Experts by personal experience aren’t always right (guest post)

  • August 19, 2019

Professor June Andrews discusses her discomfort about advocacy based upon the questionable (but unquestioned) personal experience of individuals.

Dementia is in the news.  Stories about it could be described as fashionable.  Advocacy organisations understand the power of hearing the voice of a person who is experiencing dementia themselves, and so they are on the hunt for people, preferably famous, who can come to represent the disease.  They can be people with dementia, or the relatives of people with dementia.  At a push, they can be people who sympathise with dementia, if they are famous enough to be influential even though they don’t have a back story.

Advocates have an honourable role in the campaign of any charity to raise funds.  It’s often described as raising awareness.  But in truth, awareness is already pretty high so you can be sure the main aim is to get funding for the charity, which is often focussed on a cure.

There are two problems with this sort of representative advocacy.

Problem 1 – the unquestionable legitimacy of “personal experience”.

The press officer at the charity is not a clinician, so when someone turns up with a diagnosis, they take it on face value. The way news is curated by media editors and controllers demands tropes like “victim” or “hero” and some virtue signalling or novelty.  If the person with the diagnosis is articulate and personable, they will be good to undertake media roles for the charity. The public gets most of their information from general media, so that’s the way to let them know they need to fund a particular charity and secure a cure.  Media coverage is so relentless and fast, the representative needs to be nimble and well prepared to get the best from any opportunity that arises.

Dementia is a progressive degenerative condition, but the press officer can’t stop to ask any questions when the person is still stable, at the same level, years later.  By that time the dementia representative patient is busy and in demand for appearances world-wide.  So pervasive is the idea of “nothing about me without me” that conference organisers know they will be heavily criticised if they fail to put a person with dementia up on the platform.   The media-experienced-dementia-experienced personalities get heavily worked.  They see it as a duty and a mission, whatever it costs them. 

I have recently been alerted to the fact that any question of whether they actually have what a clinician would think of as dementia is blocked.  Dementia clinical experts are puzzled, because mild dementia is a transitional phase but these mildly affected media representatives go on for years.  If someone has been on the circuit for a long time, clinicians can with confidence say that this person is definitely not like any other dementia case.  The charity can’t afford to go anywhere near this. However odd it might seem to people who really know about dementia, the representative (who almost certainly has some other complex illness) is put up in public as just “a person with dementia”. News values demand an interesting person with dementia who is happy to be exposed in the media.  If you have one, you keep them as long as possible and are, to be honest,  grateful if they seem to survive longer than usual because it’s hard work to keep finding people with a fatal, progressive, cognitive disease and a thirst for publicity.  You invest in what you’ve got.

Any suggestion that the patient’s sense of entitlement is out of control is taboo. When organising dementia events, you may sympathise with requests for free places for people with dementia.  When they then expected travel and hotel accommodation for themselves and their partners, with a few days on either side to overcome their fatigue, organisers can’t always afford it.   My own experience is that refusal causes profound offence, and can give rise to well publicised anger and unfavourable comparisons with other conference organisers. We’d get accused of profiteering on the backs of people with dementia and failing to give voice to people with dementia.  Actually our job was not to give them voice.  It was to educate professionals about the latest research, and practical things like how to manage continence, and terminal care.   The person with dementia talking at the event was usually preaching to the converted. We had more educative value from dramatic representations of the sort of complex problems that could never be revealed in the first person account of one individual.

Problem 2 – erosion of the legitimacy of professional expertise

The second problem is related. In the environment that has been developed with the strong encouragement of the advocacy organisations, any one of these “dementia-experienced” selected representatives trumps the knowledge or experience of the rest of the world.  The individual is sanctified with an almost religious fervour, in that anything they say cannot be contradicted. Crossing them gives rise to shock and outrage.  Those who might be seen to hold heretical positions such as questioning the diagnosis or wanting to meet without a token dementia person in the room often do so secretly because to speak openly about this sort of thing can affect your funding or your job prospects.  You risk a sort of excommunication. Or you hide.

 When you’ve upset the dementia lobby, they mobilise an articulate person with dementia who goes along with their mainstream view to attack you. From experience, it is personal and vicious.  If I was earlier in my career, I believe I’d be silenced by them.  The decider is that I don’t have dementia and they do, so anything I say that they disagree with is evidence that I have no knowledge. In this way, people who have worked with hundreds of affected families and people are marginalised. One individual can say on the basis of their personal experience, with the backing of an organisation, that this is only a “so-called” expert.  Social media heats up.  It’s dangerous to come out with an alternate point of view because you’ll get attacked.

