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Bates, P. (2012)"Wash and brush up?", Mental Health and Social Inclusion, Vol. 16, Iss. 2, pp. 97-102. http://dx.doi.org/10.1108/20428301211232522

Peter Bates ~ Dirt, Disgust, and Denial

In opening a conversation about how to work with people who are dirty and unwashed, it is unsettling to raise the subject of the human disgust response. All our liberal inclinations are alerted to a possible violation of the principle of non-judgemental respect and we are ready to defend smelly people we have known from insult and misunderstanding. Perhaps, in raising the topic, I will become disgusting.

At some point, I guess we have all been troubled by the sights, sounds and smells we encounter on rare occasions in working with people who are losing the battle for daily survival. Whether it is unpleasant body odour, verminous hair or seeping wounds, a glimpse into someone’s mouthful of half-chewed food, a spillage of bodily waste or an admission of repugnant behaviour towards others – we all have found a trigger that fires up the human disgust response. It shapes our interactions and so we should understand it and ourselves if we are to work successfully with others. Denial is no solution.

Research as shown that three threats  – pathogen, sexual  and moral – universally trigger a characteristic facial expression as well as withdrawal, shuddering,  immune strength and nausea. These responses protect us from disease, reproductive risk and collapse into anarchy and the death of the tribe that would inevitably follow.  By the same logic, strangers evoke disgust, as they may bring unfamiliar diseases, while women respond more strongly than men, as they have to be disgusted enough for both themselves and their children.

The disgust response starts early - giving a 14 month old child a new toy, along with a 15 second ‘disgust message’ leads to the toy being avoided for an hour or more. It also generalises beyond the stimulus itself. Disabled individuals activate similar responses to those with contagious diseases, even when the observer is explicitly aware that they are neither sick nor contagious. The presence of a disgusting smell in the interview room results in people making more severe moral judgements, reduces the amount of money that they will pay for certain things, and strengthens their resolve to use a condom in future sexual activities.

So how do mental health workers deal with all their reactions when faced with a smelly, dirty or disgusting person? Disgust is plastic, as shown by the upscaling of negative responses to obesity in recent years and also by the positive learning shown by children who discover that vegetables, olives and wine are delightful. Of course, it may be that all mental health workers have already eliminated this unbecoming disgust response from their repertoire – but I fear not. Meanwhile, the primitive blend of fear and fascination that forms human disgust is itself deeply moral, as, like the birds, we set aside our own need for survival in order to give a warning cry and save the flock. Thus there is a way to take care of our own needs whilst prioritising those of others and reaching for the goal of respecting, understanding and supporting the person who troubles us.

‘The degree of civilization in a society can be judged by entering its prisons.’
- Fyodor Dostoyevsky

Last month, Claudia Hammond from BBC Radio 4’s All in the Mind visited HMP Grendon, the only prison in Europe which is run completely as a therapeutic community (TC).  The focus of the programme was to speak with prisoners, most of whom are serious offenders serving indeterminate sentences, and staff members to find out how the prison works and how they seek to address issues of reoffending.

As the programme identified, in a prison TC offenders are continuously encouraged to understand why they offended and to take responsibility for what they have done.  Grendon staff members noted during the programme that because residents have a stake in not only their own but others therapy, there is a strong sense of accountability.  Reality confrontation is crucial as members are encouraged to confront each other with honesty and frankness.  Jones’s (1968) concept of social learning is utilised so that every social encounter between residents and staff members could potentially be one in which residents gain new insight about their own behaviour and their ways of relating to others.  These principles are found in most TCs, and as with most TCs, the way it all works in practice is complex and at times chaotic.  However, as Hammond’s visit to Grendon highlighted, in a prison setting, these issues become even more multifaceted.  Not only is applying therapeutic principles challenging in a prison (Rawlings, 1998) whereby the goals of safety, security and therapy do not always fit comfortably together, there are the financial costs and the political issues at stake.  The type of specialised therapy on offer within a prison TC is expensive, requires a high level of commitment from prison administration and staff (Wexler and Prendergast, 2010), and as members at Grendon pointed out, the perception of spending public money on helping, rather than punishing, offenders is not always politically popular.

However, the value of this type of approach cannot be diminished by its challenges.  A few years ago I had the opportunity to visit a prison TC as part of the Community of Communities Peer Review Process.  Residents engaged with our team openly about what it is like to address personally painful issues with other people on a daily basis.  Like any TC, the meeting was full of mutual support, honesty and the occasional argumentative outburst, all of which the entire group had to manage.  Unlike other present day TCs, residents were together 24/7 and opportunities for reality confrontation, support and honest reflection were always available.  Such a regime, whilst far from easy, was clearly valued.

As for the commitment that this type of approach requires, the staff members I have met over the last several years from various prison therapeutic communities demonstrate that they are committed to their roles and helping prisoners.  They echo what Grendon staff members report in Hammond’s program, namely that offenders do learn to work together in order to take responsibility for their actions, there is little violence on the units, and more importantly, they can point to research (c.f. Wexler and Prendergast, 2010; Newton, 2010) that indicates that reoffending rates do go down.

Of course one visit to a prison community and a few conversations with staff members are not enough to definitively argue why these communities are worth their challenges.  But it does give pause for thought and reflection about the potential of people to help other people, especially in a prison.

Surely one of the hallmarks of a democratic society is where offenders can learn to see the impact of their actions from another’s perspective, to experience ‘victim empathy’ (Smartt, 2001:13).  Such insight does not fade with time as one has to live forever with this knowledge.  Greater awareness of these issues*, including more research and programme’s like Hammond’s, is needed in order to continue this conversation about the value of a prison therapeutic community in our society.

(*In addition to All in the Mind, former prison governor Tim Newell has published a review (publically available) in the Prison Service Journal on Dovegate: A Therapeutic Prison in a Private Prison and Developments in Therapeutic Work with Personality Disordered Offenders (released 2011), by Dr Eric Cullen and Dr Judith Mackenzie, which touches on similar issues to ones discussed above.)

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
E: This email address is being protected from spambots. You need JavaScript enabled to view it.
References:
All in the Mind (2012) BBC, BBC Radio 4. Broadcast on 8 May 2012. Available through BBC iPlayer: http://www.bbc.co.uk/programmes/b01h667n.

Jones, M. (1968) Beyond the Therapeutic Community: social learning and social
psychiatry. New Haven: Yale University Press.

Newton, M. (2010) Changes in Prison Offending Among Residents of a Prison-Based Therapeutic Community. in Shuker, R. and Sullivan, E. eds. Grendon and the Emergence of Forensics Therapeutic Communities: developments in research and practice. Chichester: Wiley-Blackwell.

Rawlings, B. (1998) The Therapeutic Community in the Prison: problems in maintaining therapeutic integrity. Therapeutic Communities 19(4): pp.281-294.

Smartt, U. (2001) Grendon Tales: stories from a therapeutic community.  Winchester: Waterside Press.

Wexler, H.K. and Prendergast, M.L. (2010) Therapeutic Communities in United States’ Prisons: effectiveness and challenges.  Therapeutic Communities 31(2): pp.157-175.

The IMH Blog is pleased to reblog the following post from Sarah Dale from her blog, Creating Focus.  You can view the original post on the link below:

Tales from the Cheltenham Science Festival 2012 by Sarah Dale Regular readers of my blog and newsletters will know that I am a fan of the Cheltenham Science Festival. True it’s something of a relief that geekdom seems to be gaining in social acceptability these days.

These things are all relative however, and psychologists are maybe in a different place from pure mathmeticians for instance. My own observational study seems to have confirmed this by  going along with my other half (an engineer who’s a pure mathematician at heart) to a mathsjam event at 10pm on Saturday evening. I went – I have to admit under some duress - on the promise there would be no quadratic equations to contend with after a long day and a very relaxed evening of curry and wine.

