Thursday, October 21, 2021

Do psychiatrists really want to reduce Mental Health Act detentions?

The Royal College of Psychiatrists (RCPsych) is concerned that reform of the Mental Health Act (MHA) will require extra psychiatrists. It has told the Government that proposed changes (see my summary) cannot be absorbed within the existing workforce (see RCPsych webpage). It bases this conclusion on an independent report which it commissioned from The Strategy Unit. 

I’m not surprised by RCPsych’s concerns. The White Paper proposed that detailed Care and Treatment Plans (CTPs)  - for children, young people, autistic and learning disabled people these will be called Care, Education and Treatment Plans (CETPs) - will be put on a statutory footing and must be in place by day 7 of detention and signed off by the clinical/medical director by day 14 and become living documents to be amended and reviewed. The pivotal person to do this work would be the Responsible Clinician (RC), who will usually be a consultant psychiatrist. In its response to the White paper consultation, the government said it would seek to ensure that these new statutory Plans take into account existing requirements round care planning, that they encourage joint working and that there is flexibility regarding the contents of the Plans so that they are truly patient led. The Care Programme Approach is being replaced by personalised care and support planning (see eg. previous post) and I'm not sure if it's clear what impact this is having, and statutory plans need to reflect these changes. The government also said it would work with stakeholders to review the proposed timelines and governance structure to ensure that any statutory requirements placed on staff are aimed at facilitating a culture of high quality, co-produced care and treatment planning for all patients detained under the Act. Even taking the apparent mollification of these statutory Plan requirements following the consultation, the likelihood is that psychiatrists workload will have to increase to meet the demand.

Actually, the analysis by The Strategy Unit estimated that the primary driver for an increase in psychiatrists will be the additional time required to prepare and attend Tribunal hearings. I'm sure the statutory Plans will be helpful for that preparation. What surprised me was that none of the scenarios The Strategy Unit used anticipated a reduction in detentions (and presumably therefore Tribunal hearings), including what the report called DHSC assumed growth. The impact assessment (see previous post) produced with the White paper assumed that investment in the Long Term Plan in crisis teams and community mental health teams would slow historical increases in detentions, independent of MHA changes. It did not present monetised benefits for the proposed changes in the Act, instead using a breakeven analysis to illustrate the amount of benefits per patient required to offset the costs of the policy. For example, a reduction of 2 days in the average length of detention was said to be sufficient. 

The sensitivity analyses by The Strategy Unit and the government are complex and I'm not sure I understand them completely.  I'm not against increasing the number of psychiatrists, particularly for inpatient work. What I would like to know is what the government thinks the impact on detentions will be of a new Bill, but I guess we won't get this information completely until the Bill is produced next year. Is it really assuming that detentions will continue to increase despite the changes in legislation, as The Strategy Unit seems to suggest? 

In fact, I have been arguing in several previous posts (see eg. Doctors have too much power in the current Mental Health Act) that the proposals do not go far enough to reduce compulsion. For example, repealing Community Treatment Orders (CTOs) (see eg. another previous post) would both reduce coercion and probably costs. The government does not want to re-open this issue as it caused so much controversy when CTOs were introduced by the 2007 amendments to the Mental Health Act (see my webpage, now largely defunct). But the evidence is that they have not been effective (see another previous post). 

Fundamentally, the new Act should help reverse the re-institutionalisation of mental health services that has taken place over recent years (see previous post), particularly by reducing the number of secure beds both in the NHS and private sector. There doesn't seem to be much point in reforming the Act if this process does not lead to a reduction in detentions and enforced treatment. I think detentions can be further reduced, maybe even further than the government seems to think they can be, by repealing CTOs, expanding Mental Health Tribunal powers (see eg. previous post) and improving advocacy (see eg. another previous post). I wish RCPsych would engage more with these issues than apparently seeking to block reforms of the Act, which, after all, are designed to reduce unnecessary coercion.

Tuesday, October 19, 2021

Are mental health services exploiting the pandemic?


The impact of the COVID-19 pandemic worldwide should not be minimised. Official counts of death may substantially underestimate true death rates, but even these figures show COVID-19 has killed more than 4.5 million people (see article). The grief and disruption to communities and livelihoods is significant.

Understandably there is concern about the impact on people's mental health, not least because of lockdowns to prevent deaths (see previous post). The COVID-19 Mental Disorders Collaborators have recently published a systematic review in The Lancet of what they say is data reporting the prevalence of major depressive disorder and anxiety disorders during the pandemic. However, there were very few surveys that met their inclusion criteria from low and middle income countries. And, most of the surveys used symptom scales that only estimate probable cases of depression and anxiety. And as the authors say, they assumed the predictive validity of such scales remained constant between before and during the pandemic. However, as they also admit, this assumption has the potential to bias their estimates. To quote from them, "For example, high scores on anxiety disorder symptom scales might reflect a natural psychological and physiological reaction to a perceived threat (ie. the COVID-19 pandemic) rather than a probable anxiety disorder".

Similarly, Rethink yesterday released information (now corrected although not sure if there has been sufficient adjustment) suggesting "Symptoms of psychosis soared during pandemic", and this news story was taken up by the media (eg. The Guardian). It's not clear to me that these figures may in fact be due to an artefact, because of how first episodes of psychosis have been counted (eg. see twitter conversation).

What I want to comment on is how people seem to want to use the pandemic to obtain more funding for mental health services. I'm not saying mental health services are well funded. But data by NHS digital suggests numbers of adults in contact with mental health services is not yet back to pre-pandemic levels (see my tweet). Nor is it clear how extra funding would be used, as psychotropic medication and psychological therapy are not necessarily indicated to deal with the stresses and strains of the pandemic. Mental health services do need to be realistic about what they can do to help people (see eg. previous post).

Wednesday, October 13, 2021

Evaluating ECT effectiveness

Tania Gergel writes a very personal account in BJPsych of the benefits she has experienced from having ECT treatment. She discusses her treatment in the context of the academic literature about ECT and acknowledges that not all ECT recipients have had such positive gains.

I just wanted to pick up what Gergel says about her reasons for dismissing arguments challenging the effectiveness of ECT (see previous post). No-one is denying that ECT can have a placebo effect and I’m not wanting to undermine her faith in her treatment. 

