Month: April 2014

On advertising psychiatric drugs, or how van Gogh could have kept both his ears

It’s no secret that psychiatry (and psychology, come to that) has a blemished history and that our forbears have been responsible for many crimes against humanity. It’s difficult, in an age of medical ethics and patient involvement, to consider what it must have been like to have been subject to treatments such as trepanning and lobotomy, and I know that many modern-day professionals wrestle with the treatments with we continue to prescribe and provide, even though we tend not to force people into submission. One significant exception is Sectioning, however, which effectively removes an individual’s rights and, depending on the type of Section (named so because the conditions of detention refer to specific sections of the Mental Health Act), can compel people to be treated, whether they consent or not. This perhaps merits a blog post of its own, but, regardless, it will be apparent that the concept of treatment by compulsion is fraught with dilemmas. However, as a general rule, we try to give people the right help and to only do what they are happy for us to do.

 

As a psychologist, I do not prescribe medication and I struggle with the notion that psychological distress can be cured by a pill. Some medications may reduce ‘symptoms’, such as we think about them, but I’ve never taken the view that all ‘mental ill-health’ is the result of chemical imbalances. Sure, there is may be an association between dopamine levels and what we call ‘psychosis’, or between serotonin and that which we term ‘depression’ but my clinical experience leads me to believe that difficult experiences are often implicated in suffering. Early adversity and trauma tend to have long-lasting effects; many of them profoundly negative. Big Pharma, of course, peddles the theory of chemical imbalance and their tactics are, whilst hardly subtle, rather dubious. Drug company-sponsored lunches at hospitals and medical schools are common, and lots of clinicians have offices containing freebies, though usually they’re nothing to get excited about. In addition, drug companies market their products like any other manufacturer would, although anti-psychotic medication is, of course, rather different to a top from H&M. This is a fairly typical ad for an antidepressant drug, although it’s a little old:

 

The premise being ‘take this and you’ll enjoy life. The insinuation, therefore, being ‘don’t take this and you won’t enjoy life’. In the UK such marketing is permitted only in specialist publications such as medical journals, although there is research which suggests that the more a drug is marketed the more likely it is to be prescribed. In the US, on the other hand, marketing regulations are rather more lax and it wouldn’t be unusual for the public to come across such things on public transport, in magazines and on television. Unsurprisingly, patients often go to their doctors asking for particular medications. It’s a bit of a minefield, frankly.

 

So far so standard. Over the weekend, though, I came across a couple of adverts on Twitter which made me deeply uncomfortable. They were tweeted by @psychiatrypics and, frankly, they didn’t go down too well with the social media collective. Exhibit A:

 

 

Ludicrous to describe bipolar disorder, characterised by extreme highs and lows in mood, as akin to ‘war’ and offensive to suggest that ‘peace’ can only come in the form of a pill. Stigmatising as well, to suggest that everyone who has such highs and lows would necessarily want and need medication; that one could not live normally and well, despite such fluctuations. Hugely powerful, nevertheless. Exhibit B, then:

 

 

A more abhorrent load of tosh I could not imagine. There are so many things wrong with this I barely know where to begin. Let’s start with the facts. van Gogh died in 1890. The term ‘schizophrenia’ was coined in 1911 by Eugene Bleuler, although its linguistic  predecessor, dementia praecox, was in use in the early 1890s.  Regardless, van Gogh never received a diagnosis of any kind and it is crass and unhelpful to diagnose him posthumously. He was obviously a troubled man, but a troubled man who created some of the greatest art the world has ever seen. To assume that a tablet would have stopped him being troubled (look at his lovely smile!) is nothing more than marketing hocus pocus; completely impossible to prove one way or the other. And then there is the small matter of the fact that, had it not been for the fact he was a troubled man, we might never have had a self-portrait to begin with. We might never have had Night Stars or Cafe Terrace, two of my favourite paintings. Yes, van Gogh was touched by things which were obviously painful; he was also touched by genius. Perhaps those attributes could only exist in tandem. Perhaps Zeldox would have calmed the things which tormented him but we will never know for sure. To suggest that it would have prevented him cutting his ear off trivialises his suffering, and that of all those who are similarly troubled. It  is offensive, and, because of the implicit promise it makes to people who may be in deep distress, and those who care for them, it is manifestly dangerous.

