Category: RITB

Through the Glass Doors is an autobiographical illustrated book, co-created by 16 previous patients of Huntercombe CAMHS hospitals. It details the horrors vulnerable children face every day at the hands of Huntercombe (now Active Care Group) in placements which supposedly provide specialist mental health care and treatment. The book, alongside a letter of recommendation which provides lived-experience based solutions to Huntercombe’s failings, has been sent to a number of key medical and political figures in the hopes it will stir a response, in turn drastically improving the quality of care provided by Huntercombe and wider CAMHS and adult mental health services.

@nimahunt

throughtheglassdoors

The suffering is horrific. NHS dentistry, community physio, podiatry, are effectively gone now. What’s left is hard to access and limited in what they offer. NHS dentistry has become an emergency antibiotic and extraction service (after weeks or longer). Patients are often pushed into paying privately.

There’s a link between oral health and cardiac health, right up to sepsis. The cost of not having access to routine dental care (fillings, crowns, root canal) is high. Patients are in serious debt for emergency treatment, root canal & crowns. NHS dentists don’t always refer patients on for gum disease treatment and let it progress to extraction and dentures.

In the US it’s said you can tell poverty by looking at people’s mouths, the same will be true here. I will never forget a film I watched a few years ago of Americans queuing up all night (including wheelchair users) outside a warehouse for free medical treatment and dentistry.

No privacy, exam chairs, beds all set out. People shaking violently having entire mouth tooth extractions under local anaesthetic.

There’s also no appreciation of the impact of antidepressant and antipsychotic medications on dental health which can cause dry mouth increasing the risk of decay, but mental health services nor NHS dentists inform patients of products to help with this. Acute patients might have periods of sugar laden liquid meds.

Dentistry should not be a luxury.

For me critical psychology was a revelation. It explicitly verbalised what I had been thinking. I still remember my first steps in challenging the certainties of, shall I say, positivist psychology and coming across writings of psychologists who were thinking in similar terms was a revelation. It’s all changing now.

I suppose my relationship with psychology has always been tenuous. As a linguist, understanding and teaching about the role of context, positivist psychology has always been a problem. I remember taking part in a discussion on a PhD proposal in which the student sketched a project on perseverance. I made a point that, surely, perseverance is always contextual, depending not only on, for example, our personality, but also the stakes involved or social importance of the task. And so, your perseverance in getting a new T-shirt is extremely unlikely to be similar to that of trying to resuscitate your child.

In response, I heard that my point was well made, but psychology was interested in ‘pure perseverance’, only that was perseverance proper. And so, the student invented a fatuous procedure that, apparently, enabled them to measure this purity of perseverance and correlate it with all sorts of psychological stuff. Psychologists nodded, I shook my head.

And here come the critical psychologists. Their writings challenge the certainties of mainstream psychology, much as discursive psychology did. All of a sudden, statistics does not provide us with much comfort, while questionnaires are not magic tools harvesting psychological experiences. As I was reading more and more, I was smitten.

Time for a reservation, as I move to offer critique. I do realise that critical psychology is not a homogenous group of people and there are disagreements within such a varied group. I also understand that Twitter psychology might not be representative of its entirety, although it’s worth saying that very prominent psychologists have accounts on Twitter and they are vocal representatives of their subdiscipline, both in proclaiming themselves part of it and in sometimes loudly dismissing those who disagree. I also accept that for rhetorical effect what follows is likely to be somewhat exaggerated.

And so, to continue, misfortune befell me – I joined Twitter. Daily I started witnessing quarrels, skirmishes and veritable battles between critical psychology and the regular one. Arguments I knew and continue to know very well have been rehearsed right, left and centre…Except something else happened. At some point I realised that more often than not I was joining with the ‘bad guys’, with ‘regular’ psychologists (and psychiatrists, to be fair). I started crossing the floor more often than I would have thought possible. When I noticed it, reflected on it, I realised a paradox. I continued to agree with the criticals (at least for the most part), but I actually didn’t want to be seen to agree with them.

What I found extraordinary was that it was the ‘enemy’ who seemed more open and prepared to listen. It was the enemy who was falling back on evidence. It was the enemy who was prepared to question and reflect on their assumptions. Indeed, over the last months, I have written more blogs criticising ‘critical psychology’ than anything else. From PTM framework, through irrational insistence that changing a few words will introduce world peace (under the guise of ‘language matters’), all the way to the recent report called “Understanding depression”. What all those documents have in common is the assumption that they are the revealed truth and those who (dare) criticise them are fatally wrong. There is an intellectual dishonesty underpinning even the major documents which, you would hope, would carry the nuance and sensitivity to other perspectives.