I understand fear and rage, and as a psychiatric nurse, I’ve worked with lots of that.  What offends me is the channelling of that by organisations and lobbies for their own ends, using people with dementia, patients, dementia sufferers – whatever you are allowed to call them – as a human shield. They like to imagine they have the moral high ground, but they don’t.  For them, it’s just business and the sooner we reveal that, the sooner other sorts of experts will be able to say what they know without needless anxiety.

Does using substitutes or proxies for self-harm help?

  • August 10, 2019

An intriguing recent study was done no favours by melodramatic misreporting of its findings.

Substitutes or proxies for self-harm include doing painful but non-damaging things like holding on to ice cubes or eating hot peppers.  They are quite commonly cited in advice about self-harm.  For example, when I put <How can I stop self-harm?> into a search engine recently, using substitutes came up in the advice offered by my own Royal College, by a private healthcare chain and by a 3rd sector organisation.  There’s actually very little evidence behind this advice, so it was good to see a recent study exploring the experiences of young people with such approaches.

The study had two parts: an online questionnaire to which 758 people replied, and an interview with 45 people. What were the main findings? Only 7/758 people who completed the questionnaire said they had used any of the techniques; it isn’t known why the other 99% hadn’t. In the interviews, 29 people said they’d used at least one of the techniques – some found they didn’t help at all, some found they did. 

This sort of small numbers qualitative study can’t tell us how common certain experiences are, only what the nature of such experiences might be. So the Sky News opener “Many of the techniques used to reduce self-harm do not work for most people…” could only be accurate if the sentence had finished “…because most people don’t use them”. Unfortunately that wasn’t the message being conveyed.

There’s a further twist.  In the questionnaire study 18 people, and in the interview study at least 6 people, said they had used one of the techniques (snapping an elastic band against the skin) as a means to self-harm. Now, given that one sort of harm reduction involves “strategies that aim to ensure that the same method of self-harm [AOH: in this case damaging the skin] has less medically severe consequences” this might be less of a bad thing than it sounds – elastic bands do less harm than broken glass or razor blades.  The news report (of course) took the opposite tack “The therapies could even become abusive in their own right”.

My experience is that most mental health professionals are rather sceptical about proxy or harm minimisation approaches, thinking that if they do help some people then any effect is likely to be fairly weak or transient given that they don’t tackle underlying problems. They might provide a bit of breathing space but they can’t substitute for therapy. I don’t think most will mind very much that such techniques get a poor press through this report, although we could do with some more discussion about what part they might play in selected situations. However, what they should mind is yet another example of mental health reporting being slanted by poor understanding of science and a need for dramatic headlines.

Psychiatry’s worst idea

  • August 2, 2019

Here’s a typical news story from a local paper – about a police call that led to a house search prompted by smelling cannabis.

“The search of the property unearthed two dozen plants being cultivated with a hydroponic system in a cupboard and two more in a nearby wardrobe, said Mr David Swinnerton, prosecuting. Police estimated the crop had a potential yield of over £7,000.

However it was claimed at court that […] might have been pressured into growing the drugs. Mr Thomas Griffiths, defending, said unemployed […] who had several previous convictions and had recently become a father, suffered from a personality disorder and might have been exploited by others because of his naivety.

What does it mean to say that a defendant in a case like this has a personality disorder?  Here’s the answer from the NHS website

“A person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person. There are several different types of personality disorder. This page gives some information about personality disorders in general, linking to other sources for more detail.”

In other words, personality disorder is a diagnostic label attached to who you are. To my mind this is psychiatry’s worst idea – the use of diagnostic labels to describe somebody’s personality.

Here’s an edited version of what I said in my book Undertstanding and Responding to self-harm

“There are real problems with this way of thinking. First, and rather obviously, it leads to an emphasis on the individual as the source of their problems and therefore downplays the role of other people and circumstances…

…Second, the diagnosis is often experienced as a way of saying ‘the problem is about who you are as a person’ and it is widely used in a critical or dismissive way by professionals in health and social care. The person on the receiving end can easily be stigmatised and become (rightly) angry – that anger then being used as further evidence of what’s wrong with them. Not surprisingly, lots of people given this diagnosis don’t like it and don’t like the effect it has on the way others treat them.