Gergel argues that ECT would not have continued for 80 years if it wasn’t effective. But apparently successful interventions have been removed from medical practice when they have later been considered to do more harm than good. Examples in psychiatry would include leucotomy for psychosis and malarial treatment of dementia paralytica. The originators of both treatments were awarded the Nobel prize at the time because their discoveries were mistakenly thought to be advances in knowledge. In fact Cerletti was also nominated for the Nobel prize for ECT treatment of schizophrenia and manic-depression. ECT is no longer generally seen as indicated for schizophrenia.

Medicine has always exploited the placebo effect. Dramatic treatments like ECT may seem to be needed in desperate personal situations. Of course ECT was first introduced without anaesthesia and muscle relaxants, and such unmodified ECT continues to be given in some parts of the world. 

Doctors’ belief in their treatment and patients’ faith in it is a powerful mutually reinforcing combination (see eg. my book chapter). Randomised controlled trials were introduced to try to move on from the bias of such personal claims. The trouble is that there is still bias in clinical trials (see eg. my webpage). Even if there is a statistically significant difference between ECT and sham ECT in controlled trials, this difference could be because trials are unblinded, for example, through side effects of ECT treatment. For example, trial subjects may become aware that they have had real ECT because of the initial ECT side effects, such as headache. In which case if unblinded, expectancy effects could still be a self-fulfilling prophecy leading to an overestimate of treatment effectiveness. 

In general, we should be sceptical about the effectiveness of medical interventions because research methods are malleable enough to lead to exaggerated positive claims for treatment benefit (see eg. previous post). Individual experiences like that of Gergel, however well expressed in the BJPsych article, do not really solve this issue.

Thursday, October 07, 2021

Outcome of maintenance treatment of depression

Gemma Lewis and Glyn Lewis have a further article in The Conversation (see previous post), this time about their recent ANTLER study, which looked at whether patients in primary care who have been taking antidepressants relapse when they stop them. As they say, over the following year, 56% of people who stopped their antidepressants relapsed, compared to a sizeable 39% of people who relapsed even though they continued their antidepressant. 

They then go on to say that the study demonstrated that many people can come off antidepressants safely, whereas I’m not convinced that’s what the study necessarily shows. Of course there are problems with generalising the results of a controlled trial to the real world, and subjects who discontinued their medication in the trial were given placebo, rather than no medication. It would have been interesting to have had a third arm in the study looking at the relapse rate of a no medication group. And to know what happened to the placebo group after the end of the trial. Furthermore, the study does not show whether people can manage without antidepressants longer-term after a year.

The Lewises also say that “Neither researchers nor patients knew which group people were allocated to”. This is not correct, as they report information about unblinding in a supplementary appendix to their paper. They found that “71% (162/228) in the discontinuation group and 47% (108/232) in the maintenance group correctly guessed their randomised group at any time before being unblinded”. People in the trial were better at guessing their allocation if the antidepressant was stopped. Trials typically turn a blind eye to the methodological problems of unblinding (see eg. my eletter). It is possible that the statistically significant advantage found for continuing antidepressant could be due to nocebo amplification through unblinding, in a similar way to which the statistical advantage for the effectiveness of antidepressants could be due to placebo amplification (see eg. previous post). 

People are understandably fearful about stopping antidepressants (see eg. previous post). The subjects in the ANTLER trial were said to feel well enough to consider stopping the pills. From the information in the  supplementary appendix, some seemed to have stopped taking any antidepressant when coming out of the trial, both in the maintenance and discontinuation groups. 

It is not easy to distinguish withdrawal symptoms from relapse. Anxiety about treatment withdrawal can lead to both relapse and withdrawal symptoms (see eg. Moncrieff et al, 2021). Discontinuation problems from antidepressants should not be minimised (see eg. another previous post) and the ANTLER study confirms that long-term outcome of the treatment of depression is not always as good as might be hoped (see previous post). This is a different message from the headline in The Conversation article.

Wednesday, September 22, 2021

Steps towards improving mental health advocacy

VoiceAbility and over 50 other signatories have written to the Secretary of Health and Social Care (see webpage) calling on the government to make an unequivocal commitment to improving advocacy as part of the reform of the Mental Health Act (MHA) (see eg. previous post). I think an opt out approach to advocacy is essential in any new legislation. Extension to informal patients is also important, although priority will need to be given to detained patients. I have supported VoiceAbility’s call as a step to what is needed in the new Bill.

I would also emphasise what the letter says about ensuring high quality advocacy services. I think the best way to do this is for Independent Mental Health Advocates (IMHAs) to work much more closely with mental health lawyers and independent professional experts, ideally, I would say, in an integrated nationally provided advocacy service. As the letter says, such an improvement in advocacy would need to be properly funded. I came across the agreed common themes from the Mental Health Act Reform Group (which became the Mental Health Alliance) formed in the context of the last time the MHA was reviewed leading to the 2007 amendments. This was before advocacy had been introduced by those amendments. As far as I know, there has not been an official review of the effects of the introduction of those changes. I suspect any such review would confirm that there is a very variable advocacy service nationally. I think this is partly because of current piecemeal commissioning arrangements, which may be better replaced by a nationally provided service.

I think the government still needs to provide adequate resources nationally for advocacy, as originally suggested by the Mental Health Act Reform Group. The interests of detained patients need to be better represented, if necessary before the Mental Health Tribunal, on matters both of detention and treatment (see eg. previous post). I think there are savings that can be made by abolishing Second Opinion Approved Doctors (SOADs) and reorganisation of the Tribunal (see another previous post) that could be invested in advocacy.

Sunday, September 19, 2021

Accepting uncertainty in psychiatry

Psychiatry has difficulty dealing with the limits to its knowledge about mental illness (see eg. previous post). Owen Whooley in his book On the heels of ignorance: Psychiatry and the politics of not knowing highlights how psychiatry has dealt with its ignorance by holding out the expectation that it will eventually find the answers to mental illness. Of course these are never fulfilled. People do need understanding and treatment for their mental health problems and these aims may explain, but do not justify, exaggerated misrepresentations about what psychiatry does know (see eg. another previous post). 

