Zero suicide: zero insight

A healthcare conference will take place shortly to discuss an aspiration to achieve zero suicide (1). Of course no one would deny that this is a worthy aim. The programme reminds us that:

The Prime Minister has announced £2 million in funding for the Zero Suicide Alliance (ZSA) over the next 2 years. The funding will help to reduce suicides across the NHS, with the aim of achieving zero inpatient suicides.

If a person with suicidal tendencies has been admitted to a mental health facility, wouldn’t we expect them to be protected from themselves? Close observation and the prevention of access to a means for carrying out suicide would surely be expected as a matter of course. That is why they have been admitted. Similarly, when someone is admitted for an appendectomy, we would expect the availability of a surgeon to carry it out. It is true that some suicidal people are extremely clever and determined. Although zero inpatient suicide is the expected target, there may be an occasional person who manage to achieve it despite the best of measures. A fund of two million spread across numerous mental health facilities might be a help but it is hardly a bonanza. Also, it does not address suicide outside mental health facilities.

As regards the prevention of suicide across the population as a whole (including people in prison), the logistics of prevention are far from obvious. According to the Samaritans: just under 6,000 people take their own lives every year. [This compares with just under 2000 killed in road traffic accidents and around 25,000 seriously injured in this way annually]. In order for suicide to be preventable, it must be predictable. The recommendations set out in the Government’s Five Year Forward View for Mental Health policy on suicide prevention and reduction makes: a commitment to reduce suicides by 10% nationally by 2020/21 (1). This 10% reduction certainly has greater chance of success than 100%. However, people must get the kind of help that they want. It has been reported that one quarter to one half of people who have already attempted suicide do not attend follow-up appointments (2). A major stumbling block to prevention is that in primary care, where most depressed mood with suicidal tendencies is diagnosed, approximately three quarters of suicide deaths are of individuals who are unknown to secondary care services (3). Of various interpretations for this figure, the following are credible (a) that people who are liable to kill themselves conceal this fact successfully from others (b) that they are not taken seriously when they draw attention to their state of mind (c) that they are taken seriously but an appropriate service is not available (or available quickly enough) (d) that the kind of help available is unwanted or ineffective. Perhaps greater priority should be given to researching these possibilities than to inpatient services that should, in any case, be preventing suicide as part of their regular functions.

(1) Health Care Conference: Towards zero suicide. (2018). https://www.healthcareconferencesuk.co.uk/event/1224

(2)  Miret, M., Ayuso-Mateos, J. L.,  Sanchez-Moreno, J., Vieta, E. (2013). Depressive disorders and suicide: Epidemiology and risk factors, and burden. Neuroscience and Biobehavioral Reviews, 37, pp. 2372-2374.

(3)  Hawton, K., Casanas, I., Comabella, C., Haw, C., Saunders, K. (2013) Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147, pp. 17-28.

Mental health and discrimination at work

According to Ruby Wax, (entertainer and mental health campaigner): If you become mentally ill, don’t – whatever you do – tell your boss (1). I know what she means but we need to take a closer look at what the Law says about discrimination at work. I am basing this post on what I have learned from offering therapy to people whose problems centre around work and also on some findings from research on the topic.

If you consider yourself to have a ‘mental health problem’, when can you accuse your employer of discrimination for not taking this into account? The Equality Act (2010) was designed to cover discrimination against a person for all kinds of reason, including having a disability. You might be surprised to learn how the Act defines a disability resulting from a ‘mental impairment’. The ‘impairment’ and the effect it has on normal daily activities must be present for a year or more. So if your ‘mental health’ has suffered from, say, a sudden bereavement or bullying colleagues, you must demonstrate three things: 1. the impairment is expected to last at least a year (unlikely for many kinds of stress) 2. the mental impairment must be labelled as such by a professional (i.e. getting a GP or a psychiatrist to stamp your official record with a stigmatised diagnosis) 3. Have an impairment that is not excluded from the Act. The excluded categories are chiefly the less desirable forms of ‘mental impairment’ such as an addiction to alcohol or nicotine, being a fire-setter, voyeur or exhibitionist, or having a tendency to abuse others sexually or physically. If you satisfy all three conditions, your employer is obliged to make reasonable adjustments to your working conditions. The charity MIND gives some examples of allowances made on grounds of ‘mental health’ (2).

