Friday, September 11, 2020

“[P]ast 20 years have not been good for the quality of care [in mental health services]”.

BJPsych Bulletin
has an interview with Tom Burns, who I have mentioned previously (eg. see previous post). He talks about the OCTET study on community treatment orders (CTOs), which I have also discussed before (see post). Personally I think CTOs should never have been introduced (see eg. another previous post) and Tom now thinks he made a mistake in promoting them. It always strikes me as ironic that there used to be so much concern that a few detained patients were being kept on S17 leave too long, whereas essentially CTOs provide just such a 'long-leash' arrangement. As far as I can see, the introduction of CTOs has led to insufficient use of S17 trial leave. This almost certainly has reduced the opportunity for arranging informal community care without CTO.

Tom is also critical of DSM-5 (see eg. previous post). He's right to focus on descriptive psychopathology as a strength of psychiatry. He calls it 'diagnosis', which can be misleading because history and mental state examination actually lead to a formulation which includes differential (not necessarily a single and certain) diagnosis and aetiology. Diagnosis should not be overemphasised in psychiatric assessment (see eg. previous post). 

Tom's also right about the fragmentation of services over the last 20 years. Hopefully the community mental health framework for adults and older adults will provide a basis for development but it does need leadership to implement it. Despite what Tom says, I haven't abandoned the use of the term 'patient', although also use the term 'service user', even 'survivor', certainly recognising the importance of mental health advocacy (does he?). Tom rightly expresses concern about clustering, which was supposed to support so-called payment by results, which seems to have been quietly dropped (see post on my personal blog). As he also indicates the overpreoccupation with risk has been damaging (see eg. my unpublished article and talk).

A younger version of Tom Burns sounded more optimistic in an e-interview. He even noted the "sense of excitement and 'importance' of psychiatry" created by RD Laing and how anti-psychiatry made the profession "glamorous, albeit controversial". He's still writing about the history of anti-psychiatry (see previous post and my letter).

(With thanks to Suman Fernando who alerted me to the recent interview)

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