Category: Mental health services

New NICE guidelines on self-harm: show it’s not possible to hit three targets simultaneously
  • October 9, 2022

Writers of NICE guidelines have to take on three tasks. They have to marshal the evidence and integrate new findings into the existing guidance. They have to present their findings in different formats to suit different audiences. And they have to ensure that any guidance can reasonably be taken up, by taking into account such research as there is on barriers to implementation.

In the context of self-harm these tasks are more than usually demanding. Most obviously there just isn’t that much new evidence – a symptom of underfunding as much as it is of researcher indifference or incompetence. And such research as there is may be based upon populations far removed from the typical UK patient seen in ED or primary care. Much practice is therefore consensus or opinion based and new guidance cannot simply take the form – now modify treatment regime A by substitution or replacement to make Regime B.

Second, much self-harm is seen initially by practitioners who have no great depth of knowledge of self-harm theory or research; even when working in mental health services they are often generalists rather than part of a specialist self-harm team. Guidance therefore needs to take the form of clear and specific pointers to action, of a sort that does not rely on implicit knowledge.

And third, existing culture could not be described as conducive to dispassionate evidence-based practice. Influential and unhelpful ideas about personality disorder, non-suicidal self-harm or emotional instability exert a dismaying amount of influence.

It strikes me that these three demands are impossible to reconcile into a single document, as the latest NICE guidelines on the management of self-harm illustrate.

In an effort to stay based upon evidence the review recommends only two psychological treatments, neither with advice about how the recommendations will be read and implemented: CBT-informed therapy the definition of which does not take account of interpersonal factors and which will therefore be interpreted as “CBT-lite” by most people, and DBT for young people with “significant emotional dysregulation” without indicating how that will be determined in routine clinical practice or what happens to all the other young people who aren’t getting a label of emerging borderline personality.

Some of the advice to non-specialists is unhelpfully vague – I don’t think the average GP needs to be advised to refer to mental health services if they are concerned after assessment in primary care, and I don’t know that school staff will know without some specifics how to meet the recommendation that they identify “self-harm behaviours”. On the other hand some key questions – about the role of diagnosis in management decisions, how to get to the meaning of suicidal thinking with a patient, the important differences between one-off presentations in crisis and long-standing repeated self-harm, the origins and response to professional stigmatising – are hardly touched on.

Implementation challenges don’t get much of a look in. To give one example: it’s impossible to discuss how to improve self-harm services if we don’t acknowledge that aftercare is likely to require referral to CMHT who can’t/won’t see people without a “serious mental illness” or clinical psychology who won’t see suicidal people or who will if they’ll sit on a months-long waiting list.

I don’t think the problem here is primarily down to the expertise of the guideline group, which contained some experienced and sensible clinicians. A major problem resides in remit. This is a three-in-one document: a (short!) document giving a synthesis of what’s new in research; an assessment and treatment manual written with specific readers in mind (so actually a series of manuals) and a trouble-shooting guide to tackling current problems in service provision. NICE guidance just isn’t set up to meet such diverse aims and I wouldn’t therefore expect these latest guidelines to make much difference to the grim reality of service provision for people who present after self-harm.

New NICE guidelines on management of self-harm won’t lead to the changes needed – lack of investment and the culture in mental health services will see to that.
  • January 28, 2022

It is more than a decade since NICE last published guidelines on the assessment and management of self-harm, so the recently released new guidelines (out in draft for consultation) will be read with some interest.

What we find is a mixed bag. For the most part the proposals are unexceptionable, the generation of novel ideas and advice no doubt hampered by the desperate lack of funded research in the area. Some suggestions are not impressive – for example a blanket endorsement of CBT for all adult self-harm is limited to put it mildly, and the section on harm minimisation is ill-informed and muddled.

There are, however, some welcome recommendations, most notably “1.6.4 Do not use aversive treatment, punitive approaches or criminal justice 5 approaches such as community protection notices, criminal behaviour 6 orders or prosecution for high service use as an intervention for frequent 7 self-harm episodes.” – a clear response to the HIN/SIM scandal and one that will make a difference, not least because it is supported by NHS England.

My guess would be that this is the only recommendation likely to make a substantial difference to service provision in the next few years because there are two barriers to change that NICE can’t really influence – the first is lack of resources and the second is culture in mental health services.

