Not may people realise how big this is...

This week I received an interesting email, in my role as moderating clinical messages on the National PD website (www.personalitydisorder.org.uk)  from somebody whose son has finally found a specialist service for what is probably diagnosable as Emotionally Unstable Personality Disorder. This is after agonies of  being passed from one service to another, nobody being able to help, and no honesty about the likely diagnosis.

It is so encouraging to hear from somebody who can see the size of the problem here – I so often feel that I’m ranting on about something that nobody is interested in. And the response from ‘the system’ is so corporate, anodyne or cautious to render it meaningless: “so much is being done to improve community care”, “the government’s first priority is public protection” and “all the European metrics show how well we are doing” are all things I have heard recently, and the last was from the government’s director of mental health in a very uncomfortable personal conversation I had with him. 


With the growing despair that the world of mental health is going the wrong way, several of us who are ‘medical psychotherapists’ met John Alderdice in the Lords last week (he is a retired medical psychotherapist himself).  His advice was to get local and make a fuss (as there is no central control anymore beyond awfully empty and arid things like ‘No Health without Mental Health’)  – but to focus on good MH stories where it is being done well. Personally – since reading Paul Mason’s ‘Why It’s Kicking Off Everywhere’ – I have been trying to send a daily tweet and a weekly blog about it all (hence you reading this!). I know it takes a while to get these things going, so I will persevere for a few months yet - or until I am 'silenced'!

I started medical life as a GP – but, being most interested in the ‘soft psychiatry’ that they were very good at teaching us as part of the GP training in Cornwall in the 1980s, decided to return to Oxford to train as a psychiatrist – but was sorely disappointed with what I found. Although I remember thinking how much more opportunity there was to do psychosocial practice better in primary care, and being sorely tempted to go back to being a GP, I remember my trainer’s wife – a feisty Bodmin magistrate – saying, as her parting shot to me, ‘at least go and do something about PD, Rex!’.


Since then, I think I have had a fair stab at that – although usually in the teeth of opposition to my determinedly ‘biopsychosocial’ approach. But I did get a reasonably lucky break for my consultant job, when in 1994 I was appointed to develop a ‘therapeutic community’ as part of a regional psychotherapy service in Berkshire – then another when I was invited onto the DH working party to help write the government’s PD policy guide ‘No Longer a Diagnosis of Exclusion’. It was only when I had to diagnose our service users for Royal College of Psychiatrist student examinations in about 1998 that I realised that all our 'patients' had Borderline Personality Disorder!  In the DH working party, I ended up causing quite a stir by gathering a gang of about twenty very unhappy – and generally rejected – service users from across England and setting up focus groups with them and fairly senior civil servants. Suddenly, somebody realised that there might be a problem here.

That was in 2002, and over the last decade many flowers of excellent service have been blooming – but there are still many areas of desert. That is as true geographically (88% of England has no ‘tier 3’ PD services) as it is professionally (unfortunately, the inherent conservatism of my own profession either sees the psychosocial approaches as ‘not real medicine’ or are frightened of the challenge to their authority that it might imply. 


Furthermore, what little hope that there was for further development of community services for PD has been largely dashed by the recent ending of the national programme – and effectively insisting that IAPT is “the only show in town” (see last week's blog entry). 


One glimmer of hope that we are holding onto is that the time is indeed very opportune to ‘do it locally’. If we could organise a good campaign to educate and inform the CCGs before they come into operation next April – which means me and like-minded colleagues (in our ‘spare’ time), and three days a week of Fiona (a passionate and energetic graduate of a proper PD treatment programme). 


Our fear is that the message will be lost in the clamour for ‘really important’ NHS services – and that people who are ‘attention seeking’, ‘manipulative’ and  ‘their own worst enemy’ don’t deserve public money.


Our hope is that three things will  get recognised (1) good treatment is now available – and GPs and psychiatrists no longer need to tear their hair out with these ‘difficult patients’ (3) the burden of suffering – patients, families and friends – is immense and (3) good treatmet availability will save far more money than it costs.

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.  

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.

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.

The trouble with therapeutic communities…

Is that, although ahead of the game in so many ways, they’re just a bit slow in cottoning on to what you need to do to survive. And unless they do survive in some recognisable form, the radical core of what they do differently (quality of relationships, basically, though nobody has ever described it well enough to catch fire) will be lost. The crown jewels will be dismantled and used in all sorts of other settings – being very pretty, maybe, but losing the beauty and power of ‘the whole thing’.

