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On psychology getting its priorities right

Well, it’s been a year since I last blogged, and frankly that’s probably a good thing. I had anticipated a reduction in productivity and so it came to pass. 2017 turned out to be a year in which I changed job several times, moved house and watched two people die, so it’s fair to say it was eventful. Oh and I got a kitten, who is sweet and funny and of whom I am very fond, despite the fact that she constantly gets in the way and that I now get absolutely no peace in my own house. So all in all, keeping my head down – relatively speaking – was probably necessary.

I write this as I journey to Cardiff. My only blog of 2017 was written shortly after a trip to Liverpool, technically because I was speaking at the UK’s main clinical psychology conference, but mainly because I and some friends had organised our own (not exactly rival but not exactly not rival) events: a fringe festival bringing mental health and the arts together, and then a one-day conference looking at psychology going ‘beyond therapy’. Cardiff is the venue for this year’s events, both the main conference, which I’m not going to, and the fringe events, which I am proud to be a small part of.

I think it’s important to be proud of your contribution to your profession. Not in the way that many of us are – considering ourselves experts; getting caught up in the arrogance that can pervade; judging people based upon their academic output – but of the important stuff. Of going to work and doing what needs to be done to help people. Of using the knowledge and skills you have to try to bring psychological ideas to new audiences. Of doing it all in a way that tries make things better. The small things that are really the big things. Often unsung, but vitally important.

I am privileged to do what I do for a living, and I am privileged to know so many people who go above and beyond to try to fly the flag for better health and social care services, and who critique the policies that cause so much damage. Almost all of these people do huge amounts of work – usually for no money and very little in the way of glory – to do these things. Our profession is stronger for them, and lucky to have them.

So I am very dedicated to the profession of clinical psychology. But sometimes I have real concerns about other psychologists. And this past week has brought that to the fore.

A week ago a new document was launched looking at an alternative to psychiatric diagnosis. This blog is not a review of that document, because it’s 400 pages long and I haven’t had a chance to read it properly yet. The principle tenets of this framework are as follows:

And when I’ve finally read it I might write something on it, but there are plenty of people cleverer and better-read than me who will likely do a better job. And 400 pages is no small task. It was actually my planned train reading but I only got to page 18.

I have no major problem with the framework, though I don’t believe diagnosis is going to fall overnight, and I don’t know how health, social care or welfare systems would operate if it did, so I’m not getting too excited just yet. And it does strike me as interesting that a team of white professionals has written a 400-page document talking about power – and, whilst there was a consultancy group, consultancy is not the same as authorship and as a brown Muslim woman I absolutely own my response to that defence – but in the main I’m interested in seeing what impact this framework has on policy, because that’s where it needs to take root.

I do have a problem with the reaction of my fellow professionals to the same document. People who dislike or disagree with the framework have pulled it to pieces and questioned why it was ever written. Now, sure, pull it apart – we need to critique ourselves and our practice – but to denounce it as heresy is unhelpful, particularly if you don’t have the courage to write your own alternative framework. Being catty on Twitter is undignified. It does all of us a disservice. We should be better than that. It’s not that I can’t see why people might be sceptical – when my patients need the be signed off work their employer needs a diagnosis. So does their insurer. If they have OCD or a specific phobia it’s probably helpful to be able to give it a name, because talking about intrusive thoughts and compulsions is all a bit psych-speak for most of us. Labels and names and categories have their uses and we can’t lose sight of that. But there are diagnoses which are very harmful – I speak here of ‘personality disorder’ – and we do need to think very carefully about how we move away from decades of iatrogenic harm based upon a label that tells you that you are defective to the very core. Perhaps, then, trying to look at the whole spectrum of human distress within one framework – even one that’s 400 pages long – isn’t the ideal place to start. But there are ways of saying it, and a substantial number of people haven’t demonstrated much understanding of that.