I have not yet encountered a client who is aware of the Act or made use of it. ‘Mental health’ problems at work seem to invite one of two responses from an employer. The first is sympathetic, accommodating, and informal. This often depends on whether a manager has experienced something similar themselves. It helps if an employee’s skills are of particular value to the company. An employee might be able to use their health insurance policy (sometimes a company perk) to access therapy. If work becomes too stressful and affects ‘mental health’, the person may attempt to move departments, take unpaid leave, use up a holiday allowance instead of ‘going sick’, apply to work part-time, ask to spend more days working from home, or simply seek out a new employer. In other words, there is an attempt on both sides to accommodate to a difficult situation and smooth it over.

The second kind of response from an employer and employee is formal and legalistic, involving grievance procedures, Human Resources department, and Occupational Health. The people I see as clients (mostly in skilled jobs) are not inclined to view their ‘mental health problem’ as an enduring impediment to working normally and certainly do not wish to have a psychiatric label entered on their staff record. This is not because they shun the stigma of mental ill-health but because it is very likely, in practice, to harm their future career prospects. To be labelled (e.g. as a ‘depressive’) risks providing a spurious reason for future dismissal or is a handicap when being considered for promotion. A significant proportion of time in therapy is therefore spent discussing strategy and impression management, bearing in mind a client’s ultimate objectives. People are reluctant to pursue a grievance when they feel that they are being discriminated against unless they already have plans in place to change their job.

Research findings back up my own impressions. The Department of Work and Pensions has funded research into the impact of ‘mental health’ on employment. They are concerned because ‘mental ill health’ is given as the main reason for people being unable to work due to sickness (2). As in many areas of social life, the medicalisation of problems that have understandable causes and require pragmatic remedies gets in the way of devising sensible policies. As Irvine (3) states: What emerged from my studies was that some people did not talk about difficulties at work because they did not consider themselves to have a mental health problem at all. Rather they saw what they were experiencing as a perhaps intense but nevertheless ‘normal’ level of stress or emotional distress. There were also people who had talked to others in their workplace about difficulties of one type or another that they were experiencing in their home or work lives, but they did not express these in medicalised language, hence again did not disclose a ‘mental health condition’ as such. 

Consistent with my own experience, only a minority of Irvine’s respondents were aware of the Disability Discrimination Act (DDA, 2005): Very few felt that knowledge of the DDA would have made a difference to their employment outcomes . . . seeing any difficulties in carrying out their role as their own responsibility and not something their employer should be expected to accommodate. . . . people did not perceive their mental health issues as a ‘disability’ or even see themselves as being ‘ill’ in some cases. Irvine notes that this raises questions about the salience and applicability of disability employment legislation in the context of common mental health problems (3). 

Yet another example of the obfuscation caused by the mental health conspiracy.

1. Wax, R. (2015) Should you tell your boss about mental illness?

https://www.theguardian.com/commentisfree/2015/jul/06/mental-illness-stigma-ruby-wax-work-employers

2. MIND (2014) We’ve got work to do.  

https://www.mind.org.uk/media/1694795/back-to-work-report_2015_web-v3.pdf

3. Irvine, A. L.  (2015) Mental health and employment: Context, concepts and complexity. University of York Social Policy and Social Work.

http://etheses.whiterose.ac.uk/11786/ 

 

IAPT Manual, 2018: Newspeak confronts reality

The IAPT Manual, 2018:

The new IAPT Manual from NHS England (1) presents the Newspeak version of the expanding Improving Access to Psychological Therapies (IAPT) service. Duplicity is inevitable when non-medical interventions are forced to present themselves as medical. Otherwise, they would presumably not be funded as part of the National Health Service.

Medical terminology is apparent everywhere in the document. The focus is on ‘disorders’ (mainly ‘anxiety’ and ‘depression’) for people who suffer from these conditions. Evidence-based treatment must be administered at the appropriate dose. Adherence to protocols of NICE-recommended therapy is critical to good outcomes. Recovery in IAPT is defined in terms of caseness, in other words, whether a person scores above or below a threshold level of symptoms.

