Jenelle Clarke – The Value of Prison Therapeutic Communities

‘The degree of civilization in a society can be judged by entering its prisons.’
– Fyodor Dostoyevsky

Last month, Claudia Hammond from BBC Radio 4’s All in the Mind visited HMP Grendon, the only prison in Europe which is run completely as a therapeutic community (TC).  The focus of the programme was to speak with prisoners, most of whom are serious offenders serving indeterminate sentences, and staff members to find out how the prison works and how they seek to address issues of reoffending.

As the programme identified, in a prison TC offenders are continuously encouraged to understand why they offended and to take responsibility for what they have done.  Grendon staff members noted during the programme that because residents have a stake in not only their own but others therapy, there is a strong sense of accountability.  Reality confrontation is crucial as members are encouraged to confront each other with honesty and frankness.  Jones’s (1968) concept of social learning is utilised so that every social encounter between residents and staff members could potentially be one in which residents gain new insight about their own behaviour and their ways of relating to others.  These principles are found in most TCs, and as with most TCs, the way it all works in practice is complex and at times chaotic.  However, as Hammond’s visit to Grendon highlighted, in a prison setting, these issues become even more multifaceted.  Not only is applying therapeutic principles challenging in a prison (Rawlings, 1998) whereby the goals of safety, security and therapy do not always fit comfortably together, there are the financial costs and the political issues at stake.  The type of specialised therapy on offer within a prison TC is expensive, requires a high level of commitment from prison administration and staff (Wexler and Prendergast, 2010), and as members at Grendon pointed out, the perception of spending public money on helping, rather than punishing, offenders is not always politically popular.

However, the value of this type of approach cannot be diminished by its challenges.  A few years ago I had the opportunity to visit a prison TC as part of the Community of Communities Peer Review Process.  Residents engaged with our team openly about what it is like to address personally painful issues with other people on a daily basis.  Like any TC, the meeting was full of mutual support, honesty and the occasional argumentative outburst, all of which the entire group had to manage.  Unlike other present day TCs, residents were together 24/7 and opportunities for reality confrontation, support and honest reflection were always available.  Such a regime, whilst far from easy, was clearly valued.

As for the commitment that this type of approach requires, the staff members I have met over the last several years from various prison therapeutic communities demonstrate that they are committed to their roles and helping prisoners.  They echo what Grendon staff members report in Hammond’s program, namely that offenders do learn to work together in order to take responsibility for their actions, there is little violence on the units, and more importantly, they can point to research (c.f. Wexler and Prendergast, 2010; Newton, 2010) that indicates that reoffending rates do go down.

Of course one visit to a prison community and a few conversations with staff members are not enough to definitively argue why these communities are worth their challenges.  But it does give pause for thought and reflection about the potential of people to help other people, especially in a prison.

Surely one of the hallmarks of a democratic society is where offenders can learn to see the impact of their actions from another’s perspective, to experience ‘victim empathy’ (Smartt, 2001:13).  Such insight does not fade with time as one has to live forever with this knowledge.  Greater awareness of these issues*, including more research and programme’s like Hammond’s, is needed in order to continue this conversation about the value of a prison therapeutic community in our society.

(*In addition to All in the Mind, former prison governor Tim Newell has published a review (publically available) in the Prison Service Journal on Dovegate: A Therapeutic Prison in a Private Prison and Developments in Therapeutic Work with Personality Disordered Offenders (released 2011), by Dr Eric Cullen and Dr Judith Mackenzie, which touches on similar issues to ones discussed above.)

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
E: lqxjmcl@nottingham.ac.uk

References:
All in the Mind (2012) BBC, BBC Radio 4. Broadcast on 8 May 2012. Available through BBC iPlayer: http://www.bbc.co.uk/programmes/b01h667n.

Jones, M. (1968) Beyond the Therapeutic Community: social learning and social
psychiatry. New Haven: Yale University Press.

Newton, M. (2010) Changes in Prison Offending Among Residents of a Prison-Based Therapeutic Community. in Shuker, R. and Sullivan, E. eds. Grendon and the Emergence of Forensics Therapeutic Communities: developments in research and practice. Chichester: Wiley-Blackwell.

Rawlings, B. (1998) The Therapeutic Community in the Prison: problems in maintaining therapeutic integrity. Therapeutic Communities 19(4): pp.281-294.

