The Five Year Forward View Mental Health Taskforce

The FYFV for MH: The Independant MH Taskforce Report.

Following the NHS Five Year Forward View (5YFV) published in October 2014 work has been under-way to implement this. We are told from the foreword of the original document that this Forward View represents the:

“…shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders. It sets out a vision of a better NHS, the steps we should now take to get us there, and the actions we need from others.” (p.2).

Bold words. In some places putting my critical hat on highly improbable words I’d say. However putting all that aside I stepped forward to be part of the recent consultation for how the 5YFV might look for Mental Health in particular following the Mental Health Taskforce public engagement findings. This was held in Cambridge last week but for one reason or another I couldn’t make it on the day. So I added my tuppence via email having scrutinised the Taskforce documents and commentary from the other consultants. This is what I said. It speaks more to what was missing then what was present in the current plan for mental health. (I’ve lightly edited this for grammatical clarity. Some would say I should edit this more heavily in this regard!).

I have been able to review the slides and the strategy workshop documents. I largely agree with much of my colleagues comments I have to say – I would like to add the following points:

Models of research – the need for more ethnographic and autoethnographic approaches as a research methodology is clear as a means of both challenging and complementing the more biological models of research. A strand of funding then and a significant one at that is needed, e.g. from within a respected research funder such as the NIHR that is dedicated to funding qualitative research would serve to (a) legitimise these chronically disregarded and marginalised forms of research (b) foster parity between the disciplines rather than division.

This would also speak to the liberal sprinkling of comments around social determinants. Social determinants are well established – now we need interventions based on our understanding of social determinants – e.g. Haslam et al.’s work as well as continuing to explore the specific social determinants and factors in place for people with mental health difficulties that are geographically and contextually relevant (see: http://www.sciencedirect.com/science/article/pii/S0165032714000573,) . Hence the ethnographic/autoethnographic approaches mentioned above.

Topics

There has been some research into the impact of the current welfare system on the mental health and lives of people with disabilities and mental health problems. The direction of travel of the current research is clear.

More research is needed on:

  • income inequality and mental health
  • workfare/psychocompulsion
  • in work and out of work benefits,  sanctions and the process of assessment and mental health
  • housing and mental health
  • the efficacy, effectiveness and safety of recovery colleges

Policies and processes of benefit assessments should be subject to evidence-based scrutiny/direction. They are not. It seems that evidence is rarely the meaningful guide to policy direction and development in spite of the money spent on the civil service, evidence reviews, consultations and strategies. There is rising media, lived experience and scientific evidence of the distress and deaths (people killing themselves) due to the assessment and sanctioning processes. (see e.g. White 2016 https://kar.kent.ac.uk/59731/1/insights-32.pdf.,  Perkins et al. 2017 http://www.emeraldinsight.com/doi/pdfplus/10.1108/MHSI-12-2016-0039).

I would strongly suggest that a specific theme of social determinants and social interventions is merited to give due regard and credence to all of the above.

As part of the upcoming Critical Mental Health Nursing volume I am developing the argument that compliments my approach to mental health nursing education, namely that MHN’s  must shift towards political-psycho-social activism. This represents in some small way a bit of that on my part. The bullet points with the exception of the final point on Recovery Colleges were raised by MH activist colleagues Recovery in the Bin.

Courtesy of and with kind permission granted from: http://www.yearoftheduck.com/trojan-duck/

Critical Mental Health Nursing

I published Recovering from Psychosis: Empirical Evidence and Lived Experience in 2016 and having done that you would think that was enough and I should get on with business as usual. But no. I had already started working on a second book idea which was originally going to be a book on Recovery Oriented Nursing – a sort of how-to guide combined with a critical perspective on it. And then everything went pear-shaped. Well, no not really. I started approaching people and talking about the book looking for contributors because another solo effort seemed to be a bridge too far and one that I’ll revisit later (yes there is a Book III idea wanting to get out). Instead surely editing a book and having others write the chapters was easier? The astonishing naivete.

Now we are some 3 months into the writing process for book two. It’s not a Recovery Oriented Nursing book as you may have gathered as the conversations with contributors and gathering co-editors took shape. That and the fact that another book exactly on that topic turned out to already be in press. Instead we have a completely different animal – Critical Mental Health Nursing. Offered up in conjunction with the Critical Mental Health Nursing Network.

CMHN is a vehicle. For multiple perspectives from nurses being critical of nursing, from people who have had experience of being cared for by mental health nurses, from professionals of other disciplines working alongside nursing to be heard. It will have a strong applied to practice focus, an ethnographic and autoethnographic flavour along with empirical evidence, multiple-theoretical-analytical approaches, and is driven by the authors and not the editors. At least that’s the plan! More to come as I have it. We are looking to see it published in 2018 by PCCS.