I continue to be disappointed with critical psychology (mostly its British version, at least) which uses a sledgehammer in dealing with its ‘enemies’. There are no arguments, no attempts to understand an Other. No, if you disagree you are in fatal and ultimate error, possibly just stupid. Recently, I was shocked to see those who disagree with the #UnderstandingDepression report being dismissed in highly disparaging terms and with no counterarguments.

That’s not critical psychology I used to read. It doesn’t have even the shadow of its former intellectual depth and clout. Today, it doesn’t argue anymore. It shouts.

This post has been long coming, I am sure I will get a lot of stick for it. I also know that this will be one of those posts that will result in tens of blocks and as many unfollows. What spurred to me to writing it was a recent Twitter exchange I took part in. Extraordinarily again, the only argument those progressive critical psychologists were able to offer was that those who disagreed just misunderstood ‘the real message’. And all from the position of delivering the truth to the minions.

But what really irritated me was this exchange:

I mean, really?! Like really?! If someone does not follow in your footsteps, there is no possibility of meaning or understanding? This is megalomania, this is psychological Trumpism, for pity’s sake.  This is no critical psychology – this is bombastic, grandiose psychology so full of itself that the solar system seems too small for it. This is psychology walking on water.

And so, to repeat my reservations. Of course, I understand that I look at a snapshot of psychology in a particular context. And yet “Understanding Depression” has the imprimatur (those familiar with Vatican’s censorship will appreciate the word) of the BPS. I am really not talking about a few rogue psychologists from a galaxy far far away.

As I walk away from critical psychology as it is (not that it cares about it at all, not only am I a nobody, I am also fatally wrong), I am still up for a fight with positivist psychology, with all those smitten by the alphas, r’s and whatever other letters psychology throws at you. But I would like to be seen as someone who can be persuaded with an argument. There are wonderful quantitative studies, there are zillions of people for whom their nosological diagnoses were a godsend, there are also so many bad qualitative/critical studies that they could blight global agriculture.

And, finally, for pity’s sake, let’s assume, once in a blue moon at least, that we can be bloody wrong!

By Dariusz Galasinski, this article first appeared on his site dariuszgalasinski.com

Elaine tried desperately to get help for her son during the final days of his life. She felt he was too unwell to ask for help himself. His mental health had deteriorated and he was hearing voices. He was having suicidal thoughts and she was worried that he was going to end his life. He was under a community psychiatric service for people who experience psychosis.

When she asked the mental health crisis team to contact him over that final weekend, they told her that her son needed to phone them. They had often said that they wanted him to take more responsibility. Their usual approach was to tell Elaine: “He is welcome to call us”.  He never did, and tragically he took his own life on the Monday morning, while Elaine was downstairs on the phone trying once again to get help for him.

At the inquest into his death, the coroner commented that he had “mental capacity”. In her summing up, she said that he had the mental capacity to make decisions. The coroner made that statement based on psychiatrists’ evidence at inquest. They emphasised during and after the inquest that James “frequently” had capacity.

In fact, none of us know whether he had the capacity to make decisions or not, in the period leading up to his death. No one from the mental health teams had spoken to him for several days.  A person’s mental capacity to make decisions can change from hour to hour. High levels of distress or mental illness are just two of the factors that can affect it. And James had a history of psychosis.

So why is it so important for psychiatric professionals to emphasise that someone has mental capacity? Too often, it seems to be about “responsibility”. If the person is assessed as having “mental capacity”, then the mental health team can argue that they have no responsibility to do anything. The mental health crisis team didn’t contact James, despite his mum’s pleas. But he had mental capacity, so they didn’t have to – that seems to be the sub-text.

But James’ mum had described James’ deteriorating mental health to the crisis team. He had completely isolated himself, was hearing voices and had a history of psychosis and she explicitly said that she was frightened that he was going to kill himself.  Armed with that kind of information, professionals surely have a duty to take active steps to contact, assess and support the person.

When professionals refer to “mental capacity” as a reason to stand back and place responsibility on the person who is in crisis, I would remind them of article 2 of the Human Rights Act: the Right To Life. It takes precedence.

It is as if the “right to life” is being usurped by the “right to take your own life” when someone is in mental health crisis. Surely the balance is all wrong. If you are in mental health crisis, it is a time when you are least likely to be able to think clearly and rationally, or to be able to “weigh information”. Despite this, the system appears to respect your right to take your own life.

Surely there is a duty to do everything we can to help the person to survive. We should protect life, whether or not someone is assessed as having “mental capacity” – and whether or not they are detainable under the Mental Health Act, which is a different piece of legislation.