The chief (but not exclusive) IAPT therapy is CBT which is a psychological, not a medical approach. Consequently, there is a mismatch between the tasks and roles of a CBT therapist and the description of IAPT in this document. The impression given is also at variance with training curricula published elsewhere (2). The ‘stepped care’ method of providing the IAPT service means that the least intrusive/expensive intervention is provided first, and if this fails to resolve the problem, a person is referred up to increasingly intensive therapy provided by more highly skilled workers. I haven’t seen a description of the screening (triage) that is carried out on new referrals (or self-referrals) but it is presumably rather brief and based on an assessment of ‘symptoms’. In 2015-16, approximately one-third of new referrals (or self-referrals) were not accepted into the service and a further third who those who were accepted attended for only one session (3). What exactly is going on? Who is being rejected and why? What does one session of therapy amount to?

According to the IAPT Manual: A person-centred assessment completed by a trained clinician is a crucial part of the care pathway.  Presumably, this takes place some way up the path, not at the triage stage. Judging by the very detailed specification of what the assessment covers, I estimate that it would take at least two hours to complete, which makes me question whether the prescribed assessment is simply aspirational. Based on extensive experience as a CBT therapist, I have never known one client’s problem to be identical to another’s. Assessment and formulation are crucial. However, IAPT therapy is strictly railroaded into Adherence to protocols of NICE-recommended therapy, which is said to be critical to good outcomes (1). Do we really know that is true or is it part of the Newspeak? This protocol-driven approach is not even consistent with the published curriculum for High Intensity CBT therapists (2). This states that a trainee must demonstrate self-direction and originality in tackling and solving therapeutic problems and to practise as a scientist-practitioner. How many ‘original’ deviations is an IAPT therapist allowed?

If the results for IAPT matched results that have been published in the journals I would be happy. The actual results do not match up. The IAPT Manual states that NICE recommends that a person should be offered up to 14-20 sessions depending on the presenting problem and the number of sessions should never be restricted arbitrarily.  We have now entered Never-Never land. The average number of sessions for people who began therapy was between three and six (3). The success rate (according to criteria that can be questioned) was as low as 38 percent for so-called post-traumatic stress disorder and 37% for so-called agoraphobia. A successful outcome for agoraphobia has been reported in the journals as close to 80% since the 1980s (4). The low success rate for PTSD is entirely understandable if therapy is as brief as three to six sessions.

The cost and effort involved in training psychological therapists is high. It is stated (5) that High intensity interventions are usually delivered by therapists who will have received several years of specific training and supervision in a particular therapeutic approach, and will usually have been trained in a recognised health care professional role (e.g. counsellor, nurse, psychologist, psychiatrist, social workers etc.) and may be registered with an appropriate professional body (e.g. BABCP, BACP, UKCP).  In other words, the training goes far beyond learning some recommended NICE protocols. The published curriculum for High Intensity IAPT training lasts one year and  combines academic study and supervised practise in a service context (2). Applicants have probably already acquired a variety of skills. If they already have a professional qualification it is unclear why they should be attracted to a job in IAPT. Having worked as a trainer myself, I know how difficult it is to cordinate all the necessary facilities in one locality (academic, supervisory, selection and assessment, practice placements, etc.). Since 2008-2011, when a number of courses were set up to provide training for High-Intensity therapists, many of them have since closed: 29% of all courses are no longer offering places (6). This may reflect the practical difficulties just mentioned and the fact that Universities find it much easier to offer straightforward classroom-based teaching.

Nevertheless, IAPT marches on regardless. At what point will the emperor’s new clothes be revealed for what they are?

1. NHS England (2018) The Improving Access to Psychological Therapies Manual.

https://www.england.nhs.uk/publication/the-improving-access-to-psychological-therapies-manual/

2. Department of Health (2008). Improving Access to Psychological Therapies. Implementation Plan: Curriculum for high-intensity therapies workers.

https://www.uea.ac.uk/documents/246046/11919343/implementation-plan-curriculum-for-high8208intensity-therapies-workers.pdf/88d52978-44ca-47ad-a317-d9b8e1042ef4

3. IAPT (2016) IAPT Annual report, 2015-16. http://content.digital.nhs.uk/catalogue/PUB22110/psych-ther-ann-rep-2015-16.pdf

4. Hofmann, S. G. & Spiegel, D. A. (1999) Panic control treatment and its applications. Journal of Psychotherapy Practice and Research, 8(1), 3-11.