When David Owens and I wrote a lament for the state of self-harm services in the UK my friend Nav Kapur wrote a Pollyanna-ish reply, but in truth the situation is dire. Existing services like CMHT’s and IAPT will see hardly anybody and those they see will get an appointment neither on a timescale nor in the numbers needed for the nature of the problem. Liaison psychiatry services do most of the assessment but none has the clinic capacity to arrange therapeutic follow up. The few specialist services there are will see a small number of referrals for intensive longer-term therapy but only if strict eligibility criteria are met. There are several reasons for this state of affairs, but one of them is undoubtedly lack of investment in trained staff to do the work. Against a background of government “austerity” cuts, money has been found for psychotherapy provision in the NHS (through IAPT) and for an expansion of liaison psychiatry services, but none of it has found its way into the budget for self-harm aftercare. You can come up with as many recommendations as you like about support for people who self-harm, but if there are no services to deliver that support then nothing’s going to happen.

Culture eats strategy for breakfast, and the other piece of the puzzle resides exactly in culture. There are plenty of people who think, and behave as if, self-harm isn’t that important and the people who do it are just a bit of a nuisance. Patient feedback about services repeatedly makes this point – ED isn’t a great place, waiting to be seen is stressful, assessment doesn’t achieve much if there are no useful services to which somebody can be pointed after the assessment, but a lot of this can be tolerated if it doesn’t come with a message of hostility or indifference from the clinician seeing you. Of course it isn’t every clinician but it’s enough…especially for those unfortunate enough to have copped a diagnosis of personality disorder.

These two things play off each other – negative attitudes lead to, or at least lead to tolerance of, poor service provision, and lack of services leads to stressful uncomfortable encounters in which it is all too easy to slip into a hostile or blaming frame of mind.

I don’t think this is all there is to it but these two factors, which I have named here rather than unpacked very carefully, seem to me a good part of why the draft NICE guidelines bring such a sense of anti-climax. Most clinical conditions are now managed in established services delivering care that might be improved by careful attention from a positive and trained workforce to standardised evidence-based practice; that’s what NICE guidelines are for. In self-harm those conditions just don’t apply. Let’s not blame the NICE guideline development team, let’s look elsewhere for solutions.

Why are self-harm services so poor?
  • May 13, 2021

In the latest addition to the BMJ series What your patient is thinking, an anonymous contributor writes of their personal experience of seeking help for repeated self-harm: “I am more than a body to stitch up and label”. Their conclusion is familiar and depressing “I do not expect long term input from NHS mental health services anymore, but there should at least be crisis input available for self-harm”.

I say familiar because it is no news to anybody, surely, that self-harm services are not in a fit state for the scale and importance of the task they should fulfil. Of course, a significant part of the problem is the shameful under-funding of our mental health services, a policy pursued with gleeful vigour by the UK government since the banking crash of 2008. But that alone won’t do as an explanation – we have known about poor services for decades and it’s not the first time I’ve touched on the topic in my blog yet there is still no sign of real improvement. Why is it that so little changes? Apart from the serious external constraints, I see three factors that are internal to mental health services.

The first is attitudes. I’m not going to rehearse the well-known argument about negative attitudes among staff – they exist, they’re unprofessional, they’re not universal. They affect the immediate individual exchange, but in a way what’s more important is the resulting lack of priority given to self-harm services when they are in competition for limited resources. One aspect of this that isn’t often enough pointed up is the unwillingness of clinical psychology services, and more recently IAPT, to get involved. The IAPT therapies manual (v.4, 2020) only mentions self-harm once, to say that the risk needs to be assessed without saying what to do about it. A typical local IAPT service will therefore say “In line with National IAPT standards, the service does not work with…people who present with active risk of significant self-harm”.

A second problem is muddled thinking about the nature of self-harm and especially what it means to say that self-harm is non-suicidal. The big culprit here is the idea of non-suicidal self-injury and how readily what should be (if it means anything) a description of an act becomes a description of a person. The result is that repeated self-harm is not seen as serious, or at least not serious enough, to merit special attention even though it is in fact a risk for pretty much all the poor outcomes you can think of in psychiatry.