This isn’t to say that people don’t have recognisable and enduring characteristics. We all know somebody who is particularly obsessional, prickly, paranoid or prone to emotional outbursts. Sometimes these characteristics do indeed seem important in explaining self-harm. For example, impulsivity is a tendency to act on the spur of the moment, without much thought and without consideration of the consequences. This characteristic is quite commonly associated with self-harm, especially when it is coupled with negative ways of thinking.

What isn’t right is elevating these observations into diagnostic statements – putting people into categories as if somebody’s personality is a mental disorder – which is indeed where personality disorder sits in the main diagnostic systems used worldwide.

There’s another practical problem with this ‘diagnostic’ approach to personality, which is how little use it is in explaining anything… circular reasoning is really common in practice, [for example] using repeated self-harm as part of the basis for diagnosing a personality disorder and then using the diagnosed ‘condition’ to explain the repeated self-harm.”

And that’s not to mention the observation that a “disorder” that’s inherently part of who you are tends to “get better” over quite short periods of time.  

It’s perfectly possible to practice psychiatry, and the law, without this diagnostic practice. Time we all started doing just that.

Self-harm – book review (guest post)

  • July 30, 2019

Most booksellers and libraries stock a range of self-help books. In these straightened times the NHS insists that: “Self-Care is Good For Us”. Books on prescription is a clinical intervention nowadays, with GPs ‘prescribing’, that means recommending, a book from a list of titles available in local libraries. Mental health features most commonly in books on depression, anxiety and eating disorders.
Books on self-harm have long been missing from the shelves. The exceptions are handbooks aimed at parents of teenagers. Self-harm is a chapter of its own in books on BPD, such as ‘Borderline Personality Disorder for Dummies’ or ‘Borderline Personality Disorder the Survival Guide’.  While there is powerful survivor literature including personal accounts of self-harm, this is found online only once you know the right publishers, blogs and websites.
This weekend I was surprised to come across a book that is all about self-harm. It is called ‘Understanding and Responding to Self-Harm, The One Stop Guide.’ The author is Professor Allan House, a psychiatrist with a clinical and academic background in Liaison Psychiatry. The note on the front says it all: “A clear, thoughtful, essential guide.”
The book is intended for a wide readership; people who are newer to self-harm to those who may have harmed repeatedly, as well as their friends and families. The case studies and quotes cover a range of ages, whereas most interest in society is focused on young people and self-harm.  I would add that many mental health professionals, including those working in Liaison teams within Accident and Emergency (A&E) departments, would benefit from reading this book and thinking again about their fixed ideas about self-harm.
I fall into the category of someone who has self-harmed repeatedly. I do feel the worst is behind me. I am now in my early 40s and still have times where in moments of desperation I will hurt myself, mainly by cutting my skin. I took paracetamol overdoses for a few years in my twenties. I developed anorexia as a teenager and it has been a seesaw relationship around eating distress and self-injury ever since. I don’t hate myself or meet the stereotypes that are presented about self-harm and BPD. I am shy but have good friends. I am very diligent in my full-time job. I don’t often feel angry but mostly feel sad and deep thinking.
In some ways I know too much about self-harm and live with the emotional and physical scars. But still I am excited about this book and have recommended it to my private psychologist, friends and other health professionals I come across.
The best feature of the book is that it does not label people who self-harm or dismiss their distress. One section starts “To my mind, one of the most unhelpful ways that psychiatry has of talking about people and their problems is the use of diagnostic labels to describe somebody’s personality. Psychiatrists talk about personality disorder..” The author then outlines the problems of this approach which “downplays the role of other people and circumstances.” The circular diagnosis as ‘explanation’ is described. This insight feels brave and far reaching, especially written by a psychiatrist.
The book feels very current and live. There are pages about taking care around social media. There is analysis about the misleading reporting of statistics about young people and rates of self-harm.
While there is a huge amount of information included the most unhelpful assumptions have been left out. I despair when reading about the endorphine theory around self-harm. The ‘science’ goes that people who cut will feel a rush of adrenaline. I was in a minor injury unit yesterday and the nurse suturing my arm asked if I got a ‘whoosh’ from doing it. I felt a lot of pain, distress and tiredness so a ‘whoosh’ would have been mere fantasy. The book does not make a link with addiction as some people, even service user organisations, insist is the case. Their position is that people who self-harm do it as they are addicted to the ‘behaviour’ and pain. I do everything I can to avoid pain so this idea again makes me uncomfortable. Given the stigma around drug and alcohol addiction, I do feel an addiction model makes our lives even more challenging. I wish that cutting my body, with all of the pain and consequences, were as physically easy as drinking from a bottle.
