Connor Kinsella: Off Duty

Jumpers for Goalposts: A Reality Check for Non-League Football

2012-01-19T16:16:00.004Z

Yes, I haven’t written a blog post for aeons. And No, this contribution has little or nothing to do with social care unless you count the demise of non-league football clubs as a mental health issue, which if you’re a fan of Northwich Victoria, Kettering, Rushden & Diamonds or Darlington I guess it does. So here goes.

In a series of excellent, well-argued pieces by Mike Bayly and Ian King of the Two Hundred Percent blog, the recent demise of clubs from the arse end of football’s pyramid are spelt out and arguments made for the end of the sort of financial mismanagement by legions of developers, chancers, crooks, dreamers and general Billy Big Bollocks-types that have infected the non-league game for many years.

I once spent nine very long months as the Supporters Trust rep on the Board of the well-known basket case that is Weymouth FC. The history of our financial ups and downs has been recorded in all it’s lurid and entertaining detail here, but in November 2009 Weymouth FC really did reach a point where an Administrator stood poised and ready to take over a club which was worth far more as a cut-price property asset than it was ever going to be as a football club.

To cut to the chase, a Board of Directors made up of local fans and business people who had themselves waded in at the eleventh hour to rescue the Terras from a previous crisis were finally forced to wave a white flag and accept a takeover from the previous owner of Cambridge United who, in his own words had been “ hounded out” by their fans amid proceedings described by one BBC correspondent as ‘comical’. And while ‘comical’ is still a word all too often used to describe the George Rolls School of Management, he actually came up with the goods as promised (the word 'actually' being of crucial importance in this sorry tale) and we’re now still in business enough to have been stuffed 6-0 by Alfreton Town last Saturday whilst saying goodbye to a promising FA Trophy run. We could veer off here to talk links with some less than savoury characters and the now doomed Rushden & Diamonds, but that’s another story.

So we’re still here despite a back story filled with dodgy geezers, unpaid bills and unwelcome letters from everyone from the Gas Board to the Inland Revenue. These things will always be part and parcel of running a football club down here in the nether regions, so why bother?

Love, of course. Definitely not a Liverpool or a Fergie or a Tevez sort of love.

The Premiership is all too often followed by replica shirt wearing, Sky subscription watching goons who’ve never eaten a Pukka pie in their lives but are actually proud of the sofa-induced pressure sores on their arses and shoot their load at the very thought of getting a retweet from Wayne Rooney.

On the other hand, our love of the game is knowing the names of most of the characters stood within a centre-circle of our ‘spot’ on the terraces. We can buy our centre-half a post-match pint, and even discuss tactics with the goalie when he comes to plumb in our washing machine the following Monday. We see ourselves as a cut above those Premiership goons. We actually go to games. We eat pies. We have a genuine and often highly knowledgeable love of the game. But for all that devotion to non-league in all it’s tin pot glory, recent history shows that all too often there simply isn’t enough bum through turnstiles to pay the bills. Something has to give, and I’d argue that a considerable part of that ‘something’ is players wages. Not big wages I'll admit, but enough to put a very big red chunk of 'red' in the Profit-Loss spreadsheet.

Weymouth FC are currently playing in a league where we don’t even have names on the back of our shirts. But after a run of good results and fine performances which have left us within an optimist’s wet dream of the play-offs for Blue Square South, we were hopelessly outclassed last weekend by an Alfreton side currently hovering around the bottom of the Blue Square Premier. And when I say outclassed, I really mean OUTCLASSED. It was the sort of gulf in quality immediately obvious to even the least football-literate of spectators. And the gulf in cost of watching these two sides? Two of yer English pounds. Terras fans are currently paying £11 to get through the turnstiles at the Bob Lucas Stadium. Their Alfreton counterparts will be paying £13 to watch their next home game. And we (along with most other clubs in our league charging similar prices) wonder how the hell to balance the books with a couple of hundred devotees stood among the tumbleweed on a Saturday afternoon. It’s a little like going down the local chippie and getting charged Gordon Ramsey prices for a piece of Cod.

Forget the old adage that ‘football is a business like no other’. That’s cobblers. Football is a business exactly like any other. Profit and Loss. Supply and Demand. But unlike the big boys of the higher leagues our profit doesn’t come from replica shirt sales in Kazakhstan. Our only relationship with Sky Sports is the Champions League game showing on the telly in the club bar. Profit comes from the turnstiles, bar takings, a bit of sponsorship from local businesses, and the prudent use of club facilities on non-match-days.

And here’s my argument. It’s one of those Elephant in the Room observations that I’ve failed to see discussed elsewhere. Players at this level get paid. Some players at this level even have agents. And while most players at this level aren’t quite puffing and wheezing their way through ninety minutes with a hangover, a beer gut and a fag at half-time, they are at the end of the day entertaining little more than a few hundred fans hugging a cup of hot chocolate on a Tuesday night or Saturday afternoon.

Perhaps it’s time for a line to be marked in the non-league sand, and really have a deep think about the wages we pay non-league players, or even whether we pay non-league players at all.

So, I hear you ask: “How the hell do we attract players to non-league who are prepared to give up time for training and play one or even two games a week?”

Well let’s think about it.

a) If a player really loves playing football, he’ll play football.
b) He gets the chance to play in front of a decent crowd attracted by ninety minutes of ‘not spectacular but better than pub league’ footie for a couple of quid. This more than allows the club to pay the ‘leccy’ bill for the floodlights and a bus to get to away games. It beats the hell out of Sunday morning down the park.
c) He gets to strut his stuff in front of scouts from bigger clubs. Even if he only gets as far as Blue Square or League Two he can still earn a few bob alongside being a student or rewiring a house or being ‘Derek from Accounts’, and there’s always the DJ Campbells who really work their way out of non-league and can forget the building site for good.
d) And of course, there’s always the small chance of a televised FA Cup match where he gets to wave to his Mum.

So unless Saint Mario of Manchester City is preparing to pay a secret visit to your struggling non-league club with a carrier bag-full of cash dumped out of the Maserati window, it might be worth a thought before those of us who really love our non-league are going back to putting those jumpers down as goalposts.

The Mad, Mad World of Psychiatric Diagnosis

2011-10-31T18:16:00.008Z

Is it time to tear up the rule book and design a system of mental health diagnosis that is user-friendly, scientific and weighs less than a small fridge? Connor Kinsella thinks we're long overdue.

You’ve dimmed the lights, lit the candles, chilled the wine, smoothed down the Egyptian Cotton and put Barry White on repeat shuffle. But your partner seems far more interested in catching up on this week’s hot new blog from TownPlanning.com. You forlornly pick up the CD cover and whisper “Sorry Barry. Not tonight.” But you see, it’s not you, it’s your partner. Or more precisely, their HSDD. Eh? Oh sorry, I meant to say Hypoactive Sexual Desire Disorder.

I’m not making this up. This is a genuine diagnostic label plucked from the weird and labyrinthine world of psychiatric classification, where the everyday and the humdrum of human behaviour becomes labelled and filed as a ‘disorder’ and not your partner’s lack of enthusiasm for scented candles and a set of clean sheets.

There are two classification systems in use throughout the world of mental health care. In the UK and Europe, clinicians generally refer to the ICD-10 Classification of Mental and Behavioural Disorders published by the World Health Organisation, but clinicians and researchers worldwide also refer heavily to the American Psychiatric Association’s DSM-IV system.

Both systems provide a means of reference to both practitioners and research scientists, and have made considerable progress in moving mental health diagnosis away from 'a case of the vapours’ or ‘nervous exhaustion’ and toward a scientifically valid and standardised means of being able to tell a patient they suffer from Schizophrenia, Bipolar Disorder or Anorexia Nervosa. Diagnostic classification has also paved the way for researching mental health conditions which, unlike most physical illnesses, are invisible to the blood test or scanner.

As a nurse I’ve spent many valuable hours helping people understand their emotions, thoughts and behaviours within the context of a psychiatric diagnosis and the treatment that is being offered to them. People who are unwell are generally more than happy to know exactly what is wrong with them. They want to be able to put a name to their collection of signs and symptoms, even where those signs and symptoms are clouded (as is often the case with mental health) by more than a little subjectivity. Psychiatrists can and do get it wrong for all sorts of reasons, but our current evidence base is certainly strong enough to be able to offer a firm and often reassuring definition to most people suffering most of the common mental disorders.

The American Psychiatric Association has for some years been working on the latest version of the DSM franchise, a term not inappropriate by way of the rather large financial income the AMA receives from its publication. The robustly named DSM-IV Task Force has been taking hits from all directions while it’s exclusively medical membership (itself a bone of contention) have sat on the various sub-committees coming up with shiny new diagnoses such as Disruptive Mood Dysregulation Disorder, which as far as I can glean could just as well be described as ‘Stroppy Teenagers Being Stroppy Disorder’. There is also a proposal for a new Apathy Syndrome (a possible explanation for X-Factor’s less than sparkling viewing figures these last few weeks?) and another little beauty aiming straight at the heart of anyone reading this. Yep, you guessed it. Internet Addiction Disorder.

The critics are not just critical but fully tooled up with an arsenal of brickbats with which to slap the DSM-V Task Force hard across the buttocks, a phrase destined to have this blogger labelled with Sado-Masochistic Smutty Reference Disorder or it’s nearest relative. The British Psychological Society and the American Psychological Association have both weighed in with extensive criticisms of the proposed DSM-V prior to it’s publication in the Spring of 2013. But there are many, many more missiles being aimed at the Task Force and, lets face it, it’s hardly a moving target.

With diagnostic toolkits so loaded with the potential to change peoples lives, deny or facilitate state benefits such as Disability Living Allowance or Incapacity Benefit, and the template by which researchers worldwide base what is a growing and increasingly useful body of good science, do we really want labels based on a single case report written by an obscure psychiatrist which has no basis in research evidence nor any form of genuine scientific validity?

Do we really need, as is proposed by the DSM-V Task Force, even lower thresholds for diagnoses such as the already controversial Attention Deficit Hyperactivity Disorder, a 'condition' which has already made huge profits for the pharmaceutical industry and is set to become even more profitable with the suggested lowering of the bar?

For the jobbing mental health professional it is safe to say that a large percentage of both ICD-10 and DSM-IV is already of little or no use to anyone other than the odd psych-nerd playing Mental Health Trivial Pursuit with their psych-nerd friends. What both professionals and those who come to them for help really need is a diagnostic system which actually reflects this salient fact. Psychiatric diagnosis really isn’t rocket science.

Medics worldwide may secretly fantasise about that ’House moment’ where they wander into the clinic eating a sandwich and looking as if they’ve just got out of bed, casually saving the patient's life just as they flatline with an incredibly obscure diagnosis that nobody else has heard of.

But in real life I would challenge any mental health professional to come up with more than a dozen clearly delineated, well researched diagnostic labels used in day-to-day psychiatric practice. Hippocrates came up with a quite reasonable psychiatric classification while most of us were still throwing spears at mammoths, so how have we managed to come up with such a convoluted and often meaningless plate of spaghetti as DSM and ICD?

Our diagnostic systems are already unwieldy, unscientific and wildly over-inclusive. Revised models ought to be filtering out the nonsense and returning us to some semblance of science and common sense. But DSM-V is scaring the pants off far too many well qualified observers for the critiques to be merely a hobby horse of those still clinging to battered copies of The Divided Self.

Psychiatric diagnoses are big labels applied to many, many people and are far too important to be based on bad science, personal ego and a book that is often of more use as a door-stop than a frame of reference.

Right. I’m off to my analyst via the scented candle shop. Wish me and Barry luck.

A Longer View of Winterbourne View

2011-10-12T09:05:00.001+01:00

Thanks to a few sleepless nights of keyboard bashing and the odd complementary tweet from The Guardian's @patrickjbutler his employers have kindly (and perhaps unwisely) invited me on to their new Social Care Comment site. Here's my take on the aftermath of the Winterbourne View scandal.

There have been many initiatives, reports and government level strategies in recent years but few, perhaps none, have hammered at the ramparts of care for learning disabled adults with the force of BBC’s Panorama expose Undercover Care: The Abuse Exposed.

Broadcast on 31 May this year, Twitter exploded almost immediately in response to some of the most unwatchable scenes on television in many years. As the blogosphere and online communities followed not far behind in an eruption of public horror, it was clear that that the care of society’s most vulnerable people had hit a watershed. My own blog posts on the subject and the comments of many both on my own site and countless others made me realise I wasn’t alone in being unable to sleep that night and getting up out of bed to bash seven bells out of my laptop.

But the media bandwagon rolls on and even those most horrified by those scenes are once again tweeting about X-Factor or the bedroom antics of Premiership footballers. Those of us who work in social care might suspect that the status quo has resumed. The sadists within our ranks have resumed their water-boarding, and the senior executives of companies providing care can once again get back to a nice round of golf. So what, if anything, has changed in 133 days?

As a social care training provider my colleagues and I meet hundreds of support staff from local authorities, charities and other care providers up and down the country, and strange as it may seem in the few months since that edition of Panorama I’m left with a glass which is, if not quite half full, is certainly far from empty.

Firstly, we can look to the already well publicised structural changes that have taken place. Both Castlebeck and the Care Quality Commission (CQC) have not just been caught with their trousers down, but suffered the acute embarrassment of being caught in a very intimate moment by an elderly relative popping round for a surprise visit. “Coo-ee, the door was open and… oh dear!”

But my recent experience of running training for care staff perhaps tells us about more than the closure of poor quality homes and a rapid increase in CQC inspections. A public who once knew, saw or heard little about learning disabled people and assumed that it was still the NHS and local authorities providing for them now seems to have woken up to the fact that much of our social care system is now run at a very tidy profit by executives who think more of feeding a racehorse than meeting the needs of a young woman with autism.

Thanks to the Winterbourne View scandal and the subsequent demise of Southern Cross, we now seem now more capable of demanding the sort of excellent, small-scale services where individualised care is more than just an empty mission statement written on a dusty wall plaque. We might even argue that the average man or woman in the street is now much more aware that the care and support for their vulnerable relatives is worth a good deal more than a healthy bottom line, particularly when that comes at the price of shoddy management, poor staffing and a training culture which means little more than the annual fire lecture.

But no television documentary is ever going to completely rid social care of the occasional rotten apple who, through a combination of individual inadequacy and limp supervision, will quickly go on to sour the rest of the fruit bowl. But we can hope that in the aftermath of Winterbourne View we can all blow the whistle and perhaps get those who could and should have been listening to realise that Panorama wasn’t just a one-off. We’re all watching now.

Connor Kinsella is an author and training consultant at JCK Training http://www.jcktraining.co.uk/.

Supporting People: Not

2011-08-23T03:35:00.015+01:00

Many local authorities are now slashing and burning their way through vital community services, leaving highly vulnerable people without essential support. Thanks to Keith Cooper and the Guardian Housing Network for inspiring yet another sleepless polemic, mostly aimed at 'Dave'

It’s not often I start a post with a big, fat, steaming turd of a lie, but let’s do it anyway. I offer my apologies to all turds for the comparison. They really don’t deserve it:

"And I want to say to British people clearly and frankly this; if you are elderly, if you are frail, if you are poor, if you are needy, a Conservative government will always look after you" David Cameron: 4th May 2010

Courtesy of The Guardian

I remember watching with awe and amazement Cameron spouting this mantra over and over again on the pre-election campaign trail. He said it on the live TV debates. He said it on visits to Day Centres, usually with sleeves rolled up and gurning over a girl in a wheelchair. He said it bloody everywhere to anyone who would listen, and I remember thinking how remarkable it was that the leader of the Conservative Party was starting to sound like the hybrid spawn of Ghandi, Mother Theresa and that nice lady in Borehamwood who devotes her life to saving hedgehogs.