Autoethnography, cognitive psychology, folk-psychology: Thoughts on connectionist approaches to mind.

So, a long time ago I made a casual promise on twitter to write a blog about connectionist implications of approaches to theories of mind and consciousness. Foolish. However, that idea has bubbled away and recently re-emerged in discussing some aspects on the inter-relationship between language, mind, and truth. I’ve edited this and reproduced it here. Make of it what you will.

Connectionist approaches to mind, particularly Smolensky’s sub-symbolic approach, would say in my interpretation of it that words are something like socioculturally negotiated categorical descriptors and are connected associatively to world-events by dint of learning-training experiences. Our experience of language/words/thoughts/beliefs in a computational-philosophical framework is of a virtual machine underpinned by Connectionist mechanisms that are highly attenuated informationally-primed sensitive pattern matching machines – amongst other things. Indeed the best connectionism networks we have to date ‘deep belief networks’ which are forms of boltzmann machines are able to make categorical distinctions of written numers for example – you can show them lots of example ‘1’s’ and it can recognise that it is a ‘1’ even when highly ambiguous or the mechanism is damaged. The learning process that does this is never specifically tutored on what is a ‘1’ or told the desired output it learns to discriminate without such labels. What I take from this is that language is arbitrary and negotiated and built on top of lower-level sub-symbolic cognitive consciousness supporting mechanisms that are primarily concerned with finding statistical regularities – reducing surprisal and anticipating and reducing information-error. Language itself is a virtual machine on top that enables us to express and converse but is subject to sociocultural influences and is in of itself not a necessary prerequisite of conscious experience. On this basis whilst I consider words to be necessarily useful and meaning rich vehicles for experience they can only ever be at best to ourselves partial approximate descriptors of ‘raw experience’ (or qualia) and are always thus potentially subject to revision, oppression and the imposition of others mediated ‘truth’.

This is a talk by Geoff Hinton on deep-belief nets recognising numbers, without instruction. The video starts at 21 minutes – his demonstration of brain states and mind states is cool. https://www.youtube.com/watch?v=AyzOUbkUf3M

With autoethnography I’m with Ellis and am not so concerned with ‘truth’ more with stories that impact emotionally upon the reader and stimulate empathy compassion. ‘Evocative’ autoethnography if you will to my mind has as much value – if not potentially more than ‘Analytical’ strands. I get different things from both. We are tasked in the nursing-education world, courtesy of the Francis report and our CNO, via the 6C’s, with imbuing nursing with requisite care and compassion – (amongst other empirically opaque ‘C’s’) and are forced to leave aside the political injustice of the government’s reduction of the myriad of recommendations to holding our profession accountable for these failings as we do so. I would argue that these, along with the Courage C, are sound reasons to promote the autoethnographic movement within mental health nursing in particular, and nursing in general.

In applying a connectionist approach I’m seeking to undermine the ‘psychological truth’ of psychological models by exposing what I consider to be the shaky foundations they rest on.

Geoff Hinton’s talk I linked you to is a classic example – he seriously talks about models of brain state and models of mental state. They are linked but not the same. As I’ve expressed before elsewhere in various talks about more philosophical-existential aspects of mind, based on my understanding and previous work on connectionist theory and models I see the mind as a ‘virtual machine’ or ‘extra-dimensional property’ – they are inherently hypothetical. Minds themselves and the associated language labels – beliefs, thoughts etc employed in cognitive and clinical psychology are a construct. I may behave and have experiences that can be described as ‘having a belief’ and that is a convenient way of talking about that experience and associated behaviour, but I’m quite convinced that what ‘really’ underlies this is nothing like either the folk-psychological account of mind and mental behaviour nor the clinical psychological version – they are both kinds of approximation. This is evident to me from how classical-AI systems can be built out of sub-symbolic AI systems. The former has rules, categorical labels and so forth much like a lingua franca of the mind. The latter is the machinery underneath that scaffolds all this and has no clue or interest in the above.  Thus I would argue that connectionist approaches are potentially quite liberating for this reason, and that it allows us to hold these folk-psychological, cognitive-psychological and clinical psychological models lightly as mere approximations, not by necessity truth.

Troubling Definitions of ‘Mental Health’

Troubling Definitions of ‘Mental Health’

Image result for mental health

Lately thinking over dialogues I have been observing and participating on twitter, online and in practice has led me to the conclusion that there is a significant socio-political problem at the heart of ‘mental health’ practice. This comes from an assumed idealism of what constitutes ‘mental health’ itself. Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organisation, 2013).