It is positive that the book covers all levels of self-harm. The author even highlights how ‘superficial’ self-harm counts and brings a different kind of pain: “There has been a tendency to be dismissive about (this) scratching.. However, it’s worth bearing in mind the common observation that superficial cuts can be considerably more painful than sharp deep cuts, and that the person who self-injures in this way may be putting themselves through much greater pain over a long period of time, suffering for longer, and feeling even more stressed and constrained to keep their psychological and physical pain secret”. I have never read a more validating few sentences than these words. I wish that my own self-harm hadn’t become more serious, largely a result of meeting others who self-harmed in residential treatment settings. I was in as much emotional pain when my self-harm didn’t require outside help as I was later in life sustaining more significant injuries even leading to blood transfusions. The severity of self-harm really doesn’t correlate to the level of distress.
From the outset the author makes clear that self-harm isn’t done for ‘attention.’ I wish this book could put an end to this prevailing view. Many people who repeatedly self-harm will be discouraged from going to A&E or asked “What are you doing here again?” We are told to ‘take responsibility.’ The most help available is a dismissive ten minute chat after several hours wait on a chair in hospital. It is as though we are treated in a cold way as too much ‘attention’ would provide an incentive to return.
There are questions the book raises which warrant further discussion. While the majority of those who self-harm may not have a ‘serious mental illness’ there is still individual suffering which should not be ignored. No diagnosis at all though means that someone in great distress may struggle to access treatment and welfare benefits. There does need to be more written about those of us who self-harm repeatedly since a marginalised group. It is repetition which results in the heartsink reaction from health professionals, diagnosis of BPD and eventual withdrawal of help as we are seen to have ‘capacity’. The author recognises that through self-harm we may become less ‘seen’ and taken much less seriously. I think of my own self-harm as getting the same response as the boy who cried wolf. In time people turn away and don’t believe the pain as it happens too frequently. Health services often seem to wish we would just quietly go away, which we often do but just take our pain to other places. 
The book is realistic about the help available on the NHS. While recommending talking to someone and speaking to the GP, there is no automatic referral to secondary care community mental health services. In fact these services are still more likely to focus on psychotic conditions. I often feel like it is a human rights issue that those who self-harm can be turned away from treatment as they don’t meet the criteria or should simply learn better coping strategies. If someone with a different diagnosis than BPD was suicidal or doing serious harm to their body the response may be very different. My experience is that the risks go beyond an injury especially with physical depletion and anaemia. It feels as though perceptions of others change once they know and it’s possible to disclose too much when in crisis.
There are practical steps which are life saving, including harm minimisation. The book is realistic about progress sometimes being slow, but remembering the person isn’t a label or their self-harm. It is all too easy to dehumanise those who self-harm, to see us as a limb to be stitched, a personality disorder, someone taking up a bed unnecessarily, a patient wrongly assumed to have a high pain threshold. The author sees us as people for whom self-harm may be just a small aspect of lives that matter.
I needn’t say how well researched the book is since written by an academic yet it explains things in a clear, concise way including data sources which indicate prevalence of self-harm. The writing is informed by years of talking to people who self-harm and trying to understand. He also touches on psychological explanations including the influence of early life experiences and the impact of emotional abuse and neglect for some, though certainly not all, later driven to self-harm. There is also acknowledgement of the environments in which self-harm surges, especially in women’s prisons.
This is a book written in a sympathetic way. You feel the author is on your side. You wish that there were professionals like him in local services who cared about self-harm and wanted to reduce the immense pain. I hope that at least by more people reading the book there will be education, reevaluation of current attitudes and awareness of self-harm affecting people beyond teenage years. This may be a first step towards achieving the understanding and compassion that we deserve.


Do we actually know how to talk about self-harm?