But ‘spending’ and ‘cuts’ were never far from the spiel either, Cameron’s point being that whatever they had to do to reverse the public sector overspend of the previous mob, it’s okay. Vulnerable people wouldn’t suffer. "A Conservative government will always look after you."

The awful truth of what is happening to community care has been slapping me in the face like a wet fish ever since the grinning Dave and Nick garden party at No.10 way back in May last year. I earn a living running courses for social care staff up and down the UK, and I notice things. I notice how much less cheerful are the delegates who come to my courses. Is it my crap jokes? Have people really become homicidal at the mere sight of a Powerpoint slide? Well, probably yes, but this hasn’t been the reason for the pervasive gloom in my training rooms.

The fact is, I’m working with large groups of people who are not only attending the last course they’ll ever get under the previous training budget, but more seriously are facing the prospect of reapplying for their own jobs, or being handed a P45 and a note of thanks 'for all their valuable service'.

These aren’t the bureaucrats and middle-managers with incomprehensible titles and Mickey Mouse job descriptions. These are front-line, face-to-face support workers who do the often gutty work of helping people who really can’t get on in life without the help of that Warden, Carer or Support Worker who helps out with anything from benefit claims to suicide prevention.

But sometimes something is so blindingly, dazzlingly obvious that it never really hits home until you see it in black and white. On paper or on a laptop screen, the effect is the same. And yesterday, thanks to The Guardians Housing Network, I read the confirmation of all that I’ve been hearing these last sixteen months:

Courtesy of The Guardian: Author Keith Cooper 22.8.11

Supporting People cuts leave housing sector unable to help most vulnerable

Now I can certainly help you understand why a 17-year old service user stubs out fag butts on his arm or help you devise a risk assessment and management strategy for your supported housing service, but mention ‘ring fencing’ or ‘local housing allowance’ and I’m likely to look at you as if you’re spouting the combined works of Stephen Hawking in Mandarin Chinese. But I do know a little about Supporting People, the programme of funding established specifically to provide community support for vulnerable people.

People whose lives are shattered by mental illness, drugs, alcohol, homelessness or often a bit of each. Ex-offenders, people with learning disabilities or the frail elderly are also the very folk supported by Supporting People, usually with the invaluable provision of four walls and a roof, and a regular visit of one of those front-line, face-to-face support workers.

Supporting People (SP) is a fund distributed to local authorities to spend on housing and support provision for vulnerable people. The providers may be in-house local authority staff, but are more likely to be independent providers or charities who receive a portion of the local SP pot every year to help those who really can’t get by without support. The Guardian report highlights the massive re-allocation by some (not all) local authorities of SP budgets away from their original targets and into … well, I don’t know what, but it certainly isn’t going to be spent on providing sheltered accommodation and a warden for 80-year old Doris, or helping Gary get his life back on track after a 5-year jail term.

David Cameron and Housing Minister Grant Shapps will undoubtedly argue that their government have barely touched SP funding (true), and it’s those nasty councils who’ve pulled the rug right from under the already unsteady feet of the vulnerable. But this sounds to me like Hitler blaming the Holocaust on a few SS officers who got a bit over enthused with the gas tap.

But back to my real world - the training room, where I spend coffee breaks and lunchtimes staring disbelievingly at yet another support worker telling me “Yes, Connor, this is a very useful course, but to be honest I’ll be stacking shelves in Tesco in six months so there won’t be much call for your insights on Dual Diagnosis.”

And I ask, rather fearfully, what will happen to the twenty or so clients on their caseload when they’ve chopped the staff allocation in half? “Don’t know. Haven’t a clue” is invariably the answer, but neither of us needs a crystal ball to imagine the misery, the mayhem, the reversal of fortunes and the undoing of what often amounts to years of hard work by a support worker who, whether at the end of a phone or the end of a sofa, is quite possibly turning lives around and staving off inevitable chaos.

I often use a technique called Mind Mapping to help staff think about the work they’ve done, often for a particularly difficult or vulnerable client. There are inspiring success stories, the odd dismal failure, but more often the seemingly humdrum case of a service user encouraged to reduce their intake of White Lightning from four litres a day to two.

I ask the support worker a simple question: “Where would this tenant be if it weren’t for your support and a roof over their head?” The answer is usually death, prison, homelessness or very long spells detained in a psychiatric unit.

With rapidly diminishing training budgets and fewer and fewer people left to do training with, I don’t expect to be asking these questions for very much longer, or to be talking job security over coffee and biscuits. But if I were, I’d expect the answers to feature less and less inspiration and more and more White Lightning.

Thanks for that, Dave.

Borderline Personality Disorder Part Three: A Game of Two Halves?

2011-08-17T17:46:00.003+01:00

As an author and trainer I’ve written enough about mental health to wallpaper a small room. I've travelled the length and breadth of the country running courses on personality disorder, and can list the DSM-IV diagnostic criteria while hopping on one leg and loading the dishwasher. I’ve also spent many years working with personality disordered people in secure units, in acute admission wards, in the community. I’ve spent literally hours at a time trying to prevent patients gouging out their eyes, setting fire to themselves or trying to hang themselves with a bath towel, all the while trying to avoid the saliva aimed at my face and blotting out the screaming and shouting with ‘nice thoughts’ about home, family and the post-shift kebab.

As a senior nurse I would try to reassure less experienced colleagues that the hostility, venom and sheer nastiness was nothing personal. “It’s about them, not you” I said. And if that sounds less convincing than a cliché from a bad rom-com then you probably agree with 99% of the nurses I’ve said that to over the years. But I knew what I meant.

So I know a lot about BPD, then? Er, actually no.

Before reading Sian’s posts I assumed, with the eyes of one who has for many years seen BPD from the ‘professional’ side of the ward or treatment room, that BPD rendered a more or less constant diet of chaos, misery, institutionalisation and sometimes death. Through training and writing I try hard to dispel the idea that all individuals with BPD are manipulative, wildly emotional and self-destructive, but if you're paid to treat or support people with this diagnosis, it's always seen as bloody hard work and universally unpopular.

But Sian’s articles have wiped more than few scales from jaded eyes. I’ve known her for years through our shared support of a non-league football club. If it were possible to diagnose an institution with a psychiatric disorder then Weymouth Football Club would pretty much tick all the boxes for personality disorder and then some. But I didn’t know until recently that she’d experienced any more psychological angst than anyone else stood on those freezing terraces, and it seemed almost obvious to ask her to contribute to this subject from the point of view of someone who has seen the movie, bought the T-Shirt, and been to bed with “gin and razor blades”. And if you don’t know what the last sentence means, you really need to read Part One of this series.

I was also keen to hear Sian’s account of her encounters with ‘the system’. I’m certainly no apologist for the many, many faults of a mental health structure which has not so much failed over the years but never really got it’s act together in the first place. To use a football analogy, we’re talking several hundred years of hurt here.

As Sian puts it, we have: “A system that insists that mental illness is no longer taboo but hasn’t yet worked out how to deal with it. Whether through ignorance, lack of funding or wilful desire, it just doesn’t take us seriously.”

And it’s just this sort of voice I wanted readers to hear as opposed to some of the increasingly 'shouty' anti-psychiatry bile spouted on just about any online forum having the words ‘mental’ and ‘health’ in the title. I asked Sian for a service user perspective that might inform and stimulate without stereotyping all mental health workers as a battalion of burnt-out, syringe brandishing stormtroopers whipping out section papers at the mere suggestion of deviation from the cultural norm.

To quote Sian again: “The two sides of the equation – let’s call them ‘the professional’ and ‘the patient’ – ought to be travelling in the same direction, should, really, be striving for the same goal but I would suggest that isn’t always the case.”

No it most certainly isn’t, for reasons that are far more widespread and complex than can be tested on the attention span of our readership. But I’d like to think that my guest blogger has eschewed anti-psychiatry polemic for a considered argument as to where at least some of the problems emerge. Sian highlights a rigid mental health care bureaucracy focussed on crisis management and firefighting, often where an inferno might have been averted with the pre-emptive application of a damp tea towel. And please let’s not have any ‘lack of resources’ argument here. Early intervention can save lives AND money.

At the more individual end of the scale, Sian offers us a glimpse of the ‘piss poor professional’. This is a phenomenon I know only too well as being far too common in mental health care but perhaps a sad inevitability where the lure of a grateful orthopaedic patient offering boxes of Quality Street is always more attractive than a middle-finger salute from a terrified schizophrenic who thinks you’re a CIA assassin. Note to self: finish off that ‘rogue care worker’ article you’ve been waffling about since Winterbourne View.

I probably don’t agree wholeheartedly with everything Sian argues. As a self-confessed science nerd I’m excited by much of the recent research evidence pouring out of the world’s ever growing collection of CAT and MRI scanners, and I will argue that BPD or any other mental disorder cannot be explained purely by environmental circumstances or social construction. But like Sian I do believe very strongly that ‘patient’ and ‘professional’ should be travelling in the same direction. So how can we do this?

Only by both sides dropping their weapons and beginning to realise that there is nature AND nurture, that there is medication AND talking treatments, that not anyone wearing an NHS badge is the spawn of Satan and that not everyone labelled as BPD is a spitting, screaming attention-seeking nightmare. A little understanding could go a long way on both sides of the void.

I could go on but let’s save that for another time. To paraphrase Star Trek’s Mr Spock, sometimes the needs of the reader outweigh those of the blogger, so let’s just leave it there and say a very big Thank You to Sian Lacey Taylder. May we soon be reunited in our derision of a dodgy back four.

Find out more about Sian and her published work at: http://www.sianlacey-taylder.co.uk/

Visit JCK Training for details of in-house courses on Borderline Personality Disorder and our other health and social care subjects.

Borderline Personality Disorder: A Guest Series from Siân Lacey Taylder (2)

2011-08-16T10:10:00.004+01:00

Welcome to the second part of our series on Borderline Personality Disorder. If you missed Part One and want to catch up, it's here.
I had asked Sian to think about not only BPD per se, but to give us some of her 'warts and all' insights into the mental health system. I think most readers will agree that UK mental health services are hardly the gold standard even compared with far less developed nations, but simply shouting that a service is crap is a rather empty exercise without any attempt to explain why it's crap, which is fortunately not a criticism we could level at the thoughtful and insightful account we have here.
Part Three will be published tomorrow, and is my brief attempt to address some of Sian's arguments and observations from the point of view of one who has been part of 'the system' that Sian and many others have often found so wanting, but which occasionally does have a glimmer of light at the end of the tunnel.

You should know that some of my best friends are mental health professionals. Indeed, my best friend is a clinical psychologist and I’ve nothing against the profession per se.

True, there have been occasions when the system has let me down – sometimes quite badly. Like the time when, in the immediate aftermath of a serious trauma, a trainee RMN pitched up with the suggestion that I be referred to an alcohol dependency unit without being aware of my specific circumstances (I had, as it happens, just been raped).

Or the time my GP sent me to the local A&E because I’d carved ‘Siân is a bitch’ into my forearms (yes, I even did the circumflex); the duty psychiatric nurse asked me a few cursory questions then told me to ask my doctor for a course of Prozac.

Or the time when, sensing an imminent descent into the emotional abyss, I contacted my local community mental health team to ask for help. The reply I received was courteous but patronising, more or less implying that unless I staggered into the surgery with my wrists already slashed there was nothing they could do.

The upshot of all this? The worst in short-term planning. Instead of trying to avert the crisis why not wait until it comes crashing through your front door in all its bloody glory? Those few pennies you might save by limiting preventative care will be peanuts when you’re presented with the bill for my incapacity to engage with society – and pay my taxes.

Please don’t misunderstand me. I’m not suggesting the entire NHS should rearrange its priorities to account for my every change in mood swing, and I’m sure some of you – from the Julie Burchill School of Empathy, perhaps – will be shouting at your computer telling me to get a grip. I don’t want your pity, I really, really don’t; all I’m asking for is a little more consistency and some ‘joined up thinking’.

For example: I have been, more than once, referred to a therapist of some kind but the referral always comes with some sort of proviso. Normally it’s a limited number of sessions; last time it was six which was just about time for us to get to know each other. I had the option to continue on a private basis but a recent outbreak of BPD had left me with a paltry, part-time income.

Then there was the time I struck up a productive relationship with a Freudian psychotherapist. What should have been – and did, indeed, start out as – a fractious, adversarial relationship ended up like a marriage made in heaven.

Does it sound like a physical relationship? In some ways it was – only without the intimate contact, of course – because it has to be intense. Sadly, after a summer of psychotherapy, she suddenly disappeared. I never did find out what happened to her; I managed, eventually, to get an appointment with someone else but when I told him I was feeling better he declared me fully restored to health and no longer in need of therapeutic support.

Three months later I was up to my old tricks again and never really let up for the best part of eight years. I should add that in all that time various GPs, medical professionals and even the police were nothing less than understanding; what constrained them, what we were all fighting against, was – still is – an inflexible, unimaginative system. A system that insists that mental illness is no longer taboo but hasn’t yet worked out how to deal with it. Whether through ignorance, lack of funding or wilful desire, it just doesn’t take us seriously.

But I’ll say it again. I don’t want your pity and I certainly don’t want to stretch the resources of an increasingly-underfunded public service which, in any case, can’t offer much more than a metaphorical plaster and a patronising pat-on-the-head. On the basis that prevention is usually better than cure what I would really like to see is a radical rethink on the nature of BPD; of what it means to be sane or insane. It’s an argument that is more sociological than medical because BPD is as much a political condition as a psychological malady.

In Madness Explained, an excellent exposé of the myths surrounding mental health, Richard P Bentall argues that mental illness is not a product of brain dysfunction than can be cured – usually with medication – but a series of symptoms only a minority of which cause significant problems for the ‘sufferer’. In the words of one Amazon reviewer ‘I go to the doctors and they want to drug me to get rid of everything 'wrong' with me and flatten my personality ... when only 10% of these symptoms are actually causing me any distress!’

Perhaps we should dissect the nomenclature. According to Bentall, the term Borderline Personality Disorder was coined to ‘describe a type of personality characterised by extreme emotional instability, severe problems of self-esteem, self-destructive behaviours and intense and unstable relationships with others’. All well and good; that’s an accurate-enough description of my own condition but phrased in a manner which would seem to render me pretty much incapable of living anything resembling a ‘normal’ life.

Not that I've any desire to live a ‘normal’ life; sounds like complete and utter madness to me. The fortunate truth is that I'm perfectly capable of being a fully-functioning, productive member of society – for most of the time. There are certain environments in which I couldn't survive: the office, the nine-to-five; the corporate world or the micro-managing boss. But within the relative freedom of self-employment I thrive.

But society loves labels; whether it’s class, race, gender or sexuality it insists on packaging the relevant behaviour and prescribing it as the norm. Then capitalism comes in and sells it back to us; we no longer live lifestyles, we consume them.

Society will tolerate a certain amount of variation from the norm – the English love an eccentric, after all – but it also has its boundaries and when we transgress them we are considered deviant.

Deviant, disordered and, sometimes, dangerous.