Third, and lying behind much of these other factors, is the damaging idea of personality disorder, who you are as a mental illness, and especially the idea of borderline or emotionally unstable personality disorder. Inherent to this diagnosis is the notion that somebody has a sort of inbuilt emotional instability to which self-harm is a response. This formulation comes with a downplaying of experienced life adversity as causal, and with an over-emphasis on framing responses in terms of personal responsibility rather than need for specialist help. It flies in the face of what we know about the many reasons for self-harm that simply aren’t captured by thinking of it as a symptom of an abnormal personality.

Mental health services are off the pace here. Self-harm is a hugely important mode of presentation by people who want and need help and we should rethink how we are going to respond in more effective ways than we currently do. Otherwise we’ll be reading pieces like this one in the BMJ for another 25 years.

Should the police be included in mental health crisis teams?
  • April 27, 2021

A spin-off from the practice of police officers wearing body cams is that the footage (in the UK) provides material for fly-on-the-wall documentaries about what day-to-day police work is like. One of the insights you learn from that TV coverage is how often the police are called to incidents where a significant part of what’s going on is explained by the mental health problems of one or more of the protagonists. And one part of that work is generated by people who repeatedly access the crisis services, either by calling 999 or by presenting their distress outside the home to others who then call the emergency services.

It is widely accepted that responses to this phenomenon of frequent crisis contact are not always effective. One recent development has been the emergence of the High Intensity Network of teams delivering what is known by the (frankly silly) name of Serenity Integrated Mentoring. These teams include both mental healthcare staff and police officers, share information and decided on a plan aimed at reducing this so-called high intensity service use.  That plan can include the possibility of formal action by the police, including the use of community behaviour orders or prosecution. I have recently become aware of this scheme and of some of the concerns being raised by patients who have experience of it and by service user activists. I had been alerted to it by a friend who is a service user and activist, and from my reading of social media posts by those people seeking an investigation and curtailing of this activity.  I have come to the conclusion that there are indeed some important concerns being raised: this is not just a Twitter storm in a teacup. I will outline what I take to be the main issues.

First there is the practice of sharing confidential clinical information with police officers. This has been justified by an appeal to the idea that people are only included in the scheme in an emergency, and that sharing is therefore in their best interests.

Here for example is a Tweet from the Network’s director. It is clear however that this idea of data sharing as high-threshold urgent action is being stretched to justify routine sharing of clinical information on all patients managed by the team. To quote the Network’s own description of the people under consideration “They are constantly an emergency case, just fluctuating at different levels of intensity, causing varying levels of impact. Our strong argument therefore is that all agencies involved in the network can share personal data and clinical data about these service users at any time, both in a preventative capacity when they are not using emergency services and in a reactive capacity when they are.”

Second, there is a question about informed consent from patients in the scheme, who must by definition have mental capacity.  There is much made in HIN/SIM documents of the need for consent, and it is said that lack of consent (telling described as “refusal to engage with mentors”) must be respected.

Here is a slide from a talk given about SIM by a team member. The nature of consent in this situation is highly problematic, since it is clear that in these integrated teams the prospect of coercion remains an active option for those who engage in what the team consider undesirable behaviour and yet who “fail to engage”.

The SIM operational delivery guide confirms this overlap of processes, with clinical staff able to contribute to the discussions about police responses to antisocial or illegal behaviour and police able to contribute to discussions about clinical risk management.

Some of the vocabulary used in HIN/SIM documents is not reassuring when seen from a service user perspective. For example stating that “The project team will be dealing with service users with often high risk, malicious and litigious behaviours.” and suggesting (as in this Tweet from the director) that patients do not have the right to share and discuss their care plan with people of their choosing. The FAQ section of the HIN/SIM website notes “Our teams operate multi-agency panels each month to assess which patients should have their consent removed…”

This approach, implying a seamless move from therapeutic responses to coercive responses, is one of the commonest complaints evident in online discussion of the scheme. Because police involvement is evident in all aspects of the process then consent to participate can hardly be given without a sense of duress.

Third, there is a question about evaluation of the scheme and especially assessment of harms. A startling number of benefits are claimed for the mentoring scheme – based it has to be said on minimal evidence: in truth there has not been a substantial independent research evaluation at all, which is surprising considering how enthusiastically the scheme has been promoted. By contrast to the claimed benefits, there is no discussion of potential patient harms such as those that might be caused for example by people avoiding seeking help in a crisis or actively being prevented from doing so. Any deaths that might occur are described as accidental, including those attributed to (a new term to me) accidental suicide.  