  • July 1, 2019

Stories about self-harm are everywhere. One of the recurring features of these stories is that they include calls for more mental health services – especially for young people.  A few suggest that self-harm is something to which we should all be able to respond. For example, 3rd sector organisations such as Young Minds and Samaritans recommend being open to talking with people who self-harm – surely that’s right if up to a quarter of young people are affected.

There’s nothing wrong with this advice except that it doesn’t come with much help to guide people in what they should actually say.

Here for example is what BBC say at the bottom of a typical news item about self-harm:

What adults can do to help a child who is self-harming:

  • Show you understand
  • Talk it over
  • Discover the triggers
  • Build their confidence
  • Show you trust them
  • Choose who you tell carefully
  • Help them find new ways to cope

Difficult to disagree with, but how does it help a worried parent or friend who can’t show they understand because they don’t understand, or doesn’t know what “talk it over” means or how to “help them find new ways to cope”?

After a look around for sources specific advice, I decided that some direct simple and specific advice was needed and so I wrote my book Understanding and Responding to Self Harm, just published by Profile Books. The book offers practical suggestions:

  • For a person who self-harms [1] planning to disclose to friends or family [2] planning to talk to your GP [3] managing contact with a hospital emergency department [4] getting help from the mental health services
  • For a close friend or family [1] how to respond if you learn somebody you know is self-harming [2] what you can do that helps practically.

National media and self-harm

  • June 28, 2019

Coverage of self-harm in our national mainstream media is unhelpfully unbalanced. News stories almost always report that there’s a massive crisis/epidemic of self-harm in young people underway. There does seem to have been an increase but the coverage rarely says exactly what it is that’s increasing. The accompanying story is pretty much always about a young woman with a long history of self-cutting with the implication that’s what it’s about. See for example this BBC news item. To balance up a bit…

  • A recent report in Lancet Psychiatry, based on 2014 results from the Adult Psychiatric Morbidity Survey, which is published by NHS Digital, was widely covered as showing this dramatic rise in self-harm in young people. It did indeed report on a marked increase in young people but it also showed that people of all ages and both genders report higher rates than they did a decade ago. Self-harm is presented in the media as almost entirely a problem for young women but 5% of all men say they have self-harmed at some time.  Self-harm is also presented as almost entirely affecting teenagers but 5% of those over 35 say they have self-harmed at some time. UK figures show that a quarter of those who go to hospital Emergency Department after self-harm are aged 40-59 years.
  • Self-harm is presented as almost always about cutting, but when asked in the Adult Psychiatric Morbidity Survey more than half people who say they have self-harmed say they have swallowed something or done something else other than cut themselves. Similar findings emerge in the Millennium Cohort Study, widely publicised by the Children’s Society.
  • Social media use is presented as clearly a cause but studies show that people can find it helpful and supportive, a non-judgemental environment in which to discuss worries about eg social or sexual identity. Important when something like a third of people who self-harm don’t confide in anybody they know.

 The truth is that we won’t help people with self-harm until we start taking a more balanced approach to discussing the real issues. “What’s fuelling the terrifying rise in self-harmers?” screams Mail Online 6 March. That’s not a great way to start a conversation, nor indeed a great way to label people who self-harm.

Government White Paper: Online Harms

  • June 24, 2019

The Government White Paper: Online Harms has been out for consultation for the past three months. Its main proposal is to establish a regulator charged with ensuring that a duty of care is exercised by all those who produce, host or distribute potentially harmful online material.

This sounds like an idea with which few could disagree, and the consultation questions are mainly about how to make it work properly. There are however some real problems raised by the inclusion of online content about self-harm.  The other topics covered by the White Paper include incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. While it’s difficult to imagine a socially desirable component to the online presence of any of these activities, the same doesn’t apply to self-harm.  Here’s my own reply to the consultation’s Question 8…

Q8:  What further steps could be taken to ensure the regulator will act in a targeted and proportionate manner?

In relation to self-harm, the main need is for a clear and specific definition of the nature of harmful content.  It is responsible management of such content that constitutes the duty of care to be imposed on those who make self-harm content available online. The White Paper talks about “content and behaviour which encourages suicide and self-harm” (para 7.32) and “content that provides graphic details of suicide methods and self-harming” (para 7.34). Neither definition is specific enough to inform practice and without a tighter definition the regulator is at risk of idiosyncratic or inconsistent intervention.