Because that’s what it all boils down to, isn't it? My personality is on the borderline; the borderline of what? Of what society perceives as functional and dysfunctional? Normal and abnormal? If, during a period of intense emotional distress, I feel compelled to cut myself I am doing so for a reason. I don’t expect to be condemned for my behaviour and even on the warmest summer day I’ll cover up the scars to spare your distress.

The problem is that the cutting comes with the territory; it’s a coping strategy to deal with a society I consider to be alien and hostile (there’s the paranoia talking) and any attempt to treat it, to remove it from my emotional repertoire, would be tantamount to a full-frontal lobotomy. It would kill my creativity, imagination and character stone dead.

Your sanity is my insanity; your chaos my order. Madness is as much environmental as it is neurological, if not more so. I'm a bit like a snake in the grass: leave me to my own desires and I’ll cause you no harm; trap me and try to change me and I’ll do my best to bite back.

Find out more about Sian and her published work at: http://www.sianlacey-taylder.co.uk/

Borderline Personality Disorder: A Guest Series from Siân Lacey Taylder (1)

2011-08-12T14:36:00.002+01:00

There’s been precious little blog action on these pages in recent weeks, partly because normal life and work do occasionally interfere, and partly because just about everyone capable of reading a blog or a tweet has been so totally fixated with phone hacking, the Murdochs and ‘riots’ that to dwell on anything else would be pissing into a very large gale.

But if you’re ready for something a little different here’s a brief series of articles which has little to do with seedy hacks or family bags of basmati rice, but has everything to do with how mental health professionals go about the business of treating and supporting their patients, and how that process often goes so miserably wrong. This is of course a huge subject which we’ve broken up into short articles focussed through the lens of Borderline Personality Disorder (BPD) and written from the remarkable and very personal viewpoint of Siân Lacey Taylder.

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. If you’re fed up with Z-list celebrity bore-fests and ‘misery memoirs’ packed with yet another account of dysfunctional childhoods and nuns gone bad, Siân’s account of self-harm, love, world travel, gender reassignment and non-league football might just be the antidote of choice.

I asked Siân to post two short articles which might say a little about BPD which would be as original, entertaining and thought-provoking as she is herself. I also wanted her own picture of the relationship between providers and users of mental health care, as I suspected she might offer a more balanced and thoughtful perspective than some of the anti-psychiatry bile now coming out of the ‘survivor’ agenda, ‘survivor’ being a term I repeat through gritted teeth.

To borrow an analogy from the sport which first brought us together many moons ago, I think she’s ‘played a blinder’ with these articles, and hope they entertain, provoke and stimulate you as much as they did me when I read the drafts.

Part Two of this series is here and my commentary on Sian's observations will appear here on Wednesday 17 August.

When Connor very kindly asked me to contribute to his excellent blog from the perspective of someone living with BPD (Borderline Personality Disorder) I think he was preparing himself for a metaphorical kicking. ‘I’m getting a bit hot under the collar over the survivor movement's constant haranguing of the mental health professions’ he told me, as if he could almost feel me winding myself to vent my spleen.

I want to say ‘it ain’t so’ but that would be telling an untruth. The two sides of the equation – let’s call them ‘the professional’ and ‘the patient’ – ought to be travelling in the same direction, should, really, be striving for the same goal but I would suggest that isn’t always the case.

Why? Surely ‘the professional’ works with ‘the patient’ and in her/his interest?

To answer that question I would like to describe, in sometimes quite graphic detail, the ‘realities’ of living with BPD and its various relatives (amongst others Narcissistic Personality Disorder, Paranoid Personality Disorder). Forget, for a few minutes, any textbook or clinical definitions, put any preconceptions to on side and try to see how from my perspective.

Let me begin by stating the bleeding obvious. There is no typical BPD ‘sufferer’ and maybe the condition lends itself to a greater variety of manifestations than other, similar, maladies. There is no one-size-fits-all and therein, I think, lies the first of the problems I would argue that the mental health profession – not necessarily the practitioners but the managers and commissioners, still believe in a universal panacea.

That stipulation - not necessarily the practitioners but the managers and commissioners – will become a recurring theme.

Some of the clichés are true enough. The underlying theme is one of instability and insecurity, in every aspect of life: emotional, professional, financial. But ‘instability’ is a pejorative term; in the mindset of the mental health professional it’s symptom of BPD that really must be cured and I think that’s something we need to address.

More of that anon. I haven’t yet mentioned the almost fanatical devotion to extremes. Everything is black or white; there can be nothing inbetween. Grey represents tedium and orthodoxy, the mediocre and the banal; characteristics that should not just be avoided but sought out and destroyed at all costs. I once had a psychotherapist who tried to persuade me that the grey was, in fact, in silver. I was lost in a haze of antidepressants at the time and she very nearly fooled me.

Very nearly, but not quite because deep down inside, you see, I don’t want to be ‘cured’. I’ve become so viscerally hostile to anything that might be construed as conformity or compromise that it might appear, to the neutral and/or relatively rational observer, that I seek out adversity even in places where it doesn’t really exist. For example, writing this essay – some would call it a rant – I soon realised that I wanted the reader to either love me or hate me; the last thing I desire is pity because pity is the preserve of the weak and the wretched. I don’t so self-pity, I don’t do misery; I only do self-destruct.

And that’s the Narcissistic aspect of BPD. I’m so often overcome with loathing for my fellow human beings that I could easily be mistaken for a misanthrope. Yet when I love someone I love them with a passion that soon veers into self-destruct. I rarely vent my anger on others; hatred – and violence – always turns in on itself.

BPD has led in more directions than there are points on the compass. On the negative side it fuelled a latent gender dysphoria which ended up in gender reassignment surgery (in tabloid talk that’s a sex-change). It’s brought me to the verge of alcoholism and anorexia and encourage – yes, encouraged – me not only to self-harm but to revel in it; for several years gin and a sharp blade were my constant and sometimes exclusive bedfellows and I would literally spend hours gazing lovingly at the rows of knives on display in my local supermarkets. I tread a thin line between wealth and destitution; I’m perennially in debt because I don’t understand money in the same way as many of you do. If it’s there, I spend it; if it’s not, I borrow or blag and something always comes up in the end.

You can see how it can lead to a precarious existence. One more than one occasion BPD compelled me to quit my job, my home and my family to seek refuge on the other side of the world but guess what? Those bastard little demons saw it coming; they packed their bags and followed me; they turned up in El Salvador 48 hours later on my hotel doorstep.

You don’t believe me? Ask the duty manager; he’s the one who talked me down. And he didn’t laugh when I told him that although I hated those bastard little demons I couldn’t live without them. If there’s one phrase that defines the nature of my BPD it’s my relationship with those bastard little demons; I’m drawn to that which ought to repel me. Like a moth to a flame.

Finally it drove me to two overdoses, the latter of which was, I concede, pretty damned stupid and could well have proved fatal.

But I survived. And you know what I’m going to say next, don’t you?

I don’t regret any of it.

Because, ridiculous as it might seem, there are positives and even if they appear to you to be vastly outweighed by the negatives, and if you were to offer me a pill or a course of therapy that put everything on an even keel I’d tell you where to stick it. What you call normality I call subservience; what you call instability I call a voyage of self-exploration. You’ll note how everything revolves around the self; the ego is the sun around which the rest of humanity must revolve. There are those who know me who would speak of my gregarious, outgoing personality – and that’s the key word, isn’t it? Personality. They would describe me as generous of spirit, intelligent, quirky and good company but they would be describing the ‘good’ Siân; some of them have known me long enough to come across the ‘bad’ Siân but she keeps herself to herself; locked away in her own little world.

The ‘bad’ Siân, of course, is the Siân the mental health professionals want to treat. They’d like to eradicate her from the face of the earth. Trouble is, more often than not I prefer the ‘bad’ to the ‘good’ and I don’t want to be rid of either.

Still with me? Well done! Now, with Connor’s permission I shall, in the second and concluding part of this polemic I shall endeavour to find some common ground on which mental health professional and service users might meet and smoke the pipe of peace.

It’s not going to be easy!

A Few Notes on Twitter from a Weymouth Pub

2011-07-25T14:22:00.001+01:00

It was the ‘great punk trouser disintegration incident’ of 1977 that taught my teenage self that blindly following trends wasn’t really for me. It’s a long story, but involved desperation to be an ‘angry punk’, the dyeing of hair, the fashioning of a pair of trousers out of a bin liner and safety pins, and a homecoming gig by The Dammed at some dingy dump in Croydon. Needless to say I returned home with little more than a ripped T-shirt, a pair of pants and ridiculous hair which copious amounts of saliva and lager had turned green.

I was determined not to follow the herd and Twitter was never going to be my thing. "Huh, just another fad" I thought, especially as my radio stations of choice (5 Live, Radio 4 and 6 Music) couldn’t manage three and a half seconds of air time without mention of the ‘T’ word. Grrr.

But eventually even Mr Independent here started to feel like the chubby kid with two left feet who always gets picked last for the playground footie match, and as the old saying goes, if you can’t beat ‘em, join ‘em. So in February this year I signed up and entered the Twittersphere.

And then what? Where do you start? Well of course, we can follow whoever we like. My own community is made up of people I know from the real world, people whose writing I admire, people who can make me laugh in less than 140 characters, and people who share my eclectic views. And while I have absolutely no interest whatsoever in what Jedward had for their fecking breakfast, there are a few well known broadcasters and journalists who I feel I sort of know through the radio and TV but have come to know even better from their Tweets and even the odd online conversation.

Which is a very cool thing about Twitter, and brought me to an ‘overheard’ conversation between the writer and documentary maker @jonronson and a few of his followers, who had begun to think that Twitter had not only started to dumb down but was also getting intolerant and nasty, particularly in the light of recent events in Norway and the death of Amy Winehouse. It’s hard to paraphrase Tweets, but “the overall vibe has changed for the worse this past year or two” is, to quote Mr Ronson, more or less the nub of the argument.

Now this chimed very loudly with a theme I’d been discussing with my old mate @RJSwitterings a few nights before. Every fortnight or so we meet up for what we ludicrously and somewhat menopausally refer to as a ‘sesh’, which in our language means ‘session’. This generally involves circling a few of the harbour-side pubs, generating a brand of conversation which generally gets increasingly daft as the evening wears on. For example, this week’s ‘sesh’ was dominated by @RJSwittering’s truly shocking confession that he had virtually no knowledge of the puppet-powered genius of Gerry Anderson, and my attempt to inform and educate as to how Captain Scarlet became indestructible. I could tell my lecture hadn’t really got through when my partner in beer asked if Captain Scarlet could revive himself from being decapitated and dissolved in acid. Yep, it was that sort of evening, and I gave up. And so the conversation turned to Twitter.

Now this natter came to several key conclusions, and they are so important to the future of the internet that they deserve to be heard far beyond the confines of two blokes in a pub and the nervous looking family of tourists who were inching away from our table and giving us those “Mummy, those men are frightening me” looks. So here goes.

Conclusion Number One:

There really ought to be a facility for unpopular dudes like us (at time of writing, 44 followers between us which will inevitably drop once this blog post appears) to actually know why so many people ‘Unfollow’ us. Nobody, according to our edict (5 pints plus by this stage) should be able to click the red ‘Unfollow’ button unless they complete a compulsory text box saying why they have cast aside a former object of digital affection.

We even suggested a series of quick-click templates such as ‘I’m unfollowing you because you are a self-obsessed, narcissistic prick and you are so unoriginal that you actually follow Stephen Fry along with 4 billion others. Twat’. But that was quickly discarded as going well over the pre-requisite 140 characters, so we replaced that with: ‘Cos you’re a dick’. But it’s unlikely that either Twitter or a 3^rd party app developer will ever be as enlightened as this.

Conclusion Number Two:

We also decided (6 pints plus) that Twitter should consider a sort of social stratification. Reason? It’s become far too bloody big, far too full of idiots, and far too full of the online version of teenage lads doing 'wanker' hand gestures behind the TV news reporter. Twitter needs to be tidied up. It seems that what was once a boutique little enclave of nice, well-meaning nerds Tweeting about beta-apps and Star Trek conventions has quickly become over-populated with trendy North London media types before gaining ground with PR-advised celebrities. And once ‘slebs’ joined the bandwagon and the rank and file finally realised that you could follow Wayne Rooney’s taste in Y-Fronts, that was it. Meltdown.

We can trace the chronological evolution of Twitter with the following examples:

2006: “Just posted video on how to upgrade microprocessor – cool!! http:/YouTube/GeekFest

2009: “Dinner at The Ivy. Discussing next TV project. J-Lo at next table”

2011: “At least now Amy Winehouse can do her lines off the most shiny surface known to man. Jade Goody's Head”

The first two are imaginary or paraphrased, but the latest is cut and pasted directly from Twitter. Coming as it does from the Frankie Boyle school of really hilarious comedy (sic) I include this unpleasantness as it says a great deal about the state of Twitter as highlighted by @jonronson et al, and as much as those extremely clever people who come up with amazing stuff like Twitter try to stay ahead of the curve, the online 'div patrol' will always catch up.

Try checking out a single online debate, be it the online comments section of a broadsheet article or the forum of a local non-league football club, and find examples of a straightforward discussion that doesn’t ultimately descend into personal insult, ranting, and interpersonal online points scoring. The Guardian's Comment is Free section is as good an example of the 'who you fuckin' staring at' school of online debate as any, and these are, well, Guardian readers who are meant to wear sandals and walk around folk festivals eating falafel and smiling.

And so back to our idea of socially stratifying Twitter, or even better, the whole bloody internet. Here's a rough sketch of how it works:

Internet One: for reasonably intelligent, coherent people who can discuss weighty stuff, funny stuff, interesting stuff and generally tweet and blog to their heart’s content without descending into the online equivalent of a Saturday night ruck.

Internet Two: for people who just want to flog stuff, write love letters to Justin Bieber, convince you to open a Nigerian bank account and become a millionaire, look at Christine Aquilera’s knickers as she gets out of a car, or browse enhanceyourpole.com etc etc.

Internet Three: for people you wouldn’t piss on if they were on fire.

And so by the end of the evening, we conclude that our fellow Britons are largely a bunch of ignorant arseholes apart from 1) Us, 2) the cool, intelligent people we follow on Twitter who inform, educate and amuse us, and 3) our friends and family who aren't on the internet because they generally have better things to do.

And after Pint number 7? We forgot what the fuck we were talking about, no matter how good or clever it seemed at the time.

PS Many thanks to @BendyGirl for her very helpful comments on this post, and to @mrsnickyclark for proving that you can write about disability and ‘heavy’ issues and also do funny swearing

UK Mental Health: Lessons from the Third World?

2011-06-22T06:06:00.005+01:00

Re: Mental health services in crisis - tell us your stories The Guardian 21.6.11 Amelia Hill

It can’t be a very ‘happening’ news day when the Guardian’s lead story is ‘Mental health services in crisis over staff shortages’. Not that I have a problem with that, it’s just a little like proclaiming ‘Piers Morgan is a Twat’. It’s not really a story, more a statement of the obvious shoved into the media spotlight on one of those rare days when the coalition haven’t done a U-turn and Premiership footballers are shagging each other’s wives in the relative safety of Dubai or LA rather than the VIP areas of Manchester nightclubs. I’m no sub-editor but I might have shortened the headline to just ‘Mental health services in crisis’. Full stop.