Perhaps on the face of it this positive spin on what constitutes good ‘mental health’ may seem benign and aspiringly inclusive. I find it question-begging. Shouldn’t we all wish to ‘work productively and fruitfully’ and ‘contribute to our community’? Shouldn’t we all wish to realize our potential? And it’s in reflecting upon the superficially desirous goals that I strike upon some potentially stony ground. If mental health is about realizing potential, getting on with life and being a contributing citizen – to paraphrase the definition – then what if my circumstances are such that I am obstructed from attaining any or perhaps all of these? Am I thus devoid of a state of mental well-being as a result? Are these truly necessary conditions for flourishing mental-well-being? If so then what of those who are for whatever reason unable to deal with the stresses and strains of day-to-day living and contribute to their national insurance contributions?

I had a troubled phase of my life (in the mid-latter part of my 20’s) where I was deemed unfit to work and signed off sick. This was because of my ‘mental health’. Already we are in some a kind of tautological trap before we’ve even got started. What sense does it make that I can be deemed ‘unfit for employment’ by virtue of my mental health that is defined as partly as a capacity to contribute to working life? Excluding me from work on these grounds is excluding me from a component of activity that constitutes my mental health! How do I regain this part of my mental health and be seen as ‘fit for employment’ despite my mental health if being in employment is considered to be a necessary feature?

Let’s look at this from a slightly different angle. Looking at research into retirement indicates that we are treading some very swampy ground here. On one hand some research recently published by the Institute of Economic Affairs demonstrates that retirement increases the chances of suffering from clinical depression by 40% and the chances appear to increase the longer you spend in retirement (Sahlgren, 2013). This research isn’t the last word on the matter. A cohort study of people working for Electricite de France (EDF) looked at the annual trend in reported mental fatigue, depression or physical fatigue over the seven years before and the seven years after retirement. It found reductions in depressive symptoms and mental and physical fatigue comparing the year before with the year after retirement. This led to the conclusion that retirement is related to improvements in well-being (Westerlund et al., 2010). So we have conflicting evidence – some suggesting that being out of work contributes to a healthier lifestyle and better mental health and another, equally credible that it leads to a deterioration.

This suggests to me that a serious danger to guard against are adopting ways of working that map goals and outcomes that perhaps generalise well to larger populations (and are the output of research) without care and attention, unthinkingly, to the individuals with whom we are working. Whatever ‘mental health‘ is will differ significantly from person to person and will vary through time – what affords my mental health now is not the same as 20-odd years ago. So for example with a client I worked with in a community service as a CMHN (community mental health nurse) her physical disabilities precluded her from paid employment (as deemed by her and the health and social care organisations). Thus for her mental health defined as necessarily being constituted out of working contributions was pretty toxic and irrelevant. Instead her mental health was living well and having control of her life within the infrastructure of services that provided her with care. She thrived from having support that she could flex around her – being more supportive at certain times, and stepping back with confidence when she was feeling more capable of self-support. For her skills of being able to differentiate between the two and communicating this level of support need accurately – and for that to be heard – scaffolded good ‘mental health’. She felt a sense of mastery and satisfaction from being able to direct her own care as it fluctuated over time.

References.

Sahlgren, Gabriel, (2013), Working Longer, Live Healthier: The relationship between exonomic activity, health and government policy, http://www.iea.org.uk/publications/research/work-longer-live-healthier-the-relationship-between-economic-activity-health-a [Accessed on 17/03/2014].

Westerlund H, Vahtera J, Ferrie JE et alEffect of retirement on major chronic conditions and fatigue: French GAZEL occupational cohort study. British Medical Journal 2010; 341:c6149

World Health Organisation, 2013, Mental health: a state of well-being, http://www.who.int/features/factfiles/mental_health/en/ [Accessed on 17/03/2014].

Why the Mental Health Act needs a review of Community Treatment Orders #ChallengeCTOs

Community Treatment Orders: What’s the Evidence for Legally Enforced Treatment?

In my upcoming book on Recovering from Psychosis (Williams, In Press) I have a chapter that critically reflects on the potential abuses of the widely discussed ‘recovery’ movement. Within this reflection a point I make is  that an organisational requirement to developing clinical practice founded upon partnership in decision-making necessitates a shift in terms of power and authority within professional roles and practices (Slade et al., 2014). This is particularly problematic in the case of treatment under section within the Mental Health Act (1983; 2007) and it is hard to see how services can maintain a recovery approach when this legal enforcement of aspects of treatment are in place. What follows now are my reflections on CTO’s excerpted from my current book draft.