What is the challenge in coming up with a workable definition of harmful self-harm content?

There are three issues here:

  • Examination of online material about self-harm reveals substantial diversity in form and content. Those who post and those who respond to posts are engaged in conversations not just about the manifest topic of self-harm and suicide, even when the relevant posts are explicitly tagged as self-harm: content is also about emotional problems more generally, about relationships, fitting in or belonging, and about attractiveness, sexuality and body image. The mixture of textual and visual messaging leads to communication the ambiguity and irony of which can be missed by reading one without the other.
  • Much of this is regarded as helpful by those who access it, and that includes direct communication about self-harm including images of self-injury. Such images can help an isolated person (anything up to a half of people who self-harm don’t confide the fact to anybody in their personal life) feel less alone. The images may come with messages about self-care or harm minimisation. It is reasonable to conclude that content some people find unhelpful is found helpful by others, and that whether a particular content is found to be helpful or unhelpful by a particular individual depends upon the immediate circumstances in which it is accessed.
  • It isn’t clear what the pathway to harm is, following exposure to self-harm material online. Words like graphic, explicit or glamorising are in themselves not tightly defined but they imply that the underlying mechanism is an invitation to copy the behaviour. Linking this argument to suicidal behaviour is problematic – for example most online images of self-harm are of self-injury (cutting or burning) and yet these are extremely rare methods of suicide, especially in young people. If the putative pathway to suicide isn’t copying then presumably it is by exposure leading to low mood and hopelessness – in which case it isn’t clear that images of self-injury are more problematic than other mood-influencing content.

What is the risk of disproportionate or untargeted action?

For much of the content covered by the White Paper, there really isn’t much doubt about what’s bad and needs to be suppressed – drug dealing, distributing child pornography, inciting terrorism. In the case of self-harm however there are risks of going too far in suppressing content. Those risks reside in the diversity of material that comes under the online rubric of self-harm; the likelihood of blocking access to material experienced as beneficial by isolated and unhappy people, and the uncertainty about what’s genuinely harmful in self-harm form and content. Clumsy, excessive or inconsistent intervention – in the name of reducing harmful exposure and (by implication) habituation or normalization – may have the unintended damaging consequence of increasing the sense of disconnectedness and burdensomeness experienced by people with mental health problems who self-harm.

What steps to take?

There are two steps:

If the White Paper is to include action on self-harm content then the regulator needs expert and specific advice on what content should be regulated and limited immediately – even taking into account the considerably uncertainty outlined above. That is, the advice should identify that material for which we can be confident that harm is likely to accrue from accessing it and the risk of harm obviously outweighs the possibility of benefit.  This advice should be provided by an expert panel that consults a diverse range of academics and mental health specialists. Its recommendations should be for limited immediate action given how little we know about harms.

As a second step, the regulator should seek regular reports on emerging research findings that support changes to its practice – to ensure that practice is evidence-based rather than opinion-based.

What is Liaison Psychiatry?

  • June 21, 2019

Liaison psychiatry involves clinical practice, teaching and research in psychiatry that takes place in non-psychiatric settings.  In the UK that has meant mainly in acute (general) hospitals or in specialist settings such as neurology centres, although there have been small scale attempts to practice liaison psychiatry in primary care (general practice). The rationale for liaison psychiatry is that people with mental health problems don’t get the best care if they are being seen in a non-psychiatric setting, unless there is a specialist team available to see them where they are.

The main areas of activity in liaison psychiatry are:

  • Mental health problems that co-exist with physical disease, which is sometimes called co-morbidity or multi-morbidity. Each condition tends to complicate the treatment of the other and can lead to poor outcomes for the patient.
  • Medically unexplained symptoms such as pain, chronic fatigue, weakness or loss of bodily feeling. These conditions often have a psychological component, although it upsets some people to say so.
  • Psychiatric emergencies such as suicidal behaviour, acute psychosis, or delirium – all of which are seen in acute hospitals.

Liaison psychiatrists can work in the emergency department, on acute inpatient wards, in specialist hospital departments, and in their own specialist outpatient clinics.

The Royal College of Psychiatry has a Faculty of Liaison Psychiatry . There’s more information on the Faculty website. The textbook Seminars in Liaison Psychiatry covers the subject in detail: the 3rd edition is currently in preparation.   