Where new ideas for mental health come from

But I have just heard of a plan – from that modern-day foundry of mental health ideas which is Nottingham’s Institute of Mental Health (IMH) – that would truly blow Maxwell Jones’ socks off. Here it is – just floated to the local mental health services there, by Nick Manning (who is Director of IMH):

there should be a ‘peer workers’ management buy-out, rather than just peer support, so that peer workers managed the service and ‘contracted in’ just those types of staff they wanted for the service

I have sent a half-serious reply to Nick Manning that we’re all set and ready to go: we have an established TC in the NHS, a Community Interest Company social enterprise with a current lottery grant for greencare, and an active group of service users, some of whom will soon finish the main phase of their intensive therapy programme, who are well-versed in therapeutic empowerment – as well as being energetic, resourceful and committed.  Not to mention being utterly committed to making real changes for themselves, desperate to escape the ‘benefits trap’, angry with many aspects of the mainstream MH system, and determined to get a life worth living for themselves.

Where new ideas for mental health go to?

But, probably because I’m a psychiatrist, and not a service user or a manager, it’s unlikely that I’d get an idea like this over the first hurdle – especially as I have had such a spectacularly unsuccessful history of innovation in dear old Berkshire since 2002. I’m meeting Nick next week and I expect he will gently tell me to stop flogging a dead horse – things they do in Nottingham just wouldn’t work in the affluent South East (like Slough!)

But – what about if we get a small team of interested service users together? With a really good idea for taking the pressure off the statutory services and doing it better themselves? Almost like a group version of personalised budgets. And how about ‘employ your own therapists’ as an alternative to ‘payment by results’?

Although I expect it is very unlikely to happen, I’d be first to apply when they advertise for their own psychiatrist…

Just why don't they get it?

A busy fortnight of meetings, with three last week all about local matters, then three this week all with people from further afield. This blog entry will try to illustrate that all the hope seems to be 'out there' and not 'back here'.
In the interests of fairness, anonymity and not to mention self-preservation - all names and distinguishing features have been fictionalised...

LAST WEEK

Week 1: meeting 1 - senior manager, Craig O'Reilly...
GS      There's a great variety of good things going on out there
Co'R   We need just six types of complex needs service elements
GS      If only we could do mental health differently
Co'R   Tell that to the commissioners, not to me
GS      We have been cut to less than half the staff we had 3y ago
Co'R   And there's worse to come - we have to cut £4m

Week 1: meeting 2 - less senior manager, Barry Southmore and even less senior manager, Mikey Davidson...
GS      There are great opportunities here to do it better
BS       Do you know about the organisations' strategic plan?
GS       But this is about implementing government policy
MD      Don't threaten me
GS       So we need to shut services then
BS+MD No comment

Week 1: meeting 3 - local manager, Maria Freeman and GP commissioner, Raheed Gursha
GS       There are great opportunities here to do it better
RG       But we do need to treat people with proper illnesses
GS       There are excellent things going on elsewhere in the country
MF      Let's include some of these ideas in our shortlist of how to improve local services
RG       OK, maybe
GS       Good - but we will have to start about doing things very differently
MF+RG There's a lot more meetings before we can decide

THIS WEEK

Week 2: meeting 1 - national campaign coordinator, Smita Chatterji
GS       What do you think of our idea for expanding greencare access for severely affected MH populations?
SC       It's just what should be happening, what's the problem?
GS       We've been stopped from doing it by the NHS managers.
SC       Find a friendly local councillor - they should love it. Failing that, an MP. It is what the CCGs should be commissioning nowadays.

Week 2: meeting 2 - national commissioner, Dick Wenniford
DW      Why don't you give up trying with that lot? You have been banging your head against a brick wall for many years now.
GS        Because I believe in it, live here, and am very loyal to my own area - and once they realise, it will actually save them money and give a better service
DW      You may kill yourself in the effort.
GS        But there's a chance it may just get better - we're having a new chief executive soon
DW      Can we help from the centre?
GS        Probably not.

Week 2: meeting 3 - international conference with famous keynote speaker (KN) and subsequent tea party with Sicilian colleagues (SC)
KN       Yes we agree about most things, and there's not much hope that the Government has 'got it', in the way we need things to be - like epistemics
GS        Just why don't they get it?
KN       Good question...
SC        Are you residential?
GS        No - the community is in the head - not the buildings or the leader or the staff.
SC        That is so obvious and so cheap. Why are there not many more of them?
GS        Hard to say. Just why don't they get it?