It is hard to collect citable evidence on such outcomes from informal reading because so few people are willing to come forward in an identifiable way, but I have seen them reported by reliable sources and there is no reason to doubt that they happen, even if nobody is trying to quantify them.

Complaints are likely to be interpreted in particular ways “Making complaints against staff can often be a way in which service users (at times of stress) attempt to avoid consequences or responsibility. They can also be used in an attempt to distance themselves from the staff who are supervising them so that they do not have to continue with the programme.” And staff who have to respond to what are called allegations are invited first to watch a video prepared by HIN. “The video informs the investigators about the nature of high intensity cases and the behavioural disorders commonly found in these cases. It also explains the motivations for making false allegations and common behaviours that may be witnessed after the allegation has been made.”

In summary: the approach represented by the High Intensity Network has apparently been adopted by more than half the Mental Health Trusts in the country, despite lack of robust evidence for its effectiveness or harms. Reasonable concerns have been raised about the approach to information governance and the sharing of confidential information and about the blurring of boundaries between therapeutic (health services) responses and coercive (police service) responses.

Much of the promotion of this particular scheme has been individualised around the person of Paul Jennings, a policeman who started the SIM programme in the Isle of Wight and now directs the High Intensity Network. Jennings has a rather idiosyncratic take on the issues which no doubt influences the tone of debate: he talks about mental health problems in prisons as if they are relevant to this different context, and his rationale for SIM as a response to what he calls behavioural illness is a mixture of naïve behaviourism and a sort of paternalistic encouragement to people to give up bad habits. Nonetheless, there is more to be questioned here than can be put down to one person’s influence. The problems outlined about confidentiality, consent and coercion are inherent to any scheme in which health care staff and police staff are fully integrated into a single team. There is a serious question about whether the Royal College of Psychiatrists should be supporting such developments at all. It is a worry that so many psychiatrists are likely to be involved either directly or tangentially in this way of working, without these issues being resolved. There are other ways to develop productive working relations with the police and the other agencies involved with crisis care.

Acknowledgments:  There is an impressive social media presence on this topic.  As a start try searching Twitter using #HighIntensityNetwork or #Stop Sim. It is activist and service user-led work that has brought the problems to the fore – critical discussion led by mental health professionals has been bordering on non-existent. The quotes in this piece come from:  HIN/SIN Operational Delivery Guide (SIM London version, March 2018); SIM Business Case  and SIM FAQs (from HIN website www.highintensitynetwork.org unfortunately unavailable since June 2021)

SIM__-_Business_Case_Commissioner_v4Download
SIM-Operational-Delivery-Guide-1Download

Getting to grips with human trafficking and modern slavery:
  • January 3, 2021

Like most people, I suspect, I have had a hazy idea of human trafficking as something to do with women from Eastern Europe being forced into sex work and men being trapped into low-waged agricultural or other jobs.  Occasionally stories surface about vulnerable individuals trapped in dire conditions by unscrupulous families, and most recently about the fate of 39 trafficked Vietnamese who died in transit. Prompted by the Many Stories Matter book group in my university, I decided to find out more and have been educating myself as a starter with two books on the subject.

Modern Slavery: A beginner’s guide. Kevin Bales; Zoe Trodd; Alex Kent Williamson. Oneworld Publications 2011

Bales, Trodd and Williamson are academics with long-standing interests in slavery and commitment to its abolition.  All three are now based at the University of Nottingham in England. Not surprisingly, their book is a model in presenting the global facts about trafficking and slavery (a distinction helpfully clarified early on) and their diversity in the modern world. The book has something of a US bias because of the origins of the authors, but really doesn’t suffer for that.

Some of the book’s messages are predictable ones: risky environments are made by poverty and the social disruption caused by globalised destruction of rural life and the drift to slum dwelling. Displacement through environmental degradation and war are major contributors.  At an individual level exploitation of groups is defined by ethnicity, caste (in India), religion and especially gender. The highest prevalence of slavery in the world turns out to be in India, in the form of coercive/indentured labour and domestic servitude linked to the caste system.