Community Treatment Orders (CTO’s) were introduced as a means of reducing the need for admission and detention in inpatient settings. The data on rates of admission and implementation of CTO’s does not support these ideas, and neither do early randomized trials evaluating the efficacy of CTO’s. According to the Health and Social Care Information Centre (2009; 2013) rates of detention to inpatient facilities in the U.K. increased from 47,600 in 2007/2008 – 2008 being the year in which CTO’s were introduced – to 50,408 in 2012/2013.

Within the limitations of designing and implementing randomized control trials those conducted to investigate the efficacy of CTO’s in reducing the need for admission to hospital each unequivocally indicate that CTO’s do not have an impact statistically on such outcomes (Burns and Molodynski, 2014). There is in counter-balance to this some evidence that the use of CTO’s can reduce the length of hospital stay for certain groups of people (Light, 2014).

As Light (2014) points out in discussing the whys and wherefores of the legitimacy of CTO’s in the face of unfolding contradictory and in places unequivocally negative evidence is that the process of study design, choice of ‘outcomes measures’ and what kinds of evidence inform evidence-based care are philosophical matters. An implication of such studies thus far on CTO’s is that inpatient treatment in some sense is the result of a failure of the CTO. That is there is an assumption that the function of community care is to prevent the need for inpatient treatment. In a clinical context this does not always make particularly good sense – sometimes the purpose of community mental health care is to facilitate access to inpatient care. It has also been argued that CTO’s, like recovery, amounts to a process – wherein what benefit is entailed within the treatment order is in the improved access and availability of clinical resources to the person (Kisely et al., 2013).

These studies also fail to speak as to the qualitative nature of experiencing a CTO – the most recent studies of which in Australia (Light, 2014) paint a consistent picture of distress and ambivalence about the use of CTO’s there. Strangely, whilst studies of lived experience or qualitative data tend to have a reduced regard in terms of health-economic decision-making where randomised trials are seen as the gold-standard for research, a rebuttal of the OCTET trial evidence by Mustafa (2013) argues against the withdrawal of CTO’s based largely on evidence from a fictitious case of anecdotal evidence of its efficacy! It’s a perversely inconsistent world where on one hand we have arguments against the narrow use of existent psychological therapies for psychosis based stoutly and solely on hard-won expensive scientific empirical evidence (via RCT’s) that has limited room for the complexity of user-experience outside of often researcher originated numerical scales of symptom intensity. Yet again we have arguments for the persistence of a typically unpopular form of legally enforceable intervention in the face of the same kind of evidence that draws on a putative case of user-experience to justify this. We are well overdue embracing mixed-methodologies in psychological health ‘science’ and finding ways to draw upon user-experiences so that we can provide interventions that are both empirically valid and experientially attentive.

Given that mental health services is under-pinned by professional mandate to be ‘evidenced-based’ (Goodman and Ley, 2012) and so far CTO’s fail to meet the much prized and costly gold-standard of evidence – how can we be justified in their persistent mandatory usage in the Mental Health Act as is?

This, amongst other arguments, is the basis for the #ChallengeCTOs campaign. We are calling for a review of the relevant legislation that governs the usage of CTO’s. If you agree that a review is warranted you can help get this heard in Parliament by signing up to our e-petition: http://epetitions.direct.gov.uk/petitions/67906.

References:

Burns, T. and Molodynski, A.(2014), Community treatment orders: background and implications of OCTET trial. Psychiatric Bulletin, 38, pp3-5.

Goodman, B. and Ley, T.(2012), Psychology and Sociology in Nursing, London: Sage Publications.

Great Britain. Mental Health Act 2007. London: The Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/2007/12/contents (accessed 30/06/14)

Health and Social Care Information Centre (2009), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment – 1998-1999 to 2008-2009, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].

Health and Social Care Information Centre (2013), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment, England – 2012-2013, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].

Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, et al. (2014), An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res,47,pp 650-6.

Light, E. (2014), The epistemic challenges of CTOs: Commentary on Community treatment orders. Psychiatric Bulletin, 38, pp6-8.

Mustafa F., (2013) On the OCTET and supervised community treatment orders. Med Sci Law doi:10.1177/0025802413506898

Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., Perkins, R., Shepherd, G., Tse, S. and Whitley, R. (2014), Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13(1), pp12-20.

Williams, S. (In Press), Recovering from Psychosis: Empirical Evidence and Lived Experience, Routledge Press.