We cannot even be fully confident that all professionals are assessing mental capacity accurately. I have described in a previous article how a paramedic and a policeman made entirely different assessments of my mental capacity, on a night when I intended to end my life. I believed I had received messages to end my life on that date.  Astonishingly, one of the professionals concluded that I had mental capacity. He said that I could understand and retain information. Fortunately the other professional quickly intervened and detained me. My ability to weigh information was clearly being impacted by the “messages” I had received. (Reference: Why do mental health professionals tell patients “It’s your decision to end your life”? https://www.savinglives.blog/uncategorized/suicide-why-do-mental-health-professionals-tell-patients-its-your-decision/ )

It is this ability to “weigh up information” which I think professionals may be getting wrong quite frequently. Depression often affects our ability to weigh information. We see life through its distorted lens. If depression makes you feel that things will never improve, that there is no hope and that you have no worth, then this is affecting your ability to weigh information and make decisions. And yet frequently, someone will explain all that and be assessed as being capacitous and able to make the decision to end their life. We know this from what we witness with clients at our Suicide Crisis Centre. I frequently express concerns to our local mental health services about individual clients, when depression appears to be impacting on their thought processes.

We have to redress the balance to place more of the responsibility on us, as professionals. It is our job to protect life.  I run an independent Suicide Crisis Centre where we focus on doing everything we can to help our clients to survive. We actively intervene, whether or not we think someone has mental capacity.  We know that the person is probably about to make a decision that they would not make if they were not highly distressed, or mentally unwell. Therefore, protect life – always.

For information about the Suicide Crisis Centre, which provides face to face support: http://www.suicidecrisis.co.uk

Elaine kindly gave her permission for me to write about James, who was known to his family as Jay. Elaine added: “Jay didn’t want to die. He wanted help. He was crying out for help.” Elaine found out about our charity after Jay died. We attended his inquest in 2019, to support his family. This article draws on evidence from the inquest. Our thoughts are with Jay’s family as they continue to fight for justice for Jay.

Other sources of help include The Samaritans on 116123 and the NHS 111 service (just call 111).

 Joy Hibbins is the author of the book “Suicide Prevention Techniques: How A Suicide Crisis Service Saves Lives”:  https://www.jkp.com/uk/suicide-prevention-techniques-2.html

Reproduced with kind permission of Joy Hibbins Saving Lives ©.

Rita Binns

The Covid-19 outbreak has changed all health services. The changes have been far reaching and stretch beyond the pandemic. The pandemic has also highlighted pre-existing inequalities in the NHS – this blog is based on one person’s experience of accessing care and treatment for self-harm. From what other people have told us, they are not the only ones dealing with the same problems.

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While emergency treatment has remained available, going to Accident and Emergency (A&E) is a changed experience. Now you have your temperature taken on arrival and are placed in a different waiting area depending on ‘Covid status.’ Staff who greet and treat you are wearing personal protective equipment. At present there are plans, drawn up by the Royal College of Emergency Medicine, to try to limit attendances to those who are referred by 111, their GP or are brought in by ambulance. This change, if introduced, could have a profound impact on people with mental distress, who already feel they are actively discouraged from attending A&E even when they feel at risk of completing suicide.
I self-injure by cutting at times of extreme distress. My self-harm is acutely painful, cyclical and compulsive in response to a number of events which become a personal crisis. The pandemic has made me avoid hospital services through fear of disapproval, shaming, concern about unknowingly infecting others or being infected, and taking up scarce resources.
I know that NHS services may see any temporary cessation of self-harm as a success. In reality, it is still a daily battle to stave off self-harm when I am alone and in difficult circumstances. Because of the lock-down, I have had no video or face to face contact with my two family members for four months. I am forced to work from home in a housing association flat that has no garden or balcony. I have lost the pastimes that served as a distraction and reason to live. I have needed to switch to Skype with my private psychologist, though I am getting used to this. I feel incredibly lonely and have suicidal thoughts at times given the way we now must live for a long time yet.

In truth I felt abandoned by NHS services long before the outbreak changed the services available. Mental health services view my self-harm as ‘impulsive’, ‘longstanding’ and due to Borderline Personality Disorder (BPD). These ‘specialist’ services, provided by a single mental health trust, avoid getting involved at all costs. It feels as though I have been blacklisted and that this status, along with the wretched diagnosis, will never be reviewed.