Smartt, U. (2001) Grendon Tales: stories from a therapeutic community.  Winchester: Waterside Press.

Wexler, H.K. and Prendergast, M.L. (2010) Therapeutic Communities in United States’ Prisons: effectiveness and challenges.  Therapeutic Communities 31(2): pp.157-175.

Sarah Dale -Tales from the Cheltenham Science Festival 2012

The IMH Blog is pleased to reblog the following post from Sarah Dale from her blog, Creating Focus.  You can view the original post on the link below:

Tales from the Cheltenham Science Festival 2012 by Sarah Dale

Regular readers of my blog and newsletters will know that I am a fan of the Cheltenham Science Festival. True it’s something of a relief that geekdom seems to be gaining in social acceptability these days.

These things are all relative however, and psychologists are maybe in a different place from pure mathmeticians for instance. My own observational study seems to have confirmed this by  going along with my other half (an engineer who’s a pure mathematician at heart) to a mathsjam event at 10pm on Saturday evening. I went – I have to admit under some duress – on the promise there would be no quadratic equations to contend with after a long day and a very relaxed evening of curry and wine.

What were the first words to greet us, as we found the table of mathematicians calmly calculating away in the midst of modern Hogarthian-style drunken excess swirling around them? Yes – “we’re just doing some quadratics”.

Well, I thought to myself, I like to be open-minded but you can count me out.

So one of the joys of the festival is that it can accommodate me (psychologist, aspirant writer, maybe five on the geekometer) and my husband (who I think scores more highly, though I wouldn’t like to state how much more highly as the figure will be subjected to various mathematical tests before I can press publish).

This was illustrated nicely in one particular moment when he was podcasting about the maths behind board games whilst I was whiling away an hour entitled What happens when you pray?. The panel included atheist psychologist Chris French and broadcaster and Church of England priest  Rev Richard Coles (if you’re my age you may remember him as an ex-Bronski Beat and Communard with Jimmy Sommerville – takes me back to my undergraduate Rock City days here in Nottingham). It got close but being British and polite kind of skirted round the really heated debate that I would have liked to see as to whether being religious and a scientist are mutually exclusive or not. Hot potato stuff. Cheltenham, are you brave enough?

Brains and minds

There was a bit of a brain theme to the events I had chosen to go to. A live brain scan event (expertly facilitated by Evan Davis) looked at whether you can tell from brain activity whether someone is lying (early days but you can see the potential).

Given the live nature of the event, it occurred to me that it would be interesting to put the Festival’s slightly performance-pressurised Director, Mark Lythgoe, in the scanner and look for what happens in the brain in stressful situations – but maybe that’s for another day. Derek Jones, from Cardiff University, delivered a highly accessible and engaging explanation of what an MRI scan actually does – made me realise I didn’t know that I didn’t know that.

We also saw Bruce Hood speak about children’s brain development and the sense of self. It’s fascinating stuff. I’m not a developmental psychologist but I do wonder how much the neuroscience will confirm or deny long held theories such as Piaget’s work, or personality theory. We must be getting close to being able to do that I guess – are the Big Five personality factors visible in the brain? I don’t know if anyone knows the answer to that (yet).

And the highlight for me – mindfulness with Mark Williams

I have written about working through Mark Williams and Danny Penman’s book, and eight week mindfulness programme before, which you can read here. So it was a delight to attend a session chaired by Kathy Sykes (festival Director with Mark Lythgoe), where Mark Williams was speaking along with David Sillitoe, BBC correspondent who has tried mindful meditation for himself, as well as reporting for television on it.

The session itself was interesting, drawing on the sound neuroscience backing up ancient claims for meditation. Mark, as a clinical psychologist, comes across as the style of psychologist I have aspired to be from an early age, and still do – practice based on solid scientific evidence with an ever present curiosity about developments in the field, as well as striking me as the kind of person you would want to turn to in times of distress (his field is to do with treating depression). I think it’s always valuable to meet people who provide that professional inspiration, in whatever field you might occupy. David’s reflections as an initially somewhat cynical experimenter with this topic were also highly relevant. His use of the word “counter-intuitive” particularly struck me – both I and clients have found aspects of mindfulness practice to be very counter-intuitive given our western life-styles and the way we’ve been educated to strive towards achievement rather than cultivating awareness of the present.