5. NHS England (2015) Adult IAPT Workforce Census Report. 

https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/09/adult-iapt-workforce-census-report-15.pdf

6. BABCP (2018) Accredited IAPT Training Courses.

https://www.babcp.com/Training/IAPT-Accredited-Courses.aspx

Biomedical chimeras

The UK Department of Health and Social Care has funded King’s College, London, to develop a ‘bioresource’ of 40,000 people who have (or have been in the past) diagnosed with an anxiety or depressive disorder (1). These diagnoses apparently apply to one quarter to one third of the entire population. One purpose of the project is genetic profiling, presumably to help discover neuro pathways in the brain that could be modified by medication.

The sample of volunteers they wish to recruit, however large, is bound to be arbitrary and heterogeneous. There must be numerous people who could be or could have been given an anxiety or depression diagnosis who, for local and idiosyncratic reasons, were not, and a large number who should not have been so diagnosed due to the unreliability of diagnostic criteria. The sample is also biased by consisting only of volunteers. One previous attempt to find genetic characteristics associated with ‘major depression’ was unsuccessful (2). The authors stated that only a large sample comprising more than 50,000 subjects may be sufficiently powered to detect genes for depressive sumptoms. One reason for this negative result may be the fact that a questionnaire assessing ‘major depression’ is a hodgepodge of unrelated phenotypic behaviours. Another is that fact that ‘major depression’ (if it has any meaning at all) is almost certainly polygenic. If each gene contributes only a very small amount to ‘risk’, then it is only when a large number of randomly varying characteristics converge in a single individual that a genetic determination becomes evident.

The enthusiasm for investing in biomedical research into mental health seems unbounded. This project seems to be a fishing exercise, and seems entirely unjustifed when the target sample is one third of the entire ‘normal population’ who happen to have been subjected to an arbitrary diagnostic assessment.

1. Eley, T. (2018) Major new study to ‘serve the mental health community’. Interview with Professor Eley. The Psychologist, October, 2018, pp. 18-19.

2. Hek, K., Demirkan, A., Lahti, J. et al., (2013) A genome-wide association study of depressive symptoms. Biological Psychiatry. 73(7), 667-668.

Co-production: Who is co-producing what?

MIND recently commissioned a report from NEF (the New Economics Foundation) reviewing the evidence on co-production in ‘mental health’ (1). The NEF’s principles cannot be faulted. Co-production is about being equal partners in designing and delivering services, working in reciprocal relationships with professionals, and removing the distinction between professionals and recipients. They contrast this approach with the traditional one of ‘doing to’, in order to educate and cure them so that they conform to idealised norms and standards.

It is immediately apparent that MIND’s understanding of co-production is at odds with NEF’s principles. However, NEF concedes that the commissioned review helps to position the network of local Minds as market leaders of high quality, recovery focused, personalised services that individuals want to buy. MIND’s foreword refers to ensuring that millions more people are able to access the mental health services that will help them recover and stay well.    

To be cynical, this is rather like a tobacco company investing in e-cigarettes. A citizen who is a service user or buying a service is not engaged in co-production except in the sense that they are an essential element in the production process (as consumer). Of course, a citizen might wish to purchase the services of a professional and this reverse the power differential. The citizen is now in charge, and assuming that they have not been duped, they can end the relationship at will.

In the review, the NEF rows back on its principles somewhat when it refers to ‘doing with’ as a much deeper level of service user involvement that shifts power towards people. In case this is not entirely clear, it means that people’s voices must be heard, valued, debated. It would be foolish to deny that anything more than even a modest shift away from coercion would be welcome, and the evidence reviewed by NEF certainly supports the benefits of so doing. The review is a useful summary and describes 15 different projects. Benefits are seen in improved social networks, social inclusion, skills and employability, prevention, and addressing stigma.

However, what has this to do with ‘mental health’ except for reducing the need for services? According to MIND, one of their objectives is to increase access to services. We want to ensure that millions more people are able to access the mental health services that will help them recover and stay well. Recovery and staying well imply illness. If the outcomes of co-production are defined in this way (in the form of curing disorders as defined by WHO or the American Psychiatric Association), the citizen has already ceded power to the medical professional. The type of service that the citizen is invited to co-produce has already been ordained.  