What were the first words to greet us, as we found the table of mathematicians calmly calculating away in the midst of modern Hogarthian-style drunken excess swirling around them? Yes – “we’re just doing some quadratics”.

Well, I thought to myself, I like to be open-minded but you can count me out.

So one of the joys of the festival is that it can accommodate me (psychologist, aspirant writer, maybe five on the geekometer) and my husband (who I think scores more highly, though I wouldn’t like to state how much more highly as the figure will be subjected to various mathematical tests before I can press publish).

This was illustrated nicely in one particular moment when he was podcasting about the maths behind board games whilst I was whiling away an hour entitled What happens when you pray?. The panel included atheist psychologist Chris French and broadcaster and Church of England priest  Rev Richard Coles (if you’re my age you may remember him as an ex-Bronski Beat and Communard with Jimmy Sommerville – takes me back to my undergraduate Rock City days here in Nottingham). It got close but being British and polite kind of skirted round the really heated debate that I would have liked to see as to whether being religious and a scientist are mutually exclusive or not. Hot potato stuff. Cheltenham, are you brave enough?

Brains and minds

There was a bit of a brain theme to the events I had chosen to go to. A live brain scan event (expertly facilitated by Evan Davis) looked at whether you can tell from brain activity whether someone is lying (early days but you can see the potential).

Given the live nature of the event, it occurred to me that it would be interesting to put the Festival’s slightly performance-pressurised Director, Mark Lythgoe, in the scanner and look for what happens in the brain in stressful situations – but maybe that’s for another day. Derek Jones, from Cardiff University, delivered a highly accessible and engaging explanation of what an MRI scan actually does – made me realise I didn’t know that I didn’t know that.

We also saw Bruce Hood speak about children’s brain development and the sense of self. It’s fascinating stuff. I’m not a developmental psychologist but I do wonder how much the neuroscience will confirm or deny long held theories such as Piaget’s work, or personality theory. We must be getting close to being able to do that I guess – are the Big Five personality factors visible in the brain? I don’t know if anyone knows the answer to that (yet).

And the highlight for me - mindfulness with Mark Williams

I have written about working through Mark Williams and Danny Penman’s book, and eight week mindfulness programme before, which you can read here. So it was a delight to attend a session chaired by Kathy Sykes (festival Director with Mark Lythgoe), where Mark Williams was speaking along with David Sillitoe, BBC correspondent who has tried mindful meditation for himself, as well as reporting for television on it.

The session itself was interesting, drawing on the sound neuroscience backing up ancient claims for meditation. Mark, as a clinical psychologist, comes across as the style of psychologist I have aspired to be from an early age, and still do - practice based on solid scientific evidence with an ever present curiosity about developments in the field, as well as striking me as the kind of person you would want to turn to in times of distress (his field is to do with treating depression). I think it’s always valuable to meet people who provide that professional inspiration, in whatever field you might occupy. David’s reflections as an initially somewhat cynical experimenter with this topic were also highly relevant. His use of the word “counter-intuitive” particularly struck me – both I and clients have found aspects of mindfulness practice to be very counter-intuitive given our western life-styles and the way we’ve been educated to strive towards achievement rather than cultivating awareness of the present.

One of the strengths of the festival is that a talk to an audience of probably a thousand people can be followed by a “talking point” move to another marquee where, on sofas, it is possible to continue the audience questions and shift to a more relaxed seminar style event. So, for me, this developed into something very much like a book coming to life. Probably the most enjoyable way of learning for me.

A reflection that chimed well with one of my recent newsletters (Fads and Mockers) was that of the popularity of mindfulness as a fashion at the moment. There are any number of books and courses about this right now – in an unregulated market that makes it very difficult to work out what’s sound and what isn’t. Mark’s comment was that at first he felt the need to try to police that somehow. He soon realised that was nigh on impossible and then described it as watching the tide come in and out and you then have to assess what’s left on the beach. He recommended starting at the Mental Health Foundation site, Be Mindful, for anyone wanting to find out more.

And in the meantime the Oxford Mindfulness Centre, where Mark is based, has produced some really good videos. I’m including two here – one, a short introduction to mindfulness, and the second a full lecture about it if you have more time and interest.

Enjoy!

[youtube=http://www.youtube.com/watch?v=CyiwVwwjFtQ&feature=player_embedded]

[youtube=http://www.youtube.com/watch?feature=player_embedded&v=wAy_3Ssyqqg]

Posted by: Sarah Dale

Sarah Dale is a chartered occupational psychologist and author of Keeping Your Spirits Up. She has a business background as a chartered accountant, and runs her own consultancy, Creating Focus. She is currently looking for inspiring women of age sixty plus to interview or to invite to write letters to her as part of her plans for her next book. For more details, contact Sarah on This email address is being protected from spambots. You need JavaScript enabled to view it. or 07748 494688.

Sarah’s website is www.creatingfocus.org and she can also be followed on twitter (@creatingfocus) or Facebook (Creating Focus).

In this re-post from the JKP blog, Dr Peter Ladd asks some important questions relating to traditional mental health diagnosis, and shares his own thoughts about where he believes it is heading in the future.

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Does the Semantics found in the DSM IV Create a Problem for Clients? The DSM IV is sophisticated in basing diagnosis in mental health on statistical probability. The Client Empowerment Model of diagnosis in mental health found in Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients, (Ladd & Churchill 2012) is sophisticated in presenting a holistic perspective. The lack of a holistic perspective found in the DSM IV may be partially attributed to the semantics found in it. For example, the DSM IV has such labels as Bi-Polar Disorder or Obsessive/Compulsive Disorder. Semantically, a person may incorrectly say, “I am bi-polar or I am obsessive/compulsive.”

From a strictly medical model, such semantics do not make sense. In medicine one does not say, I am cancer or I am stroke. However, with some mental disorders one can personalize them as though they were connected to one’s identity. A client empowerment model does not focus on labels but on patterns. For example, a person might say, “I have a pattern of bi-polar disorder or I have a pattern of obsessive/compulsive disorder. These statements are not connected to one’s identity. They are accurate semantic statements of a pattern they are in. Such unsophistication in DSM IV labels may lead to increasing the severity of disorders rather than reducing them. Most clients do not find meaning in statistically formulated symptoms but in understanding the semantically formulated patterns of their disorders. For example, if you asked someone, “Tell me who you are?” A person would not add up all of his or her negative symptoms and produce a label of how they see themselves. Most likely they would point out those characteristics that describe their unique way of being in this world. This means that it may be important in diagnosis in mental health to significantly separate a person’s mental disorder label from their identity.

The DSM IV is not sophisticated enough to achieve this function. A Client Empowerment Model of Diagnosis presents a client with a diagnostic pattern that specifically changes the discussion away from one’s identity to a pattern of experience that a person is going through. In practice, using a system that statistically categorizes mental disorders based on empirical probability has an explicit advantage for insurance companies, pharmaceutical companies and for the mental health practitioner yet such sophistication may be detrimental to clients, if these mental disorders are not presented in a more sophisticated, holistic and collaborative manner. Perceptually, clients may confuse the mental disorder label with their identity. The question to be asked may be, “Do we have a responsibility as mental health practitioners to diagnose in a manner where diagnosis is beneficial for all involved?”

The Direction of Clinical Diagnosis in Mental Health Mental health practitioners have a responsibility or at least a professional mandate to include tests instruments within a clinical diagnosis. Some of these instruments are; mental status exams, objective testing, personality testing, motivational interviewing, behavioral, emotional and environmental testing.

However, the most noted test instrument used by mental health practitioners has to be the Diagnostic and Statistical Manual of Mental Disorders or more commonly referred to as the DSM IV (APA, 2000). This book is mostly a standardized classifications system so that all mental health professionals are speaking the same language. This manual breaks down into; Axis I – clinical mental disorders, Axis II – personality disorders, Axis III – medical conditions relating to mental disorders, Axis IV – psychosocial events and environmental concerns and Axis V a global assessment of a client’s ability to function.