Psychiatry needs to accept the inevitable uncertainty of its practice. Actually, psychiatry’s expertise should come from recognising this is the case. It may worry that it will lose its authority if it shares this truth with people, but the profession’s continued existence should not depend on psychiatrists having to, as Whooley says, “affirm the ‘knowability’ of mental illness”. “We are all complicit” in accepting psychiatry’s “inflated hype”. 

Friday, September 17, 2021

Is my brain health mine?

Current editorial in The Lancet talks about promoting good brain health. Ironically, it uses the concept of ‘brain health' to encourage a focus on social determinants of mental ill health. It suggests this might be a way of moving on from a reductionist view of mental illness. 

I suppose such an editorial reflects how seriously we need to take the neuro-turn in modern culture (see previous post). We now tend to view ourselves in terms of our brain. But, to quote from Thomas Fuchs (see previous post), "I'm rather glad not to be my brain, but only to have it". 

Disease has been understood as physical pathology since the mid-nineteenth century (see eg. previous post). Doctors also need to be person-centred (see eg. another previous post). The trouble is that primary mental illness does not have a physical representation as such in the brain, although of course the brain mediates our thoughts, emotions and behaviour, including mental illness. My brain can be diseased, causing for example delirium and dementia, but primary mental illness is functional not structural (see eg. previous post).

Does the health of my brain have to do with me and not just my brain? Is it not my health that’s at issue rather than my brain’s?

Thursday, September 16, 2021

The implications of enactivism for psychiatry

I don’t think I fully appreciate all the nuances in the recent debate in Philosophy, Psychiatry and Psychology (PPP) about the implications of enactivism for psychiatry. I’ve mentioned before (eg. see previous post), the book by Sanneke de Haan entitled Enactive Psychiatry. It was published before Kristopher Nielsen had completed his PhD thesis, in which he had independently developed his own ideas about the psychiatric implications of enactivism. There are differences in their views and they disagree about the significance of these differences. In the PPP journal, Nielsen (2021a) compares the two perspectives, followed by comments by de Haan (2021) and Richard Gipps (2021) (see his previous guest blog post), and a rejoinder from Nielson (2021b). 

As I said in a recent previous post, I think enactivism can be a way of revitalising Engel's biopsychosocial model. Mental processes need to be understood in a dynamic, integrated and enactive way, as they are embodied in the brain and the body more generally, and embedded in the environment, which is social and cultural, affording various possibilities of action to the organism (see eg. my article). Mental illness cannot be isolated in material processes in the brain, excluded from people's relationship with their environment. 

In some ways, such an anti-reductionist position is not new (eg. see another article of mine). I do think, though, that enactivism can be seen as a more thoroughgoing basis for anti-reductionism. Like Sanneke, I worry that Kristopher's position is not explicitly anti-reductionist enough. There is evidence for this in his interview with Awais Aftab. Kristopher still wants to understand mental disorders in an "entitative and more mechanistic way". He may well make too much of the biological functionality of human values, although I think there is merit in seeing mental illness as failed adaptations, as did Adolf Meyer (see eg. previous post). I summarised, in another previous post, how Sanneke demarcates 'abnormality' from 'normality'. I'm also not sure what Kristopher means by somatic and mental disorders being "probably continuous with each other". As I've highlighted before (eg. see previous post), the organic/functional distinction of mental disorders, which was abolished by DSM-IV, needs to be reinstated. 

I also have questions about the implications of Sanneke's views. For example, how do they relate to American pragmatism (eg. see previous post)? For all her emphasis on the existential dimension in mental disorders, how does her perspective relate to existentialism as a philosophy (see eg. another previous post)? 

As I've also been emphasising in this blog, there are links with other phenomenological perspectives, such as that of Thomas Fuchs (see eg. previous post); cultural perspectives, such as that of Laurence Kirmayer (see eg. another previous post); and other critical perspectives in psychiatry, not least Foucault (see eg. last post). I have been trying to bring them together under an umbrella term of relational psychiatry. 

This is not some grandiose project, but an attempt to encourage psychiatry to move on from its misguided belief that primary mental illness will be found to be a physical disease. Relational psychiatry also has practical implications, and is not merely an out of touch academic dispute about the implications of enactivism for psychiatry. There is some urgency about the need to improve the treatment of people with mental health problems. A recent focus of this blog, for example, has been on the current reform of the Mental Health Act (see eg. previous post), as the rights of people with mental illness can be abused.

Thursday, September 09, 2021

Foucault understood relational psychiatry

John Iliopoulos (see his guest blog post) has an article in BJPsych Advances on 'Foucault understood critical psychiatry'. As I’ve said before (see eg. previous post), John corrects the common misunderstanding that Foucault was against the Enlightenment (also, see further previous post). As he says, “The Enlightenment may have been marked by the triumph of rationalism, but it was also an age of critique”. Reason may decide the truth of shared meaningful knowledge, but its limits were recognised in Kant’s pragmatic anthropology (see previous post).

Modern psychiatry had its origins in the Enlightenment in two major phases. From the late 18th century, anthropological understanding, in the sense of understanding human beings as psychophysical entities, saw madness as a “private truth outside the common horizon of reason”. Psychiatry’s role was to detect such delusional thinking. However, by mid-19th century, positivism saw mental illness as a dysfunctional natural mechanistic process. Foucault’s analysis critiques the marginalisation of the anthropological attitude by positivism in psychiatry.

As John says, abnormality in general became the object of psychiatric knowledge, not merely delusion. I’m not sure if I agree with what John seems to imply that the potential this perspective creates to explode “the diagnostic field uncontrollably” merely relates to a positivistic attitude to mental illness. My previous post highlighted how Foucault in the History of madness recognised that mental illness already incorporated neurosis by the end of the 18th century. But in the 19th century, the development of pathological abnormality undermined the concept of functional disorder (see another previous post). In fact, positivism encouraged speculation about the biological basis of neurosis, such as Beard’s neurasthenia (see previous post). 

I would also emphasise the importance of anatomoclinical understanding in Foucault’s account more than John seems to do (see eg. previous post). After all, Foucault moved on to the Birth of the clinic after the History of madness. He must have done this because he wanted to understand how the development of the idea of illness as physical pathology was implicated in psychiatry.