People I would consider to be quite eminent – by which I mean long in the tooth – have been hostile to the point of vitriol. The authors have been attacked in a most unpleasant way. Clinical psychologists (thankfully very few of them, though) have used Twitter as a platform to call those who disagree with them – including people who use mental health services – stupid or unenlightened. The word ‘stupid’ has actually been used. It’s gone so far that I and some similarly perturbed colleagues had a look at the social media guidance provided by our professional and regulatory bodies. Someone else has grumbled about it being our new professional ‘policy’. It’s nothing of the sort. It’s a model; a construct; not an ultimate truth. You’d think people trained as social scientists would understand that notion. Instead, we’ve had people saying things like ‘Not in my name!’, as though the the document was tantamount to the dodgy dossier which led to the Iraq invasion. It’s ridiculous, and its unprofessional, and it makes me ashamed.

Psychologists – particularly of the clinical variety, it seems – have really got to up their game. We lord about declaring ourselves to be reflective and able to consider a range of perspectives and then we act like this. It’s a disgrace. But it’s also the wrong battle to be fighting.

Today some data was published showing that in poorer parts of the UK life expectancy is decreasing for the first time since 1945. This appears closely linked to cuts to health and social care, as well as welfare changes. The decrease has only been observed since 2011. It’s not hard to make the link. But has there been a social media furore from my colleagues over this? Was it mentioned once in any presentation today? Was it ‘eck. But this is what we need to be talking about. These are the battles we need to fight. Not squawking about changes that might or might not affect policy over the next decade; shouting and stamping about the people who are dying now.

I simply don’t understand why more of my colleagues aren’t beating the same drum. Sure, my perspective is heavily coloured by my demographics and the experiences that have come with them, but surely even the most privileged person must understand that the basics of food and shelter and dignity keep people level. Not entirely level, but they make a good start.

Really what I’m saying is that I have been profoundly disappointed by some of my colleagues recently. And if I’ve been disappointed goodness knows what the public has made of it. And we have got to change. Not just for the sake of clinical psychology but for the rest of society. If we don’t wake up to that we’re going to perish. And that really would be a shame.

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On five more years of a Tory-led government

As an NHS employee, I’m meant to have been in purdah since the dissolution of Parliament. I probably didn’t do purdah very well – people like me tend not to. Now the election is over I assume I can say what I like (though obviously nothing I say is ever anyone’s view but my own).

I began working in the NHS four years ago, when I started doctoral training. Before that I was on an NHS placement as part of my Master’s degree. Before that I worked for a charity and before that in a specialist NHS personality disorder unit (the only one of its kind in Europe).

In my non-work life, I am a charity trustee. It’s a young charity – only five years old – and it aims to help those in poverty. We give grants; we fund a food bank. It horrifies me how many people use that food bank.

I am, as you will gather, a believer in collectivism, in socialism, in giving a damn about your fellow citizen. So obviously I have watched the dismantling of the public sector (and health and social care in particular) with a growing sense of fury.

I have seen people who have been homeless for years, despite having children, because they were declined for re-housing. I have seen people fall between two boroughs and there be a tussle over who needs to help them (and pay for that help) because of the way services are now commissioned. I have seen people with no food in the cupboards and no money to buy any. I have been told that Social Services ‘can’t see anyone until the new financial year’ because there’s no money. I have been told that unless you can pay £18 an hour for care you can’t have any because the budget is all gone.

And these are just my stories. My colleagues will tell you of people who can’t come to clinics because they can’t afford the bus fare; of people whose HIV treatment is ineffective because they can’t buy enough nutritious food to maintain their immunity. People are dying every day because of these gaps in the system, and that’s without taking into consideration the massive increase in suicides.

I confess I wasn’t that hopeful that the manifesto pledges related to mental health would come to much but I did think that a Labour government would at least turn the tide and end this dreadful privatisation and commodification of healthcare. I felt pretty positive – not an outright win, but maybe a Labour/SNP coalition which scrapped austerity (and Trident with it). The BBC coverage last night was as patronising as ever and I soon gave up, although not before I had seen that awful exit poll. I went to bed, hoping it would be ok.

It wasn’t.

In the office today, all the talk is of the end of the NHS, the collapse in living standards, the impossibility of being able to find affordable housing. On Twitter, it’s the end of the union, the lurch to the right, the need for electoral reform. And in truth, I feel absolutely broken.