But why? The prod for the story comes from the retirement of Professor Dinesh Bhugra as President of the Royal College of Psychiatrists. Dinesh is a man I barely know personally but who has a professional reputation as a doctor who has combined high-flying eminence with the sort of decent, caring persona that now seems as rare in the mental health professions as an NHS Manager who doesn’t punctuate every other sentence with ‘going forward’. His is a voice I will gladly listen to and take note of above and beyond any half-baked politik-speak from the Department of Health civil servant or, God forbid, a politician. Understandably, Bhugra’s concern centres on his own profession’s lack of ability to attract doctors to psychiatry from the sexier reaches of medicine or surgery, swanning around the wards with a stethoscope and a British National Formulary tucked into a white coat pocket.

But he also points toward what I call the 'Bedlam Factor'. In-patient psychiatry which used to be, in the olden days of my asylum student nurse youth, divided into Acute Admission, Long Stay or Rehabilitation, Elderly Mentally Ill and Locked Intensive Care is now little more than a series of ever decreasing beds for ever increasing levels of nightmarish psychiatric distress housed within the crumbling ruins of our various Something Somewhere NHS Trusts. The comments from Guardian readers, many of whom have experienced the rawest edges of mental illness for themselves, are punctuated by stories of services falling apart at the seams led by a psychiatric ideology of medical model-ness propped up by labelling, diagnostic box-ticking, inappropriate detentions and powerful medications.

Some of the more extreme anti-psychiatric views are a little hard to take for an experienced mental health professional who has, I hope, helped a considerable number of people over the years using the sort of skill and empathy that has made me proud to be a psychiatric nurse along with the countless numbers of superb professionals with whom I’ve worked over the years. And using the comments section of a left-leaning broadsheet website to blame our sub-standard mental health care on the current government really is a bit rich. Our current problems go back much, much further than any single administration or era can lay claim to.

As a blogger and occasional author of 'proper' books I often find myself a thousand words into a blog post or chapter before realising that what I’m writing is complete and utter bollocks. No amount of re-writing, editing, cutting and pasting will rescue the piece. If it’s that bad I simply delete the thousand words and start from scratch.

The entire mental health system in the UK is more than just bollocks. It’s a bloody great set of diseased, swollen bollocks riddled with tumours and elephantiasis. Can we delete and start again? Do we have models elsewhere to cure the disease? Yes, I believe we do.

Dinesh Bhugra is certainly not alone in citing staff shortages in both medicine and the other disciplines as being at the core of our diseased system, but the story goes deeper and wider than a simple lack of bums in jobs, assuming that the staff vacancies are there in the first place which, as Guardian contributors have made clear, is far from the truth.

As both a former Ward Manager of a Secure Unit and a Community Psychiatric Nurse I long ago swapped the ward keys and the NHS lease car for a yearly self-assessment form and the words 'Training Consultant' on my passport. In case you’re wondering, I like to ensure that my status as a ‘trainer' is not confused with one of those people in a vest and trainers who shouts about ‘feeling the burn’ and talks about ‘reps’.

But through various friends, family and especially training delegates I still see all too clearly how our mental health infrastructure works. Or doesn’t, as is usually the case. I still get to hear on a daily basis how fundamentally poor our mental health services are and how our prisons have become the new default asylums. I hear about people who listen to the voice of Barack Obama bellowing “CIA” in their ear, or whose sole ambition is to swallow dive from the top of a multi-story car park but whose ‘keepers’ I wouldn’t want looking after a pet Gerbil let alone those suffering the deepest moments of delusion, hallucination and utter despair.

I hear hair-raising stories of mental health professionals who appear to need a small aircraft flying a banner marked ‘potential homicide’ before they can so much as think of the words ‘risk assessment’. Time after time we read inquiry reports following homicides and suicides, and time after time we hear the same old crap spouted by Chief Executives. “Patient care is our paramount concern”. “ We've taken on board the Inquiry's recommendations.. “ etc etc, while the same situations crop up again and again, usually followed by the standard inquiry finding of professional boundaries getting in the way of good old communication, a total misreading of confidentiality and the Data Protection Act, and just sheer incompetence which all too often seems to be swept under the rug marked 'lack of resources', 'staff shortages' and even 'the Receptionist being on sick leave'.

We have a mental health system clinging on by its fingernails supported only by a medically-led multi-disciplinary team approach now well past it’s sell-by date. It takes a brave soul to see the elephant lurking ominously in the corner of the room, but I know a number of senior psychiatrists who will acknowledge at least privately that they their job involves little more than diagnosing, prescribing and the yeah-ing or nay-ing of Mental Health Act decisions.

Despite the ridiculously bloated diagnostic manuals which attempt to pathologise every aspect of human behaviour from severe mental illness to a kid who gets stroppy with his Mum (Oppositional Defiance Disorder, in case you ask) the process of diagnosis in psychiatry is not usually very taxing. Thanks to Stephen Fry and various documentaries and media articles, the bloke who works behind the bar at my local has a reasonable idea of what Bipolar Disorder is, and I think quite a few of us now know that if someone spends an hour checking their that their doors and windows are locked before finally getting out of the house, they probably have 'that Obsessive Compulsive Thingy'.

And as for therapy, most psychiatrists spend most of their treatment time writing prescriptions for anti-depressants (to treat Depression) or anti-psychotics (to teat Psychosis) or maybe a mood stabiliser (to treat Bipolar Disorder). But Geoff down The White Hart probably knew that as well. I’ve probably been struck off the Royal College of Psychiatrists Christmas card list at least three or four times in the last two sentences, but hopefully you get the point.

Now I’m not saying for a moment that if I were mentally ill I’d want anyone who hasn’t spent many years of hard medical school graft prescribing me medication that has the potential to leave me staring at walls for hours on end or keeling over with a lethal mix of SSRIs and something I picked up from Holland and Barrett, but most competent doctors have the ability to diagnose most non-exotic mental disorders and scribble their signature on a prescription pad. The real graft and skill of mental health care goes into a therapy programme for the patient with the windows and doors issues, or the social and family support of the person hearing the voice of Barack Obama.

Radical thoughts? Not really. A very good friend of a mine is a Professor of Psychiatry called Vikram Patel. His academic affiliation is not to the psychiatric establishment, but to the London School of Hygiene and Tropical Medicine. I was lucky enough to be in London in March for his inaugural professorial lecture along with Dinesh Bhugra and a number of other notable figures from the great and good of psychiatry. Vikram spoke with great passion about the Global Mental Health movement and the World Health Organisation’s Mental Health Gap Action Programme (mhGAP). Eh?

Okay. It’s not often that my ego will allow even a close friend’s book to be bigger and better than my own literary efforts, but Vikram’s ‘Where there is no Psychiatrist’ is the acknowledged bible of how to do mental health in parts of the world where there is no such thing as a brass nameplate on a door and where MRCPsych might as well be ‘Hello’ in Klingon.

Vikram (who now owes me at least a pint) has researched and set up programmes all over the so-called Third World (or if you prefer, the ‘developing nations’) whereby local people are trained up to assess mental disorder and put in place therapy and support programmes for local people presenting with psychological symptoms. They come from the same cultural and ethnic backgrounds as their 'patients' and are trained to understand the difference between, for example, someone who 'hears voices' but is otherwise perfectly happy, and someone suffering a severe psychotic illness and may require further assessment and perhaps anti-psychotic medication prescribed by a visiting doctor. They possess the local, cultural understanding of how mental disorders arise from both factors such as brain pathology AND the social and environmental factors which are so often brushed aside in our traditional Western model of mental health.

To paraphrase Rolf Harris, ‘can you see what it is yet?’

Countries as poor and riddled with life threatening diseases such as malaria and HIV are starting to realise that early, local interventions aimed at addressing mental health issues can dramatically reduce the risk of contracting life-threatening illnesses such as HIV. They can reduce suicide. They can reduce crime. They can reduce drug and alcohol abuse and a whole host of very expensive social ills. And they can do all this with a basic, cheap but well designed and targeted training programme with all but a smattering of expensive, highly qualified medics and multi-disciplinary staff to supervise the work on the shop floor.

We have known for many years that brief psychological interventions can be at least, if not more, effective in treating many forms of mental disorder than endless prescriptions for anti-depressants and tranquillisers. Instigated by the previous government, the Improving Access to Psychological Therapies initiative aims to get GPs to refer people with mental health problems to therapists as an alternative to the script pad.

It means well, but if I were referred to my local IAPT service in Weymouth I would be trotting along to a dilapidated prefab building plonked in the car park of a community hospital. Yes, it’s handy for parking but looks more like a Crack den than a sanctuary for my distressing psychological issues. This is how seriously we take mental health in the UK, even within a relatively prosperous seaside town in Dorset.

Faced with a choice, would I rather have support from a trained local with a very short waiting list and a clear plan of action supported by a visiting medic who can prescribe any medication I might need. Or would I plump for an appointment with a highly qualified professional for whom I have to wait six months for a fifteen minute appointment before being given a prescription and a further appointment for a CPN, Occupational Therapist, Social Worker or Clinical Psychologist who will, if I'm lucky, put me on yet another lengthy waiting list?

Well I know where my mental health would rather be trusted, but please feel free to leave your comments and please don’t hesitate to put me on your Christmas card list. I have a feeling I may need the your support.

Challenging Behaviour: How to Avoid Kicking the Cat

2011-06-21T16:38:00.002+01:00

I ran a course yesterday for Residential Care Staff. The imaginatively titled Challenging Behaviour and Dementia course is always interesting in that it reminds me of some of the difficulties care staff have to face, even working with elderly clients. As always, the story of the course is that even little old Doris (85) can and does pack quite a punch when she wants to!

Now according to Google there’s an awful lot of people typing ‘challenging behaviour’ and ‘challenging behaviour definition’ into the little white box, which means if you’re here right now you’re a) writing up a college project or b) working with a bunch of service users/patients/clients who are posing difficulties of one form or another.

Now, I know how it works with students. You just want something quick and dirty to cut and paste into your Word Processor. Yep, been there. So if you just want a definition, here it is. In fact, here’s two!

Definition 1: ‘any behaviour which negatively effects both the ’perpetrator’ and those around them to a significant and/or frequent degree’ (Kinsella 2010)

Definition 2: Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (Emerson 1995)

If that’s fulfilled your essay needs, glad to be of service. Bookmark this page and we may see you again ….

Otherwise, hang on in there. We’re going to outline some of the key skills we need in dealing with the sort of challenging behaviour which can be problematic, highly unpopular, scary and generally pretty awful, often to the point where we really don’t want to go into work and face another shift. But challenging people with challenging behaviours are no less deserving of our efforts than anyone else, so let’s take a brief look at some of the stuff from the JCK Training Managing Challenging Behaviour course which I hope might be helpful and even save you that extra bottle of wine/shouting at the TV/shouting at family and those occasional feelings of wanting to put our heads through a wall. And of course, we want to avoid kicking the cat. Working with Challenging Behaviour is’nt easy.

The nature of challenging behaviours presented by an elderly care home resident may be very different from those presented by, for example, a young person with borderline personality disorder, but the way we are going to approach the behaviours does not change - we are going to try and replace instinctive, reactionary responses with a more systematic, model-based approach. But first we need a few basic assumptions.

Any service user (or human being for that matter) has the potential to behave in ways which are anti-social, aggressive and likely to have a negative impact on themselves and others. In fact, think of the last time you phoned a call centre. After spending five minutes listening to Greensleeves (no, bloody Greensleeves) interspersed with the patronising grind of ‘your call is important to us but please hang another minute while we make another £4 billion out of your sorry arse’ before eventually getting to speak to a human being called Malcolm, you are probably going to feel like telling Malcolm to shove his headset somewhere dark and possibly a bit damp. See? We can all get a bit challenging sometimes.
The service user is at the heart of our discussion, assessment, planning and evaluation. This may appear to be a statement of the obvious but once a challenging individual has become associated with aggression or worrying behaviour (or put less technically, 'scared the crap out of us') that person can easily become marginalised and begins to drift further and further from involvement in their own care. We shall try to avoid this as much as possible although it’s fair to say that some service users will never be able to participate in their own care. In which case a family member or nearest relative will hopefully be only to glad to be involved.
It may seem at first glance that a person with severe cognitive impairment caused by dementia or a learning disability behaves in unpredictable, random ways, but all human behaviours occur for a reason and attempting to identify why challenging behaviour occurs is a key aspect of our project.
We are not aiming to ‘cure’ the service user of their challenging behaviour. We are simply aiming to reduce the severity and frequency of the target behaviour so that life is better for the service user and people around them.
Our final assumption is that the advice offered here can offer generic principles of good practice and a guide to using a structured approach. However, there are no magic wands. Local conditions, client characteristics, resources and restrictions will all govern how challenging behaviours are defined and recognised locally, and how we go about managing these behaviours.

The CAPEd (sic) Crusader

In our Challenging Behaviour course we introduce a framework for working with challenging behaviour. Like all frameworks or models we tried to come up with a sexy acronym to help you remember the various bits, but all we could come up with was CAPE.

Yes, BANG, WHIZZ or KAPOW might have been more appropriate (and sexy) but the letters didn’t fit. So we have CAPE. So what does CAPE stand for?

Clarification
Assessment
Planning
Evaluation

Let’s take look at these stages and what they mean for us.

Clarification

We start by asking the question: What is the behaviour? This may at first sight appear a simple and straightforward task, but there are some common pitfalls especially when writing down or recording an incident in a service user’s notes or in untoward incident documentation. We need to be careful here to actually describe the behaviour, not the emotion behind it.

Writing ‘he got very angry’ in your notes is a description of how he feels, not of the behaviour itself. Right now we need to simply record what has actually ‘happened’. For those of a grammatical bent, we need ‘verbs’ not ‘adjectives’.

We also need to be aware of the possibility that an incident we are trying to describe may become the subject of further investigation, for example by the police or by a safeguarding vulnerable adults panel, so detail is good. Very good.

A key determining factor in where we go next is whether a behaviour meets a stated definition of challenging behaviour. We have defined challenging behaviour above but of course I’m here and you’re there. Local circumstances and environment will be key in determining what is significant or frequent enough to warrant further assessment and perhaps an action plan. A person banging their head against a wall or shouting at a support worker will be seen in quite different ways in different environments, which in itself will demand quite different plans and interventions.

Assessment

The first stage of our framework has asked the 'What' question. Our Assessment stage is where we attempt to look at the Who and Why and How questions, so perhaps we are going to get our hands a little ‘dirtier’ in this stage. But the effort expended will be well worth the effort as we attempt to address problem behaviours rather than simply accepting, putting up with or condemning them.

So where do we start? Hopefully with a clear and concise description of an incident or series of events based on our Clarification stage, but remember this is a structured, proactive approach to challenging behaviour and there are some key questions we may wish to ask:

Is there Consensus within a staff team that what has been observed constitutes challenging behaviour according to an agreed definition or baseline?
What is the Frequency of the behaviour? Are we looking at a standalone event or one of a series of incidents?
What is the Impact of the behaviour? Ask the same question of the service user him or herself, and depending on location and circumstances, support staff such as yourselves, family members, neighbours or other. Or couched in other words, who were the victims of the behaviour and how are they affected?
If a there is a Victim as such including of course, the perpetrator(s), what are their characteristics? This is particularly important if there is a regular pattern to the challenging behaviour.
Is there a Pattern of behaviour? In residential care for example, mealtimes are often a flashpoint for confrontation. Over a longer period of time, seasonal changes may be important or incidents may be seen to occur at a particular time of day.
Is there a Precipitant for a person’s behaviour other than those we have already mentioned? Remember our starting position that behaviour almost never occurs purely at random regardless of the cognitive or functional abilities of the perpetrator.
Drugs and Alcohol. It may be a question of judgement whether or not we refer to substance use or misuse, but most of us are more than familiar with the association between intoxication and self-destructive or anti-social behaviour. Our assessment may require more than a simple association between, for example, a client’s habit of drinking a four-pack of nuclear strength lager for brunch and his or her subsequent hostility on home visits, but it is always attempting to assess exactly how and why a substance affects the perpetrators behaviour as opposed to simply stating that ‘they get angry when drunk.’