My experience has been primarily one of signposting and aborted referrals. I’ve had one off assessments that lead to nothing more than more signposting and ‘action plans’ that act as service back-covering tick-lists. All this leaves me feeling worse than ever.
There are misconceptions about those who self-harm feeling some high or adrenaline rush. My experience is that there is no high, pay off, or euphoria. There is only torture which is heightened by the response from NHS mental health services. I do feel the re-emergence of my self-harm in ‘later life’ can be partly attributed to iatrogenic damage.
There is no NHS service help for people who self-harm. It is a service gap which no-one talks about, including the NICE guidelines, NHS providers or Clinical Commissioning Groups. The only way of accessing a chat is to injure, get wound closure by A&E and then see a Psychiatric Liaison practitioner as a one off. Liaison and CMHTs will always assess and discharge someone back to the GP, no matter how serious the recent injury or risk of either accidental death or disability. I was seen by the CMHT in February and told: “you have capacity to make bad decisions and that is the law.”

There is a slightly different approach to suicidal intentions expressed, but still the response to those is that it is our ‘choice’ if we want to kill ourselves as we have ‘capacity’ to do so. This is especially true for people who have been given the diagnosis of BPD where suicidality is seen as a trait rather than a concern.

Self-harm deserves the same level of concern as physical ill health, attempted suicide, eating disorders or addictions. I appreciate there are shortcomings in all mental health services due to historic underinvestment, but eating disorders and addiction services do still exist in principle. Instead self-harm is seen as ‘longstanding’ and not an ‘acute mental health need’, for which someone needs therapies designed for those with ‘dysfunctional behaviours’ which come under PD. There is no crisis care as Crisis and Home Treatment Teams tend to say that they can’t make any difference to ‘chronic difficulties.’ People who self-harm may indeed feel in crisis, as I often do, but they are treated as though doing what they always do, as if it was a hobby rather than a sign of immense inner distress. I sometimes feel I could suffer amputation and still the non-response would be unchanged.

The lack of secondary care help for self-harm, apart from basic medical care, could be understood if there were primary care mental health services. I do believe that GPs and practice nurses are often dedicated and excellent, as my GP surgery has been. But still I now have the third named GP in one year due to GPs leaving the practice. During the Coronavirus pandemic, it has been more difficult to see a GP or practice nurse, phone 111 or access care for injuries. People with mental health issues have mostly all been left to fend for themselves unless they become very ill with the virus.

I have tried to raise with clinicians and commissioners how lacking the response is to self-harm but am just told that “services are not set up in the way that they used to be.” It is as though the reduction in mental health services over the years (due to demand, underfunding, imposed boundaries for BPD, staff shortage and raised thresholds) justifies the worsening of attitudes. The message seems to be that we just have to get used to this basic level of endless signposting service, with any actual intervention aimed at younger people or florid psychoses. It is signposting with no existing service for most of us, just an endless frustrating hunt with advertised crisis text lines along the way. Charity helplines will never replace consistent low- level support that would help people with long-term distress to survive and avoid crises.

I don’t think the lack of resources can be used as an excuse for the current treatment of self-harm in the mental health sector. Using more compassionate and sensitive language doesn’t cost any money. Health professionals should stop using insulting language immediately, and this should be part of any training programme. I could come up with a long list of clinical insults to exclude for starters; Impulsive, PD, chronic, behaviour, neurotic, enabling, and emotional regulation. Liaison teams are making matters worse when they advise medical staff on self-harm by saying not to show emotion or give attention. The doctors and nurses I have met in A&E have often been far more professional, thorough and caring than any of their mental health colleagues.

The NHS front line has deservedly been praised for the heroism and dedication shown during the pandemic. I share that admiration and gratitude to medics who have put their lives at risk because they care as a vocation. But care still needs to be extended to people who self-harm. If the aim is to keep mental health patients out of A&E to help with infection control, then we need alternatives including physical wound care, crisis support and access to a service rather than another plan that isn’t really a plan. All mental health professionals should try to grasp that those who self-harm are not one homogenous PD group. Individuals are not harming to present a problem to the service, but because inner pain has become too much to deal with in any other way. It is an opportunity to listen and avoid further harm.

Boris Johnson’s argument for an acceptable number of deaths for herd immunity to work is a useful analogue to look back at how propaganda about benefits was to push through austerity.