As John says, Foucault is actually “sceptical of the anti-psychiatric quest for non-oppressive modes of psychiatric power and the humanist and postmodern efforts to moralise or relativise psychiatric truth”. Instead, his critique highlights the value of the anthropological outlook of alienists in the origins of modern psychiatry. Fundamentally, he did not think mental illness should be reduced to brain disease (see yet another previous post).

Monday, August 30, 2021

Effectiveness of ECT still uncertain

A BJPsych Advances article by Ian Anderson, who I have mentioned before (eg. see previous post), has critiqued the review by Read et al (2019) of the methodological problems of the available 11 RCTs and 5 meta-analyses comparing ECT with sham ECT.  Anderson agrees that the RCT evidence has limitations, as do the meta-analyses. 

Impeaching clinical studies is easy as there are always methodological difficulties. Essentially, Read et al are saying that the statistical advantage for ECT over sham ECT has not been demonstrated, whereas Anderson thinks it may have been. I do think, though, that Anderson ought to spell out which studies he is relying on for that conclusion. 

As with antidepressant studies, where I think the statistical difference overall in clinical trials between active and placebo treatment cannot be denied, placebo amplification, for example through unblinding, could still explain any statistical difference (eg. see previous post). Read et al argue that none of the ECT studies convincingly demonstrate they are double-blind. 

Friday, August 20, 2021

Enactivism can help clarify Engel’s biopsychosocial model

As I’ve said before (see previous post), I think Engel’s biopsychosocial (BPS) model can be made more explicit by utilising enactivism. My last post argued that Engel’s BPS model needs revitalising. Enactivism may be a way to do so. As Sanneke de Haan says in a recent paper, “Just like the BPS model, an enactive approach argues for a holistic conception of psychiatric disorder”. I also agree with her that “enactivism offers a [more] coherent account of how physiological, psychological, and social processes relate” than does Engel’s model on its own. People have been able to wrongly claim that they are adopting the BPS model, when in fact they have been using it in a eclectic way that does not spell out how the biological and psychosocial connect to each other (eg. see previous post).

I’m not sure if I agree with Sanneke that “Questions about causality are questions about ontology”. As I said in my article, I think anti-reductionism is primarily explanatory rather than ontological. What’s needed is a new epistemology (see previous post). Still, enactivism’s focus on the ‘life-mind-continuity thesis’ is helpful. As I keep emphasising (eg. see previous post), organisms, unlike machines, are self-organising and self-reproducing systems. Sanneke’s enactive psychiatry sees psychiatric disorders as abnormal sense-making (see previous post). Causes are non-linear when complex organisms are understood in a dynamic way (see another previous post). How living wholes cause their parts is actually unknowable to us (see yet another previous post). Cognition is more than mere information processing, as it is embodied in the brain and the body more generally and embedded in the environment, which is social and cultural, affording various possibilities of action to the organism (see my article). For psychiatry to continue to use a biology which sees mental illness as a static entity rather than a dynamic process is outdated. Enactivism may well help psychiatry to move on to a more relational mental health practice.


(With thanks to an MIA blog post by Micah Ingle)

Monday, August 09, 2021

Scientific validity of a pragmatic biopsychosocial model

The Academia platform has reminded me of a paper by Bradley Lewis on ‘The biopsychosocial model and philosophical pragmatism: Is George Engel a pragmatist?’. Like me (eg. see previous post), Brad argues that “Engel’s model is worth revitalising” (p. 299). I’m not as convinced as him that Engel “based the model on Von Bertalanffy’s biological systems theory” (p.300) (eg. see my article). General systems theory was a suitable conceptual basis for discrediting a reductionistic approach to biology for Engel but I don’t think he was necessarily making the biopsychosocial model dependent on it. As Brad points out, Engel saw the biopsychosocial model as more scientifically valid than biological reductionism. I agree with Brad about the similarities between Engel’s model/philosophy and pragmatism. Of course, Adolf Meyer, whom Engel also quotes, was very influenced by American pragmatism (eg. see my book chapter). 

Brad is interested in postpsychiatry (see his guest blog in a previous post). Postpsychiatry is perhaps the best known version of critical psychiatry (see another guest post from Pat Bracken and Phil Thomas). As I’ve been saying (eg. see previous post), a more truly biopsychosocial model, which critiques the biomedical model to produce a more relational practice, is needed not only for psychiatry but also for medicine in general. This was what George Engel meant when he proposed his biopsychosocial model.

Tuesday, August 03, 2021

Long-term segregation of people with learning disability and autistic people should be prevented

The government has responded to a review of people with a learning disability and autistic people who have been placed in long-term segregation (LTS) under the Mental Health Act (see letter from Helen Whatley, Minister of Care). The independent Oversight Panel was chaired by Baroness Hollins (see her letter to the Secretary of State). As the thematic review says, “some of the issues highlighted … are considered likely to be applicable in many assessment and treatment units (ATUs) and secure hospitals more generally and not just for those people who are subject to LTS”. In general, there was little evidence of any therapeutic benefit from hospital admission, and people’s health, dignity and well-being had been harmed.

As I've said before (eg. see previous post), I'm not convinced proposals to improve the situation through Independent Care (Education) and Treatment Reviews alone is the best way forward. Obviously people who have ended up in long-term secure provision do need to be helped to move on. But there is also a need for prevention of further such cases by prohibiting admissions to secure facilities under civil detention arrangements (see eg. another previous post). Secure hospitals should be reserved for criminal cases. As the review found, many of the patients in long-term segregation had actually acquired a criminal record through being in hospital. Such restrictive treatment needs to be stopped and such challenging people managed in a more open and therapeutic way. Psychiatric treatment is not just about custody.

Monday, August 02, 2021

Rights-based reform of mental health law in Scotland

The Scottish Mental Health Law Review has produced an impressive July 2021 interim report. It follows a ‘human rights model’ of disability. It sees the aim of legislation as being to secure human rights, which should be respected, of all those who may currently fall within the category of ‘mental disorder’. It will consider further, including with people with lived experience, about replacing the term ‘mental disorder’ with ‘mental and intellectual disabilities’. Specific mental health and capacity legislation needs to  be reinforced by legislative, policy and practice reform in a wider human rights agenda. Complete removal of compulsion, if it can be achieved, will have to be progressively realised and mental health law reframed to ensure it gives effect to an individual's rights, will and preferences in a non-discriminatory way. Although not straightforward, it should be possible to do this so that it is compliant with the UN Convention on the Rights of People with Disability (UNCRPD) (see eg. previous post). 