Neuroscience may be on the verge of giving the DSM IV an alternative perceptual view of diagnosis with such instruments as; PET scans, MRI’s, and CT.’s and Mindfulness Research (Plante, 2011). However, such neurological research is limited to the laboratory setting without some form of phenomenological thinking. Neuroscience has stirred up a renewed interest in phenomenology or the study of experience (Siegel, 2010). In other words, human experience causes neurological changes, and neurological changes are best understood through studying human experience. Such a notion takes mental health diagnosis in a different direction than the DSM IV that adds up symptoms in order to give a diagnosis based on statistical probability.

From the consideration of a new neurological/phenomenological perspective brings rise to this question, “Are the only accurate mental disorder diagnoses made by adding up symptoms from the DSM IV, in order to render a diagnosis?” At this point, it is only fair to mention that such a question is not completely answerable, yet it does give possible direction to the future of diagnosis in mental health.

However, such a question does reflect the sentiments of those mental health practitioners and neuroscientists that are finding a need for each other’s information. Furthermore, it may raise questions as to the direction of psychological diagnosis from a strictly medical model, statistical probability perspective. Should psychological diagnosis rely only on a statistical probability of symptoms, leading to a diagnosis? Or, should we rely on neuroscience research and combine it with phenomenological experience in developing a more bio/psycho/social/spiritual (Holistic and Person-Centered) model of diagnosis? This may be the moment to consider a different model of diagnosis with the ultimate release of the DSM V, and the book, Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients is one attempt at presenting a different model.

Peter D. Ladd May 2012

American Psychiatric Association. (2000) Diagnostic and statistical manual of mental health disorders (4th ed.). Washington DC: Author (Original work published 1952).

Ladd, P. & Churchill, A. (2012) Person-Centered diagnosis and treatment: A model for empowering clients. London, UK: Jessica Kingsley Publishers.

Plante, T.G. (2011). Contemporary clinical psychology (3rd ed.). Hobaken, NJ: John Wiley & Sons.

Siegel, D.J. (2010) The Mindful therapist: A clinician’s guide to mindsight and neural integration. New York, NY: W. W. Norton and Company.

FYI, the book could be found via the following link: http://www.jkp.com/catalogue/book/9781849058865

As reported on the Association for Therapeutic Communities (ATC) website, the organisation and structure of the ATC is changing:

‘Following several years of development work ATC is joining forces with a sister charity The Charterhouse Group (which specialises in supporting therapeutic communities working with children and young people) and we have formed a new charity "The Consortium for Therapeutic Communities" - referred to as TCTC.’

TCTC has developed a Manifesto for the new organisation. Comments and feedback are very welcome and should be sent to This email address is being protected from spambots. You need JavaScript enabled to view it..

In addition, there are some upcoming TCTC events for those involved in or interested in therapeutic community research:

TCTC Research & Development Group - Tuesday 3 July 2012*This session will focus on outcomes measures in TC’s and will specifically explore:

• What are outcomes for? • What do outcomes really communicate? • What do commissioners require? • What options do we have?

Confirmed guest speakers: Dr Mark Freestone and Dr Steve Pearce Time: Lunch and Registration 12.30pm, Seminar 1pm - 4pm Venue: Royal College of Psychiatrists, Centre for Quality Improvement, Standon House, Mansell Street, London Cost: £5.00 (payable on the day) (an event flyer for 3 July 2012 is available for more information)

TCTC Children and Young Peoples Sector Group - Thursday 5 July 2012*This is a quarterly special interest meeting for all those working with children and young people in therapeutic settings. It provides a networking opportunity with other TC managers and practitioners, and a chance to gather advice and support – practice, operations, regulation, tendering, policies. Confirmed guest speakers: Jonathan Stanley and Dr Tom Harrison Time: 10am - 4pm Venue: PETT, Barns Centre, Church Lane, Toddington, Cheltenham, Glos. GL54 5DQ Cost: £40 per delegate/ £90 with B+B (full lunch and refreshments included) (an event flyer for 5 July 2012 is available for more information)

*To book a place at one or both of these events, please contact TCTC: e: This email address is being protected from spambots. You need JavaScript enabled to view it.t: +44 (0)1242 620 077

They are realising that indicators of economic activity simply don’t tell us enough about societies’ goals of enabling good lives for their citizens. That is why a number of national governments are pursuing initiatives to create new measures of progress, why April saw the UN host a High-Level Meeting on Happiness and Well-being, and why next week’s Rio +20 international sustainability conference includes negotiations on indicators that go ‘beyond GDP’.

It is also why we nef (the new economics foundation) created the Happy Planet Index. The HPI is the leading global measure of sustainable well-being. As a new measure of human progress, it measures what matters: the extent to which countries deliver long, happy, sustainable lives for the people who live in them. The 2012 HPI report, published today, ranks 151 countries based on their efficiency – the extent to which each nation produces long and happy lives per unit of environmental input.

The results  – which you can easily explore in detail on www.happyplanetindex.org – show that we are still not living on a happy planet. No country has good performance on all three indicators of life expectancy, experienced well-being and Ecological Footprint. But some countries do considerably better than others – and those that do best are not who you might expect. None of the top ten countries ranked by overall HPI score are among the world’s richest – in fact amongst the top 40 countries by overall HPI score, only four countries have a GDP per capita  of over $15,000. The highest ranking Western European nation is Norway in 29th place, just behind New Zealand in 28th. Costa Rica tops the HPI table with a substantial lead – due to its very high life expectancy which is second highest in the Americas, and higher than the USA, experienced well-being higher than many richer nations and a per capita Footprint one-third the size of the USA’s.

The HPI results provide evidence for something we instinctively know to be true – that progress is not just about wealth, and that it is possible to live both happily and sustainably. They show that while the challenges faced by rich resource-intensive nations and those with high levels of poverty and deprivation may be very different, the end goal is the same: to produce happy, healthy lives now and in the future.

In these challenging times we urgently need a clear compass to help us all move in the right direction.  The Happy Planet Index, with its clear compelling vision of progress towards sustainable well-being for all, can help nations and other groups around the world come together with a common purpose.

Nic Marks
Founder of the nef Centre for Well-being

When I asked if I could produce this piece I was quite excited as I enjoy writing, although my University tutors may not think so. I am always saying one day I will write a book so let’s hope this will put me further on in the journey towards my goal. I could bore you with the minor details about the fact that I have just become a grandma, which is far from boring and I am looking forward to being able to book another holiday this year. I love to go cruising.

I am in a privileged position to oversee what happens in the Patient and Public Involvement world around the East Midlands and South Yorkshire. This does keep me busy and will often see me catching up on work on the many bus and train journeys I do each month.  When I can work out how to use the wi-fi.

For my first post I thought I would give you an overview of how I got involved and the difference it has made to me.  I am not new to research: I studied at college doing a Business Studies Diploma in the 1980s, and was enthused by the concept and techniques of research but applied them in different fields, including marketing.

I became involved with the Mental Health Research Network when I went along to a meeting organised by the East Midlands and South Yorkshire regional office, held to encourage people with experience of mental health problems to get involved in its work. I have a diagnosis of personality disorder, and was working at that time for the Nottinghamshire Personality Disorder and Development Network, a community service run by Nottinghamshire Healthcare NHS Trust.

When I left the Network, I started working on a freelance basis for the hub, organising regular conferences that brought together people with experience of mental health problems, student mental health professionals and researchers.

In June 2010, I was successful in an application for a part-time post at the hub: and now work as a ‘Clinical Studies Assistant’ where my remit is to engage and encourage people with personal experience of mental health problems who live in the East Midlands and South Yorkshire area to get involved with both the work of the hub and Service Users in Research, and to introduce them to research teams who want expert input and advice. Researchers in the area are very keen to get people involved with their studies,’ what tends to happen is that they approach me first of all, and then I approach individuals who have the relevant experience.’

