive at one of those over-professionalised conferences with a lot of men in suits talking about receptor subpopulations and the latest meta-analyses of different dose regimes.
what I was expecting, and dreading...

Thankfully, how wrong I was! The venue was ‘The Extended Therapy Room’, a conception of the energetic and charming Carina HÃ¥kansson; it is a therapy centre for family placements – akin to an adult adoption agency for those with severe mental health problems. However, we did talk about receptors (and how little they matter in real life), and robust evidence (particularly, how little there is that's relevant in clinical practice).

This was the first workshop of the International Institute for Psychiatric Drug Withdrawal, and I was hoping to find practical information about safe withdrawal from all the different psychotropic medications, and to become part of a social movement to swing the pendulum of psychiatry back towards psychosocial means and methods. I was well-satisfied in both – and also found myself part of a warm and welcoming network of people who talk about things like ‘just being human’, 'holistic care', 'relational practice', 'biopsychosocial formulations', 'reductionism of diagnosis' and the importance of the service user voice. Not quite into the realms of ‘democratisation’, but not bad for a start!

There’s too many interesting things to mention them all here, but just to name-check Olga – a fantastically articulate ex-service user who was very nearly poisoned to death by the psychiatric system a few years ago, and Sami Timini, a British psychiatrist who has a powerful presence in the ‘Critical Psychiatry Network’ (fellow psychiatrists – do join up, for some fantastically erudite and challenging online discussions!).

In the final group we all spoke of one thing that we’re going to do before the second and final part of the course in October. I’m going to put mine here, so it’s like a public commitment...
And it is to lobby NICE to produce a guideline on ‘withdrawal from psychiatric medications’. My starting two shots are the following emails, which I have already sent to the Critical Psychiatry Network and to Tim Kendall (who is National Director for Mental Health in NHS England):
Hello CPN Colleagues
I’m just at the training course for psychiatric drug withdrawal run by the International Institute for Psychiatric Drug Withdrawal (IIPDW) including CPN’s own Sami Timini.  It’s very stimulating and interesting – especially to hear of the Norwegian policy directive for each area to have a non-drug mental health facility. The participants in the course are mostly Scandinavian and multidisciplinary, including several carers and experts by experience. So here’s one idea that Sami and I were talking about: Why not lobby NICE to set up a guideline for SAFE WITHDRAWAL FROM PSYCHIATRIC MEDICATIONS?
The reason being that, even amongst experts here, there is little solid evidence for what are the best ways to withdraw psychiatric medications (except perhaps benzos) – despite the generally accepted view that long term use and polypharmacy is a Bad Thing. And the increasing evidence of long-term harm, and the public disquiet.
Could CPN ask Tim Kendall to set one up?
Or is there a formal process we could lobby through?
It would probably need some much better-informed research-savvy people than me, like Joanne and Sami, to make the case.
But NICE guidelines now carry so much (spurious?) authority, that it would certainly create a (useful) stir.
Any thoughts?
Hi Tim
I’m just at the first workshop of the International Institute for Psychiatric Drug Withdrawal in Gothenburg.
It’s clear from the discussions here that nobody really knows what the protocols should be, and there are no easily available or unbiased guidelines on the subject – despite recommendations about no long term use, increasing evidence of long-term harm, and many unhappy service users and carers.
Any chance of setting up a NICE guideline on it?
Or is there a formal process we should follow?
Many thanks
Watch this space to see what comes of it!

Sunday, 2 April 2017

The 'Human Development' consultation

Many of the fundamental principles behind the 2002-11 National Community PD Development Programme come from a developmental view of human relations. This is very different from the psychopathological frameworks always used by psychiatrists and psychologists - which are enshrined in policy and law in many ways, with the authority they thus convey.

Here is what Nick Benefield and I wrote about it in 2008, in our editorial for a special edition of  'Mental Health Review Journal':
When human development is disrupted, the psychological, social and economic consequences can reach into every area of an individual’s personal and social world, resulting in alienated and chaotic lives and repercussions throughout their communities.  The causes of this disruption may cover the whole range of physical, environmental, psychological, social and economic factors: from an unlucky genetic inheritance to a difficult birth, child abuse, inadequate parenting, failed attachment, trauma or emotional deprivation. The causes can also be poverty: material poverty, or the poverty of expectation that leaves individuals feeling powerless to have any impact on the world in which they live.