I'm pleased to see that Scottish mental health law reform takes UNCRPD into account, whereas I think the review in England and Wales essentially avoided the issue (see previous post). Service users and carers are front and centre of the Scottish review and three people with lived experience are part of the Executive Team, whose work is being intensified before the review is due to complete its work in September 2022.

Monday, July 26, 2021

Representing people without mental capacity

As I said in a previous post, I have concerns about people with lived experience of dementia being seen as representative of all those with dementia. The nature of dementia is that people do not generally recognise they have dementia. I appreciate those who have been given a diagnosis of dementia speaking out about it, but there are many others diagnosed with dementia who do not always have a voice.

Similarly, yesterday was Schizophrenia Awareness Day (see Rethink webpage). In a tweet, I welcomed Rethink promoting those with lived experience of schizophrenia. But, there are many people diagnosed with schizophrenia who do not see themselves as ill and have no insight into their condition. They do not come forward to talk about their illness. A proper understanding of schizophrenia and dementia needs to fully represent those without mental capacity.

Friday, July 23, 2021

Critical psychiatry talks

Pleased to see that a group of trainees (including Tom Stockmann, current CPN co-chair - mentioned in previous post - and already a consultant) have started a spin-off group from the Critical Psychiatry Network (CPN) where they have been having guest speakers in zoom sessions with like-minded trainees. These sessions have been converted to podcast episodes and have started to be published (see website). 

Although CPN has been going for over 20 years (see my article), I suppose it could be said that it has not always been very good at cultivating trainees over the years. Psychiatric training is a bit of an indoctrination (see previous post), so trainees do need support (see another previous post). Originally, CPN was formed in 1999 out of a Maudsley trainees’ critical psychiatry group (led by Joanna Moncrieff, the other CPN co-chair) coming together with others, like myself, who had been influenced by anti-psychiatry (see eg. previous post). It’ll be interesting to see how a younger group less directly influenced by anti-psychiatry can take critical/relational psychiatry forward.

Wednesday, July 21, 2021

Learning from Italian mental health law

As I’ve mentioned before (see previous post), Franco Basaglia in Italy was twice found not guilty of criminal liability following patient homicides. There has been considerable damage in this country caused by services being blamed for homicide by psychiatric patients (see eg. another previous post). The original motivation for such concern came from SANE, when its argument that asylums should not be closed because their rundown was causing homelessness amongst psychiatric patients was shown to be false. SANE, therefore, changed its tack to blaming rundown for psychiatric homicides even though these had not in fact increased. This campaign was reinforced by the Zito Trust, formed after Christopher Clunis unfortunately stabbed Jonathan Zito at Finsbury Park tube station. Homicide reports became mandatory even though they are often flawed, following the first by Blom-Cooper et al for Jason Mitchell (later accepted to be flawed by one of its co-authors, Adrian Grounds). Ray Goddard, the consultant for Jason Mitchell, had his picture put on the front page of the Sun (see previous post).

I actually think the reform of the MHA in England and Wales needs to learn from the Italian experience of removing the ‘risk’ criterion from Mental Health law. The reason for involuntary treatment was no longer that the patient is dangerous but that they need help. The psychiatrist is, therefore, not obliged to repress and control social dangerousness. I also think that current reforms can learn from the ban introduced on admitting any further patients to the traditional asylums in Italy, which encouraged them being phased out. Too many people, including people with learning disability, seen as difficult to manage and place are currently ending up in inappropriate secure provision, often in the private sector. Any further such civil admissions should be prohibited  to secure provision (see previous post), reserving secure psychiatric beds for people who need an alternative to prison. The government has said it wants to close such provision, at least for learning disability, following the Panorama exposure of abuse in Winterbourne View and Whorlton Hall, but has floundered in doing so, blaming lack of community resources, which of course is only part of the reason. Such civil detentions should be managed in more open environments, which if admission to secure beds was prohibited, would happen.

It might actually be worth reading what Italian law says (see english translation)  It states very simple principles that involuntary health treatment must be implemented respecting people’s dignity and their civil and political rights. For some reason the government wants to change the current principles in the Code of Practice (maybe to make them simpler?). It wants to put new principles on the face of the Act, which in my view water down the current Code of Practice principles (see previous post). It would do far better to copy the simple statement from Italian law. 

Saturday, July 17, 2021

Making the most of Mental Health Act reform

The government has published its response to the consultation on the White paper on Reform of the Mental Health Act (see previous post). It says it will "now work closely with stakeholders to build on what we have learnt at consultation, and to test and develop our policy proposals to make sure that our approach is right and that everyone benefits from the reforms" (see my summary of White paper and government's response to consultation).

The direction of travel in the White paper has generally been supported. As I've been saying (eg. see previous post), I think the proposals do need to be taken further forward. I'm particularly pleased that advocacy services will be extended and their quality improved (see previous post) and that Mental Health Tribunal powers will be extended (see another previous post). Even though there was no consultation on reforms to Community Treatment Orders (CTOs), the government says it will work closely with stakeholders to make changes (see previous post). Where I think the government might be missing out is what to do about the abuse in secure learning disability services exposed by BBC’s Panorama programme (see previous post). It does intend to proceed with its proposal to improve the supply of community services for people with a learning disability and autistic people to reduce the number of people being admitted. However, it does not seem to take on board that most of these people do not need to be in secure facilities and that civil detentions should therefore be prohibited to secure facilities (see previous post). The same applies to those with serious mental illness who are difficult to manage or place, who do not need to be in secure facilities unless there is a court order imposed after a crime. Secure psychiatric facilities should primarily be seen as an alternative to prison.

Stakeholders do need to be involved in taking these reforms forward. As the government also says, legislative reform is only part of what’s needed to improve mental health services. They also need to be transformed by work undertaken by NHS England and NHS Improvement (NHSEI) (see previous post).