The structures and terminologies used in mental health research are many and varied and can be quite scary. In my future postings I hope to look at some of these and give you my thoughts on them. Time has been good to me and I have attended many meetings and training events to learn the language. It’s like living in another world. But don’t be put off by that Mental Health is a very exciting area of research and if I can just get one more person involved I shall be happy.

Take care till next time.

Debbie Butler
Patient and Public Involvement Coordinator
NHIR Mental Health Research Network
Mental Health Research Network
East Midlands Hub

This week we have a guest-blog, from the Vice-Chancellor of the University, talking about the opening of the institute.  You can see the original blog, and other posts from the Vice-Chancellor the link below.

From the Vice-Chancellor's desk » Opening of The Institute for Mental Health.



Last week we opened the new Institute for Mental Health on the Jubilee Campus, with Dame Sally Davies, the Chief Medical Officer, as our Guest of Honour.

The incidence of mental ill health is growing. According to NHS data, the proportion of the English population meeting the criteria for one common mental disorder has increased from 15.5 per cent to almost 18 per cent over the last 20 years. This incidence is forecast to grow further as a consequence of demographic change, principally an ageing population.

Mental illness causes considerable personal and familial distress. Indeed, recent work at the Harvard School of Public Health estimates that mental health is the leading cause of all disability-adjusted life-years, followed by cardiovascular disease and cancer. It also has significant economic costs, estimated at over £105 billion per annum in the UK in 2009 (up from £77 billion in 2007).

Despite its growing incidence, the distress it causes and its consequences for individuals, families and communities, mental health remains something of an under-researched and under-resourced area. This is no doubt partly due to competing priorities, partly because it is a complex spectrum of illness, and partly because research is inherently multidisciplinary. The last of these makes it harder to build the teams necessary to address complicated conditions and have impact on patient care and outcomes.

Working in partnership with Nottinghamshire Healthcare Trust, we created The Institute of Mental Health in 2006, under the leadership of Professor Nick Manning. Remarkably quickly it gained a national and international reputation for its fundamental and service facing research. In part this is due to the health of the University – NHS relationship and what we each bring to the partnership. In large measure it is down to the skill of Professor Manning and his research leaders in bringing together staff from such a wide array of disciplines: Medicine and Health Sciences, Business and Management, Education, Law, Sociology and Social Policy. The Institute now has the biggest concentration of interdisciplinary research power in the UK; creating critical mass at this scale not a straightforward task.

Almost 200 staff in Nottingham are now focused on, among other things: old age and dementia, ADHD and neuro-developmental disorders, mood disorders, recovery and integrated healthcare. About two thirds of those are University staff and one third NHS staff. The Institute also has a wide range of partners – regional, national and international – and multiple sources of funding, most notably from the National Institute for Health Research.

Mental health research is a profoundly important area and meeting the needs of an expanding patient population will be an increasing challenge for society in general and the NHS in particular. The IMH is already making a significant contribution to our understanding of a distressing range of complex illnesses, their diagnosis and treatment.

As Dame Sally Davies noted in her address, the IMH is a genuine partnership between higher education and the NHS, a partnership grounded in a shared agenda to make a difference in what is sometimes described as a ‘cinderella’ area.

The combination of high quality research undertaken at scale persuaded the University and Nottinghamshire Healthcare Trust to invest in a new building. Bringing together our research teams and clinicians into a single purpose built facility will create even more opportunities for collaborative and transformative research. In time that can only benefit patient care and recovery.

Symbolically it is entirely appropriate that the new building is located on Jubilee Campus, itself a beacon of regeneration and renewal.

Professor David Greenaway

Vice-Chancellor

There has been something of a tea-cup storm over publication of findings from the TREAD study in the British Medical Journal on June 9^th (Chalder et al 2012). TREAD is an inventive acronym for the NIHR funded TREAtment of Depression with physical activity study which was conducted in Bristol and Exeter between August 2007 and October 2010. The BMJ paper was published online on June 6^th 2012 and so cyberspace was already buzzing before my own paper copy came through the letter box. The reason why is of course because the findings, as they were presented, were counter-intuitive and challenged practices many GPs and their patients find attractive. The episode also provides insight into ways in which a combination of the press’ and professional’s separate but complementary interests in simplifying the complex can result in misleading impressions.

Martin Robbins provides an account of how it went from a journalist’s perspective. The paper’s abstract reads "The addition of a facilitated physical activity intervention to usual care did not improve depression outcome or reduce use of antidepressants compared with usual care alone.". A related press release read “New research published today [6 June] in the BMJ, suggests that adding a physical activity intervention to usual care did not reduce symptoms of depression more than usual care alone.”, and included a quote from Prof. John Campbell, General Practice and Primary Care, University of Exeter: "This carefully designed research study has shown that exercise does not appear to be effective in treating depression.". In the early hours of June 6^th, only a short time after the press embargo had been lifted the BBC reported "Combining exercise with conventional treatments for depression does not improve recovery, research suggests.". Later that morning the Guardian appeared with the headline “Exercise doesn't help depression, study concludes. Patients advised to get exercise fare no better than those who receive only standard care, researchers argue”. This was followed by a number of online reactions by other journalists writing for the Guardian and the Daily Telegraph, and other commentators. Sharp eyed colleagues spotted all of this and the original BMJ paper was the subject of our clinical work-place journal club on June 11^th.

One of the earliest responses posted by the BMJ was from Stephen Pilling and Ian Anderson who led the development of NICE Guidelines for the Treatment and Management of Depression which were published in October 2009 and which recommend the use of exercise as a “treatment” for depression (Anderson et al 2009). On June 8^th they posted criticism of the TREAD report drawing specific attention to two perceived shortcomings. The first of these was that the intervention “tested” by TREAD was not in fact exercise itself, but contact with an exercise facilitator. Their NICE recommendations had been based upon understanding of research directly considering structured group exercise and as a result they did not regard the TREAD intervention as comparable. The second was that their recommendation was that exercise should be used as a treatment for “mild” to “moderate” depression, and the mean Beck Depression Score of TREAD subjects on entry into the trial (32.1) suggested that they were better thought of as in the “moderate” to “severe” range.   Other postings identify a variety of other technical and anecdotal concerns about the trial.

All of this could be nothing more than a storm in a tea-cup were it not symptomatic of several familiar and consistent strands, and didn’t result in misinforming or confusing vulnerable people who listen to the radio or read newspapers. Three questions are worth considering, and there may be more.

• How did so high profile a medical journal publish findings from so flawed a trial?
• Why did the press pick up upon its conclusions in so misleading and uncritical a way?
• What are the wider implications for understanding how we conduct and disseminate mental health research?

Was the trial flawed? What would Austin Bradford-Hill, credited father of it make of contemporary use of the term “Randomised Controlled Clinical Trial”? Chandler et al acknowledge that “Owing to the nature of the intervention, none of the participants, general practices, clinicians, or researchers performing the outcome assessments could be blinded to treatment allocation.” (page 2). Somehow the strict experimental requirement of double blinding has been allowed to lapse and clinical trials are considered randomised controlled clinical trials and elevated to premier status in the evidence hierarchy even when subjects and those involved in their treatment are aware of their treatment status. The whole purpose of RCT methodology is that it provides a way of controlling for the effects of that myriad of variables, predictable and unknown, which might influence the outcome of a complex phenomenon such as an episode of illness or emotional distress. We know that placebo or expectancy effects are considerable in mental health and yet we have drifted away from strict adherence to research protocols which control for them. Where investigated some 80% of antidepressant trial subjects correctly guessed whether they were taking control or trial medication on the basis of experienced side effects (Rabkin et al 1986). Someone I am clinically involved with who had agreed to take part in another investigator’s trial of a psychosocial intervention informed me that they had been allocated to the control arm. “How did you figure that?” I asked. “Because they told me.” was the reply. I doubt that Austin Bradford-Hill would respect that as an RCT and he would probably have similar difficulty with TREAD, but both are likely to be considered RCTs and their findings respected as such.