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On the mental health of gay women (and how little we know)

One of my clinical interests is the mental health of people who identify as lesbian, gay, bisexual and transgender. It is also one of my research interests, but unfortunately I haven’t been able to conduct any research into the area yet (hopefully that will happen post-qualification). We know broadly speaking, that people who are LGBT tend to experience stigma and prejudice, that HIV, for example, can result in psychological difficulties and that young LGBT people are more likely to self-harm and to attempt suicide. Mental health services are also not always set up to listen to the experiences of sexual minorities. It all says much about mental health provision, and it doesn’t say a lot that is positive, to be frank.

 

Happily, there is less stigma surrounding sexual orientation these days, but it’s patently obvious that all is not rosy. Nevertheless, sexuality is at least now debated in the mainstream media without too much vitriol. I came across two articles last week, both in broadsheets. One was about the prevalence of sexual assault on the gay scene; the other was about notions of ‘campness‘ and internalised homophobia. I found Strudwick’s article more thought-provoking, I must confess, but that’s because I have debated what it means to be ‘camp’ several times with several people. Strudwick’s writing revealed something that had previously been unknown to me.  So far so good. But both articles made me think.

 

Strudwick and Jones are both gay men, and both their pieces were about gay men, which is fair enough. Reading them, though, I realised how much more ‘visible’ gay men, and gay male ‘culture’ (as though it is a homogeneous beast) is. Neither piece acknowledged females, but, then, why should they, necessarily? They were specifically about gay men and their experiences. I wouldn’t expect gay men to write about gay women, particularly, but I found the notion thought-provoking nevertheless. The fact is, I don’t know that I’ve ever come across any articles in the mainstream media which address these topics amongst women.  I realised that I have no idea whether there is sexual assault amongst gay women. I don’t know whether ‘butch’ and ‘femme’ are seen positively or negatively, or whether they are tinged with shame or homophobia. I don’t know if there is an ‘ideal’ for gay women. I know that I have seen women who are gay or bisexual professionally and that for some sexuality has been something that they wanted to discuss, in the same way that some gay or bisexual men have wanted to do so. But other than that, I am pretty ignorant. So I asked someone I know and had a look at the research findings. And what, you may ask, did I learn?

 

I learned that if you search for ‘lesbian mental health’ on Google Scholar you get this. You get pages and pages of results talking about lesbian and gay populations, and lots about lesbians, gay men and bisexual folk, but, of the first sixty, results, only half a dozen or so focus exclusively on gay women. Most relate to victimisation, satisfaction with mental health services or, in one case, compared gay women to their heterosexual sisters. Most of the papers were from the 1980s and 1990s; the most recent was published in 2008.

 

This struck me as extraordinary. We know that gay people often have a tough time, not because they are more vulnerable to mental health problems per se, but because we live in a culture in which they continue to face stigma and oppression. We know that up to 10% of the population identifies as non-heterosexual (the precise figure depends on the survey). If you search for ‘gay men mental health’ you get 350 000 Scholar results; all of which talk about gay men. Yet my search for data relating to gay women turned up 109 000 results; the majority seeming to be about all gay and/or bisexual people. Is it the case that gay women are happily immune to the difficulties which seem to be prevalent amongst gay men? Perhaps, but I wouldn’t be so sure. Is it the case that female sexuality, often glossed over across academic disciplines has been also woefully neglected in mental health? Quite possibly. The absence of research into the are certainly suggests that’s a possibility. And the critical question for me, as a clinician, is what does this mean for gay women who are struggling with their mental health, whether or not it is related to their sexuality? Gay women are rather more invisible in popular culture than their male peers, but there’s little mention of it; much less any outcry. We create mental health services targeted at gay men and the problems they may present with. I don’t know of a single similar NHS service for women; and as far as I’m aware, provision in the voluntary sector isn’t much better. If the research isn’t there, we don’t know what the problems are, if any. If we don’t know that we can’t provide appropriate services. But it’s also about value and whose voice is worth hearing; whose story is worth exploring. I don’t know if the mental health of gay women is something enough clinicians and academics are concerned about. There are cultural and historical reasons that have resulted in gay men’s mental health being studied and it is a good thing that we have made progress in that area. But it is possible to be gay without being a man and I don’t think we’ve got to grips with what that can mean for people; the way that being a gay woman is often akin to being a minority within a minority. Being a minority, of any kind, is rarely easy. If there are gay females out there who could benefit from input from mental health professionals, but who are not getting it, the fault is ours. But by that token, responsibility for doing something about it also rests with mental health professionals, and that will require us to start valuing the experiences of a group which has been heretofore neglected in both the scientific literature and in our collective professional mindset.