Tuesday, July 13, 2021

Towards a more relational psychiatry: A critical reflection

Abstract of my recent BJPsych Advances article below. This article follows publication of my editorials in BJPsych and BJPsych Bulletin:-

Criticism of the biomedical model of psychiatry that regards mental illness as brain disease has been labelled ‘anti-psychiatry’. Critical psychiatry arises out of so-called anti-psychiatry, but has additional roots in transcultural psychiatry, its alliance with psychiatric user/survivor groups, and the methodological critique of the neuroscientific basis of mental health problems and psychiatric treatment effectiveness. It is not opposed to psychiatry as such and argues for a person-centred shift for practice and research. This article discusses how a more truly biopsychosocial model, which critiques the biomedical model to produce a more relational practice, is needed not only for psychiatry but also for medicine in general.

Tuesday, July 06, 2021

Promoting relational practice

Trevillion et al (2021) in a qualitative study identified that people using community mental health services think relational practice is the best way to provide support for complex emotional needs. This overarching theme was made up of four sub-themes: (1) understanding (2) interpersonal connection (3) consistency and continuity and (4) adaptability and accessibility (see conceptual map).

Supportive relationships may be more important in treatment than any medication or psychological therapy. Therapeutic relationships need to be prioritised in services (Dale et al, 2020). Although some participants in the study had experiences of good practice, there were also experiences of severely stigmatising treatment, a lack of effective support and service fragmentation. Staff need to work holistically and collaboratively with service users. Inclusive, non-judgemental and non-discriminatory approaches should be adopted. Experiences of trauma and other difficulties need to be acknowledged. Patients need to be treated with respect and dignity.

Relational psychiatry promotes relational practice. Its theoretical basis about giving up trying to establish biological causes of mental illness provides a framework for person-centred care (see eg. previous post).

Monday, June 21, 2021

Doctors have too much power in the current Mental Health Act

As I’ve been saying (see eg. previous post and my eletter), a new Mental Health Act (MHA) needs to go further than current government proposals for reform. In a chapter in a recent book, George Szmukler & Larry Gostin (2021) provide a helpful history of mental health legislation. 

As they point out, the 1959 MHA was the first time judicial authorisation was not required for compulsory admission. The Act could be said to have promoted a ‘medicalism’ over ‘legalism', in that it introduced primarily medical rather than legal controls over detention and treatment procedures. Such an arrangement requires doctors to manage these responsibilities appropriately. The 1983 MHA, which Larry Gostin himself influenced through his campaigning as legal officer for Mind, provided more safeguards for the rights of detained people; in a way a kind of ‘new legalism’. The containment of 'risk' (see previous post), which motivated the 2007 amendments to the Act, again gave more power to doctors with the introduction of community treatment orders. The changes encouraged doctors to deploy compulsory powers to manage risk: a ‘new medicalism’. 

Doctors in fact have too much power as detention and coercion are not always the most appropriate responses to the management of mental illness, including its risk. As Baroness Wootton pointed out in relation to the 1959 MHA, doctors have been laid open to "the exercise of powers which the public would regard as arbitrary in other connections” (quoted on p.72). There will be inevitable uncertainty about psychiatric diagnosis and treatment, and whether detention is appropriate and enforced treatment necessary. Mental health services’ ability to detain people and treat them against their will needs to be more open to scrutiny and control. The 1959/1983 Acts were reforming Acts in the context of deinstitutionalisation, when traditional asylums were being opened up and the rights of detained mentally ill people promoted, but there is now a focus on increasing security leading to reinstitutionalisation (see previous post). As the independent review chaired by Simon Wessely found, mentally ill people are not always being treated with dignity and respect (see eg. previous post). They need to be supported rather than necessarily have treatment imposed on them (see previous post).

To provide more balance to the authority of doctors, advocacy services need to be developed further, so that patients have a right to an independent opinion of their own choice on medical, nursing and social matters (see previous post). I think this should be a nationally managed service to include Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see another previous post). If necessary, any conflict between the Responsible Clinician (RC) and advocacy services, both on detention and treatment matters can be adjudicated by the Mental Health Tribunal, with the Tribunal having the power to require the RC to reconsider a specific treatment decision, as well as order discharge, leave, transfer or community services, either immediately or within a recommended time period.

The other main change that is needed is to prohibit any further admissions of patients detained under civil proceedings (Part II patients) to secure facilities (see previous post), as secure facilities are more suitable for people detained under criminal proceedings (Part III patients) as an alternative to prison. The government recognises that too many people with learning disability and autism are being detained inappropriately in secure facilities (see previous post), but the same also applies to those with serious mental illness. 

Although the government does want to reduce coercion in mental health services, it does need to base this reform on the rights of people with mental health problems. There is evidence that it is actually watering down these principles (see previous post). It isn't just earlier and more frequent access to safeguards against detention and enforced treatment that are needed (see previous post), but a shift, hopefully led by doctors, towards more open and therapeutic treatment. Treatment should not be inhumane and abusive, as it can be currently (see another previous post), and doctors' decisions must be made in the best interests of patients.

Monday, June 14, 2021

A new epistemology for psychiatry

Germán Berrios and Ivana Marková have a chapter in Kirmayer et al’s (2015) book Re-visioning psychiatry on ‘Towards a new epistemology of psychiatry’. As they point out, biological psychiatry tends to be seen as true, only hindered in its progress by its financial under-resourcing (see previous post). Instead they suggest psychiatry needs better conceptualisations and methodologies to treat and research impaired mental functioning.

They emphasise the hybrid nature of psychiatry, in that not all mental symptoms can be explained as natural kinds but rather are incongruous "admixtures of organic/biological and sociocultural components". The combination of biological and semantic elements in the hybrid object means that the functional specificities of the brain signal are lost. In other words, "a simple and direct (cause-effect) relationship between the brain signal and the symptom" is precluded. The meaningful nature of mental symptoms cannot be located in the brain (see previous post). 

Germán and Ivana distinguish between mental symptoms that have either primary or secondary brain inscriptions. In those with a primary inscription there is a relatively direct relationship between brain inscription and symptom; whereas in those with secondary inscription the meaningful nature of the symptom must be represented in the brain but no "alteration of brain activity is necessary or sufficient for this type of mental symptom formation because it can only occur in an intersubjective space". 