The above is just a small selection of areas we might want to examine during our assessment, but our most useful tool is our own knowledge and rapport with the people with whom we work, and let us not forget that often the best informant of all is of course the person presenting the challenging behaviour. I often find when running courses that the most obvious question of all hasn't been asked of the challenging individual: Why do you do it? This isnt always an easy question to ask depending on the individual and the circumstances, but can (if put skilfully and non-judgementally) yield surprising results.

Planning

This is our ‘doing’ or ‘intervention’ stage. Whether we are referring to ‘Action Plans’, Care Plans’, Support Plans’ or any other terminology which essentially means the same thing, most health and social care organisations have some form of written plan which clearly states what we are hoping to achieve and do with a service user.

We need clear consensus between ourselves as a staff member, our colleagues and collaborators from other agencies (such as professionals from Primary Care Trusts or Social Services or supported housing) as to how we describe challenging behaviours, our assessment and how we are going to respond. If and when appropriate, our planning should include as an essential of best practice a clear collaboration between ourselves and the service user.

Remember one of our initial assumption s from our very first page: we are not attempting to ’cure’ the perpetrator or change his or her personality, but simply reduce the frequency of challenging behaviours, the impact of those behaviours on others and themselves, or preferably both.

Evaluation

By now we have hopefully concluded that a consensual, structured, proactive approach to challenging behaviour is more likely to achieve our outcomes than staff response which is haphazard, reactive and fuelled by panic, fear or resignation. There is always the potential for staff who work regularly with challenging behaviours to become ‘over sensitised’ to verbal or physical aggression, self harm, destruction of property or any other of the challenging behaviours we have identified and set out to manage.

Evaluation is a means of at least trying to ensure that we see worrying or dangerous behaviour for what it is, and whether we are are constantly evaluating informally over a cup of coffee with colleagues and service users, or more formally through meetings and reviews, our intention is to review the outcomes of our Plan in terms of impact, frequency and quality of life, add to our assessment and look toward the short and long term future which will hopefully mean a much better quality of life for service users, and a less worrying time for your cat.

Emerson, E. (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties Cambridge: Cambridge University Press.

Kinsella, C. (2010) Working with Challenging Behaviour JCK Training

Visit JCK Training for details of health and social care in-house courses, including Working with Challenging Behaviour

Glee for Free No More

2011-06-15T16:42:00.000+01:00

Sky One has ruined my life. No more Glee unless I’m prepared to cough up for a Murdoch subscription. I’m almost desperate enough to dig one of their flyers out of the bin and give them a call, until I remember a previous dalliance with Sky Sports which left me with bugger all but some mediocre football, a large bill and pressure sores on my arse.

So for purely selfish reasons I’d like to suggest a few reasons why E4 should have a shufty down the back of the sofa for a few more shekels to TRUMP Murdoch and bring Glee back to a terrestrial audience. And if you’re wondering why a social care blogger is writing stuff about a slightly daft TV show when there's plenty of far more worthy topics to munch upon, well it’s not just a TV show. It’s a weekly dose of serotonin-pumping, feel-good musical energy entertainment and source of POSITIVE MENTAL HEALTH FOR APPROXIMATELY 1.6 MILLION PEOPLE. That’s why.

Glee is cool

I say this to most normal people and they visibly recoil. In fact, if you’ve ever poured salt on a slug the instant ‘melt’ thing is exactly the reaction you tend to get at the mere mention of the show. But Glee is gradually contagious and every fan probably has a ‘conversion’ story to tell. You have a family member, a partner or friend who starts off being a bit sniffy about Glee.

You settle back for the first scene. It might be Finn’s gormlessly handsome face registering that “Uh? What happened to my brain?” look, or a full frontal of one of Mr. Schuester’s sweater collection, but the Glee-sceptic huffs, says something under their breath about ‘High School Musical 4: Post-Puberty’ and whips open their laptop with a disdainful flourish. They’re probably reading sites dedicated to celebrity hair transplants and ‘How to lose 10lb by eating grass’ so they’re in no position to take to take the moral high ground, but you just let it pass so as not to miss a millisecond of goings on at William McKinley High. But resistance is futile. Eventually the mask drops, scales fall from eyes and the laptop is abandoned to witness the full glory of daft teenagers singing and dancing their way through high school. And then there are two of you.

The Glory of Sue

Now purely in the interests of research I’ve just taken the E4 Glee Personality Test. Fortunately, weird half-perv/half-nerd student blogger with glasses and crazy hair Jacob Beth Israel wasn’t an option, but apparently I am most like Mr. Schuester. I think for a while there I was veering toward Rachel but managed to avoid ticking the ‘I want to be a showbiz star at any cost’ option and left with dignity intact.

Online opinion seems divided as to who is everyone’s favourite character. Personally I think if there is a ‘star’ of the show it’s surely the slightly androgynous, track suited she-wolf and head of the Cheerios Sue Sylvester. I wonder just how many viewers of various persuasions have fantasised about having Sue as their school PE teacher, chasing them naked and yelping from the shower with the flick of a moist towel, and …. let's move on.

Glee gives good ‘issue’

With sexuality, gender, ethnicity, disability and all round ‘otherness’ hogging the plot lines, Glee ticks off more boxes than a London Borough of Lambeth Policy and Procedures Manual, and critics do complain about the almost demographically perfect spread of ‘diversities’ among the Glee club members.

But the show has to be credited with sweeping aside political correctness and getting well and truly stuck in to some quite awkward stuff that other shows might well consider a bit too ‘gloopy’ for the target demographic.

Kurt’s struggle with his sexuality is as good an example as any. He’s bullied at school, he hangs out with girls, he squeals at the mere mention of Lady GaGa and his mechanic Dad fails to understand why Kurt thinks a carburettor is a designer shoe. The term ‘coming out’ seemed a bit of a misnomer for Kurt as he’d been showing a pretty full deck of cards ever since Episode One, but Dad proves to be a saint and transfers our glamorous heroine to a private boys school with it’s own show choir.

The Warblers are the all-singing, all-dancing troupe who somehow manage to spend sod all time studying and huge amounts of time wearing silly blazers and flouncing about to Beyonce numbers without ever getting severely beaten up. Ever. And things get even better for Kurt when he meets all round star, man-love idol and wearer of sensible but expensive leisure-wear Blaine who finally enables Kurt to be true to himself.

The mental illness box is ticked by School Counsellor Emma and her Obsessive Compulsive Disorder, a plot design that started off as caricature and the source of some rather (admittedly good) gags but has evolved into a more serious issue as time has gone on.

The eventual and obvious consummation of her relationship with Will Schuester is comically ruined by her morbid fear of men’s bits and bodily fluids, not to mention Will’s sensitive yet rampant masculinity. Now correct me if I’m wrong, but I’ve always imagined Mr Schu’s crown jewels as the cleanest this side of the Tower of London and Obsessive-Compulsive Emma really had no need to worry. I do need to worry about the fact that I’m imagining anything to do with Will Schuster’s genitalia. Which rather grimly brings me to my final point.

Sad Epilogue

As a middle-aged bloke who likes football, beer, owns a German Shepherd and has a taste in music which usually involves moody synth people sequencing a chainsaw or smelly blokes with guitars, I’m probably not in Glee’s target demographic. I'm not in the slightest bit ashamed to say that I love the music, the characters, the dialogue and the sheer joie de vivre. But after holding me in it's warm terrestrial embrace for two whole series Glee has finally cast me aside like a used tutu and moved across to the Murdoch table with all it’s glitter and it’s gold. Sodding hell, I’m starting to sound like Kurt. Time to go.

Winterbourne View: A Tale of Boiling Frogs, Perfect Storms and the David Brent Analogue

2011-06-08T17:35:00.001+01:00

Last Tuesday was quite a day. It started at midnight with a growing sense of resentment over a TV programme and the realisation that I wasn’t going to get any sleep. It continued into the dawn with the sound of my hammer-blow two-fingered typing on an already delicate laptop, and finished with the very weird sensation of listening to myself on Radio 4’s The World Tonight.

Thanks mainly to a tweeted recommendation from The Guardian’s Patrick Butler, my very brief attempt to explain the horror of Winterbourne View quickly went viral, carried along on a tide of national revulsion prompted by secretly filmed footage of a ‘hospital’ for learning disabled adults.

An imagination already heavily influenced by Star Trek and further excited by sleep deprivation pictured banks of overstrained iPlayer servers burbling, shaking and belching out smoke before exploding in a shower of tape. Either Captain Kirk had asked the computer too many illogical questions, or Panorama had just touched a very raw public nerve. Through a thick media fog of Cowells, Coles and talent show titbits, the British Public were for once actually noticing learning disabled people.

Now that the media hoo-ha has died down, political knees have been jerked in some way or another yet to be fully determined, and we’re all moving on from abuse to hair transplants, I’d like to acknowledge the time and effort spent on the replies to my article. Many readers must have spent a great deal of time and effort crafting carefully worded, insightful analyses of the problems at Winterbourne View and beyond, and perhaps we can take a closer look at some of these points before last week’s headlines become this week’s cat litter.

Boiling Frogs and Perfect Storms

Taken as a whole readers' comments seemed to indicate a ‘top to bottom’ failure of care, not only of learning disabled adults but of the elderly and mentally ill, with the failings at local, regional and governmental levels all adding their ingredients to the perfect storm: catastrophic failures of care.

Several readers were highly reluctant to point the finger at individuals, or as one contributor put it, the ‘coal face workers'. They argued that the type of care worker portrayed on the programme were more often than not the product of poor frameworks put in place by their managers, their managers managers, their managers managers managers and so on up the line toward government itself.

I have some reservations about removing all aspects of individual blame from institutional abuse, but that’s a big subject and deserves an argument of it’s own which I’ll post tomorrow.

In the meantime Phil Wolsey deserves special mention for introducing me to a new terminology: ‘boiling frog culture’. This is a more than capable analogy of how ‘bad culture’ can gradually pollute even the most enthusiastic individuals. Unless you’re squeamish about amphibians it’s well worth looking up, but let’s just say Phil’s analogy describes how Happy Frog becomes Braised Frog very quickly and without the hapless creature ever really noticing.

David Brent et al

Plenty of you talked about governmental failings, budget cuts and their relationship to an ever descending level of care and the lacklustre response of the Care Quality Commission. We’ll get on to this bigger picture shortly, but Dee asked a very pertinent question: Where were the managers at Winterbourne View?

I’ve been around long enough to have been both a manager and one of the managed, so this was a question I never really asked during the programme but inspired more than a few thoughts on front-line care management once I read Dee’s comments.

Contrary to the plot formula of Casualty and Holby City (i.e Managers/Bad Guys vs. Nurses and Doctors/Good Guys) a functioning system needs managers. They’re a soft target. They come into management in a variety of different guises, several of which loom particularly large in my memory.

First up, there’s the Hapless Incompetent.

The HI is prematurely promoted beyond their own ability by high turnover organisations desperate to keep the more capable of their shop floor staff within that organisation, curiously forgetting that a very competent ‘shop floor’ carer isn’t necessarily a skilled manager. Although several of you argued that pay is not a major issue for many care workers, a larger salary may prove a very attractive inducement for staff members who have traditionally been low paid, and who among us would turn down the chance of a few extra quid even if we had the self-awareness to recognise our own limitations? If we add in a lack of support or training for our new appointed HI, the results are sadly predictable.

There’s also the David Brent Analogue.

The DBA is the bright and breezy new member of staff who, barely in possession of an ID badge, commences the grand corporate scheme. The nameplate is on the door, the office décor is beige with a bit of pastel relief, and daydreams are filled with the fond thought of spinning endlessly around in that faux leather reclinable. In my admittedly anecdotal analysis, these are often people who cannot bear to spend any more time than is absolutely necessary with the smells, sights and sounds of the care environment. The DBA hides away behind a desk updating Facebook, laughing at cat videos on YouTube and finding as much opportunity as possible to get invited to meetings, especially when the coffee and biscuit stash is looking a little light in the top drawer. Knock on the door? No problem. Up pops the Excel spreadsheet, cue furrowed brow and a hard stare at the monitor. “Come in.”

I’m sure you’re thinking of many more caricatures to add to this collection (comments please – that could be fun!) but my third category of manager is the one I like to think I’ve had the pleasure of working with many times over the years. I can’t think of a smart or even stupid moniker to describe them, but if we could come up with a sexy sounding mnemonic that included the words Teacher, Leader, Strategist and Exemplar, we might be getting close.

These are the managers who balance the spreadsheet and working parties with the needs of both their staff and service users. They are not only visible but actively demonstrate the sort of communication skills and leadership which, I believe, form the best possible training for less experienced staff. They answer questions, spend time with people, observe the often subtle dynamics of an environment, mould and rectify where necessary, and are still capable of getting the admin done and the duty rota up on the intranet. They encourage good practice but stamp hard on the sort of culture so obviously in evidence at Winterbourne View. I’m quite sure they are still out there in numbers, but for how much longer?

The care industry is in a state of flux. Not long ago we ‘enjoyed’ a flourishing bureaucracy and seemingly limitless funds for both the public and private sectors to hire yet another Assistant Director of Stationery or a Strategic Bogroll Supplies Officer. But if what I hear on my courses is anything to go by, we now seem to be plummeting quickly from a state of gross over-management to hardly any management at all. Budget cuts are ridding the care sector of many highly capable front-line managers and I’d be grateful for any heads up on whether the Strategic Bogroll Supplies Officer is still in post, but I can hear the ticking of the attention-span clock so let’s move on to the bigger picture of governmental failings that so many readers highlighted in their comments.

Big bins or small homes?

Rob described recent budget cuts at his place of work and the inevitable impact on the quality of care his clients will receive, which he anticipates will lead to growing frustration and greater levels of challenging, disruptive behaviour. He also raised a question echoed by Alison Giraud-Saunders from the Foundation for People with Learning Disabilities. In the aforementioned Radio 4 interview, Alison pointed out something about Winterbourne View that had brushed my subconscious only to disappear amid the full body blow of the images on display.

Why on earth, in 2011, are learning disabled people being housed in large, secure institutions, and why was there no mention of the role of the commissioners and care managers responsible for sending people to this so-called hospital?

Let’s not kid ourselves that people with autism and learning disabilities cannot (at times) be difficult, aggressive, and very challenging to work with, even within the finest establishments with dedicated, caring support staff. But with very few exceptions this is not a group of people who warrant detention behind electronically controlled doors.

I worked for many years in secure psychiatric units where patients who had usually committed serious offences were assessed, cared for, treated and detained at the same time under the auspices of the Mental Health Act. These were people suffering from personality disorder or severe mental illness.

People with Learning Disabilities, Autistic Spectrum Disorders or Acquired Brain Trauma make a negligible impact on crime statistics, and even those presenting ‘challenging behaviours’ are generally more likely to injure themselves or perhaps those who attempt to prevent them banging their head off a wall or throwing themselves from a window.