On the misuse of psychological therapy for dastardly ends

I have grumbled at length about the endless list of psychological therapies available and my feeling that many of them serve the interests of their inventors, as it were, more than the interests of the people who need some help. Similarly, I have written elsewhere about what distinguishes a psychologist from a psychiatrist. Of course, they’re not the only folk who reckon they can help if you’re having a tough time; lots of other people will happily have a go at helping, although they generally ask that you cross their palm with silver from the outset. There are counsellors and therapists and life coaches who will vie for your custom and they are all eminently Googleable (and many are very, very credible). It’s probably difficult to discern what differentiates any of these from the others and to understand what makes them different from psychologists. I have no expertise in this, so I will leave it to you to Google it if you wish, although I certainly can’t guarantee clarity. My concern is about the lack of regulation amongst these people, all of whom tell you they can make your life better. As someone who has more expertise in psychology, I shall write of what I know.

 

Until recently, anyone could claim to be a psychologist, whatever their qualifications or lack thereof. A couple of years ago that changed; now ‘practitioner psychologists’. such as clinical, health or educational psychologists, have to be registered by the Health and Care Professionals Council. If I want to practise as s clinical psychologist or a forensic psychologist or an occupational psychologist, I have to register with the HCPC. Unfortunately, for reasons that I don’t really know, the term ‘psychologist’ in and of itself is not protected. So all those people sitting on bright red couches on daytime television who tell you they’re psychologists? There are no professional standards by which they have to abide. They can tell you they did a course in any kind of chicanery and that they therefore have some expertise and you can’t do a great deal about it. The only time that you might be able to do something about it is if you find yourself in the sort of position Patrick Strudwick found himself in when he went undercover to find therapists providing reparative therapy to gay people (full details here). The therapist was struck off by her accrediting body (Strudwick had her on tape stating that he had ‘probably’ been sexually abused as a child and that this way likely why he finds men attractive) but, because ‘therapist’ is not protected, she simply registered with another body which is quite content to let people peddle ‘gay cures’, which are ineffective at best and downright dangerous at worst, never mind the ethical issues. Outraged? You should be.

 

Some time ago, I had a patient referred to me with OCD. Put simply, she was tormented by intrusive thoughts that she either had or was about to harm someone. Like a lot of people, she searched for private therapy and paid a fortune for it. This person’s style of therapy? They asked their patients, in groups, to hold knives against each other’s throats. They also asked those people to walk around town, on a day-to-day basis, carrying eight-inch kitchen knives in their bags. I have rarely been so horrified at another ‘professional’s’ practice. Obviously I researched this person. They had precisely no qualifications in psychology, medicine, psychotherapy or counselling. None. But they run a service which charges a fortune and none of their employees seem to have any recognised mental health qualifications either.  What they are doing is not regulated, nor is it bound to adhere to any kind of guidelines. There is no indication that the ‘treatment’ on offer is based on the best available evidence.  The testimonials appear to have been written by people who were desperate, and desperate people will often pay a fortune for any glimmer of hope.

 

I’m not a Philistine about these things: I accept that other professions can offer valuable input to distressed people and that sometimes psychology is not the best approach. But often it is a very good one. I believe patients should get what they need, but I am fiercely protective of them and cannot abide the idea that they are being exploited by someone who may well do them immense harm whilst invoicing them for fantastic sums. Putting a knife against someone’s throat? What if it had slipped? Carrying a weapon in public? What if she had been searched? There are consequences to that kind of thing. Of course, the fact that this person came to see me after she had paid for private therapy tells you all you need to know about how successful that therapy was. I don’t claim we eliminated the problem; but she certainly wasn’t putting herself and others at risk in the process of our work. This, though, is how such people earn a living. They seek out those who are at the end of their tether and they sell them nothing more than snake oil; albeit with an enormous mark-up. And there is nothing, nothing at all, we can do to stop them.