The NEF’s conceptual framework is one of well-being, with an emphasis on autonomy, relatedness, and competence. Apparently, with the exception of the Richmond Fellowship and up2us, none of the projects used an explicit well-being framework in their evaluations. For MIND, and perhaps for other charitable organisations, the desired outcome is ‘improved mental health’. This latter concept is a convenient dustbin category that leaves power relationships pretty much the same as they have always been.

1. Slay, J. & Stephens, L. (2013). Co-production in mental health: A literature review. London: New Economics Foundation 

 

At last – the final solution for all mental health problems!

The solution is apparently simple and parsimonious and universally applicable.1

At first glance, the proposed new therapy has much in its favour. It seems to be a form of facilitated problem-solving. The therapist prompts a person to talk about their problem, to clarify their goals, and to expand their awareness of what might be causing it. It is suggested, very reasonably, that some kind of conflict is present at the centre of most problems. The focus is on self-determination, including a person’s freedom to choose the spacing of sessions and the duration of help.

All this can be simply laid out and it may represent an optimal way of conducting help. However, it is far from simple in practice. The method of levels is said to be a unified theoretical account and a single core psychological process. However, it is neither a theory nor a process. It is a pragmatic and principled means of persuasion. As such, it has much to recommend it.

Nor is the method theoreticallyparsimonious. It does not abandon the concepts of mental health, disorders, and symptoms. Presumably, the existence of a problem or a conflict can cause symptoms. However, how are symptoms fitted into the theory? They are not problems or conflicts as such. They are presumably elements in cognitive and behavioural processes. If so, why bother with concepts such as disorder and symptom? One reason for doing so is to compare this therapeutic approach with others. It is apparently better at reducing symptoms and distress. Shouldn’t the outcome of therapy be measured as the resolution of problems and conflicts? There are certainly better and worse ways of resolving things. These rest on pragmatic, ethical, social, and political criteria, not simply on the relief of distress.

Is this approach to ‘mental health’ universally applicable? Problem-solving and self-determination are certainly favoured concepts in our own society, and not without reason. However, not everyone in Western society endorses them. Across the world, there are likely to be an even greater variety of approaches to solving problems and conflicts. It cannot be assumed that everyone sees life as a matter of choosing a hierarchy of goals and finding an optimal way of resolving conflicts between them. In any case, many people are not free to choose their own goals. The problem may consist of all manner of constraints on self-determination, many of which lie outside the control of the person with a problem.

1. Mansell, W. (2018). Method of levels: Is it the most parsimonious psychological therapy available? Revista de Psicoterapia, 29 (110), 135-143.

The fantastic aim of preventing ‘mental health problems’

The Mental Health Foundation(MHF) believesthat mental health problems are preventable.1

What is a mental health problem? In a summary of ‘fundamental facts’, the MHF adopts the discourse of symptoms, disorders, and diseases.In an earlier MHF document3, an inquiry into the long-term future of mental health services, one would have expected to find a more considered answer to this question but it is not there. Based on a psychiatric epidemiological approach, it seems that almost 20% of the population are suffering from ‘common mental disorders’.2,4However, a ‘mental health problem’ is often understood in a looser sense than this, and the term could perhaps be applied to around half the population. Many ‘mental health professionals’ are also apparently sufferers.On these grounds, there is no clear divide between the mentally healthy and the unhealthy.

The means by which the authors of the inquiry into future services sought clarity (when it suited them) was to fall back on the more restrictive concept of ‘mental illness’. Although they had reservations about ‘medicalisation’, they assumed that there will still be people who are diagnosed as having a mental illness in 20-30 years time. These are people who will require care and treatment. They may be right about the needs of a relatively small group of people often described as having ‘severe mental illness’ but this group cannot be equated with everyone who is thought to have a ‘mental health problem’.

According to an attitude survey conducted on a random sample of the UK population in 2010,the general public agree that there are different classes of mental health problem. The authors of this survey sought respondents’ opinions about possible candidates for a ‘mental illness’. It turned out that 68% ‘agreed strongly’ that ‘schizophrenia’ was a mental illness whereas the proportion that regarded ‘stress’, ‘grief’, and ‘drug addiction’ as mental illnesses was around 20%. Stress and grief are presumably seen as ‘mental health problems’ (or simply as life’s hardships) rather than illnesses. The authors of the survey did not seek an opinion on typical ‘mental health problems’ but were content to define the latter as conditions for which an individual would be seen by healthcare staff. On these grounds, it follows that the prevalence of mental health problems will increase as a more and more service providers find employment.