The press by their own subsequent acknowledgement picked up upon a sensational sound-bite without questioning its source or its provenance. Exercising to improve well being is folk lore. When a prominent medical figure says "This carefully designed research study has shown that exercise does not appear to be effective in treating depression." news is breaking. “Prominent medical figures” are under pressure to maximise the impact of their research and might be tempted to present findings in a way that attracts press attention. Quoting experts is not the same as conducting one’s own investigative journalism, and it is certainly easier and less risky. Sensational medical stories are popular and so the temptation is understandable. News items reporting medical research findings that promise “a breakthrough” are all too common. However, the cynic doesn’t find it difficult to hear and see the appeal for more research funding or how far away the “breakthrough” actually is if by “breakthrough” what is meant is a radical improvement in everyday experiences of this, that or another condition. Perhaps we should consider the need for a “Medi-Levenson”, to consider the relationship between “prominent medical figures” seeking funding and good impact ratings, and the press seeking newsworthy reports of medical advance.

Two strands of this might be considered particularly relevant to the world of mental health. One is that devaluation and degradation of the strict experimental requirements expected of a definitive randomised controlled clinical trial are a particular problem in this area. The other is that our clientele are vulnerable and desperate by definition, and therefore particularly susceptible to misinformation.

The first of these is a direct consequence of the nature of the field. Expectancy and/or placebo effects do make a powerful contribution to outcomes from all forms of “mental disorder” and so it is particularly important to control for them in the course of evaluating a treatment. Unfortunately that is very difficult to do. All of our drugs have prominent side effects and trialists are obliged to warn participants of their possibility. Psycho-social interventions are even more difficult obscure. The result is that our old friend, the Emperor’s Clothes, becomes a little see-through in this context as well. We should not claim to be offering treatments that are truly tested by exacting RCT methods in the same way much of medicine presents itself as doing, but we do.

The second is self-evident but possibly deserves a little elaboration. A core feature of that most widely accepted psychosocial intervention, cognitive behaviour therapy, is acknowledgment of the reality and relevance of cognitive distortions. The problem is as much how the experience; ruminations, others’ voices, palpitations, dysphoria, anger, etc. is understood as it is the presence of the experience itself. What psychiatrists as authorities in the field tell people about the nature of emotional distress and how it might be mitigated plays an important “public health” role. Possibly one of the most damaging acts of unintended harm things we perpetrate is to claim we have answers, when in fact we don’t. This little story about exercise and depression might be a timely reminder. If you add TREAD to the other research concerned with this question then the answer has to be “this sort of research doesn’t and can’t provide a definitive answer”. If you are feeling low and you think it might help, do exercise.

To quote from Rudyard Kipling:

The cure for this ill is not to sit still,
Or frowst with a book by the fire;
But to take a large hoe and a shovel also,
And dig till you gently perspire;

 

Will ill-applied RCT methodologies ever truly improve on this?

Hugh Middleton June 2012

Clinical Associate Professor,
University of Nottingham School of Sociology and Social Policy
Honorary Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust

References
Melanie Chalder, Nicola J Wiles, John Campbell, Sandra P Hollinghurst, Anne M Haase, et al (2012) Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. British Medical Journal OPEN ACCESS, BMJ 2012;344:e2758 doi: 10.1136/bmj.e2758 (Published 6 June 2012).

Anderson, I. Pilling, S, Barnes, A. et al (2009). Clinical Practice Guideline No.90: Update: Depression in Adults in Primary and Secondary Care (Update). Gaskell/British Psychological Society. London

Rabkin, J. G., Markowitz, J. S. and Stewart J. (1986). How blind is blind? Assessment of patient and doctor medication guesses in a placebo-controlled trial of imipramine and phenelzine. Psychiatry Research, 19, 75-86

Kipling, R. (1902) Just So Stories. How the Camel Got His Hump. Accessed on line June 14^th 2012. http://www.boop.org/jan/justso/camel.htm

The twenty-first century workplace can be a bewildering setting in which to spend most of your waking existence. Those of us in western professional jobs could be considered blessed compared with our ancestors. Few can complain about risks of physical injury or life-threatening injustice.

Scratch the surface, however, and there are frequent examples of mental health under strain: sleepless nights; anti-depressant prescriptions and loneliness, to name a few.

As an occupational psychologist, I have listened to many people’s experience of work. Quite a number have been in higher education across a range of institutions, others have been in a variety of professional jobs: social workers, architects and doctors amongst others. There are some almost universal themes.

Most people are coping. In fact, most are more than coping. They are often very successful. Their colleagues or clients would probably be amazed to hear that they feel fragile psychologically, some or all of the time.

Behind the scenes, however, many feel that there are few people they can trust. They feel in fierce competition with colleagues especially if there are redundancies in the air. Some feel a sharp sense of so-called imposter syndrome – living in fear that they will be exposed for not being as good at their job as others think they are. They may rarely experience a satisfying sense of a day well spent. They are trying to meet conflicting demands on their time. They are tired. They may have an increasing sense of being overlooked or side-lined for unclear reasons. They may feel that they “are owed” by their employer, after many hours of overtime, or having prioritised their work over their family or leisure time once too often. They may simply feel that they have an overwhelming workload.

This mindset arrives gradually. Most begin enthusiastically, and most continue to be enthusiastic about their field or subject, some (if not all) characteristics of their employing organisation, and at least some of their colleagues. But it can become a draining cycle of mistrust, exhaustion and conflict.

This often results in a modern fight or flight response. Going into meetings with all guns blazing, or maybe engaging in something of a more Machiavellian nature; or alternatively, working to rule in some way. This may mean working from home as much as possible; focusing on one or two aspects of the job that are considered to have most career benefit or are the most enjoyable; or withdrawing from contact with colleagues. These are all strategies. None of them is especially comfortable (or likely to meet organisational needs effectively) though.

It seems to me that this amounts to a threat to the professional population’s mental health which is often hidden from view. Collectively, how resilient are we? At a time when we arguably need to be ever more productive, creative and collaborative, how are we nurturing a mental strength and flexibility which is up to the task?

In the face of complex working challenges, both organisations and individuals often respond by working yet harder; demanding higher qualifications, longer hours, and, given the technological advances, to be available for work almost all of the time. True, a lot can be achieved by hard work.

But I like to imagine what we might achieve if the majority of us were feeling on top form, able to think clearly and work together to maximise our strengths and support each other. Maybe I’m idealistic.

Nevertheless, just imagine.

Posted by:
Sarah Dale

Sarah Dale is a chartered occupational psychologist and author of Keeping Your Spirits Up. She has a business background as a chartered accountant, and runs her own consultancy, Creating Focus. She is currently looking for inspiring women of age sixty plus to interview or to invite to write letters to her as part of her plans for her next book. For more details, contact Sarah on This email address is being protected from spambots. You need JavaScript enabled to view it. or 07748 494688.

Sarah’s website is www.creatingfocus.org and she can also be followed on twitter (@creatingfocus) or Facebook (Creating Focus).

You may recall back in April of this year, Victoria Tischler posted to the blog, discussing the plans for a scuplture to go outside the new Institute of Mental Health building on the Jubilee Campus (see here and here).  Well, we are pleased to announce that the sculpture maquettes are now on display in the lobby of the new building. The decision to choose which artist to commission will take place on the 14th of June.  In the meantime, you can visit the new Institute art pages, where there are images of the macquettes and information about each design, and a poll where you can vote for your favourite.

 

I’ve been following with some interest the progress of the Mental Capacity Bill currently making its way through the Oireachtas in the Republic of Ireland.  Ireland is currently in the position, as the UK was several years ago, of bringing its mental capacity law up to date, in a modern, workable form.  The result was the Mental Capacity And Guardianship Bill 2008, which looked a lot like the English Mental Capacity Act 2005, but it has been slow progress, and it is currently going through committee stages in the Oireachtas.