There are a number of much smaller units which manage to combine the safety and security of both staff and residents with a pleasant, homely environment. I’ve worked with the staff and visited the homes. They have houseplants, pleasant décor, and even the odd dog. They have well trained staff who understand the bizarre, the obsessive and the repetitive along with the quieter subtleties of predicting and avoiding challenging behaviour. As far as I can see, nobody to date has done a comparative study of the effect of Laura Ashley soft furnishings on challenging behaviour against the Gulag Archipelago-look of Winterbourne View, but I know where my hypothesis money would be.

‘Economy of scale’ is of course the reason why large units like Winterbourne View have become so popular with care commissioners and those responsible for placing bums in beds. If you’ve been following the Southern Cross debacle or work in the elderly care sector, the bigger v smaller theme will be already familiar.

The Bigger Picture

It would seem from both readers’ comments and my recent experiences in the training room that a laceration of care budgets will not only force the vulnerable into bigger, cheaper but infinitely unsuitable establishments, but will also expose the raw meat of a rapidly diminishing work force. I see up and down the country how both front-line staff and their often very able managers are being faced with redundancy or re-application for jobs. I hear of closures of key services such as day centres, employment schemes and transport services leaving their former patrons festering amid a fog of endless Jeremy Kyle repeats on ITV4.

And then I remember David Cameron on his pre-election televised lectern. I remember his preaching the importance of looking after “the vulnerable, the poor and the needy” which, on the evidence so far, is a little like General Mladic professing his undying love for Bosnian Muslims.

Perhaps if there’s one message coming from the rainbow of opinions and comment posted on this site and beyond, it’s this. And it’s a very simple message. There are lots of very good care staff out there, but a few very bad ones. There is good management (at both a local and more strategic level) and of course, weak and ineffectual management. Put these together in the wrong combination and what do we get? Not just Winterbourne View, but Sutton and Merton, Cornwall and many other less well known examples. Has the bravery and persistence of whistle blower Terry Bryan and the subsequent Panorama bombshell made any difference to the likelihood of such horrors happening again?

In a week where a news story about cruelty to learning disabled people eclipsed even the mating habits of Premiership footballers, I’d like to think so. Perhaps we’re not all quite as shallow as we think.

Winterbourne View: Why does this happen?

2011-06-01T07:44:00.003+01:00

If Twitter has become the new barometer of the public mood, there were an awful lot of furious people watching TV last night. Most were effing and blinding at Britain’s Got Talent, or rather the lack of it, but for quite some time during and after the screening of Panorama on BBC1, indignance, rage and even tears appeared to be the order of the evening.

It isn’t often I start throwing metaphorical chamber pots at the television but if you haven’t yet seen ‘Undercover Care: The Abuse Exposed’ and don’t have too many throwable items nearby, this is surely a ‘must see’ piece of tele-journalism. It will have you foaming at the mouth. Here we have documentary evidence of cruel, callous staff supposedly offering care to vulnerable adults while actually doling out little more than institutionalised torture, bullying and assault.

Why does this happen?

It’s heartening to see the collective hive of Twitter so furious at the treatment of people who get precious little attention from anyone apart from those of us actually involved with learning disabled people or, like me, providing the training to help facilitate their care. But is it enough to simply tweat indignance about what we see on a secretly filmed expose? After all, by the time you’ve read this Panorama won’t be ‘trending’ anymore and we’ll all have gone back to ranting about BGT, Sepp Blatter, or Jeremy Kyle.

We may see some commentary in the left-leaning media as to how savage cuts to health and social care budgets are the inevitable precursor to many more instances of barbaric, privately run institutions like Winterbourne View. Well I can’t disagree with that point of view, and we’ll return to that theme later. But to really understand how ‘care staff’ come to be filmed aiming drop-kicks at learning disabled patients or acting out Nazi Officer fantasises in the faces of frightened young men, we need to dig a little deeper and go back a little further.

‘A Degrading and Odious Employment’

About seventeen years ago I published a research paper with a nurse colleague of mine called Chris Challoner. We had both worked in secure hospitals for some time, myself in medium secure units and Chris at Broadmoor Hospital. We were fascinated by the schism between two very different ideas of the term ‘nurse’.

The more public perception of the nurse was (and probably still is) the idea of the ‘angel’. The little girl who’d been given a toy uniform for Christmas with a big red cross on the front and a plastic stethoscope. She (for this remains a largely gendered profession) couldn’t wait to become a nurse. Having got her treasured qualification she guiltily scoffed chocolates on the Medical ward, the box of Quality Street left by just about every grateful patient as they left for home having enjoyed the tender ministrations of those ‘lovely’ nurses.

And then there was us lot. Much more testosterone, no nice uniforms, key-laden lanyards swinging from belts and certainly little in the way of a lifelong yearning to look after dangerous psychopaths behind electronic doors. We’d just sort of drifted into it, and with a bit of overtime it paid the bills. And our patients never left us chocolates.

Myself and Chris wanted to test whether nurses working in secure environments really were the sort of right-wing, Daily Mail reading lock-up merchants of the stereotype that abounded at the time alongside the notion of the ‘sandal wearing tree hugger’ found in more normal, open psychiatric units.

We were testing a stereotype and achieved what research nerds would know as a ‘null hypothesis’ – there was no statistically measurable difference between the secure unit nurses and those who worked in more ‘therapeutically inclined’ environments, at least on measures of responses to our standardised measures of political and therapeutic attitudes. But we did find out a few other things that didn’t show up in our number crunching, and which, I think, have a direct bearing on the horrors seen on last night’s Panorama.

Firstly, while doing a little research on the history of psychiatric nursing, we came across this little gem:

The evils arising from the generally indifferent character of attendants, and from the deficiency as to the resources they ought to possess, are so great that few things would benefit the insane more than devising some remedy for them.

Very topical. But this was written in 1847 by a Dr. John Connolly, Medical Superintendent at one of the Victorian Asylums, pioneering mental health reformer and a chum of Charles Dickens. It has often been said that psychiatry attracts both the best and worst of the medical professions. Mental health has never been a fashionable specialism, but does attract the intellectually curious doctor as well as those who got a medical degree but weren’t quite bright enough for a scalpel. And to some extent, the same could be said of some of those attracted to psychiatric nursing.

But Panorama featured a private hospital catering for a group of people whose care tends not to attract even the academic curiosity inspired by Bipolar Disorder or Anorexia. As a registered hospital, Winterbourne View provides secure care under the Mental Health Act for people with autism and other learning disabilities. Care doesn’t get much less glamorous than this. It’s a neck of the therapeutic woods which doesn’t attract the starry-eyed little girl with a plastic fob watch pinned to her nurses outfit.

Even a few decades before Dr. Connolly’s scathing attack on ‘attendants’, another Medical Superintendent was waxing lyrical on the same subject:

Although an office of some importance and great responsibility, the role of the attendant is held as degrading and odious employment, and seldom accepted but by idle and disorderly persons

John Haslam’s observations probably weren’t featuring in the 1809 equivalent of a Job Centre. The typical interview of the time was a quick twirl in front of the asylum boss to prove you were a) a bloke and b) a big bloke with muscles.

So hospitals dealing with learning disabilities and challenging, aggressive behaviour have hundreds of years of historical form in recruiting nurses/attendants who are more adept at ‘decking’ aggressive patients than providing any semblance of ‘care’. But two questions remain to be asked. Has anything changed, and what other reasons are there behind such appalling abuse?

A Question of Management

Our research was partly inspired by the ground-breaking 1979 documentary 'The Secret Hospital' which investigated the systematic abuse of learning disabled patients at Rampton maximum security hospital. Older readers may remember the horrifying story (among others) of a male patient with a particularly large penis who provided ‘entertainment’ for the nursing staff by way of a snooker table and a cue. If you didn’t see the programme you can guess the rest as I’m already traumatised by last night's revelations.

As a separate but recent finding on the sometimes appalling state of elderly care in hospitals has shown, the NHS is certainly no grinning standard bearer of quality care. But last night’s damming evidence did make me think of the private sector organisations with whom my company now refuses to work. In these organisations we see ridiculously high staff turnover, with the few minimum wage staff who actually show some signs of competence being quickly promoted to management as a kind of 'golden handcuff'. They leave behind a floundering workforce struggling with the demands of what are often difficult and challenging circumstances, often with a limited command of English and barely a passing awareness of the cultural norms and unspoken rules so important to working with vulnerable adults and challenging behaviours.

For our blacklisted companies (several of which were started by entrepreneur property developers suddenly made aware of something called ‘Supporting People’. Kerr-ching!) the level of training required to work with challenging adults is often summed up by the following management-speak: “Oh shit, we’ve got an inspection next month. Somebody book a course for Christ’s sake!” If anyone from CQC happens to be reading this, no. We cannot infer client abuse or malpractice from the comfort of the training room, but on at least one occasion my classroom suspicions have been proved well founded.

Fortunately, for every vision of Gothic Bedlam I come across in my travels, there are many more examples of very fine care providers who do actually commit to training and prioritise the support of staff who do what is a bloody difficult job. So why the difference?

Let's return to the research study for a moment. Our data gathering involved travelling to various different NHS units. Acute psychiatry, drug and alcohol and secure units all came under scrutiny. We met the managers of each unit to discuss the purpose of the study, meetings which, with hindsight, told us more about the attitudes and therapeutic orientation of our sample than the wads of questionnaires and measuring tools we brought. The managers ranged from the bright and enthusiastic sorts who exuded a culture of care from every pore, to the sort of indolent, world-weary pen pushers who, then as now, are so sadly common in NHS management. We were there to measure the effects of therapeutic environment on our nurses, not the impact of management culture. But as we debriefed and analysed our data after each visit (let’s just call it having a pint before anyone asks) the parallels became obvious. The attitudes and therapeutic orientation of the nurses in each unit were far more a reflection of the management of that unit than the environment itself. In research nerd language, positive management correlated positively with positive patient care.

The Outlook?

So we reach a conclusion that those among us requiring the most complex, skilled care are being left to the support of those who, often through no fault of their own, are most poorly equipped to deliver that care. This is not a mitigation for the water torture, assault, bullying and abuse of vulnerable people, but in my mind at least it’s a hell of a lot more satisfying to try and understand why these disasters happen than to simply press the ‘disgusted and appalled’ button on my Twitter account.

We’ve been left with a legacy of front-line care donated by a New Labour obsessed with installing layer upon layer of Blackberry wielding apparatchiks constantly on the look-out for the next strategy group or working party to fill that long post-lunch window. We’re left stripped of the coalface people not wearing suits, who are now in turn getting their P45’s leaving an ever dwindling workforce to deal with problems of mental health, autism and learning disability showing no signs of declining in either quantity nor complexity. Companies such as Castlebeck will be invited, along with the property developers and former used car dealers, to pick up the slack. So-called care providers will carry on using celebrity detox as a front to their profit-yielding minimum wage efforts at managing some of the most vulnerable, difficult and disturbed people in the health care system.

Thank you, Panorama. You may just have stopped the rot for a little while. Not for long, just a little while.

Visit JCK Training for details of health and social care in-house courses.

Jared Loughner and the Gabrielle Giffords Incident: Schizophrenia Unravelled

2011-05-26T22:42:00.006+01:00

This is an image of Jared Lee Loughner taken shortly after his arrest for the attempted assassination of US Congresswoman Gabrielle Giffords, the killing of six others including a nine-year old girl and the shooting of twelve other victims.

Remind you of anyone? The shaved head, the staring eyes and that entirely inappropriate smirk. A movie director couldn’t come up with a more perfect casting for the role of the classic, crazed lunatic. Jack Nicholson may have had more hair but his character in The Shining is not a million miles away from the caricature of Loughner’s grinning, haunting image. But unlike Nicholson's Jack Torrance, Loughner killed and maimed people for real. And this is one tragedy fuelled not by ghosts, but by a severe and devastating illness called Schizophrenia.

Yesterday Loughner was judged by an Arizona court to be ‘unfit to plead’. The UK mental health system is in many ways very different to that in most American states, but it’s a basic fundamental of most judiciaries that an accused cannot stand trial if they’re unable to understand the workings of a trial or to be able to communicate meaningfully with their legal defence. It is reported that Loughner has been 'paranoid' and distrustful toward his legal representatives, and his bizarre behaviour in court yesterday would certainly suggest someone who would struggle to co-operate with the rigours of any trial, let alone a case as high profile as this.

Medical reports submitted to the court reveal that Loughner has been diagnosed with a severe mental illness called Schizophrenia. He may be many thousands of miles away but Schizophrenia is Schizophrenia in whichever part of the world it manifests, generally at a rate of around one in a hundred of the population.

And other than the fact that he was able to buy weapons and ammunition as easily as we in the UK can pick up a pair of scissors, the history, the behaviour, the disturbed thoughts and the resulting tragedy are as familiar to us as the language we share. But it’s the stigma and misunderstanding surrounding conditions such as Schizophrenia which also struck me as being a common theme to both sides of the Atlantic. A quick summary of comments left on the Yahoo News website suggested that many Americans believe Loughner should be strapped to the nearest electric chair and plugged into the national grid. Asap. Crazy or otherwise.

If you’re already convinced there’s no such thing as a psychiatric defence even to a crime as horrific as Loughner’s, then you may as well click away now and take a look at Photoshopped cats dancing to Justin Bieber.

But as a UK mental health trainer I'd like to take you on a brief tour around an illness which very, very occasionally leads to events like this, but more often results in despair, loneliness, shattered lives and in some cases death. Not of other people but of the Schizophrenic him or herself. If you’re willing to persevere, read on.

What is Schizophrenia?
Schizophrenia is a severe, psychotic illness which affects approximately 1% of the population worldwide, including Jared Loughner. 'Psychosis' or 'psychotic' is one of those horribly misused words beloved of tabloid sub-editors as a shorthand for 'dangerous' or deranged'. To be psychotic is to be detached from reality, usually as a result of a mental illness, to the extent that the person becomes trapped in a mental world which is not only very real (and often terrifying) to them, but bizarre and incomprehensible to those of us on the outside not sharing this strange reality.

There are critics who object to the labelling of someone like Loughner as ‘Schizophrenic’. They would rather see mental illness as a complex collection of problems and expressions of distress as opposed to a neat little box of medical symptoms. While it’s certainly true that our key diagnostic ‘bibles’ such as DSM-IV and ICD-10 promote disorders such as Oppositional Defiant Disorder (aka moody teenager) or Hypoactive Sexual Desire Disorder (aka your partner doesn’t fancy a shag), the tendency for psychiatry to medicalise the tiniest tic of human behaviour does at times lead itself to ridicule and there are plenty of examples of the psychiatric 'system' treating the diagnosis rather than the person.

Personally I have little problem with the term Schizophrenia. It’s a distinct form of mental illness clearly describing for hundreds (if not thousands) of years much of the disordered thought, conflicting emotions and perplexing behaviour of people like Jared Loughner.

What are the effects (or symptoms) of Schizophrenia?
Auditory hallucinations are perhaps the first common feature of Schizophrenia to be happily reeled off by the exam room student psychiatrist. The rest of us just refer to ‘hearing voices’.

Voices are neither ubiquitous nor necessary for a diagnosis of Schizophrenia. If you’re hearing the voice of your partner right now telling you to get off that bloody laptop and go do something a little more useful, this may be for real (in which case you’d better save the rest of this for later and do as he or she says!) or the sort of imaginary voice that many of us hear or live with without need for particular concern.