I suggest that concepts of mental illness and psychiatric disorder should be abandoned.It is not of course possible to define away peoples’ problems but there exists a variety of non-medical approaches for their resolution. There is no need for the great majority of them to come within the remit of a ‘health service’.

At present, people commonly consult health care professionals, especially general practitioners (GPs), when they experience some form of distress. Eighty three per cent of the sample in the attitude survey said they would consult a GP about a mental health problem. For instance, it is quite common for someone experiencing stress at work (sufficient to impair performance) to get ‘signed off’ for weeks or even months. With this system, an employer can feel reasonably confident that a gatekeeper is applying control over potential malingering without necessarily knowing what the health problem is or how it is diagnosed. The blurry, somewhat meaningless, terminology of mental health performs a euphemistic function, somewhat similar to other circumstances or motives that are best left un-explicated (such as ‘waste matter’, ‘dodgy’, or ‘the departed’). The GP simply writes ‘stress’ in the case notes.

It is probably just as well that most GPs have little or no training in psychiatry and are not inclined to assign a considered diagnosis. To name something as a problem or disorder implies a judgement (by self or an agent of society) that something is amiss. Most people want to be seen as problem-free and therefore would prefer not to publicly advertise the existence of a problem. There seems to be an advantage in ‘keeping up appearances’, hoping any problem will eventually be resolved, as often happens. This is not a sign of denial but indicates an acceptance and toleration of problems, an attitude of live-and-let-live. Life is not expected to proceed without a hitch and some people are not gifted with the temperament, abilities, or inclination to choose a path in life that avoids the kind of situation that creates problems.

The contrary point of view is to nail a problem down and eliminate it. I accept that this approach may at times be necessary whether or not a problem is medicalised. However, the path of regarding ‘mental health problems’ as serious and burdensome leads to unrealistic expectations that can never be met by ‘mental health services’. The MHF states that mental health problems cost the UK economy an estimated £70-100 billion each year. This figure is around six times the amount the UK government pays annually to the EU for membership and is therefore a very large sum. For comparison, total NHS annual spending on mental health is somewhat over 10 billion.

The medicalisation of life’s problems encourages a steady expansion in the number mental health professionals who are needed to deal with them. On current prevalence figures, society will soon approach a state in which a person is either a service provider or a service user. The latter are viewed as unfortunates who need to be cared for. The MHF report inquiring into the future remarks that: One-to-one human contact, a smile and kind words have a timeless benefit to people with mental health problems. How nice, thoughtful, and caring that is. The remark implies a ‘holier than thou’ attitude, a sense that anyone with a problem deserves our pity.

The future of mental health envisaged by this MHF report would require that all problems be clearly labelled. Services will build service user’s capacity to self-manage their conditions. They will know these conditions by the label they are given. Their self-management will be guided by research that points them in the right direction. Future mental health services can be based on proven and effective service delivery mechanisms. A key element . . . will be an effective computerised system for sharing patient information both within the NHS and across boundaries with other organisations.

A consequence of having this kind of information system in place would be the ability to identify who it is that belongs to the ‘blessed’ and who to the ‘blemished’. Those unfortunate enough to be in the latter group could be quickly identified and tracked across different settings.

Out of interest, I examined my own computerised medical records held by my general practice. It stated that 18 years ago I had had a ‘mild depressive episode’. Of what use is that information without a context to give it meaning? In years leading up to that period my partner and my mother had both died from long drawn out illnesses (cancer and dementia) and I myself had been misdiagnosed for a serious medical condition requiring surgery that everyone thought, including myself, was terminal. My state of mind was not ‘mild’, nor was it simply a ‘depressive episode’. How are we supposed to characterise complex life situations as ‘mental conditions’? Casual and de-contextualised labelling can be socially damaging, especially when a ‘condition’ has undesirable connotations such as a ‘personality disorder’. In view of the risks of labelling, I am often consulted (as a therapist) by individuals who wish to pay privately. They do not want to leave any official trace of having done so. This is not driven by the shame or stigma of ‘mental illness’ but by a common sense appreciation of the tendency to pigeonhole people, and the reality that a problem can affect a person’s social functioning in a way they might not wish to advertise publicly.