The reason why this Bill has become so interesting is because, while the original Bill looked a lot like the MCA, the intervening time has seen the UN Convention on the Rights of People with Disabilities finalised and signed by member states, and it is against this background which the Irish legislation is now being debated.  The CRPD, as I have discussed elsewhere on this blog and others in more detail elsewhere, presents some major challenges for capacity legislation, and it is interesting to see how Ireland are dealing with this.

Earlier this month, the Oireachtas Committee on Justice, Defence and Equality released its report on the proposed legislation.  The report stresses the need for a rights-based approach to the change in legislation, reflecting the move in the CRPD from paternalism to respect for the individual’s ‘will and preference’.  The starting point for any new legislation must be the recognition that all people have legal capacity, and are capable of making decisions.

The current position in Ireland is on a system of wardship, whereby an individual’s capacity is assessed, and if found lacking risks complete removal of autonomy over almost every aspect of the their life.  That this system needs to be replaced is not really controversial, and the Committee are clear that this needs to be changed as a matter of urgency.  However, in their consideration of the submissions made on the draft legislation, there were two particular points of interest for those with an interest in what changes might be made in England and Wales following the CRPD (in particular the Office for Disability Issues, who are under the impression that the MCA is perfectly compatible).

The first was the discussion around best interests.  This is, of course, the principle on which any substitute decisions must be made under the MCA, when someone is found to lack capacity.  Under the MCA, the best interests test is objective, with the individual’s wishes and preferences only a point of consideration amongst a list of others, including a balance of these wishes against any potential harm.  The report highlighted the risks of this approach, some of which I discussed in my last blog post, where the ‘best interests’ can end up being just what the professional thinks is best.  Such a model is, it was suggested, paternalistic and outdated, and in real need of replacement.

What would it be replaced with?  A best interests model is only required when it is found that an individual cannot make a decision, and one must be made for them.  The Committee report commented on the need for supported decision-making, and a move away from substitute decision-making.  This is the most challenging part of Article 12 for States; does the CRPD require the removal of all substitute decision-making frameworks, or is it aimed more at removing the blanket findings of incapacity, such as the Wardship framework currently in operation in Ireland?  The Committee suggested that any reference to substitute decision-making should be in the sense of ‘last resort’, and inclusion of provisions regarding supported decision-making as a first priority needed to be made.

It will be interesting to see what the Irish Government makes of these observations, and what a completed draft of the Bill will look like.  Any significant change should be keenly watched from these shores.

The IMH's editorial blog team had the opportunity to attend today’s unveiling of the new IMH building on the University of Nottingham’s Jubilee Campus/University of Nottingham Innovation Park. Today's ceremony represents the official opening of the recently completed 4-storey building.

The IMH is a partnership between The University of Nottingham and Nottinghamshire Healthcare NHS Trust. Situated on Triumph Road, the innovative building brings together in one location the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and Lincolnshire (NIHR CLAHRC-NDL), the NIHR Mental Health Research Network East Midlands Hub in partnership with South Yorkshire Comprehensive Local Research Network, the NHS East Midlands Leadership Academy, etc. The Institute embraces numerous research pursuits, for example, the newly created Centre for Health and Justice. Today's opening ceremony takes place a year to the day since the official ground-breaking ceremony and was attended by representatives of the Institute, the University and Nottinghamshire Healthcare, partner organisations, and those involved in its construction.

A variety of speakers and presentations were arranged to celebrate the £7 million purpose-built space. Speakers included Professor Mike Cooke CBE, Chief Executive of Nottinghamshire Healthcare NHS Trust; Professor Nick Manning, Director of the Institute of Mental Health; Professor Dame Sally C. Davies, Chief Medical Officer and Chief Scientific Adviser at the Department of Health. All of the speakers spoke highly of the interdisciplinary approach to mental health embraced at the IMH, the exciting innovations occurring in applied research, and the opportunity to fuse clinical practice and research to provide original yet applicable mental health developments.

As cited in the IMH Press Release, Professor Dame Sally C. Davies said: “I am delighted to open this new research facility in Nottingham. Different forms of mental illness affect a significant proportion of people, and the research undertaken by the Institute of Mental Health will provide more evidence to improve the care and services for NHS patients and the wellbeing of the public.”

To that end, the editorial team for the IMH Blog is looking to recruit new post writers! You can write just one post, or many. It's up to you. The IMH Blog is a forum to encourage dialog about issues related to mental health broadly defined. Our aim is to capture the variety of interest and expertise that is reflected in the Institute’s diverse membership body. All interested parties are very welcome to contribute. We encourage posts from carers, service users, clinicians, academics, allied health professionals, commissioners, etc. We look forward to hearing from you!

Posted by:
IMH Blog Team

A short way down from the Department of Health building on Whitehall stands the statue of Field Marshall William ‘Bill’ Slim. Much beloved by his troops from the Burmese conflict in World War Two, there are stories that Slim was unusual in getting things done. One tale about setting up a new camp was that he would insist that sappers delayed laying paths and roads until it had become clear which directions had attracted the most use, usually the paths of most convenience or efficiency.

In a way this tale expounds both a ‘custom and practice’ approach as well as exhibiting innovation. After all how often have we seen organisations or systems insisting on doing things in a way that seems long-winded or inefficient? Human nature sometimes overtakes procedure and staff adapt an approach to save time or effort. Of course, one person’s short-cut is another’s health and safety nightmare. Knowing when it is safe to take a short-cut to improve a pathway is the key.

On my way to my office I get the chance to alight from the tarmac path onto the spongy turf. It isn’t far from the path but that briefest of periods puts the spring back in my step, changing my mindset and for a split second I feel and think differently about things. In his new book ‘Imagine: How Creativity Works’[1] Jonah Lehrer notes how new ideas and solutions to problems often arise from such a change of context, particularly when we are relaxed or off-guard.

So, what am I saying? That we should all stroll randomly about the lawns of our organisations? The gardeners would hate it; our shoes would get muddy too. But there is something about pathways that is fundamental to integrated healthcare in the twenty first century, both in terms of utilising existing flows between hospitals and community care but also allowing ourselves to think differently about going metaphorically off-piste. Now is the time to use a Slim (or should that be ‘lean’ – to adopt the management term) approach to examine what works well and strengthen those pathways as well as looking for other paths across networks that cut off the corners. The trick of course, as with all new ideas, is to get the right meld of innovation, pragmatism and efficiency. Easy to say….

Posted by:
Dr John Milton
Consultant Forensic Psychiatrist & Forensic Research Lead
Rampton Hospital Nottinghamshire Healthcare NHS Trust
E: This email address is being protected from spambots. You need JavaScript enabled to view it.
Reference:
[1] http://www.jonahlehrer.com/

Care and Custody

Recently, the Prison Reform Trust published an article entitled: Ministers outline steps to keeping ‘care not custody’ promise (http://www.prisonreformtrust.org.uk/PressPolicy/News/vw/1/ItemID/153). This article commences:

‘The Health Secretary, Andrew Lansley, and the Justice Minister, Crispin Blunt, have outlined the progress made towards diverting people with mental health needs from the justice system into treatment and care, at a Westminster reception on April 23rd - hosted jointly by the Prison Reform Trust and the National Federation of Women’s Institutes on behalf of the Care not Custody coalition’.
Accordingly, Prison Reform Trust director, Juliet Lyon, argues ‘a bleak cell in a dark, noisy prison is the worst place for someone with mental health needs’. Furthermore, Lord Bradley highlights ‘while public protection remains the priority, there is a growing consensus that prison may not always be an appropriate environment for those with severe mental illness and that custody can exacerbate mental ill health, heighten vulnerability and increase the risk of self-harm and suicide’ (DH 2009:7)(http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_098698.pdf).

Thus, discussions regarding the prison environment, the care of offenders, and the nature of custody have contemporary worth.