In 2010 I had some hope that the Lib Dems would moderate the Tories. They didn’t, or, at least, not enough. Mental health services have been battered while the need for those services has shot through the roof. Our services are being crushed in a way that physical health services are not. I work with older people, already marginalised and seen as lacking value – the rhetoric is ‘get treatment so you can get back to work’, but someone who is 86 with dementia probably won’t be doing that, and in this political climate their value is constantly questioned because there’s no economic case for looking after them well – and sometimes it’s difficult. All mental health is sometimes difficult, as all health is generally – we tend to see people who are ill or in pain and we try to help them. Sometimes we can’t – I can’t magically take dementia away, or stop you from getting older, much as I sometimes wish I could. But I try to do what I can to make life that bit less hard. All my colleagues do – whatever lies you are told, believe this: some of the kindest, most decent people I know work in health and I am proud to know them and have them as my colleagues. Believe this too – we can’t create a beanstalk without beans. We can’t help you without the necessary infrastructure and support. Some of the people I see will get better; some won’t; some will learn to manage better; some won’t. We can’t work miracles. But I love my job and my patients and I do my utmost, as do my colleagues, to do the best we can for them all.

But we can’t do it alone. We need politicians to support us and our patients. We need them to understand the causes and impact of poverty; to understand that living in crap housing on a volatile estate is bad for mental health; that caring for parents and partners places untold strain on people; that people with dementia are entitled to as much help as people with cancer. We need them to understand that we can’t look after more people properly unless we have more resources. We need them to understand the feeling of helplessness that can arise when you go to see someone and you can’t do much for them, because they need a social care package but you can’t get one because there is no money and all you can do is watch them cries tears of despair and try to support them in any way you can, no matter how feeble your attempts to do so seem.

This morning, I can barely contain my fury and my dejection. I don’t know what health and social care will look like in five years but I don’t believe it will be good for staff or patients (and I’m going to say quite bluntly that if you don’t take care of your staff they will not be able to take care of your patients. We’re sort of vital for good outcomes, in the same way that teachers are vital for good education).

So desolation is the word of the day, it seems. But the good thing about fury is that it can be harnessed. They only win if you let them. So let’s fight them – their injustice, their self-interest, their demonization of the poor and the vulnerable. Farage and co might question my Britishness (what with being Asian and all), but, dammit, I refuse to live in a Britain which screws the many over for the benefit of the few. I am very fortunate to have some good friends and colleagues who believe in the same principles as I do and who are willing to speak out against it. So we recover from the shock (sadly no awe) and start again. We write and we protest and we ask awkward questions and beat our little fists. And it might not be effective, but that’s not the point. Because what a certain breed of Tory fails to realise is that some people care more about societal good than their own back pockets.

So. A principled, angry army of psychologists, medics, liberals, lefties and assorted others is mobilising. I don’t know what it’s like to be at the bottom of the pile, but, for all those people who are frightened of what the future holds, know this: there are people out there who care and who are committed to doing our best to fight with you, because it is the right thing to do. We might not win, but we certainly won’t go down without a damn good fight. And if we lose, we lose together. Because that’s all that matters – that we stand together; that we support each other and that we try to create a fairer, more equal society. You are not alone.

On Nick Clegg’s promises of extra funding for mental health

This piece was originally written for the press and is due to be published later this month.

With a little over seven months until the General Election, all parties are gearing up to charm the electorate. A repeat of the hung parliament of 2010 is unlikely to be the ambition of any of the main parties, and it certainly doesn’t seem to have been terribly popular amongst the electorate.

Thus it was that I followed Nick Clegg’s speech on mental health provision at the Liberal Democrat Party Conference with interest. Having spent several years working in a range of mental health services, I applaud the fact that it is clambering up the political agenda, if rather more slowly than I would like. On the face of it, then, the content of his speech was positive: 75% of people referred for difficulties such as low mood and anxiety will be seen within six weeks; all those referred for psychosis will be seen within two weeks, funded with £120m over two years. Mental health charities were enthusiastic, but a closer look reveals rather more.

