Do the right thing

The Labour Party is not being terribly effective in making arguments for staying in the European Union. Having lost the General Election, the Party has become preoccupied with factional strife.  They are like a football team that has gone one down and spends more time arguing about goal keeping technique than preventing a second goal. In adversity, solidarity is always the best strategy.  People with mental health problems are facing all kinds of difficulties at present, including the destabilisation of support and services.  In the face of this, we need some solidarity between service users’ and carers’ organisations and the professional bodies of mental health disciplines.  Although there are real and healthy differences, the main mental health groups have much more in common than divides them.

I had not been working in psychiatry for very long before it became obvious that a disproportionate number of the people I saw had little money or social capital (a modern term for non-financial social resource).  Anyone can develop mental health problems, but the risk is substantially higher for people in poverty.  A strong interest in the relationship between social inequality and serious mental health problems has been the overarching theme of my career.

Medical treatment is all about striking the optimal balance between desired and unwanted effects, and psychiatry is no exception.  To me, medication is often a regrettable necessity.  Sometimes service users have reproached me for saying this, as they have a more positive view of the role of medication in helping them to manage their disorder.  Nonetheless, like many other psychiatrists, I am concerned about adverse effects, the overuse of medication and the uncontained spread of polypharmacy.

I am presently involved in work on high-dose opioids (and other drugs) for chronic pain, which are often ineffective, can make problems worse, and carry a heavy burden of side effects.  People with chronic pain are a heterogeneous group and many have complex problems.  It is always important for health professionals to listen properly to patients, and to avoid the trap of believing that peoples’ problems will necessarily conform to professionals’ preconceptions.  Where there is a contradiction between what patients say and what the textbooks say, it is usually the textbooks that are wrong.  There is no particular position that any health professional can take that automatically allies them with the majority of service users.  Listening carefully is the key to that, which is only difficult if you are easily put off by the fact that what you hear collectively is sometimes contradictory.  What I notice is that the voices of service users are no more contradictory that the voices of the professionals who are meant to be there to help them.

My last blog was about criticism of one of programmes in the BBC’s In The Mind week, a major exercise in mental health themed broadcasting.  In the programme, mental health service users described their experience in a distinctive voice.  I felt that the fact that one of those service users was a celebrity did not make it appropriate for senior academics to publicly criticise them for failing to conform to particular professional orthodoxy.  My blog turned out to be an early contribution to a controversy that has rattled around Twitter and the internet comment pages of the national press ever since.  Twitter is an arena for some pretty rough exchanges, with little space for nuance.  Participants have a dispiriting tendency to go for the player, not the ball.  I really would not want to get involved in that type of dialogue. However, the straw man of the bio-fanatic psychiatrist has featured prominently in the debate.  The President of the Royal College of Psychiatrists has felt moved to comment on this point.

Whenever I hear about the hegemony of the biomedical in psychiatric discourse, I am left wondering where all of these dogmatic biological psychiatrists hang out.  I do not mean the psychiatrists who do genomic research, as I know a few of them.  I mean psychiatrists who rigidly insist that mental illness is solely attributable to a putative chemical imbalance or genetic lesion, and who dismiss psychological and social issues as irrelevant.  Some commentators seem quite certain that these fanatics not only exist, but that they dominate my profession.  If so, they must operate in the fashion of the Illuminati, scattering like cockroaches when the light is turned on.

Probably, I know more psychiatrists than most people do.  I do not know a single serious psychiatric commentator or researcher who adheres to an extreme biological determinism.  I have met some not-very-good psychiatrists and the odd out-and-out charlatan.  Some of them say ridiculous things.  People like this exist in all walks of life.  I have come across one or two clinical psychologists who have been similar, but it would be entirely wrong to suggest that they represent the generality of their profession either.  They do not.