Mental health and physical illness: what’s the role of liaison psychiatry?

  • May 28, 2019

Discussions about services for people with co-existent physical and mental health problems usually start with a brief account of how common that state of affairs is, and how important it is.  Fair enough, but there’s another step in the discussion: how do you decide who is best placed to respond to the needs of the people affected?  Of course clinicians who specialise in physical health should know something about mental health and vice versa: my question is what to do when help is needed from specialists in this so-called co-morbidity? And more specifically, what’s the role of liaison psychiatry?

To begin at the beginning…

Below is a schematic representation of a clinical service, pictured as a simple care pathway. It acknowledges that at each stage some people will not be referred on or will refuse referral, some accept referral and do not attend, and some attend but drop out early. Also at each stage there are some who complete treatment at each level but do not improve. These groups are represented on the right.

The pathway also acknowledges, in line with standard thinking about stepped care, that some people present with such severe and complex needs that they should be referred directly to a special service.

In the UK, brief psychological therapies are usually delivered in primary care through a service known universally by the acronym IPAT (pr. eye apt) and in secondary care by a range of services, most typically clinical health psychology, or psychiatric nurse therapists working in liaison mental health services.

The numbers who move along the branches of this pathway into the complex/severe end are huge.  To take one example – figures from NHS Digital indicate that only about a third of those referred to IAPT for a talking therapy complete the course of treatment and of these only just over a half have “moved to recovery” by the end of treatment. We know from other research that relapse rates after brief therapies are high – up to 50% over the next 1-2 years.

So…the pathway above is right to indicate the need for a specialist service for complex and severe cases. What are the features of such cases? The answer is – no two cases are the same.  Here’s a list of some of the features of complex and severe problems.

1. Diagnostic complexity (physical health)

  1. Multiple or persistent severe symptoms that don’t fit standard diagnostic categories (including don’t fit standard MUS categories like fibromyalgia, CFS) or encompass multiple diagnostic categories
  2. Multiple drug treatments including opioid or equivalent analgesia
  3. Multiple physical diagnoses, including some validated (so both significant LTC and MUS)
  4. Erroneous physical diagnosis assigned in past or by 3rd parties
  5. Disability out of proportion to physical disease severity
  6. Major non-adherence or misuse of therapeutic regime, including induced illness, with serious physical consequences

2. Diagnostic complexity (mental health)

  1. Illness conviction, especially non-affective – can sometimes have a delusional quality, sometimes shared by close others
  2. Suicidal and related thinking, self-harm history or current risk

 3. Organisational complexity (healthcare)

  1. Frequent unscheduled attendance – GP surgery; ED; other healthcare
  2. Recurrent unscheduled acute admission
  3. Recurrent unwarranted physical investigation
  4. Multiple healthcare providers
  5. Drop out from or failure to respond to first line treatment, with persistent problems

4. Organisational complexity (social care)

  1. Receipt of benefits dependent upon non-recovery
  2. Various forms of assisted living for functional disabilities

5. Social complexity

  1. Wider social dysfunction – tension or conflict with others, impoverished illness-centred social network – having an impact on health or healthcare that acts as a barrier to effective brief psychological therapies
  2. Children or others as enmeshed carers
  3. Involvement in long-running and contested litigation or complaints related to health or healthcare

The origin of liaison psychiatry and the fuel for its growth in the UK (until recent years) was the demand for expertise in the management of such cases.

However, not only does a comprehensive service need a component to deal with chronicity/complexity/severity, it also needs to be able to offer integrated care – across primary and secondary care and between the various components of mental health care. So…what are the characteristics of integrated care? Here’s another list.

All this points to a (to my mind) relatively obvious conclusion. Liaison psychiatry services have an important role in the care of people with mental and physical co-morbidity and, at least in secondary care, it would be best if services were arranged so that IAPT, clinical health psychology and liaison psychiatry were brought together in a genuinely-integrated multidisciplinary service. There are barriers to that development – professional resistance is one, and in my experience mainly from clinical psychology; in recent times liaison psychiatry services have been swamped by the acute/urgent component of liaison work, not least because of NHS England policy; manpower shortages and funding limitations consequent on government policy – all play a part. It would be great to see this practical and basically cost-free improvement to care adopted as a national strategic priority by all the key interested parties.