One of the strengths of the festival is that a talk to an audience of probably a thousand people can be followed by a “talking point” move to another marquee where, on sofas, it is possible to continue the audience questions and shift to a more relaxed seminar style event. So, for me, this developed into something very much like a book coming to life. Probably the most enjoyable way of learning for me.

A reflection that chimed well with one of my recent newsletters (Fads and Mockers) was that of the popularity of mindfulness as a fashion at the moment. There are any number of books and courses about this right now – in an unregulated market that makes it very difficult to work out what’s sound and what isn’t. Mark’s comment was that at first he felt the need to try to police that somehow. He soon realised that was nigh on impossible and then described it as watching the tide come in and out and you then have to assess what’s left on the beach. He recommended starting at the Mental Health Foundation site, Be Mindful, for anyone wanting to find out more.

And in the meantime the Oxford Mindfulness Centre, where Mark is based, has produced some really good videos. I’m including two here – one, a short introduction to mindfulness, and the second a full lecture about it if you have more time and interest.

Enjoy!

Posted by:
Sarah Dale

Sarah Dale is a chartered occupational psychologist and author of Keeping Your Spirits Up. She has a business background as a chartered accountant, and runs her own consultancy, Creating Focus. She is currently looking for inspiring women of age sixty plus to interview or to invite to write letters to her as part of her plans for her next book. For more details, contact Sarah on sarah@creatingfocus.org or 07748 494688.

Sarah’s website is www.creatingfocus.org and she can also be followed on twitter (@creatingfocus) or Facebook (Creating Focus).

Dr Peter Ladd ~ Where is mental health diagnosis heading, and where does the DSM IV fall short?

In this re-post from the JKP blog, Dr Peter Ladd asks some important questions relating to traditional mental health diagnosis, and shares his own thoughts about where he believes it is heading in the future.

---

Does the Semantics found in the DSM IV Create a Problem for Clients?

The DSM IV is sophisticated in basing diagnosis in mental health on statistical probability. The Client Empowerment Model of diagnosis in mental health found in Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients, (Ladd & Churchill 2012) is sophisticated in presenting a holistic perspective. The lack of a holistic perspective found in the DSM IV may be partially attributed to the semantics found in it. For example, the DSM IV has such labels as Bi-Polar Disorder or Obsessive/Compulsive Disorder. Semantically, a person may incorrectly say, “I am bi-polar or I am obsessive/compulsive.”

From a strictly medical model, such semantics do not make sense. In medicine one does not say, I am cancer or I am stroke. However, with some mental disorders one can personalize them as though they were connected to one’s identity. A client empowerment model does not focus on labels but on patterns. For example, a person might say, “I have a pattern of bi-polar disorder or I have a pattern of obsessive/compulsive disorder. These statements are not connected to one’s identity. They are accurate semantic statements of a pattern they are in. Such unsophistication in DSM IV labels may lead to increasing the severity of disorders rather than reducing them. Most clients do not find meaning in statistically formulated symptoms but in understanding the semantically formulated patterns of their disorders. For example, if you asked someone, “Tell me who you are?” A person would not add up all of his or her negative symptoms and produce a label of how they see themselves. Most likely they would point out those characteristics that describe their unique way of being in this world. This means that it may be important in diagnosis in mental health to significantly separate a person’s mental disorder label from their identity.

The DSM IV is not sophisticated enough to achieve this function. A Client Empowerment Model of Diagnosis presents a client with a diagnostic pattern that specifically changes the discussion away from one’s identity to a pattern of experience that a person is going through. In practice, using a system that statistically categorizes mental disorders based on empirical probability has an explicit advantage for insurance companies, pharmaceutical companies and for the mental health practitioner yet such sophistication may be detrimental to clients, if these mental disorders are not presented in a more sophisticated, holistic and collaborative manner. Perceptually, clients may confuse the mental disorder label with their identity. The question to be asked may be, “Do we have a responsibility as mental health practitioners to diagnose in a manner where diagnosis is beneficial for all involved?”

The Direction of Clinical Diagnosis in Mental Health

Mental health practitioners have a responsibility or at least a professional mandate to include tests instruments within a clinical diagnosis. Some of these instruments are; mental status exams, objective testing, personality testing, motivational interviewing, behavioral, emotional and environmental testing.