Nick Clegg’s party has been in government for over four years. In those four years it has privatised healthcare, including vast swathes of mental health. It has drastically reduced funding for social care and support services. It has slashed Housing Benefit and, courtesy of Workplace Capability Assessments, terrorised those on benefits. Its policies have led to the poor and the disabled being demonised by the media and the public at large. It has cut the number of beds available for people with mental health problems by 10%. It has presided over people being ferried halfway across the country for acute admissions because inpatient units are at breaking point. It has cut funding to such an extent that recruitment has been frozen. In my own profession of clinical psychology, this is especially evident: I know of services in which the waiting time for an assessment is nine months. Austerity is bad for our mental health: our waiting lists are increasing at exactly the point at which our capacity is reducing. Nick Clegg’s government has been implicated in every bit of this wretched tale. In short, it has decimated the mental health system and ridden roughshod over those who require it.

Having spent four years watching this sustained assault on mental health services, I see no reason to be enthused. Clegg’s proposals relate to waiting times; nothing has been said about how clinicians are meant to meet those targets without a sustained recruitment drive. We have limited capacity; we can’t simply see more people because Mr Clegg tells us we ought to. We can’t do more, with less. Mr Clegg is no fool: he is well aware of this. But he is also leader of a party which is likely to be decimated at the coming election. One can hardly blame him for trying to appeal to the electorate. I just wish he wouldn’t make promises which he will break to a group he and his peers have systematically persecuted over the past four years.

On the impact of cuts in MH services and the myth of ‘parity of esteem’

This piece was originally written for publication in the press and is due to be published towards the end of the month. I have taken the liberty of reposting it here.

When I’m not writing, I work in mental health. Mental health has always been the poor relation to physical health but it is clear that the disparity between the two is increasing exponentially. Although the public sector as a whole has had to tighten its belt since the economic crash that we, the public, didn’t cause, the NHS has been particularly vilified and, courtesy of the Health and Social Care Act, effectively privatised. Our budgets have been slashed and our workforces depleted. Although there have been some cuts in physical health, the fact remains that no government which aims to be re-elected is going to restrict the care given to people with cancer or heart disease. In the great hierarchy of illness, these people are top of the tree. In contrast, the people I work with, who are amongst the most vulnerable in society, are seen by successive governments as unworthy and ignored.

Since 2005, 30 000 people have lost social care support. 2000 mental health beds – 10% of the total – have been lost in the last two years. I have worked in wards which are running at 120% capacity, so God help you if you require an emergency admission, because it’s quite likely that you’ll be shunted off to a hospital several hundred miles from your home and your family. People with mental health problems are often already stigmatised and may lack social support. To ferry them across the country, effectively cutting off contact with their family and the professionals who know them is an outrage. Imagine the same happening in physical health. Imagine being told that your sibling, who had had a stroke, was being sent 250 miles away because there were no beds any nearer. You wouldn’t stand for it. I wouldn’t stand for it. But we make those in mental health services stand for it and because they are often unable to advocate for themselves it is allowed to continue.

Services aimed at young people have also seen swingeing cuts. Recent figures indicate that staffing levels in these services are only half the recommended level; as a result hundreds of under-18s are being treated in adult psychiatric units. Psychiatric wards can be confusing, frightening places even for adults. They are entirely inappropriate for children. Such an event should take place only in an extreme situation; for it to occur routinely is reprehensible.

In January Nick Clegg declared that there was too much ‘ignorance, prejudice and discrimination’ directed at people with mental health problems. He said that it was imperative that services were valued equally. As I write, it is being reported that mental health services have been asked to cut their spending by 20% more than physical health services, despite the fact that mental health services deal with 28% of the NHS disease burden whilst existing on 13% of the budget. Our services are crumbling; our clinicians are burning out. Lives are being put at risk and as things stand, we are hurtling towards a mental health crisis of gigantic proportions.

In which I am furious at the Sun for promoting stigma against those with mental health problems and I shout at the Government

I have been meaning to blog for ages. I recently went to a very interesting conference in Copenhagen and spent three days discussing personality disorder, which is one of my primary clinical and research interests. Unfortunately, I’ve been incredibly busy and it’s had to fall to the bottom half of the to-do list. I thought I would make an extra effort today, however, since it is World Mental Health Day.