This care not custody debate is also currently discussed in the National Newspaper for Prisoners InsideTime (http://www.insidetime.org/articleview.asp?a=1200&c=care_not_custody_promise).

In January of this year a BBC Radio 4 three-part series, The Bishop & The Prisoner, from the Bishop Rt Rev. James Jones aired prisoners’ voices and narratives verbatim on radio (http://www.bbc.co.uk/programmes/b0194p7v). Bishop Jones debates the purpose of imprisonment and the transformation from offender to useful citizen. Overall, the series focuses on reducing reoffending via the central argument that containment alone is neither effective nor sufficient. Here, the care versus custody debate also arises, yet is extended to the whole prisoner population.

This discussion could be further extended to include prison staff. Tait (2008) suggests that a reassessment of the role of the prison officer is required (http://www.hmprisonservice.gov.uk/resourcecentre/prisonservicejournal/index.asp). For example, the idea of prison officers as mere ‘turnkeys’ (p. 3) could be supplanted. Instead, ‘the care of and contact with the inmates in his or her charge’ (p. 3, emphasis added) are important. Empathetic care and contact are arguably crucial in the prison environment. Poignantly, Tait (2008) suggests that developing caring inmate–officer relationships often helps inmates manage their period of imprisonment, increases prison officer job satisfaction, and develops prison officer career aspirations. Such relations require prison officers to listen, understand, and respond to inmates’ needs. Tait’s (2008) caring interactions are ‘founded on relationships characterised by respect, fairness and sociability’ (p. 5). Beneficial ramifications for both prisoners and staff appear possible here. For those in prison with mental health needs, care alongside custody is arguably necessary. Factors associated with imprisonment itself appear to predispose prisoners to mental health problems and these mental health determinants in the prison setting require further research.

Regarding a whole prison approach to mental healthcare, the WHO’s healthy prison concept is a recognition that the health of prisoners is not the responsibility of healthcare clinicians alone. Rather, it is also dependent on the ethos and regime created in the penal setting. The WHO’s Health in Prisons Project acknowledges that prisoners’ individual healthcare needs are essential; however, the promotion of a whole prison approach to health is considered vital for apt development of healthy prisons that provide appropriate care for those in custody. Importantly, Ramluggun et al. (2010) report ‘the conflation of knowledge and experience of staff working in prison places them in a favourable position to contribute to the current reform of offender health’ (p. 70) (http://nurseresearcher.rcnpublishing.co.uk/archive/article-research-in-prison-a-researcher-practitioner-s-view). Certainly, the experiential knowledge of wing staff is remarkably valuable. Indeed, the involvement of HM Prison Service staff in the development of both prison mental health policy/practice and HM Prison Service’s overall approach to prison mental health is to be supported.

Turner (2002) identifies that recovery has been described as an idea, a movement, a philosophy, a set of values, a policy mantra and also a doctrine for change.  It splits opinion between those who view it as simplistic and obvious and others who see its revolutionary and transformatory potential.  Although increasingly fashionable within current mental health policy and practice, there are precedents for recovery as far back as the seventeenth and eighteenth centuries.  For example Phillippe Pinel appointed ex-service users in a bid for a humane regime at Biceptre in Paris and William Tuke developed moral therapy and self management approaches at the York retreat (Scull, 1981).  However, the roots of recovery are most firmly established in movements of protest intended to improve conditions in asylums and to give equal rights to citizens with disabilities.  Judy Chamberlin articulates these rights based approach when she appeals for recognition of the skills and abilities of people with mental health problems to make their own decisions, run their own lives and provide support for one another (1990, 1978).  While the normative claims of recovery have been adopted within English policy, its implementation in mainstream services is heavily critiqued by service users; the main point being that recovery has come to mean all things to all people (MIND, 2008).  Indeed there is a risk that its increasingly popular status and dominance as a paradigm within policy discourses will lead to it being co-opted and distorted by policy makers and experts in the field.

With colleagues in the School of Nursing we used Noam Chomsky’s critical methodology, as an exemplar of a left libertarian position, (Edgley, 2000; 2005; 2009) to provide a theoretical analysis and test of the coherence of the recovery model (Edgley et al., 2012).  We also used it as a critical mechanism to judge manifestations of recovery in practice settings.  In Chomsky’s political philosophy we find that hope is both a pre-requisite and a pre-condition for a trusting and supportive environment.  Everyone, whether or not they have mental health problems, need these conditions to be able to access and utilise their creativity in dealing with their current reality.  For Chomsky, hope, our innate creativity and a supportive community are the necessary conditions of freedom.  In Chomsky’s view, if our society nurtured our creative potentials, then our human nature would not confine itself to searching for autonomy and independence but would instead generate interdependent arrangements.  This could have direct implications for the implementation of recovery; it suggests that those experiencing mental ill health need to be the co-creators of policy and practice, rather than its passive recipients and they need to be able to build and use their own theoretical structure such as that offered by Chomsky.  This would protect recovery from being ideologically driven and open to political interpretation and potentially more importantly provide the basis to evaluate and present evidence on its own terms.  As we conclude in the article:

“The recovery paradigm has the essential elements in place, but control over its application – and lives- needs to be reclaimed from the state and experts alike before adoption turns to assimilation or perhaps co-option turns to emasculation.”

Posted by: Dr Nicola Wright Research Fellow: Research Delivery and Support Unit Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Nottinghamshire, Derbyshire and Lincolnshire

References Edgley, A (2000) The Social and Political Thought of Noam Chomsky.  London: Routledge.

Edgley A (2005) Chomsky’s political critique: Essentialism and political theory.  Contemporary Political Theory 4: 129-153.

Edgley A (2009) Manufacturing consistency: Social science, rhetoric and Chomsky’s critique special issue: The Herman-Chomsky propaganda model twenty years on.  Westminster Papers in Communication and Culture 6(2): 23-42.

Edgley A, Stickley T, Wright N and Repper J (2012) The politics of recovery in mental health: A left libertarian policy analysis.  Social Theory and Health 10(2): 121-140.

MIND (2008) Life and Times of a Supermodel.  The Recovery Paradigm for Mental Health.  MindThink Report 3.  London: MIND.

Scull A (1981) Madhouses, Mad-Doctors and Mad-Men: The Social History of Psychiatry in the Victorian Era.  Philadelphia: University of Pennsylvania Press.

 

The NHS can’t afford to fund every new medical treatment. Budgets are limited. Resources are finite. It’s a boring fact of life, from which people like me – economists – benefit. In recent years the UK has championed the provision of cost-effective healthcare. The efficiency of the NHS owes no small thanks to NICE, which evaluates health technologies for all kinds of conditions. To do so they need to be able to compare these technologies with each other. The general consensus amongst health economists, and the approach adopted by NICE, is to use quality-adjusted life years (QALYs). QALYs are required by the NICE reference case and we have excellent tools such as the EQ-5D to capture these. The use of QALYs as an outcome is almost ubiquitous in the evaluation of health technologies. So much so that they have come to define cost-effectiveness. The area in which their use and study appears most limited is in mental health research. Herein lies a problem: from the decision-makers perspective, not knowing whether an intervention is cost-effective isn’t all that different from knowing that it isn’t.

Generic preference-based measures
Health technologies are competing for the same pot of NHS money and are therefore pitted against each other, regardless of dissimilarities in the conditions they treat. We therefore need an outcome measure that is relevant to all conditions; from baldness to bunions; abdominal pain to Zellweger syndrome. We need an outcome measure that is ‘generic’. For economists (and to some extent decision-makers), preferences are paramount. A hypothetical change in an individual’s health only matters if they (or, in practice, the public) actually assign any value to this health change. As such, the last few decades have witnessed the rise of generic preference-based measures. The EQ-5D is the most well-know of these, but others do exist. These measures enable researchers to calculate the benefits of an intervention in terms of quality and length of life – combined in to one number. Decision-makers are then presented with an illuminating ‘cost-per-QALY’ of an intervention. Such a minimalist result is of great value in funding decisions. Unfortunately, in many cases, economic evaluations in mental health are not armed with this figure. This is no doubt detrimental to future provision and research.