However, the most noted test instrument used by mental health practitioners has to be the Diagnostic and Statistical Manual of Mental Disorders or more commonly referred to as the DSM IV (APA, 2000). This book is mostly a standardized classifications system so that all mental health professionals are speaking the same language. This manual breaks down into; Axis I – clinical mental disorders, Axis II – personality disorders, Axis III – medical conditions relating to mental disorders, Axis IV – psychosocial events and environmental concerns and Axis V a global assessment of a client’s ability to function.

Neuroscience may be on the verge of giving the DSM IV an alternative perceptual view of diagnosis with such instruments as; PET scans, MRI’s, and CT.’s and Mindfulness Research (Plante, 2011). However, such neurological research is limited to the laboratory setting without some form of phenomenological thinking. Neuroscience has stirred up a renewed interest in phenomenology or the study of experience (Siegel, 2010). In other words, human experience causes neurological changes, and neurological changes are best understood through studying human experience. Such a notion takes mental health diagnosis in a different direction than the DSM IV that adds up symptoms in order to give a diagnosis based on statistical probability.

From the consideration of a new neurological/phenomenological perspective brings rise to this question, “Are the only accurate mental disorder diagnoses made by adding up symptoms from the DSM IV, in order to render a diagnosis?” At this point, it is only fair to mention that such a question is not completely answerable, yet it does give possible direction to the future of diagnosis in mental health.

However, such a question does reflect the sentiments of those mental health practitioners and neuroscientists that are finding a need for each other’s information. Furthermore, it may raise questions as to the direction of psychological diagnosis from a strictly medical model, statistical probability perspective. Should psychological diagnosis rely only on a statistical probability of symptoms, leading to a diagnosis? Or, should we rely on neuroscience research and combine it with phenomenological experience in developing a more bio/psycho/social/spiritual (Holistic and Person-Centered) model of diagnosis? This may be the moment to consider a different model of diagnosis with the ultimate release of the DSM V, and the book, Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients is one attempt at presenting a different model.

Peter D. Ladd
May 2012

American Psychiatric Association. (2000) Diagnostic and statistical manual of mental health disorders (4th ed.). Washington DC: Author (Original work published 1952).

Ladd, P. & Churchill, A. (2012) Person-Centered diagnosis and treatment: A model for empowering clients. London, UK: Jessica Kingsley Publishers.

Plante, T.G. (2011). Contemporary clinical psychology (3rd ed.). Hobaken, NJ: John Wiley & Sons.

Siegel, D.J. (2010) The Mindful therapist: A clinician’s guide to mindsight and neural integration. New York, NY: W. W. Norton and Company.

FYI, the book could be found via the following link: http://www.jkp.com/catalogue/book/9781849058865

Introducing the The Consortium for Therapeutic Communities and Upcoming Events

As reported on the Association for Therapeutic Communities (ATC) website, the organisation and structure of the ATC is changing:

‘Following several years of development work ATC is joining forces with a sister charity The Charterhouse Group (which specialises in supporting therapeutic communities working with children and young people) and we have formed a new charity “The Consortium for Therapeutic Communities” – referred to as TCTC.’

TCTC has developed a Manifesto for the new organisation. Comments and feedback are very welcome and should be sent to post@therapeuticcommunities.org.

In addition, there are some upcoming TCTC events for those involved in or interested in therapeutic community research:

TCTC Research & Development Group – Tuesday 3 July 2012*
This session will focus on outcomes measures in TC’s and will specifically explore:

• What are outcomes for?
• What do outcomes really communicate?
• What do commissioners require?
• What options do we have?

Confirmed guest speakers: Dr Mark Freestone and Dr Steve Pearce
Time: Lunch and Registration 12.30pm, Seminar 1pm – 4pm
Venue: Royal College of Psychiatrists, Centre for Quality Improvement, Standon House, Mansell Street, London
Cost: £5.00 (payable on the day)
(an event flyer for 3 July 2012 is available for more information)

TCTC Children and Young Peoples Sector Group – Thursday 5 July 2012*
This is a quarterly special interest meeting for all those working with children and young people in therapeutic settings. It provides a networking opportunity with other TC managers and practitioners, and a chance to gather advice and support – practice, operations, regulation, tendering, policies.