This seems an apt time to consider some of the issues which persist in mental health. There is the very concept of ‘mental illness’ of course, the battles between the pro- and anti-diagnosis camps, the bickering over effective treatments; all stuff that often goes on in the ivory towers that some of us inhabit. I have always believed that there are two main issues which really affect people with mental health problems and their families: stigma and funding.

i think we’re often quite proud of the way we have come to acknowledge mental health issues in this country, and, to some degree, rightly so. But often success is only lauded because it comes in a sea of perceived failure. So when MPs talk about their mental health problems in Parliament I am pleased, but the very fact that it is such a big deal suggests we still have a long way to go before we truly have an open discussion about the prevalence and impact of mental health problems.

On Monday, the Sun ran this front page:

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‘1200 killed by mental patients’. Now the term ‘mental’ went out of use many years ago amongst those us who have some compassion and humanity. News International publications are not, if you will indulge me, known for either their compassion or their humanity. Despite the story admitting that most people who have committed serious violence in the context of a mental illness, the headline will do nothing to eradicate the image of the knife-wielding patient (an image that persists, as we recently saw of the Hallowe’en costumes being sold by Asda and Tesco).

So what are the real figures, the contextual ones? Well, here are a few:

– 1.2 million people in the UK use adult mental health services

– 95% of all murders are committed by people who have NO mental health problem (remember Harold Shipman, who killed hundreds of people?)

– Half of all violent crimes are committed by people under the influence of alcohol

– Around a fifth are committed by those who are under the influence of drugs

– People with severe mental health problems are 10x as likely to be the victims of violence as they are to be the perpetrators

– They are also more likely to harm themselves than anyone else: 90% of people who kill themselves have mental health problems

Given that 15 million people in the UK will have a mental health problem at some point in their lives, and that substances are implicated in the vast majority of all violent crime, this witch-hunt against those who are often very unwell is appalling. But let’s take a look at some more stats:

– Mental health services in the UK have had funding cut by £150m since the Coalition government came to power

– 2000 psychiatric beds have been cut in the last two years. No one, not even the Sun, got angry about that. But I know psychiatrists, good psychiatrists, who openly admit that they are discharging people from hospital when they are still unwell just because of pressure on beds. I have worked on wards where there are three people to a bed and you just hope to God that no one has a relapse whilst they’re on leave, because the chances of finding a bed anywhere in three boroughs is so slim.

– Mental health NHS trusts (which are distinct from physical health, as a general rule) have lost up to 20% of their staff since the cuts came into force. These cuts affect everything from secretarial support to the number of social workers and psychologists available to see those who need such intervention.

– Some of the areas most significantly cut: crisis resolution, early intervention, home treatment teams. In short, the very people who take care of those in crisis; the very people who can intervene if they see that risk is escalating. But they can’t, can they; not when they have caseloads of 60 or 80 people. As someone who works in community mental health services, I tell you this: it is impossible to look after that many people who present a moderate risk to themselves or others and to do it well. As the cuts take hold, services have increased their thresholds and increasingly, only take those deemed to be at high risk. 80 high-risk people cannot be managed by fewer than 2 professionals, and even then they will need intervention from other members of the team.

The fact is this: mental health services are buckling under the strain. Staff are overworked and under-resourced; many are simply burning out. It doesn’t take much intuition to realise that in a job which requires you to deal with people who often have complex needs, this is unsustainable. Newspapers could do a terrific job, if they could be bothered, of putting mental health on the agenda in a positive way. They could get angry about those people who are being denied services they need, not because we don’t want to provide them, but because we simply haven’t the resources to do so. They could make services better for the one in four of us who will have mental health problems – your brother, you best friend, your partner, your mum, your neighbour, your child. They could, if they wanted to. But, like so many others, they simply add fuel to this ghastly fire which means that those with mental illness are further stigmatised, further dehumanised and increasingly seen as the ‘other’.