It is difficult to tell outwardly that a person is hearing voices. Unless they're responding verbally to their voices or laughing/grimacing at what they can hear, or decide to actually tell someone about the voice(s) in their head the soundtrack of Schizophrenia is often a private conversation.

Interestingly, the word ‘hallucination’ may have become something of a misnomer. We are now aware that the brain’s audio pathways respond to ‘hallucinations’ in the same way it responds to sounds that are as real as the radio playing away in the background as I write this. So the voice of God, or Barack Obama or Satan may be a little more real to the Schizophrenia sufferer than the term ‘hallucination’ may suggest.

Jared Loughner’s psychiatric notes were not released to the public so we have no way of knowing whether he heard voices. It is quite feasible that he was receiving what are known in the trade as 'command hallucinations' to do what he did.

What is not in dispute is the very strange, erratic behaviour he was presenting to everyone that came across him in the years and months prior to the shooting of Gabrielle Giffords and the eighteen other targets of his rage. For some years following his premature departure from college he was reported as displaying an increasing preoccupation with politicians and their shortcomings. Now he definitely isn’t alone on this one. While this doesn't warrant a psychiatric diagnosis on it’s own merit (imagine the waiting lists for a consult), the significant aspect here is the increasingly focused descent into an all-encompassing obsession, where all that mattered where his own particular objects of attention. As can be seen in what has become a macabre YouTube hit, Loughner became fixated on subjects such as ‘grammar’ and ‘currency’ and the descent of the American dream.

This sort of odd, incomprehensible behaviour is driven by what mental health professionals call thought disorder. Loughner’s strange, jumbled and rather macabre videos paint a picture of just the sort of thought disorder that will be familiar to anyone who has known or worked with a Schizophrenia sufferer. What is said, done (and in Loughner’s case) written may seem like a random collection of words and repetitive ideas, but in the mind of the Schizophrenic they make perfect sense. It’s the thought disorder and behaviour propelled by those thoughts which, often accompanied by voices, become the visible face of someone suffering a severe psychotic illness.

What causes Schizophrenia?
Neuroscience, genetic heredity and good old 'nurture' all appear to play an important role in the development of the illness, but long-term studies suggest that a genetic potential for the illness is by no means a guarantee that the symptoms will erupt into Schizophrenia.

When Schizophrenia does emerge, it does so usually in late adolescence or early adulthood. We have known for many years how the environment of a younger person who may already be susceptible to Schizophrenia can play a vital role in flicking the ‘On Switch’ for the effects of psychosis.

It is well reported that Loughner had quite a troubled childhood and was an enthusiastic teenage user of Cannabis and hallucinogenic substances such as Magic Mushrooms, although his use of drink and drugs came to an abrupt end some years before the murders, quite possibly as a response to the increasingly puritanical and quasi-religious ideas that were coming to dominate his thoughts, feelings and behaviour. It has been widely reported that drugs can ‘cause’ Schizophrenia, but this has yet to be proved and is almost certainly not the case. What is looking more likely is that heavy substance use does play a role in impacting an individual’s susceptibility to mental illness, particularly where the young brain has yet to physically mature.

How come he’s 'mad' but could drive a car, buy a gun, make videos and post them on YouTube?
If you’ve seen Loughner’s YouTube postings and read or seen the accounts of his descent into illness from people who knew him well, you may well wonder how someone this ill can possibly drive a car, buy ammunition from a Walmart, deal with a traffic cop who stopped him for jumping a red light, and know that a particular politician will be in a certain place at a certain time one Saturday morning. He also has the skills to upload his video contributions to the world wide web.

Well, Schizophrenia involves an unravelling of the personality (not a split personality) and a brain which almost certainly would look slightly malformed and peculiar to the expert eye armed with an MRI scanner. But it only takes a quick skim through Google or YouTube to see that mental illness has little effect on an individual’s ability to perform tasks such as using the internet, uploading a video or driving a car.

In the UK, one of our most well-known serial killers drove an articulated lorry during a killing spree which led to the violent death of thirteen women. Peter Sutcliffe claimed to have killed his victims as a direct command from the voice of God and was diagnosed with Schizophrenia shortly after his conviction. He remains in a maximum security mental hospital many years later and will never be released. Severe mental illness is not necessarily a barrier to performing complex tasks.

In Conclusion
It may seem strange to a British mental health professional that someone so clearly unwell and tormented by psychosis has not yet been treated with, for example, anti-psychotic medication during the four months of his incarceration, but a severe and chronic shortage of in-patient psychiatric beds means we in the UK are in no position to moralise over this state of affairs.

It would appear from reports that Loughner will now be located at a secure psychiatric facility in an attempt to relieve enough of his symptoms to allow further attempts at a trial later in the year.

A mental illness such as that experienced by Jared Loughner is not to be wished on anyone. Our current drug and psychological treatments are far from perfect and will probably remain so for many years until psychologists and neuro-scientists are better able to advance the understanding of what causes the sort of cataclysmic events seen in Arizona this January. If it’s true that Loughner had a troubled childhood this would have corollaries with many mentally ill people who in turn become violent and just goes to show we cannot look purely at neurotransmitters and genes in explaining his extreme aggression.

It should also be stated very clearly that for every Jared Loughner there are hundreds if not thousands of people just as disordered, distressed and bewildered who will be far more likely to harm themselves either by violence or self-neglect than injure another human being.

This man suffers from a severe mental illness and may possibly have other underlying personality problems. He has planned and committed a crime which has ruined the lives of many, many people, but I hope this post has made you condemn a little less and understand a little more.

Empathy, Psychopaths, Nature and Nurture: All in 1200 Words

2011-05-21T19:36:00.009+01:00

Re: 'Zero Degrees of Empathy: A New Theory of Human Cruelty’ by Simon Baron-Cohen

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I haven’t actually read this book yet, which isn’t a promising start. So if this isn’t a book review, what the hell is it? Well, it’s a brief attempt to combine the main plank of the book (the clue’s in the title) with a discussion on the nature/nurture debate topped off with a completion of my rather long previous post on Personality Disorder. The latter was in fact so long I fear some readers actually died and decomposed long before they got to the end. Apologies to you if you’re reading this in the after-life.

Professor Baron-Cohen is a well-known specialist in the study of autism, and yes, if you’re trying to place the surname it’s his cousin Sacha’s various alter egos doing the jumping around in G-Strings and spoofing ‘da voice of da yoof. Innit’. As a mental health trainer I’ve often referred delegates to the professor’s work whenever autism is discussed, but his latest theory takes a slight step away from the study of disorders such as Aspergers Syndrome and zooms down to one key aspect of the human condition: empathy. Or rather, lack of it.

Most people have a basic understanding of empathy. The ability to see the world through the eyes of another person or to understand how it might feel to be ‘the other’ is the key construct of an individual empathy rating which Baron-Cohen calibrates from zero to six. If you’re the sort of person who instinctively knows when your friends really can’t cope with your 407^th holiday snap or you descend into floods of tears before Holby City has even got past the opening credits, you probably score in the upper regions of Professor Baron-Cohens empathy scale.

Looking at the reviews and in particular the commentary from Guardian readers, it would appear the unfortunate professor has been left with a bit of a scorched arse, at least from the more liberal end of the mental health/psychology spectrum. Firstly, he dares to suggest that something as subjective and nebulous as ‘empathy’ can be scored and rated with a questionnaire. Secondly, and perhaps even more heinously to some, he suggests the existence of an ‘empathy circuit’ consisting of various interconnected brain bits which are either turbo-charged, mid-range saloon or phutting away like an old Skoda. In the latter case (the ‘zero empathy’ range), we have the ‘psychopath’. This is the man or woman who simply doesn’t understand why the elderly lady whose fingers they’re breaking could possibly get upset: “Look, I’m only after the housekeeping money. What’s yer problem, luv?”

This ‘hard science’ approach to the explanation of complex mental disorders is often described as ‘biological reductionism’ and is to many mental health professionals, sociologists and service users the psychiatric equivalent of a devastating fart in a crowded lift. Hence the less than favourable reviews from those for whom the ‘social model’ of mental health is sacrosanct.

We live in an age where huge brain scanners are soon to be miniaturised to the size of hat. These will no doubt be available at PC World with a Wi-Fi link to YouTube, leading to multiple postings from Baz in Thurrock: “This is my brain while I’m doing a poo”. Yeah, can’t wait for those clips. But more seriously, the previously complex and highly secretive brain is opening up to neuroscience like a ripe melon.

Advances in genetic research are another major tool in the investigation of mental illness. In the not too distant future our personal genome will be available to anyone who wants to know how much Viking they have rattling around them, or more seriously, how susceptible they might be to Alzheimers Disease or Schizophrenia. Look out for the ‘Test your Genome Here’ booths at Tesco.

So far, so biological, but as a very experienced mental health professional I’m also only too aware of the devastating effects that trauma, abuse and childhood neglect have on the adult mind. Our surroundings, our circumstances and the events to which we’re exposed are crucial in determining whether we crash and burn with a handful of Seroxat or skip gaily through life like one of those ridiculously smiley people at folk festivals.

I like to think that, when asked to explain the causes of this or that psychiatric disorder, I can give a reasonably balanced overview from both sides of the ‘medical v social model’ debate. But even my balanced approach hasn’t always prevented me getting the ‘stare of death’ treatment at the merest mention of a gene, MRI scanner or (say it very quietly) Serotonin.

But here’s the thing. The ‘versus’ part of the ‘nature v nurture’ debate is gradually becoming as redundant as the public phone box. Remarkable evidence has been hitting the journals of the malleability of the brain long into adulthood. We’ve known for some time now how, for example, the memory circuits of London cabbies literally rewire themselves during ‘The Knowledge’. These changes can be observed with MRI scanners, although as far as I’m aware a predilection for TalkSport radio and an opinion on immigration has yet to evidenced by neuroscience. Even our genetic make-up is far from being the indelible clump of Cs, Gs, As and Ts formed at conception. Like our brains, our genes are susceptible to ongoing renovation long into adulthood and courtesy of the outside world.

Those of us who have worked with Baron-Cohen’s ‘zero empathy psychopaths’ will be all too familiar with the histories of childhood neglect, trauma and abuse described by patients/clients/service users. But can we infer a cause of personality disorder from these stories?

Of course not. Lots of people have experienced awful childhoods which haven’t turned them into serial killers, ethnic cleansers, concentration camp guards or sadistic sexual predators. There has to be some other factor gnawing away at the nascent mind to generate what some may refer to as ‘evil’. And if you’re a sociologist thinking ‘infamous Stanley Millgram experiments’ around about now, I did promise to keep this post brief.

Recent evidence is not pointing at previously simplistic nature or nurture explanations for psychiatric disorder, but toward a ‘perfect storm’ of environmental conditions, genetic predisposition and physical brain changes. There is certainly a worthwhile body of evidence that, in the case of Personality Disorder, a congenital potential for anti-social, callous and non-empathic behaviour exists in many of us at birth. Whether or not this genetic On-Off button is left on standby or blows up the microwave is highly dependent on the sort of environment we experience both as we grow up and long into adulthood.

I would like to think that someone as undoubtedly insightful as Professor Baron-Cohen doesn’t seriously consider a wonky neural empathy circuit as the sole cause of human barbarity and that he’s been unfairly ‘dissed’ (to quote Ali G) by opinions which are perhaps not empathic enough to see both sides of an argument. But to find that out for sure I’d better get out the debit card and head over to Amazon books.

Visit JCK Training for details of in-house courses on Personality Disorder and our other health and social care subjects.

Review: Uncaged Monkeys Tour Oxford May 1

2011-05-02T18:23:00.000+01:00

Spoiler Alert: You may want to read this review of the Uncaged Monkeys Tour AFTER the show - I don't want to spoil anyone's fun!

Maybe science isn’t quite the new rock and roll, but certainly TV shows like Bang Goes the Theory (pretty people with science degrees using capillary action to make boats) and of course Wonders Parts 1 and 2 (sex god does nuclear fission in designer outdoor wear) has had science teachers everywhere flinging off their white coats and doing Gangsta Rap with Bunsen burners. Okay, the last bit was a little fanciful but you get the idea.

Robin Ince has been at the forefront of the ‘particle physics can be quite entertaining’ thing for quite a few years now, and with his rapidly growing troupe of clever people doing showbiz and the brilliant Infinite Monkey Cage series on Radio 4, we now have a theatre packed full of Oxford’s intellectual glitterati waiting in anticipation for something that will three hours later prove to have been the ultimate anti-matter/matter annihilation of Simon Cowell’s ‘chimps with self-esteem issues’ brand of showbiz.

This is essentially a multi-act cabaret fronted, curated and compered by comedian Ince and headlined by science writers Ben Goldacre and Simon Singh. Professor Brian Cox is of course a science writer as well but with the added promotion of now being a telly presenter and all-round media legend, leading to some audience members squealing and wolf-whistling his stage emergence, presumably in the hope that ‘Coxy’ would do a slow strip concluded with “Lay-deez! Would you like to see my Up Quark?” which sadly never materialised.

But what did materialise was a very smart show by smart people for a smart audience. We had Matt Parker the mathematician doing mind-boggling tricks with Coke bottle barcodes, and congratulations to the lady in the front row who did the audience parp bit. I didn’t even understand the instructions. Simon Singh riffed the power of suggestion with a take on how Stairway to Heaven really can be a Satanist call to arms when played backwards, as long as we prime our brains to expect a line that suggests Beelzebub is doing stuff in a garden shed (you had to be there), before concluding with a party piece which involved turning a gherkin into a lightbulb which I really must remember for our next barbecue.

Helen Keen rather brilliantly spiced up her history of space travel with tales of mad rocket scientists, Satanists (again), Felix the Space Cat (I think), and the little known fact that Werner Von Braun once fronted an American children’s TV show, which was bizarre enough for a rocket scientist let alone one who apparently should have been doing bird at Nuremberg if he hadn’t been rather handy with a socket set. And just to prove the bill wasn’t an XY chromosome beard-fest, another Helen (Arney, this time) provided the musical interlude with songs about Schrodingers Cat, lovelorn biochemists and a reference to Wetherspoons. She could play, she could sing, she was funny and had a Physics degree. Stereotypes, eh?

Occasionally the show did appear a little self-conscious in the way that you might imagine Comic Relief bringing together every talking head who’s ever appeared on Horizon for a nude stage rendition of Hair, but for every moment of nervous uncertainty and ‘Powerpoint say no’ moments, relief would arrive in the shape of seasoned performer and compere Robin Ince. I used to think the term ‘non-doctor’ applied to vibrator ads on dodgy old porn mags, but it could also be applied to Ince as the only act on the bill who didn’t have a string of letters after his name. But his branch of brilliance was in using great delivery and some cracking gags to reassure the audience that this really was showbiz and not just a bunch of very clever people doing very clever things in front of paying punters.

There were of course parts of the show that worked better than others. Ince requested audience members to spend ten minutes tweeting him with questions for a post-interval Q&A, a brilliant idea had the local bandwith not gone up in smoke pretty much as soon as he suggested it. But the ensuing ‘three nerds on a bar stool’ session which would have been brilliant in the snug of one of Oxford’s gorgeous old pubs, didn’t really offer the ‘instant gratification’ needed by an 1800-strong theatre audience. As a slight aside the panel might have been asked why the theatre’s seats were designed for midgets, and I’m sure more than a few punters were able to tweet “could the panel please use their collective knowledge of the laws of thermodynamics to switch on the frigging air conditioning. WE’RE MELTING UP HERE!!”