A lot of arguments about benefits hinged on an idea of mythical distinction between deserving and underserving benefit claimant, the ‘you’re alright mate it’s that other lot’ attitude (an argument also known to people who put up with racism at work), like some petty gangster protection racket we were supposed to accept that argument about ourselves, whilst selling out other claimants in the hope we wouldn’t be picked on ourselves. Obviously on accepting this protection, we are no longer allowed to criticize government policy as were we to we would subsequently lose the protection offered by the prejudiced person taking us under their wing. The protection is flimsy though as of course whilst this person is ‘acknowledging we are different from those ‘others’’, obviously so in order not to have to challenge his own prejudices given he knows more details of your case, he has to separate you as exceptional to ‘those others’ he is talking in ignorance about (so in fact the ‘protection’ is also for his own ignorance from his conscience) and you arguing your defence based on a more universal principle challenges that. However, there are others offering the same ‘protection’ to others that they in turn know who are ignorant of you. If you get shit from them, your ‘protector’ has to challenge his ideological affinities with the other bigot, and you are just expected to get used to it. So, you can be ‘killed’ at any time, where being ‘killed’ is a metaphor for putting up with prejudice, just so long as you don’t rock the boat, so the ‘protection’ is in fact just from each individual bigot.

Given this, let’s return to herd immunity. A certain number of people have to take a fall, die basically (not a metaphor this time), so the others can be protected (herd immunity – but based on poor science), an ideological argument that is in fact cover for protecting the economy. If we turn back to the early days of austerity, the attack on benefit rights came early. The first Household Survey after the coalition came to power showed a large drop in attitudes of respect for benefits, an acknowledgment of rights that had previously been stable for some time amongst the broader population.

The purpose of this change in attitude from the propaganda pushed by the government was to push through austerity, as there had been a crisis of capital it was necessary for the capitalists to consolidate their class position, this means, using Thomas Piketty’s formula for inequality, r>g (where r is the return on capital, and g is growth), increasing r again (after its drop) relative to g. Given g is growth, that includes both wages and profit from production (total revenue of all ‘firms’ – GDP (excluding dividends from shares and rents)), and that wages are paid based on the supply and demand in the marketplace for labour, but all labour-time contributes to total revenue, thus profit is the difference (after costs), then to increase r, wages had to be kept low. But this needed to be sold to wage earners. It’s quick to point to the demonisation of benefit claimants, but in an inverse of Cameron’s argument that ‘it wasn’t right that people earned less than those claiming’, it is in fact true that therefore benefit claims, especially the ‘humanitarian measure’ of how much was needed (based on relative poverty measures – in fact this form of measuring poverty was also attacked as part of the propaganda), were in fact a bottom level it is true below which it was not worth working (hence also the need for punitive sanctions for benefits), it’s just that the issue was that these wages were already too low, not that benefits were too high. The other bottom level was the minimum wage so it was here the demonization was required on top of the 1% freeze on benefits, minimum wage and public service wages (this would then have a weighting effect on supply and demand of wages in the private sphere through the competition for jobs), not just as a distraction from the attack on wages, but to give popular assent to the perceived minimum amount that wages themselves were worth in order to work.

But for a propaganda campaign like this to work that would give popular assent to austerity (with regards the other part of this campaign that involved lowering the average wage – the economics of it – it turns out, this aspect was tackled on misinformation about debt (it is worth noting that there was a ‘popular justification disjunct’ between the claim that austerity was necessary to pay off the debt, and that the debt was in fact rising)), given there were many reasons why people still understood the purpose of a social security system, it needed to meet a large enough audience.

We live in a world of targeted advertising, but it is still not an exact science, to get enough sales you still need to ‘reach’ far more people than will eventually buy. Similarly, the propaganda analogue therefore is that you need to negatively affect more people than the propaganda appeals to, to get sufficient support for the propaganda to push through its agenda. So, if demonization of benefit claimants was necessary, and part of that method was ‘deserving and undeserving’ distinctions. Then sufficient ‘genuine’ claimants had to be demonized in order to ‘get’ the perception of this mythical ‘cheat’ or ‘fraud’, at least in the popular imagination, to be a sufficiently large amount. It is here we get back to the protection racket mentioned above and its relation to herd immunity. In order for sufficient demonization to occur, a certain amount of harassment of ‘genuine’ claimants had to be tolerated. This included not allowing even the ‘genuine’ claimants to protest their treatment lest the Emperor’s New Clothes be exposed and people realise that more people were genuine than the ‘benefit bashers’ would otherwise allow, lest they realise their own behaviour might be more morally questionable than, ironically, the supposed ‘cheats’ they were demonizing. A certain amount of denial of equal rights of ‘genuine claimants’ had to be accepted, which included a silencing of them, even, by their ‘protection racket’ allies, often friends and family (who wanted a clear conscience demonizing other claimants), much as a certain amount of Covid-19 deaths had to be perceived as necessary to protect the economy, which given we are due a recession after this, and again r will have to be reconsolidated with regards g (again – before we had full recovered from the damage done by austerity) would again involve lowering the average working class wage further.