The authors of the MHF inquiry state that we take patient confidentiality seriously, not least because of the immense stigma that still surrounds a diagnosis of mental illness. However, this same stigma can also apply to a ‘mental health problem’. It is hard to credit assurances that digitally stored information is secure, especially as any individual can find their own record easily and share it, as I have done. Sharing ‘across settings’ enormously magnifies the likelihood of illegitimate access. It is also illusory to suppose that problems can be cleansed of any negative connotation by calling them ‘conditions’ or ‘illnesses’ from which anyone might happen to suffer. A problem is a problem because it implies a failing (by self or others) or a failure to meet a standard of some kind. There is no gain from having it medicalised, and the concept of ‘prevention’, in a medical sense, is inappropriate. The existence of problems is an inevitable feature of life. Problems are preferably resolved, not ‘treated’. This outcome can be achieved in a variety of non-medical ways and settings.7

  1. Mental Health Foundation (2015). Prevention review: Landscape paper.www.mentalhealth.org.uk/publications/prevention-review
  2. Mental Health Foundation (2013). Starting today: The future of mental health services. Final inquiry report.     www.mentalhealth.org.uk/sites/default/files/starting-today.pdf
  3. Mental Health Foundation (2016). Fundamental facts about mental health.https://www.mentalhealth.org.uk/publications/fundamental-facts-about-mental-health-2016
  4. Steel, Z., et al., (2014). The global prevalence of common mental disorders: A systematic review and meta-analysis 1980-3013. Int. J. Epidemiol. 43(2) 476-493.
  5. Rao, A. S. et al. (2016). Psychological wellbeing and resilience: Resetting the balance.www.bps.org.uk/system/files/Public%20files/ar_v10_resetting_the_balance_160516.docx.pdf
  6. Research Report JN 207028. (2010). Attitudes to mental illness. www.webarchive.nationalarchives.gov.uk
  7. Hallam, R. (2018). Abolition of the concept of mental illness: Rethinking the nature of our woes. London: Routledge.

Addiction to medicalisation

The intention to include “gaming disorder” in the draft revision of the WHO 11th International Classification of Diseases has created quite a furore from punters, the games industry, and commentators. Apparently, 1%-6% of adolescents and young people may be “afflicted” by gaming addiction.

According to a BBC report1, Dr Richard Graham of the Nightingale Hospital (a private clinic) welcomed the decision (I wonder why). However, he added that “he would have sympathy for those who do not think the condition should be medicalised” (I wonder why). According to an article in the New York Times2, quoting a therapist, “It’s going to untie our hands in terms of treatment, in that we’ll be able to treat and get reimbursed.” The cost of treatment? According to a figure quoted on BBC Radio 4 News (18/06/18) it’s £350 per hour. So it’s winners all round.

Three hundred and fifty pounds is a lot of money, getting close to the amount for surgery, although a lot of that fee could be taken up with the cost of hiring a room in Harley Street. Perhaps we will soon see a Journal of Gaming Disorders; conferences and workshops will be advertised; self-help manuals for worried parents will be published, the possibilities are endless. The signs and symptoms will be carefully defined and redefined in new editions of manuals of mental diseases. Different subgroups will be identified, some which will be found to show unusual activity in certain centres of the brain, corresponding to evidence found in gamblers and people with substance abuse.

Can playing games all day long become a problem? Of course it can. Is it a disease? Of course not.

  1. Gaming addiction classified as disorder by WHO (2018) https://www.bbc.co.uk/news/technology-42541404
  2. Video game addiction tries to move from basement to doctor’s office (2018)      https://www.nytimes.com/2018/06/17/business/video

A chip off the old block

A child who has ‘made it’ in the world might want to forget the parents who no longer match its self-image, even demonstrating a blind spot about its heredity.