Over-riding differences in class and educational advantage confer some with strong constitutions - or a range of poorly understood protective factors – which may be sufficient to enable them to withstand the impact of these environmental failures and emerge from their early experience to live what appear thriving and healthy lives. However, very many end up in a situation where they are excluded from mainstream society, rejected by those who might be able to help them, and destined to live lives of unremitting frustration, without the happiness and fulfilment that most of us would consider just - and expect for ourselves and our families.

These individuals, and often their families, have little psychological sense of their place amongst others or where they fit into society. School, working lives and almost any pro-social relationships are difficult or impossible to establish and sustain. They experience the world as a hostile, unhelpful, threatening or undermining environment, living in a marginalised underclass with high levels of substance misuse, self harm, criminality, and suffering severe, enduring and disabling mental distress. People in this situation will often use a considerable range of statutory services to little benefit.

A minority will receive a formal diagnosis of personality disorder and so gain access to appropriate PD intervention services. However, the majority will receive an ambiguous and often prejudicial formulation of their difficulties and will more likely to meet a range of unsatisfactory public service responses.  Dependent on the immediate presenting difficulty, this response will often be inconsistent and have little relevance to the core psychosocial problem faced by individuals who are trapped in the experience of a failing relationship with the world around them.

Current government policy on personality disorder is seeking to change this and achieve three objectives: to improve health and social outcomes,  to reduce social exclusion, and to improve public protection. Three separate policy initiatives have broadly begun to address these through the Social Exclusion Action Plan: “Emerging PD in Children and Adolescents”; “PD - No Longer a Diagnosis of Exclusion” and “Managing Dangerous Offenders with a Severe Personality Disorder”. New legislation in the form of the Mental Health Act 2007 also aims to improve access and rights to treatment for those individuals most severely affected by personality disorder.

In all three areas of this work, progress is being made. The papers in this issue of the Mental Health Review give some indication of learning and experience in the field so far. Evidence from DH funded pilots across the country is emerging to demonstrate that that answers do exist, but that they do not lie in a traditional mental health treatment model or straightforward social policy - but rather in sophisticated cross-agency work that takes in the experience and expertise from various sectors: including health, social services, offender management, housing, social security and the voluntary sector. It also involves new forms of partnership with service users themselves – where they can feel themselves as active agents in their own recovery, rather than the passive recipient of technical expertise.

This is the very beginning for a field that is more complex than a disease model or unitary interventions can address. At this stage there is a need to continue to encourage evaluated and researched service innovation, and establish a workforce equipped to meet the demand for skilled and specialist intervention. To be effective, this will require closer collaboration across public services to ensure the relevance of personality disorders is understood and informs policy, strategy and service provision across the fields of health, social care, education and criminal justice.

Since the community programme was closed in 2011, we have continued to work on the 'relational principles' behind this. The 'PD tube map' was an attempt to demonstrate the pervasive and profounf effects of what we diagnose as 'personality disorder'; and the complexity and interrelation between the systems and services we had set up to tackle it. Here is the tube map:
And a link to a higher quality pdf of it 

So, with particularly useful input from the Offender PD team at NHS England and NOMS (National Offender Management Service), we started to design a more 'serious' version. It is likely to be adopted by the criminal justice sector as a useful model, and there is interest that we are pursuing from the health and education sectors. The hope is that it could convey the importance of considering a non-linear and complexity-based framework for policy and commissioning in all public sector areas concerned with the various 'failures' of adaptive human development. 

At the recent Inverness meeting of BIGSPD, we started a consultation about the model - which has so fare been through eleven iterations. Following the very detailed and informative discussions we had about it in Inverness, here is the latest - version 12:

If you have any thoughts about it, please join the consultation and send your thoughts and ideas to Nick: .
But please don't use it or redesign it for your own purposes, as it is only an early draft at this stage. We are the copyright holders and we'll be after you if you do!