As I have pointed out before (see eg. previous post), DSM-IV wrongly abolished the distinction between organic and functional mental illness. In a way, dividing mental symptoms into those with primary/secondary brain inscriptions reintroduces this distinction, although Germán and Ivana seem to want to suggest that the differentiation they are making is not the same. For example, they complain that the organic/nonorganic distinction is too rigid. However, functional does not mean non-organic (see previous post). Similarly, they seem to imply that psychotic depression, for example, has primary brain inscriptions, whereas it's not clear to me that it is an organic rather than functional disorder.

I totally agree that psychiatry needs a new epistemology and think that relational psychiatry provides just that. For example, Thomas Fuchs’ ecology of the brain (eg. see previous post), Sanneke de Haan’s enactive psychiatry (eg. see another previous post) and Laurence Kirmayer’s ecosocial psychiatry (see yet another previous post) all have the same epistemology. The history of psychiatry shows that psychiatry has been caught in an opposition between psychogenesis and organogenesis (see eg. previous post). The distinction between mental symptoms with primary or secondary brain inscriptions is fundamental and may actually not be that much different from the distinction made by Étienne-Jean Georget in the origins of modern psychiatry in the early eighteenth century between symptomatic diseases with organic causes and idiopathic disorders resulting from purely functional disruptions (see previous post). The problem is that the success of the anatomoclinical method in medicine has led to belittling its different implications for psychiatry. We need to give up trying to establish biological causes of mental illness as such (see eg. last post). 

Tuesday, June 08, 2021

Limits to knowledge about mental illness

As I've said before (eg. see previous post), biomedical psychiatry makes unsubstantiated claims about the nature of primary mental illness by suggesting it can be understood, let alone explained, as a brain abnormality. It's natural to go beyond the evidence on topics to which we can't possibly know the answer. Even though it's absurd to make such an attempt to understand primary mental illness in physical terms, nonetheless it seems to make sense to us that we should be able to provide such understanding and explanation. We, therefore, embark on wish-fulfilling fantasies about biological causes, even believing they have been established when they have not. Neuroscientists know that biological causes of primary mental illness have not been found, but nonetheless speculate about the latest research findings which unexpectedly never turn out to be proven, as there are so many inconsistencies and confounders in the data.

The fundamental problem is that we cannot know in mechanical terms how life arises (see previous post). Organisms don't follow the same rules as physical objects and seem purposive. We can, therefore, only talk about the reasons for primary mental illness, not its empirical causes. It cannot be reduced to brain disease in principle (see previous post). Although mental illness is of course enabled by the brain, mental states have meaning, which the brain as an object lacks. However much we may hope that we can explain primary mental illness in physical terms, we can't. We need to learn to accept the limits of our knowledge and how this applies to mental illness.

Wednesday, May 26, 2021

Reducing coercion in hospital for people with learning disability and autism

My letter to Lancet Psychiatry in response to Hassiotis et al (2021) has been rejected as it is said not to add sufficient new information. I don’t agree and it concerns me that there does not seem to be sufficient discussion in the academic literature about the shortfalls in the government’s White Paper on reform of the Mental Health Act (MHA). As I have said before (eg. see previous post), the proposals should be supported but they do not go far enough in reducing coercion in mental health services, including learning disability services.

Not many people have argued as I have (see previous post) that new admissions under civil detention arrangements (Part II MHA) of people with autism or learning disability (and serious mental illness) should be prohibited to a secure hospital. I do not think the criteria for detention of people with learning disability, which already require associated abnormally aggressive or seriously irresponsible conduct, should be altered. The White paper proposes that autism and learning disability are no longer to be considered mental disorders warranting treatment under section 3. Such patients can be admitted under section 2 for assessment of factors driving any abnormally aggressive or seriously irresponsible conduct and section 3 continued if a mental health condition is the driver. My concern about this proposal is that it will result in too technical, not always very meaningful, arguments about whether there is a mental health condition in addition to learning disability. It is almost as though the White paper is encouraging the reintroduction of the term ‘psychopathic disorder’, which was abolished by the 2007 amendments, so that someone with a learning disability can then be detained if they have a psychopathic disorder as well as learning disability. I am not convinced this is the best way forward.

The White paper also talks about the warehousing of patients with learning disability and autism. Transfer to secure provision leads to unnecessarily long admissions. I’m not denying the need for more community rehabilitation, but the issues are not just about difficulty in placement and lack of appropriate community resources. It is also about developing the skills to manage learning disability patients with challenging behaviour in a more open way in Assessment and Treatment Units (ATUs). Prohibiting any further admissions of Part II patients to secure facilities by legislation will help to create the right environment for the treatment of such challenging behaviour.

Wednesday, May 19, 2021

Reversing re-institutionalisation

I’ve always tended to prefer the term de-hospitalisation to de-institutionalisation, because although the traditional asylums have closed, institutional practices still exist in the network of community, including smaller residential, facilities that have replaced them. In fact, since 1990 there has been a re-institutionalisation of mental health services, particularly with increasing numbers of secure psychiatric beds both in the NHS and private sector. For example, Rutherford & Duggan (2008) reported that the "forensic services population rose by 45% in the 10 years between 1996 and 2006". This resort to re-institutionalisation, as Turner (2004) said, partly “reflects a culture of risk management, [and] an overriding concern for public safety ... “ (see previous post). 

Despite the move to community care and the reduction in both mental illness and learning disability in-patient beds overall, the number of detentions under the Mental Health Act (MHA) 1983 continues to rise (Keown et al, 2018). This is one of the major reasons why the MHA is currently being reformed. Alongside the increase in detentions, the proportion of involuntary admissions to private hospitals increased from 3% in 1984 to 15% in 2015/6. This shift was more pronounced for forensic (Part III) patients, although also occurred for civil (Part II) cases.

Of course, part of the motivation for the rundown of the traditional asylum was the institutionalisation of patients. The new MHA needs to bring a halt to their re-institutionalisation and do more to improve the process of de-institutionalisation started by the 1959 and 1983 Acts. The White paper has talked about the warehousing of patients, primarily for learning disability patients, although this also occurs for those with serious mental illness. To complete the quote from Turner (2004) above, the other reason for re-institutionalisation is “the burdens and pressures upon services trying to manage ‘revolving-door’ psychotic patients”. These patients are seen as difficult to manage and place and have been shipped out of the NHS to private care and to low and even medium security, when they should be managed in a more open door-environment. As I have said (eg. see previous post), civil detentions of people with learning disability and serious mental illness should be prohibited to secure provision. This will allow secure services to develop their proper function of providing a therapeutic alternative to prison. The 2007 amendments to the Act, which were motivated by an inappropriate over-concern with risk, need to be reversed by repealing community treatment orders (see another previous post).

