Tuesday, March 19, 2013

The contribution research can make to care

A speech given at the ARISE conference, Liverpool 18th March 2013
Posted, primarily, in the interests of transparency.

Thank you.

Research and academic scholarship are not ivory tower luxuries. They have the potential to transform the care you offer, and to help you move from OK to good, and from good to excellent

On September 1st 1967, the Nobel Prize-winning civil rights leader Martin Luther King said, in a speech to the American Psychological Association: “There are some things in our society, some things in our world, to which we … must always be maladjusted if we are to be people of good will”.

There’s plenty going on right now that we should be maladjusted to – and there’s plenty of ways that researchers at the University of Liverpool, in the Institute of Psychology, Health and Society, can help that process of creative maladjustment, that journey to excellence.

The social and political context

Our public health researchers explore how our health and well-being are intimately related to social, economic and even political issues.

So Ben Barr and David Taylor-Robinson have revealed how economic circumstances affect our mental health, and have found how around a thousand people have taken their own lives as a directly attributable result of the economic recession since 2008.

They – Ben and David – have also revealed that the cuts in local authority spending are falling hardest on the poorest – with central government funds withdrawn most severely from the most deprived communities.

This matters, because our research starts in the social and human realities of our clients’ lives. We therefore understand that our core business is much less about treating illnesses and much more about promoting well-being.


In 2006 I published a very simple paper with Erika Setzu, Fiona Lobban and Peter Salmon. It was simple because all we did, in essence, was interview people about how they had ended up in mental health care. One quote is worth repeating at length:

Client: “I started to hear voices, but they were not nice voices, they were horrible.”
Interviewer: “Did you recognise them?
Client: “It was the man that abused me … I met this man that was a builder, in construction, you know? And he said that he wanted to give me a job, but they were all lies, he was trying to con me. He took me back to his house, he locked the door and he had sex with me. … And then other voices as well. I went to … hospital and the nurses were very good to me.”
Interviewer: “When you went to hospital what did they say it was wrong with you?
Client: “Schizophrenia, paranoid schizophrenia.”
Interviewer:  “What do you think personally?
Client: “What do you mean?
Interviewer: “Do you think it is what you’ve got?
Client: “Oh yes, that’s what I have got.”

The conclusion in my mind is rather simple. This really does look as if it’s the normal, understandable, human response to horrible trauma … mislabelled as “illness”.

This man clearly needs help – hearing the voices of your rapist must be hugely distressing (although also pretty common). And I think the care he received may well have been admirable; he says the “nurses were very good” to him.

What I object to is the idea that this experience, and the experiences of many millions more, in any sense resembles an “illness”. 

We need to recognise the pernicious danger of thinking about such experiences as if they were symptoms of ‘illness’ – with the consequent stigmatising attitudes, harmful ‘treatments’ and, equally, avoidance of the key issues; in this case, sexual violence.

We should be ‘creatively maladjusted’ to this creeping medicalization of human distress. Right now, the American Psychiatric Association is preparing to publish the latest version of its diagnostic manuals – DSM-5. It seems clear that this manifestation of the medicalization of human distress will be more paradoxically illogical, more invalid, more stigmatising, and more pervasively likely to pathologise normal human reactions than ever before.

We need to ensure that alternative voices of reason are heard. People have the right to be concerned. We need to be cool, to be elegant, to be evidence-based and we need to be humane. But we need to make it clear that we are concerned about the consequences of unrestrained diagnostic labelling.

We, at the University of Liverpool, in the Institute of Psychology, Health and Socuiety, are working with you to develop alternative, better, ways of understanding your clients’ distress, without inappropriately labeling them.


Humane care

When it comes to treatments, there are again things to which we should be maladjusted.

We must refuse to tolerate the cruel, inhuman and degrading treatment of people in psychiatric care. This includes the appalling inhumanity described – correctly – by the United Nations as "akin to torture".

But such extremes are also supported by everyday inhumanity – and by the inadequate, cruel and uncaring treatment experienced every day and in many (if perhaps not all) settings. On the same day I read the UN report, a man wrote to me describing his experiences of psychiatric 'care'. The whole incident is traumatic; from the initial involuntary admission (in handcuffs, by the police) to discharge. I was particularly struck, however, by the everyday inadequacy of the inpatient stay. This won't be terribly surprising to people working in mental health care... but the fact that this account will be recognised speaks to its truth.

My correspondent reported; "... Rather than engaging with the patients on the ward, the staff instead shepherded them around like sheep with bullying commands, threats of ‘jabs’ (injections), and removal to an acute ward elsewhere in the hospital, if they did not co-operate. The staff also stressed medication rather than engagement as a way of controlling the patients.
And the staff closeted themselves in the ward office, instead of being out and about on the corridors and in the vestibule where they should have been. The staff wrote daily reports on each patient on the hospital’s Intranet system; these reports were depended upon by the consultant psychiatrists for their diagnoses and medication prescriptions, but were patently fabricated and false, because the staff had never engaged or observed properly the patient they were writing about in their reports. The psychiatrists themselves were rarely seen on the ward, and only consulted with their patients once a week."

I certainly recognise this account. It doesn't represent absolutely all psychiatric units... but it isn't bizarre or unrepresentative. It reflects - in psychiatric rather than acute medical care - the findings of the Francis Report into uncaring and inhumane treatment in the Mid-Staffordshire NHS scandal. And we should absolutely refuse to accept it. I don't want to accept this as the status quo. And we should absolutely refuse to accept it. I don't want to accept this as the status quo.



So… what can research offer?

Another of my colleagues here at the University of Liverpool, Professor Richard Bentall – in his book ‘doctoring the mind’ - has analysed how traditional treatments, especially high-dose, long-term use of so-called anti-psychotic medication have hardly improved real-world outcome.
Indeed, Richard, and the US journalist, Robert Whitaker, have demonstrated pretty convincingly that long-term (in the short-term, the situation is ifferent) anti-psychotic medication can impede recovery.

So, instead, we have developed alternatives.

I and colleagues at the University of Liverpool – of course, in collaboration with others have been involved with many clinical trials. I accept that RCT’s – randomized controlled trials – have their limitations. I accept that CBT – cognitive behavioural therapy – is not the only fruit. And I confess… we entitled our papers with diagnostic labels such as ‘schizophrenia’ and ‘bipolar disorder’ – hey!, I, too, am the product of the social context!

But the point is that we’re developing alternatives – in my view more effective, more scientific, more humane alternatives – to old-fashioned psychiatric care.

Indeed, some of our RCTs don’t even involve CBT. More recently we’ve been collaborating with Lancaster on the development of relapse prevention strategies. We’re also working to improving access to primary-care psychosocial interventions… not only in Liverpool, but across the world. In Pakistan, my colleague Atif Rahman is developing accessible psychosocial support for women in rural communities following the birth of their children. We’re even investigating ‘body psychotherapy’ – physical therapies… but with a very different ethos to traditional ‘physical interventions’.



And our investigation of alternatives can be quite radical. The now ubiquitous
5 ways to well-being, seen across the City, was originally developed by a team of experts including Sam Thompson an honorary Research Fellow here at the University (he used to work here until taking up a place as a trainee clinical psychologist… which is, of course, a wonderful thing). 5 ways to well-being offers practical, everyday, opportunities to protect and promote your mental health.

And… it fist with radical approaches to measuring outcomes, such as the BBC well-being scale, a universally applicable measure of well-being.

All developed through the University of Liverpool Institute of Psychology, Health and Society.

So…. We should refuse to accept sub-standard care.
And… we at the university are actively working, with you, to develop and evaluate alternatives.

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