There is, however, nothing secretive about the fact that clinical psychology was born out of an alliance of convenience with an older and more established profession. As Hans Eysenck stated it in 1950: That a strong, respected and highly competent profession of psychiatry is essential for the growth and flourishing of clinical psychology appears obvious: it is perhaps no less true to say that the existence of well trained, competent, and friendly clinical psychologists can be of the utmost value to psychiatrists.1

There has been a substantial redrawing of the boundaries since 1950, with new alliances, antagonism as well as cooperation, and new power structures to deal with. Applied psychologists have now decided to march under the banner of ‘evidence-based practice’, confident that ‘the facts’ will win out in its competition with other professions. American psychologists have looked on with admiration at the UK government’s decision to invest in a psychological therapy service provided by the NHS (IAPT), while in their own country they seem to be losing the battle against the promotion of psychotropic drugs on an overwhelming scale.According to market researchers, the global depression drug market alone will reach $16.8 billion by 2020.3

Gaudiano and Miller2 view the current situation facing the advocates of a psychosocial approach as serious and challenging. It appears to them that in the global market place, ‘evidence-based’ and sound ‘value-for-money’ psychosocial interventions are losing out. What they fail to fully recognise is their own allegiance to a concept of mental illness that sets the rules of the game. They are chips off the old block. They refer to the over-medicalizing of mental health problems and define medicalization as the practice of defining and treating non-medical problems as if they were such conditions. But in the same article, they endorse the idea of improving public attitudes about mental illness, mention recovered patients relapsing after treatment, and note the importance of reducing the burden of mental illness at a population level.

Professionals who provide ‘psychosocial interventions’ are in business too, but when they share a medical inheritance, they constrain the defining characteristics of the ‘market’ of their potential consumers. By adopting the trope of health, illness, treatment, and cure, psychosocial means whatever their competitors want it to mean, and what their competitors have already persuaded the consumer to believe it should mean.

According to Gaudiano and Miller: This tendency within psychology to fail to put forward a unified front has left room for other professions to wage aggressive media campaigns to change public thinking in ways that argue against psychology and ultimately do a disservice to consumers and their families.

What would doing a service to consumers (and their families) actually amount to? Not, in my view, sharing the mythology of mental illness.

Sources

  1. Eysenck, H J (1950) Function and training of the clinical psychologist. Journal of Mental Science, 96, 710-725. Cited by Burton, M and Kagan, C in British clinical psychology in historical perspective: The genesis of a profession,(1983, unpublished). www.compsy.org.uk/listkb.html
  2. Gaudiano, B A and Miller, I W (2013). The evidence-based practice of psychotherapy: Facing the challenges that lie ahead. Clinical Psychology Review, 33, 813-824.
  3. Market Research Store.            https://globenewswire.com/news-release/2016/05/10/838292/0/en/Global-Depression-Drug-Market-Poised-to-Surge-from-USD-14-51-Billion-in-2014-to-USD-16-80-Billion-by-2020-MarketResearchStore-Com.html

Could do better!

The role of the Parliamentary and Health Service Ombudsman is to handle complaints that have not been satisfactorily resolved by the NHS itself. On 19th March 2018 it issued a report giving illustrative examples with lessons for how mental health services could do better: It is our role to ensure NHS organisations learn from these mistakes and take the necessary steps to prevent those mistakes from happening again. That a problem exists is suggested by the fact that: In 2016-17 there were 14,106 complaints made to NHS mental health trusts, with around 65% being upheld or partly upheld by the local organisation.

How many times in the past have we heard this kind of tut-tutting? How many new five year plans, reorganisations, revisions to legislation, and other ‘worthy’ initiatives have there been since a new Mental Health Act was introduced in 1959?  Are the concerns serious or is it just a pretence? As stated: According to The King’s Fund, 40% of mental health trusts in England received a real terms decrease in their operating income in 2015-16.  More recently, The King’s Fund found that, despite 85% of mental health trusts receiving increases to their income in 2016-17, funding for acute and specialist physical healthcare continued to grow more quickly, increasing the gap in funding between physical and mental health services. Furthermore, there has been a 13% reduction in mental health nurses between 2009 and 2017, with inpatient care losing nearly 25%. Almost 10% of all posts in specialist mental health services in England are vacant. 

Who should we charge with doing better?

Source:

Maintaining momentum: driving improvements in mental health care. Parliamentary and health service ombudsman. 19 March 2018, HC906. www.ombudsman.org.uk/mental-health