A less familiar finding is the importance of corruption at national government level in tolerating or even actively supporting slavery and trafficking. Sometimes this amounts to active pursuit of policies that enslave – in Burma and China for example. And although poverty makes a ready source of people to prey on, it is affluence that creates a market for trafficked people. It is rich, illiberal and corrupt countries like Japan and Israel that top the lists as recipients of those trafficked for labour or sexual exploitation.

Unlike many books on problems in the modern world, the book ends with an outline of the practical steps that can be taken to tackle slavery – starting with proper data collection and sharing, international and national anti-slavery plans should include education programmes, active law enforcement and funded rehabilitation schemes for survivors. Industry must be held to account – and especially in an interconnected global world industry must look to its own supply chains and ensure they are not supported by slavery (recent revelations about the rag trade in Leicester came to mind while reading this).  A corollary of the global scope of the book is that pointers for individual action are a bit less incisive – being alert to spotting victims, raising awareness, pressing businesses on their practices.

This is where my second book comes in – I was looking for something to help me understand more what was going on in my own country, and to think about what I might do about it.

Stolen Lives: Human Trafficking and Slavery in Britain Today. Louise Hulland Sandstone Press 2020

The blurb on her publisher’s page says Louise Hulland has been investigating the plight of victims of modern slavery and human trafficking since 2010, whereas in the book itself Hulland says she started researching for the book when Theresa May was PM, in other words in 2016, and in her final summing-up chapter she says she has spent “six months immersed in the world of ant-trafficking and slavery, speaking to those on the front line…” . In truth that’s how the book reads – as a breathless whistle-stop tour of key informants with little or no deep reading or analytic work behind it.  There is to take one example no discussion of the implications of so many faith-based organisations being involved in anti-slavery and anti-trafficking activities.

The tone of the book owes as much to lifestyle writing as it does to research rigour. The presentation consists essentially in a series of interviews apparently transcribed verbatim and introduced by odd personal vignettes.  Kathy Betteridge, the Salvation Army’s Director of Anti-Trafficking and Modern Slavery, is petite with short blonde-grey hair and is hugely passionate. Norree Webb, the Army’s First Response co-ordinator, is by contrast warm, calm and seemingly unflappable. Rachel Harper, manager of Helpline is warm and engaging. Andrew Wallis, CEO of Helpline, is tall friendly but intimidatingly intelligent. Caroline Haughey, a barrister with a special interest, is tiny and wears a bright pink jumper; she is warm and incredibly modest.  Colin Ward, a DC with Greater Manchester Police’s Modern Slavery Coordination Unit, is tall without being intimidating, calm with a warm northern accent. Apparently he’d clearly seen more than any human would wish to.

Once you get past this stuff there is a reasonable amount (although not 270 pages’ worth) of information about how slavery and trafficking are approached in the UK. Most of it is available without the padding from the Global Slave Index 2018 report on the UK. The Modern Slavery Act 2015 tidied up a messy legal framework and makes prosecution cases easier to pursue, and a National Referral Mechanism provides a framework for identifying victims of modern slavery and ensuring they receive support, but there are formidable barriers to tackling the problem at scale – not least underfunding. Not many people know, I suspect, that the main recipient of Government funding to support victims is the Salvation Army, which in turn contracts work to several partners including other faith-based organisations. The picture that emerges is of groups of dedicated individuals working for statutory bodies and in the third sector, struggling to do the best they can in the face of official indifference and hostility. The hostility comes mainly from racism and from the fact that so many victims are either immigrants without the right papers, or UK nationals who need extensive help from our (much diminished) welfare state.

What can an individual do?

As a former health professional, I thought the best place to start would be in the area of health of victims of trafficking and slavery which is, not surprisingly, terrible. Poor nutrition, physical abuse, sexual abuse, unhygienic living arrangements and inadequate access to primary healthcare contribute to poor physical health. Poor mental health comes from the burden of abuse and neglect that constitutes the defining condition of the people involved, and may be compounded by pre-existing problems that increased initial vulnerability to exploitation.

To get a flavour, I started by sampling the websites of four hospital Trusts (two acute, two mental health) and two large CCGs. None had a link to a modern slavery statement on its home page and for 5/6 a search on their website using <slavery> or <human trafficking> produced no hits. One acute Trust had a statement about its compliance with the Modern Slavery Act’s requirement for transparency in supply chains. One of the CCGs mentioned that its safeguarding teams were helping local NHS staff to recognize and respond to people who were at risk or had been trafficked or enslaved. One Trust’s maternity service had a nice page about maternity care for refugees and asylum seekers, but none of the sites indicated specific services, or even specific individuals to contact, in relation to slavery or human trafficking. I couldn’t find anything relevant in a search of the RCPsych website.

