What's psychosocial reductionism?

Allen Frances has clarified his position on psychiatric diagnosis in his Saving Normal series on Psychology Today (see article). Although he's been critical of DSM-5, in response to Lucy Johnstone, he makes clear that, for him, the biological model is essential and that neuroscience has been "enormously successful in helping us understand normal brain functioning and that over time, in very small steps, this will result in better understanding of abnormal brain functioning". However, he doesn't explain what he means by this.

And he doesn't seem to understand the meaning of reductionism. Reducing the psychosocial to physiological processes is what psychiatry does all the time. I'm not sure how the psychosocial can be reduced to the psychosocial. Presumably Frances is suggesting that the psychosocial is a simpler form of something more complex, but is it?

Reinvigorating community mental health care

It's worth looking at the article by Peter Tyrer in The Psychiatrist on community psychiatry in the context of today's report from BBC News and Community Care about what they call the crisis in mental health care. To quote from Peter's article:-

The general mantra of ‘community psychiatry good, hospital psychiatry bad’ has … led to the neglect of the proper function of in-patient care, a combination of asylum and rehabilitation. …[A] fundamental wish to improve patients’ autonomy is being removed by an overbureaucratised system of community care that is obsessed by risk, and in danger of promoting greater institutionalisation by a complex regulatory framework that denies the flexibility that is essential to good community psychiatric practice.  

Where in the UK community psychiatry used to be flexible, adventurous, creative and bold, with the many changes imposed from policy managers in recent years it has become constricted, controlled, limiting and self-serving. Autonomy for practitioners has almost entirely disappeared and been replaced by a rigid system of care that leads to patients encountering a bewildering number of health professionals, who carry out specific regimented tasks but who rarely have the chance to develop meaningful relationships with the people they treat.

His solution is to remind ourselves of the core principles of good care:-

1. if good facilities are available for patients to be treated outside hospital, they should be used as much as possible;
2. if a hospital bed is necessary it should be available when required and should be as close as possible to the patient’s home; hospital should be able to serve as a place of refuge and respite as well as a treatment centre;
3. continuity of care may not always be possible but should be striven for as a matter of principle, and all community teams should stay in touch with their patients no matter where they are placed;
4. individual or team-based treatment both have merits and their choice should be determined in collaboration with the patient and his or her carers, and maintained irrespective of treatment setting.

He goes on:-

This can only be achieved by allowing greater autonomy within teams to maintain priorities, reducing the size of the catchment area for each team so that they do not become overwhelmed and depersonalised in their attitudes.... [M]orale [needs to be raised] of a service that has been relegated to the backwaters of care for too long. 

Increase in patient suicides has followed introduction of CTOs

The headline for this piece is deliberately tongue in cheek. It's not supposed to imply that the introduction of community treatment orders (CTOs) has led to an increase in suicides, although, of course, I am aware that this is how it could be taken. It's just that the latest report from the National Confidential Inquiry (NCI) into Suicides and Homicides by People with Mental Illness has implied that CTOs have reduced homicides. I just thought it important to point out, if that claim is being made, that CTOs have not reduced suicides. In theory, CTOs could have either increased or decreased deaths by suicide and homicide. And NCI expected CTOs to have a greater impact on absolute numbers of suicides than homicides. Or maybe it thinks the increase in suicides would have been a lot worse without CTOs.

To be clear, what the report points out is that homicide by mental health patients has fallen substantially since a peak in 2006. This might not have been obvious from recent headlines in The Sun (see previous post). The report goes on to say that one of the clinical explanations may be the introduction of CTOs in 2008.

The report also notes that the number of patient suicides increased in 2011. Although the figures are provisional because the data is incomplete, a higher number of patient suicides is predicted in 2011 than in recent years. There's no speculation that this is due to CTOs; instead the "rise probably reflects the rise in suicide in the general population, which has been attributed to current economic difficulties".

After all, it was NCI that argued for the introduction of CTOs to reduce homicide and suicide. It even went as far as to predict in Safer services that 30 suicides and 2 homicides would be prevented each year. A later report, Safety first, increased that figure to 32 suicides and 3 homicides. The trouble is that the logic used to produce such estimates did not stand up, as all NCI did was assume that CTOs would prevent deaths and then produce figures based on this premise. The fact is that whatever figure was produced is not evidence of the value of CTOs, as it was only an estimate assuming they were going to be effective. Maybe that's why the latest report latches on to the reduction in homicides. NCI needs some evidence to justify its previous speculation, which it couched in pseudoscientific terms. But, of course, this isn't evidence as such because there are all sorts of reasons why the homicide figure may have gone down, in the same way as there are all sorts of reasons why the suicide figure has gone up.

Irrational homicide risk management

The Sun has been taken to task for producing the front page headline that 1200 people have been killed by mental patients in the last 10 years (see Guardian and New Statesman articles). The Daily Star had a similar report. This article quotes from Marjorie Wallace, whose intentions, I think, are to improve funding for mental health services, but her campaigning on behalf of her mental health charity, SANE, has, in my view, actually undermined services.

She complained to The Sun that a failure of communication between one agency and another has been found in 90% of homicide inquiry cases. But, communication is not perfect in everyday practice. In fact, it is commonplace for staff to have to cover 'gaps', such as not having complete information. Such imperfections are usually managed without adverse consequences.

The question is whether such homicides really reflect failings in Britain's mental health system. There has certainly been overreaction in some homicide inquiries, which do not always apply accountability sensibly. It is a phantasy, which we need to disabuse ourselves of, to believe that mental health services can have absolute control in preventing homicides by their patients (see my unpublished article and associated conference presentation). I'm not saying services don't need to be improved, but attacking them for homicides by psychiatric patients is not always the best way to improve them. Political motivation should have nothing to do with sensible risk management.