There was a prominent British psychiatrist called William Sargant, based at St Thomas’s Hospital in London, who forcefully evangelised biological treatments.  He died at the age of 81 in 1988.  He was a controversial figure.  Many psychiatrists were sceptical of some of the treatments he advocated, such as insulin shock.  Psychiatric researchers demonstrated that they were ineffective, and sometimes dangerous.  By 1981, when I started, Sargant’s views were far outside of the mainstream.  My training at two different centres had a strong emphasis on psychotherapeutic approaches, including experience of individual psychoanalytic therapy, group analysis, cognitive behaviour therapy, systemic family therapy, and two and a half years working in therapeutic communities; by no means narrowly bio-medical.  I did have a contemporary who was vocally negative about psychological approaches.  There was much concern about him, because his view that people could not change from their nature was part of a package of alarming right-wing opinions.

I have co-authored two books on psychiatric skills.  The first was about interviewing and assessment, the second was about treatment.  They were well received in the UK and the US.  The interviewing book sold sufficiently well that a second edition is in preparation.  The other won an award in the BMA book competition.  The introduction to the second can be read here (see Chapter 1 starting points).  It clearly sets out an approach to psychiatry that is the mainstream in the UK.  The books are all about patient-centred, contextualised practice.  We did not invent this approach.  It is the style of practice we were taught by our trainers and which in turn we have tried to instil in our trainees.

Some readers will be irritated, or possibly angered, by this apparent orgy of psychiatric self-congratulation.  For many of them, it will not correspond to their experience.  I acknowledge that there IS a problem with the type of mental health care that many of our patients are offered.  This blog describes a service user’s experience that talking is in short supply.  I have heard many similar accounts of UK mental health services.

The optimism that we expressed in the introduction to our treatment book, which was written in 2007, does not reflect the realities of austerity-blighted NHS services in 2016.  Even before the financial crash, the President of the American Psychiatric Association, Dr Steven Sharfstein, complained that “we have allowed the biopsychosocial model to become the bio-bio-bio model”.  His article can be read here.

Many non-pharmacological interventions have a strong evidence base.  Even when I was a trainee, there was clear evidence that behavioural family therapy aimed at reducing expressed emotion was effective in preventing relapse for people diagnosed with schizophrenia, but no one was doing it outside of academic centres.  There has been a huge effort in all parts of the UK to increase the availability of talking therapies for both common and severe mental health problems, and yet many people complain that at best they get an attenuated version of the real thing, with an inadequate number of sessions or poor adherence to an evidence-based model.  There is a persistent imbalance in the care that mental health services offer.

Psychiatrists once had control over all aspects of patients’ care.  That was a bad thing, and that era has long passed. Now psychiatrists complain that they are often not consulted about changes to services, and basic errors are made in service configuration as a consequence.  Doctors have a strong professional ethos, and one of its foundations is pragmatism.  They offer the best care they can under the circumstances.  Pragmatism is both a strength and a weakness.  Most doctors want to do the right thing.  Despite the problems, many people get an adequate service, because health professionals keep doing their best.  On the other hand, some services in the UK have few permanent psychiatrists and are dependent on expensive locums of variable quality, nursing staff are horribly over-stretched and everyone is demoralised.  Is it better to struggle on offering a less than ideal service or to walk away in disgust, in which case the service gets even worse?  What does doing the right thing look like?

The most frustrating thing about being a mental health professional in the UK at present is that we know that we could offer a better standard of help than this.  Many of us look back to a time when some aspects of care were better than they are now.  Psychiatrists would like to spend more time talking to patients.  There is widespread discomfort with the increasing use of legal compulsion, notwithstanding that compulsion is sometimes unavoidable.  Psychiatrists would like patients to be offered more psychological interventions, more assistance with social and financial problems, more choice.  No one is happy with what is happening to services in some parts of England, where hasty and badly planned change has had destructive effects.

Doing the right thing means drawing attention to the effects of service cuts, benefit cuts and the bedroom tax.  It means pointing out that the impact is not just on people who have mental health problems right now, but also on future generations who will be affected by growing up with poverty and inequality.  It means campaigning with service users, carers and our professional colleagues for good quality services that offer the full range of evidence based treatments. High profile conflict between professional groups over television programmes is a distraction that can only do more harm than good.