Tuesday, May 18, 2021

Simplifying depression

Flow Neuroscience has “truly global ... ambitions” to “make depression treatment simple and accessible”. As an article in the Financial Times, which mentions this Swedish company, says, “Technology to treat the brain has come a long way from the hundreds of volts used in brute-force electric shock therapy in the psychiatric clinics of the 1930s”. Neurostimulation (see previous post) now includes transcranial magnetic stimulation (rTMS) (see previous post), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS) (see previous post). Flow Neuroscience has introduced the first medically approved tDCS electricity-emitting headset for home use, which it says boosts an app-based behaviour therapy treatment programme. The blobs in their YouTube advertisment seem happier than the sad blob in the original Zoloft advertisement (see previous post).

Not sure how randomised controlled trials can be double-blind when comparing rTMS with sham treatment, as it causes a tingling sensation, which will break the blind. Also not sure how accessible the treatment will be (let alone value for money) as the headset costs £399 (although there’s also a renting option). Still the app is free to download. As I said previously (see post), I just wish that psychiatry could focus its efforts on providing more hope and effective treatment than neurostimulation, which is really exploiting people.

(with thanks to Alex Macauley)

Saturday, May 15, 2021

In favour of the person

I’ve mentioned before (eg. my article) that Martin Roth saw anti-psychiatry as “anti-medical, anti-therapeutic, anti-institutional and anti-scientific”. He made it sound very negative being against all those things. 

Actually, relational psychiatry is anti-positivist, anti-reductionist, anti-institutionalisation and anti-racist. It’s against all those things because the fundamental problem of psychiatry is the objectification of people.  It also recognises the limitations of treatment and that there are differences between psychiatry and the rest of medicine. 

So, what it’s positive about is people and their relations in social context. The extent to which psychiatry has a tendency to be positivist, reductionist, institutionalised and racist undermines its proper, personal task of supporting people with mental health problems.

Wednesday, May 12, 2021

Making mental health services more humane and efficient

An open letter to the media about mental health services is available to sign. It highlights the following:-

  1. lack of confidentiality in services eg. on mental health helplines 
  2. more information needed for patients eg. about psychiatric treatment 
  3. differences between psychiatry and the rest of medicine should not be minimised 
  4. patients' mental capacity, their will and preferences need to be taken more into account
  5. the dangerousness of people with mental health problems is exaggerated
Psychiatric practice should no longer be based on the notion that primary mental illness will be found to have a physical cause, but move on to a more personal, relational practice.

Monday, May 10, 2021

Risk and blame in mental health services

I've mentioned before (see previous post) that the over-preoccupation with risk in mental health services in the last 20 years or so has been counterproductive. This is relevant to the current review of the Mental Health Act (MHA) (see another previous post). The new MHA needs to reduce coercion in mental health services and risk is not always best handled by increasing coercion.

As I wrote in my book chapter, one of the reasons for the rundown of the traditional asylum was the mistreatment of patients in a number of institutional scandals. These traditional services needed to be opened up and patients moved more to the community. I've argued that the recent scandals of Winterbourne View and Whorlton Hall should similarly lead to the prohibition of any further civil psychiatric detentions to secure facilities (see previous post), so that these people if they need inpatient treatment should be managed in open door wards. A secure environment is unsuitable for most people with learning disability or serious mental illness. The new Mental Health Act must deal with abuse and over-restrictive practices within services.

As I also wrote in my eletter, many psychiatrists were opposed to the rundown of the asylum and the development of community care because of their, at least perceived, loss of power in the traditional hospital. There is no longer an active debate about whether the asylums should have been closed, because the process has been completed. But at the time, because of the relatively high level of mental illness amongst the homeless population, it was argued that patients were being discharged irresponsibly from the traditional asylums ‘onto the street’. However, follow-up studies of discharged patients (such as TAPS eg. see my book review) showed that the rundown of the psychiatric hospital, at least in the UK, was not the main factor contributing to the numbers of homeless mentally ill. The tack of campaigning organisations, such as SANE, therefore, changed to blaming dehospitalisation for homicide by psychiatric patients, leading to a focus on public safety. High profile media cases, such as the death of Jonathan Zito, who was stabbed in a tube station by Christopher Clunis, led to the formation of the Zito Trust. The new Labour government concluded that community care had failed. Any homicide by a psychiatric patient had to be investigated, despite the fact that homicides by psychiatric patients had not in fact increased. There is no standardised approach to such inquiries, however, (see Ng et al, 2020) and many of them have been destructive (see my unpublished paper).

The current reform of the Mental Health Act has to be understood in the context of the last attempt to reform it, which led to the 2007 amendments. The introduction of community treatment orders (CTOs) then was hailed as saving lives, with fantasy estimates of how many suicides and homicides would be prevented. Of course there is no evidence that CTOs have reduced deaths (see eg. previous post) and they should be repealed (see another previous post).

The forensic theory of risk comes from Mary Douglas (1992). Talk about risk is a political process. Debate about accountability is a contest to muster support for one action rather than another. People pressurise each other in society and a conformity is created. The charge of causing risk is a stick to beat opponents. Ulrich Beck (1992) advocated in his book Risk Society that science needs to stop pretending it is neutral. It needs to become more conscious of its political nature. As I said in my talk:-

There is a debate about the balance between risk taking and risk aversion. If anything, what the Risk Society seems to mean is a shift towards the risk aversion end of this relationship. The word risk has been pre-empted to mean bad risks. The promise of a good political outcome is couched in other terms. Yet any society which did not take risks would not be making the most of its opportunities for growth. Over-cautious risk-averse behaviour can be crippling.

The new Mental Health Act again needs to open up debate about the balance between risk taking and risk avoidance. The 2007 amendments were an aberation in progress towards freeing up mental health services started by the 1959 and 1983 Acts. Risk aversion is leading to too many people being detained for too long and inappropriately and forced to have treatment when it is not benefitting them. This situation needs to change and the White paper does not go far enough to correct it.