Part of the problem here is one of scale.  The Global Slavery Index (an excellent site well worth a visit) estimates that there are 136,000 people in modern slavery in the UK, about 2/1000 of the population. If we assume that half are in or around London, my back-of-an-envelope calculation puts anything from 500 to1000 in Leeds where I live, or about 1/10 of 1% of the population. Every one of those people needs help but put against the scale of problems being dealt with routinely by our under-resourced health and social services it is easy to see why slavery doesn’t get top billing.  At the same time, it is unclear what exactly is the need of services and whether it is specific or can be subsumed within other services designed to support the traumatised and exploited. There are barriers to presentation, personal and imposed by circumstances, which add to difficulties in planning a ground-up response.

Regardless, what makes work in slavery and trafficking different is the involvement of organised crime and the concomitant need for liaison with other agencies, good record-keeping and reporting. There is nothing about the current UK government that inspires confidence in the likelihood of effective action. Perhaps a small step in the right direction would be for all Trusts to identify a liaison clinician with responsibility for advising about and overseeing services and liaison with relevant statutory and 3rd sector organisations, as has been recommended to improve healthcare for people with a learning disability.

Down with “mental health”?
  • October 14, 2019

I was lucky, early in my career, to meet Professor Geoffrey Rose.  One of his (typical) quietly provocative remarks was that there are no categories in nature – I remember we touched on dead/alive and pregnant/not pregnant and then gave up trying to think of examples to prove him wrong. So for a long time I’ve been keen on the idea of illness or disability as being on a spectrum or continuum.

In my own field the umbrella term “mental health” has come to represent this idea – not that all mental disorders are the same but that they all share something important that makes them related to each other, belonging in the same category of illness.  Recently I’ve begun to wonder if it’s such a good way of talking.

An article in the Guardian newspaper this month highlighted a damning series of investigations by the Care Quality Commission (CQC) into the care offered by privately run mental health units. As I read to the end my eye was caught by the line of tabs at the bottom, linking to “related stories”, and particularly this first one in the row.


Really? How is the anger and dismay of let-down football fans “related” to the neglect and abuse of vulnerable and severely disabled inpatients in special units?

I have come to see some serious disadvantages to “mental health” as a catch-all.  There are several versions of an unintended but malign effect of the term – which can trivialise or distort the true nature of mental disorder.

  • Success or “recovery” stories from one part of society can overplay the likely benefits of intervention in what are essentially intractable problems, as pointed out recently by the parent of a child with autism, who wrote:  ‘These stories don’t show the child who is non-verbal, who screams and growls for hours on end and attacks his or her parents on a daily basis’…”For once I’d love to see a story that celebrated a child managing to say “drink”, rather than screaming for two hours. That’s our idea of success.”
  • When “diagnostic” labels are applied (especially following self-diagnosis) the result can be misleading and demeaning to others. Being socially awkward isn’t the same as having autism; lacking emotional equanimity isn’t the same as having bipolar disorder; being greedy isn’t the same as having bulimia.
  • Well known people “coming out” about their own mental problems may indeed be helpful.  A healthy society needs to be able to acknowledge and respond to all aspects of the lives of its individual members, and we are all better off for the brave people who have in recent years talked about their sexuality or emotional problems.  There is however a downside to the invited comparison, as there is to all celebrity endorsement – most people with mental disorders aren’t rich or creative or successful: if they are lucky they are ordinary; if unlucky then they are disabled, poor and harassed. 

I have concluded that we’d be better to drop the term “mental health” – making the effort instead to be specific about each particular problem in which we are interested.  Maybe it’s evidence of rising levels of distress or anxiety in school students, or self-harm in middle-aged men, or moderate levels of depression in people consulting their GP. With more specific use of vocabulary we can have a more meaningful discussion than we do currently about public health and health services for those struggling with emotional disorders and mental illness.  Changing how we discuss things is easier said than done, but I’m going to give it a try.

error

Subscribe to keep updated!