Ben Goldacre did his usual Gillian Mackeith routine (Snake Oil/Fraud/Dodgy PhD/ how he registered his dead cat as a nutritionist) and ranted about journalists who wouldn't know a science story from a Kerry Gets her Babs Out! exclusive, but if you've read even the first half of his Bad Science book you did feel like saying “Thanks Ben. That’s great. We get it now. Enough already”.

And just as the over-running show was leaving more than a few anxious punters looking at their watches and consulting the train timetable, a slightly bemused Coxy (still at times looking a little perplexed at how a particle physicst can now get gigs on Loose Women) finished off with some huge numbers, galactic photographs, a juicy rant about UK science funding and an homage to Carl Sagan.

Brilliant stuff and thank you Mr Ince et al.

Theresa Riggi: The Tragedy of Personality Disorder

2011-04-28T20:04:00.002+01:00

The idea of this blog was intended to be an excuse to get away from the serious stuff of mental health writing and training and throw a few curve balls at some of the weird and hopefully amusing stuff that pops into my head rather too often than is healthy. But occasionally there will be more serious and sometimes darker corners that I’d like to explore, especially if it offers the reader a little lifeboat of clarity in the very choppy waters of psychiatry and the tidal waves of jargon, myth and sometimes utter shite that pours out of our web browsers and many other places besides.

I spent many years working with people who had done very, very bad things and had ended up in secure psychiatric units and prisons, but even I am still occasionally stopped in my tracks by a news story that almost defies belief. Today three men have been remanded in custody following the death of an elderly couple. They were stabbed and battered with a hammer. Perhaps you, like me, even tried to imagine yourself hitting an elderly person with a sharp, heavy lump of metal on the end of a handle. But thankfully most of us (self included) don’t get further than a fleeting micro-second on this thought before returning thankfully to irritation with the Royal Wedding or deciding whether to have Couscous or Maccy D for dinner. Most of us will often settle for the idea that such offences are the result of being drunk, high on drugs, desperate for money to buy drugs, or insanity. Nice simple responses to unimaginably evil stuff is a comforting way of keeping the bad people out and returning to our normal, uncomplicated lives.

But perhaps even further beyond our everyday comprehension is the idea of a woman stabbing her three children to death. Yesterday Theresa Riggi was sentenced to 16 years imprisonment after pleading guilty to the charge of culpable homicide on the grounds of diminished responsibility. It’s probably natural to feel even more astonished about this than the Wolverhampton killings allegedly committed by three homeless men. After all, Riggi is a woman and a mother. From the little we can glean from the news reports, she is a reasonably well-heeled, middle class woman who appears in the dock not in the tracky-bottoms and hoop earrings of our stereotype ‘bad girl’ but a smart, tailored white suit, flowing blond hair and immaculate make-up. The image of the woman who has stabbed her three children doesn’t just jar with our expectations but blows them out of the water with an almighty bang.

Putting our social stereotypes to one side for a moment, it may also seem very strange to most people that a person can be found guilty of a crime, given a prison sentence and yet their responsibility for the crime is in some way ‘diminished’. Well I’m no lawyer and can’t claim to try and explain the legal mechanics of the case, which under Scottish law operate a little differently than those in the rest of the UK. But as a mental health professional, writer and trainer I’ve spent many years explaining (some would rightly say ‘trying’ to explain) something called Personality Disorder, the diagnosis applied to Riggi and the reason why her crimes were ascribed to something other than either mental illness on the one hand, or ‘free will’ on the other. And this is my contribution to helping the confused reader feel a little less confused about what is a very poorly misunderstood area of mental health.

Theresa Riggi will have been examined by psychiatrists who provide a medical report to the court. Had the psychiatrists found evidence that she believed she was being controlled by God or receiving messages from an alien mothership, heard voices in her head telling her to kill her children and had been behaving erratically prior to the homicides they might well have concluded that there was evidence of a severe mental illness contributing to what she had done. After a great deal more investigation and more concrete evidence than the hypotheticals I’ve mentioned here, they might have recommended to the court that she receive treatment in a secure hospital or psychiatric unit as opposed to the determinate prison sentence she received.

But her behaviour was not explained by a ‘psychotic’ illness such as Schizophrenia, Bipolar Disorder or severe Depression (I’ll write about these at a later date, but Introducing Mental Health: A Practical Guide might help if you can’t wait) and nor was it described as the result of an otherwise ‘normal’ person with a ‘normal’ personality.

Okay, I’ve been running courses long enough to know exactly what you’re asking now: “What is a ‘normal’ personality?” Well for the moment I’d suggest typing that one into Google AFTER you’ve finished reading this AND had several Expressos because it’s a very mysterious question and way out of the scope of this article. Lets just say if you’re reasonably nice to children and animals, enjoy your life, get on well with others and don’t fantasise about doing weird stuff with power tools – you’re probably reasonably ‘normal’. Theresa Riggi was not considered normal and was diagnosed with three different forms of Personality Disorder.

So what exactly is this ‘Personality Disorder’ thing? Anyone who has ever read a tabloid newspaper or watched CSI has some idea of what a Psychopath is. They are bad people who do nasty things. The word ‘Psychopath’ is closely related to Personality Disorder and until 2007 formed part of our own UK Mental Health Act, but is no longer used by mental health professionals other than on those odd occasions when we need a shorthand way of saying ‘person with Personality Disorder’ and we think nobody else is listening. Not terribly PC and not academically correct but much quicker than reciting the full six syllables of Pers-on-ality Dis-or-der, so for the purpose of this article I’ll do what I normally do in training and ask for permission to use a jargon abbreviation: PD. Permission granted? Thank you.

In the same way that we use ‘Dementia’ as a convenient umbrella term for example, Alzheimers Disease or Vascular Dementia, PD is also an umbrella term for a number of different types of disorder which mental health professionals refer to these as ‘sub-categories’ of PD. I prefer to call these ‘flavours’ which include some of the better known diagnoses such as Borderline PD and Anti-Social PD as well as the lesser known Schizoid, Schizotypal, Dependent or Avoidant.

But the overall meaning of PD refers to a person who is fundamentally unable to cope with life without annoying, upsetting or harming both other people and, invariably, themselves as well. They can be superficially ‘normal’ in many ways and can be gregarious, humorous, charming and even charismatic, especially when there is a ‘pay off’ for engaging others. But they are far less successful in maintaining relationships once the immediate payback has been realised, and tend to be extraordinarily self-absorbed as well as hostile and self-destructive. They live their lives in ways which are either highly methodical or completely chaotic, and have an ability to either attract or repulse others like the poles of a magnet depending the circumstances.

While roughly one in ten of the population have personalities which meet the strict diagnostic criteria for one of the personality disorders, most of these individuals won’t have been labelled by a psychiatrist or psychologist until a researcher carrying a clipboard and wads full of questionnaires has interviewed them for a research study or court report. But before you start counting up just how many of your friends, family, work colleagues or acquaintances might make up the ‘1 in 10’, it’s important to qualify that people with PD are by default often (but by no means always - see below) marginalised at the fringes of society. Male and female prisons have extraordinarily high rates of people who have PD (whether or not it is recognised or written down anywhere) as do, for example, street homeless populations, drug treatment centres and just about any of the communities most of us with a family, a dog and a family saloon don’t really want to think about unless it’s a documentary on BBC4.

On the other hand, there are some people with PD tendencies (again, usually undiagnosed) who manage to achieve extraordinary success in business, politics and other more surprising areas of life. Think about some of the less than pleasant characters that have dominated entire nations and global corporates since the time of Caligula onwards and you get the idea. Some of PD’s less savoury diagnostic criteria can be a positive boon for world domination.

Some of the flavours described by the diagnostic ‘bibles’ used by doctors and psychologists (such as ICD-10 and DSM-IV) are perhaps of less clinical usefulness than others, and we would need a very long blog indeed to describe the whole collection in any detail, but let’s return to our original question: Why was Theresa Riggi not deemed fully responsible for killing her children and what role might PD have played in this awful tragedy?

The examining psychiatrists applied three separate diagnoses or flavours to Riggi’s personality: Narcissitic, Paranoid and Hysterical (sic). The ‘sic’ bit is down to the media reporting of a disorder I’ve never actually heard of but is almost certainly and more accurately called Histrionic Personality Disorder.
Let’s take a brief look at each of these diagnostic labels to try and make sense of what happened in this case, although I of course remind the reader that we are only dealing with the minimal information as reported in the press and I have no personal knowledge of the case.

Paranoid Personality Disorder
Paranoid or paranoia are words we all know quite well and perhaps even use with friends and family. Everyone has experienced paranoia at some time to one degree or another. You’re sitting in a pub with some friends and a loud peal of laughter erupts from a table of folks at the other end of the bar, and you think “shit, I know I shouldn’t have worn these tartan shorts and the dayglo green Crocs” while shifting uncomfortably and trying to see where the laughing folks are aiming their collective gaze. This is the very mild sort of paranoia we all experience from time to time, especially if we’ve had a few glasses of wine or don’t have very high self-esteem. Or most probably both.

But in it’s full-on clinical sense, paranoia is a very intense feeling of suspiciousness and unease that destroys a person’s ability to form friendships, socialise or even pop out to the local Tesco without the very real (to them) belief that everyone in the Sauces and Condiments section is plotting to poison them. Paranoia and the false beliefs generated by psychotic illnesses such as Schizophrenia occasionally (very occasionally) lead to violence and even homicide, particularly where a person becomes so consumed with their suspicions that they feel forced to extreme acts as a means of self-protection.

Paranoid PD is a strange beast in that it manifests as severe, all-encompassing and abnormal suspicion of others without leading to the complete destruction of reality we associate with a psychotic illness like Schizophrenia. Of course, it’s a hugely difficult task to draw clear lines in the sand between a) the paranoid beliefs of the sort that can be treated successfully with anti-psychotic drugs, b) the paranoia identified by Theresa Riggi’s psychiatrists as being part of a personality disorder, or c) the result of an unwise choice of footwear and a few drinks, but hopefully the picture might appear a little clearer now.

Narcissistic Personality Disorder
Narcissus is a character from Greek mythology. He was the son of a God and Goddess who, were he around today would no doubt be described by girls as ‘totally buff’. But Narcissus knew only too well about his buffness and rejected numerous come-ons from lots of water nymphs and other mythological characters because none of the boys, girls or hermaphrodites (this is Ancient Greece after all) who fancied him were deemed by Narcissus to be anywhere near good enough for the gorgeous young chap. Stay with me here, there is a point to all this.

To cut a long story short, Narcissus caught sight of himself in a pool and fell in love with his own reflection. Which wouldn’t have been too bad if he hadn’t become so obsessed with his reflected gorgeousness that he couldn’t move from the pool and eventually faded away and died of starvation.

A person diagnosed with Narcissistic Personality Disorder might be thought of as pathologically self-obsessed, vain and arrogant to the point that they really are very difficult people to warm to. They are, like their namesake Narcissus, so in love with themselves that they reject the attentions of others as being little more than an irrelevance, but may tolerate people who can a) achieve objectives for themselves such as the confirmation of their wonderfulness, or b) are of such high status that they are actually seen as almost being good enough to be in the same company, and c) may provide the narcissist with material resources and family associations to enhance and confirm their exalted sense of self worth.

This is often a person who, to anyone else but themselves, is actually a rather strange, unlikeable person who tells very tall tales to confirm their own inflated opinion of themselves – in fact, some of us sometimes refer to Narcissitic PD as 'Walter Mitty Syndrome', but please don’t quote that in any essays or course work you may be doing.

I once worked with a colleague who would tell anyone that would listen (a rapidly diminishing number, surprise surprise) about his previous exploits of derring do as a member of the SAS. Now anyone who knew this chap would immediately know that this and his many other stories were patently ludicrous, but he not only told these obvious lies with great and even entertaining conviction but even seemed to totally believe them himself. Talking of conviction, the last time I saw him he was being arrested at work for a serious assault on his long-suffering partner of the time, and much to the relief of his colleagues was never seen again, much to the relief of his former colleagues.

Unfortunately and only in extreme circumstances, Narcisistic PD erupts in crime or extreme violence, usually as an attempt to perpetuate a lie or a self-belief. While we have no evidence as to how Theresa Riggi’s diagnosis contributed to the killing of her children, another example of the potential tragedy of this disorder is the Brian Blackwell case.

Histrionic Personality Disorder
You’ve almost certainly used the term ‘Drama Queen’ to describe someone (usually and very innacurately a female) who craves attention and needs to be noticed. We probably only call someone a Drama Queen in jest or in certain situations, but if we take our everyday meaning of this expression and amplify it to suggest a person whose entire life and personality is dominated by their unswerving need to be the centre of attention then we are some way towards understanding the clinical meaning of Histrionic PD.

I always think of television shows such as Big Brother, X-Factor etc as a potentially fertile researching ground for any keen psychology researcher looking into this disorder, and it often seems to me that half the peak-time output of ITV2 is dedicated to Histrionic PD. Unfortunately the clinical picture of this flavour of PD is more likely to be associated with dramatic outbursts of destructive or self damaging behaviour than the invitation of cameras to watch a minor celebrity having a row with a partner or getting a bikini wax.

So what we can conclude from all this? A quote from the BBC News website says a great deal about Theresa Riggi:
One of her friends, Amber Sebold, told BBC Scotland about the "wall of shock" she experienced when she heard about the killings.
"She (Riggi) always seemed very together. They were always immaculately dressed, very well cared for," she said.
"She clearly loved them very much, that was never in question."

Personality Disorder is, to repeat from earlier on in this post, a very complex and controversial subject. My personal opinion based on years of working with prisoners and psychiatric patients is that it is a very real disorder, but there are certainly many other psychiatric diagnoses that are seen as little more than doctors trying to medicalise anti-social, self-destructive or eccentric human behaviour. There is now an increasingly compelling body of evidence as to how genetic, biological and environmental factors combine to generate a ‘perfect storm’ in which a personality becomes capable of destroying the lives of both the self and others with such devastating effect.

Many of you will have read the accounts such as the one cited above and seen the photographs of a rather glamorous, expensively dressed woman posing for family portraits looking every bit the image of contented and successful family life. You have read this article and the accounts of what Riggi did to her children and are trying, probably in vain, to paste these images together.

As a keen science nerd I try unsuccessfully to get my head around the almost incomprehensible concepts of space-time, the universe(s) and the utter weirdness of quantum physics, but we are probably far nearer understanding the nuances of quarks, anti-quarks and black holes than we are to understanding the human mind, and stories such as these don’t just underline that point but squiggle underneath it with a great big smelly red marker pen.

This article has done little more than make a sub-molecular scratch on what is an enormous surface, but hopefully sheds a little light on how something as impossibly tragic as the death of three young children can be understood as well as condemned.

Visit JCK Training for details of in-house courses on Personality Disorder and our other health and social care subjects.

Third Time Lucky

2011-04-14T18:14:00.000+01:00

Q: So what went wrong with the first two attempts Connor?
A: Well, with a title like Connor Kinsella's Mental Health Blog, it was a bit limited in scope. And a bit boring. And my mate defiled version two by calling me 'dude' and asking when we were next going to play tennis.
Q: So mates are banned from commenting and you have a wider brief this time around?
A: If I think of stuff that can be written down, is a) interesting b) amusing or c) just plain daft, it might end up on here. And I've written or co-written real books in the real world so hoppefully this will be more than just ego masturbation.
Q: Er, ego what?
A: Don't worry. The spellchecker won't pick it up anyway.