Condition-specific preference-based measures
Mental health researchers’ apparent unawareness of generic preference-based measures is justifiable. The EQ-5D, for example, only includes a single question relating to mental health. There are also greater methodological problems with using generic preference-based measures in mental health; are public values representative of patients’ preferences; can severe patients understand the questions; are ‘general’ questions even relevant? There are certainly pros and cons to using a measure like the EQ-5D in mental health research¹.

Fortunately there’s a happy medium that still allows for the calculation of QALYs and, therefore, the generic valuation of mental health technologies. Condition-specific preference-based measures. These measures capture changes in an individual's quality of life based on dimensions relevant to specific conditions. The development of a preference-based measure involves two stages: development of the classification system (questionnaire) and the elicitation of values. Unfortunately most existing measures have only completed the first stage. Nonetheless, measures do exist and I implore you to research them further, get involved in their development and include them in your studies. There are measures under development that are specific to particular mental health problems, such as DEMQOL: a quality of life measure for individuals with dementia². Some of the most promising work relates to the development of preference-based measures that are specific to mental health but general across disorders. This work includes development of a preference-based measure from the CORE-OM^3,4.

Where next?
Unfortunately these measures are almost solely employed and researched by economists. Researchers involved in the evaluation of interventions for mental health need to champion these measures, as economists alone cannot. If you’re a researcher, why not try to include fledgling preference-based measures (both general and condition-specific) in your studies, and aid their development. Cost-effectiveness is often an 'unknown' in mental health. This is no longer acceptable. If mental health research and care is to obtain the funding it needs, then researchers will have to bend to accommodate these methods and engage with economists. If you do nothing else please read this⁵, then read this⁶, and do not forget to read this⁷. The long-term benefits could be huge.

Posted by:

Chris Sampson
Health economist
University of Nottingham
E: This email address is being protected from spambots. You need JavaScript enabled to view it.

References
¹ Brazier, J., 2010. Is the EQ-5D fit for purpose in mental health? The British Journal of Psychiatry, 197(5), pp.348-9.

² Mulhern, B., Smith, S.C., Rowen, D., Brazier, J.E., Knapp, M., Lamping, D.L., Loftus, V., Young, T.A., Howard, R.J. and Banerjee, S. (2010) Improving the measurement of QALYs in dementia: Developing patient- and carer-reported health state classification systems using Rasch analysis. Discussion Paper. (Unpublished)

³ Mavranezouli, I., Brazier, J.E., Young, T.A. and Barkham, M. (2011) Using Rasch analysis to form plausible health states amenable to valuation: the development of CORE-6D from CORE-OM in order to elicit preferences for common mental health problems. Quality of Life Research, 20 (3). pp. 321-333. ISSN 1573-2649

⁴ Mavranezouli, I, Brazier, JE, Rowen, D and Barkham, M (2011) Estimating a preference-based index from the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM): valuation of CORE-6D. Discussion Paper. (Unpublished)

⁵ Brazier, J., 2008. Measuring and valuing mental health for use in economic evaluation. Journal of health services research & policy, 13 Suppl 3, pp.70-5.

⁶ Jacobs, R., 2009. Investigating Patient Outcome Measures in Mental Health. CHE Research Paper 48, Centre For Health Economics: York

⁷ Chisholm, D., Healey, A. & Knapp, M., 1997. QALYs and mental health care. Social psychiatry and psychiatric epidemiology, 32(2), pp.68-75.

“Insanity is the doing the same things over and over again but expecting different results”

               - Alcoholics Anonymous

I was at an NHS meeting the other day amid a heated discussion about the importance of integrating healthcare needs across the physical/mental health divide. After I made a point about the importance of centring health strategy on the basis of clinical need (i.e. on the needs and priorities of those who actually use the service), one person commented that “business decisions and clinical decisions are not always compatible” and that “health commissioners tell us they don’t want a Rolls Royce service but are quite happy with a Mini”.

Reflecting on this, I was struck by a quite fundamental question: are clinical and business outcomes really that incompatible? And can we really polarise the options in terms of either/or extremes? Last week on the IMH blog Sam Watson posted about the moral costs of doing nothing in healthcare, and the author made some cogent arguments for finding a “quantifiable way of measuring the benefit from all government spending and then choosing the health care budget based on this”. Whilst we are a long way from achieving this in practice, there is a clear recognition that clinical needs and business needs are, indeed, inseparable.

In my own field of clinical health psychology, one of the central issues at the moment is the cost to the health care system in terms of what have been called “Medically Unexplained Symptoms” (a horrible term by the way, but that’s for another post!). These are people who experience considerable physical disability and pain, but often without any identifiable organic (medical) basis. They are usually very distressed individuals, often for good reason; not only are they seen by some medical professionals as malingers and time wasters, they are rarely given a convincing explanation for their symptoms which truly does justice to the manifold complexity of the relationship between body and brain. Pain is very rarely “in your head” but neither can it ever be “just” physical.

Furthermore, and perhaps even more confusing for these clients, it is often entirely arbitrary whether they end up in a mental health service, or in a physical health psychology speciality like mine. Sometimes they will present at both, alongside frequent attendance at hospital and GP surgeries. Ultimately, this costs more in terms of duplication of services, not to mention the cost of specialist medical assessment and expertise. Much of this can be avoided by timely, and coordinated, interventions at an early stage in the process. As we all know, this costs money; but can it really be argued that this is money badly invested?

In thinking about all of this further I realised that I wouldn’t pay for either a Rolls Royce or a Mini. I want what I suspect most people want when they buy a car: something that will not cost too much money up front, but will also not cost a small fortune in the long run. After all, you a can pick up a Rover 400 pretty cheap at the moment; but let’s be honest here, who among us are likely to invest in a car that will probably result in expensive and frequent trips to the garage, not to mention the stress and hassle that goes with it?

I’m guessing that health commissioners, being human after all, are probably not that different either. But being human implies a certain temptation to plumb for the cheap option in the hope that this time, maybe, perhaps, things will be different. With the massive changes sweeping the NHS at the moment, I hope we don’t lose sight of this simple truth: things are usually cheap for a reason, and will probably cost us more in the long-term. There really are no short-cuts here; complex needs cost.

Posted by:
Dr Simon Clarke
Clinical Research Psychologist (Physical Health Speciality)
University Of Nottingham and Nottinghamshire Healthcare NHS Trust

This is an excellent post written by Sam Watson, a blogger on the Academic Health Economists' Blog  posted on 16 February 2012 entitled 'The Ethics of Doing Nothing'.  In the post, Sam reflects about the ethics of non-action in health care provision. Though the arguments put forward mostly relate to physical health care, there are some relevant issues to consider in reference to mental health treatment. An example of this would be the justification often put forward to funding commissioners regarding the funding of expensive treatments and services such as Children and Adolescent Mental Health and Early Intervention. As many health care providers will argue, provision at early stages of mental distress may not only prevent future (and more substantial) problems but also can contribute to a better quality of life. This, ultimately, can also provide savings in the longer term (e.g. less service use in adulthood) and in other areas of social care (e.g. dependence of the welfare state). But the problem always comes back to this: with limited amount of funds and resources, how can you justify putting money into services that offer benefits well outside the time cycle of short-term budget reviews, as well as in areas which may have no direct bearing on health care? Conversely perhaps, how can you quantify quality of life and is this something you can even put a price tag on?  Yet is doing nothing the better alternative? Have a read of the post and let us know your thoughts!

 

In her second blog post, Victoria Tischler, the Institute's arts co-ordinator, writes about shortlisted applicants who each have a vision of representing mental health in a sculpture.  She also talks about the annual Koestler awards at Rampton and gives us a description of the inside of the new building!
For more information about commissioning an artwork to mark the opening of the new headquarters, please see Victoria's post from 2 March 2012.