Confirmed guest speakers: Jonathan Stanley and Dr Tom Harrison
Time: 10am – 4pm
Venue: PETT, Barns Centre, Church Lane, Toddington, Cheltenham, Glos. GL54 5DQ
Cost: £40 per delegate/ £90 with B+B (full lunch and refreshments included)
(an event flyer for 5 July 2012 is available for more information)

*To book a place at one or both of these events, please contact TCTC:
e: post@therapeuticcommunities.org
t: +44 (0)1242 620 077

Nic Marks – Measuring what matters: the Happy Planet Index 2012

Today we have another reblog – this time from Nic Marks, Founder of the New Economics Foundation Centre for Well-being, discussing the recently released figures for the ‘Happy Planet Index’.

 

Costa Rica comes out top, while the UK languishes at 41 – how did your country do?

We live in challenging times. Our financial markets are under huge stress, global poverties and inequalities stubbornly persist and the threat of climate change looms over all of our futures. A growing number of governments, politicians and ordinary people around the world are recognising the interconnectedness of these issues and the need for thinking about what “progress” really is in the 21st century.

They are realising that indicators of economic activity simply don’t tell us enough about societies’ goals of enabling good lives for their citizens. That is why a number of national governments are pursuing initiatives to create new measures of progress, why April saw the UN host a High-Level Meeting on Happiness and Well-being, and why next week’s Rio +20 international sustainability conference includes negotiations on indicators that go ‘beyond GDP’.

It is also why we nef (the new economics foundation) created the Happy Planet Index. The HPI is the leading global measure of sustainable well-being. As a new measure of human progress, it measures what matters: the extent to which countries deliver long, happy, sustainable lives for the people who live in them. The 2012 HPI report, published today, ranks 151 countries based on their efficiency – the extent to which each nation produces long and happy lives per unit of environmental input.

The results  – which you can easily explore in detail on www.happyplanetindex.org – show that we are still not living on a happy planet. No country has good performance on all three indicators of life expectancy, experienced well-being and Ecological Footprint. But some countries do considerably better than others – and those that do best are not who you might expect. None of the top ten countries ranked by overall HPI score are among the world’s richest – in fact amongst the top 40 countries by overall HPI score, only four countries have a GDP per capita  of over $15,000. The highest ranking Western European nation is Norway in 29th place, just behind New Zealand in 28th. Costa Rica tops the HPI table with a substantial lead – due to its very high life expectancy which is second highest in the Americas, and higher than the USA, experienced well-being higher than many richer nations and a per capita Footprint one-third the size of the USA’s.

The HPI results provide evidence for something we instinctively know to be true – that progress is not just about wealth, and that it is possible to live both happily and sustainably. They show that while the challenges faced by rich resource-intensive nations and those with high levels of poverty and deprivation may be very different, the end goal is the same: to produce happy, healthy lives now and in the future.

In these challenging times we urgently need a clear compass to help us all move in the right direction.  The Happy Planet Index, with its clear compelling vision of progress towards sustainable well-being for all, can help nations and other groups around the world come together with a common purpose.

Nic Marks

Founder of the nef Centre for Well-being

Debbie Butler – An Introduction

When I asked if I could produce this piece I was quite excited as I enjoy writing, although my University tutors may not think so. I am always saying one day I will write a book so let’s hope this will put me further on in the journey towards my goal. I could bore you with the minor details about the fact that I have just become a grandma, which is far from boring and I am looking forward to being able to book another holiday this year. I love to go cruising.

I am in a privileged position to oversee what happens in the Patient and Public Involvement world around the East Midlands and South Yorkshire. This does keep me busy and will often see me catching up on work on the many bus and train journeys I do each month.  When I can work out how to use the wi-fi.

For my first post I thought I would give you an overview of how I got involved and the difference it has made to me.  I am not new to research: I studied at college doing a Business Studies Diploma in the 1980s, and was enthused by the concept and techniques of research but applied them in different fields, including marketing.

I became involved with the Mental Health Research Network when I went along to a meeting organised by the East Midlands and South Yorkshire regional office, held to encourage people with experience of mental health problems to get involved in its work. I have a diagnosis of personality disorder, and was working at that time for the Nottinghamshire Personality Disorder and Development Network, a community service run by Nottinghamshire Healthcare NHS Trust.

When I left the Network, I started working on a freelance basis for the hub, organising regular conferences that brought together people with experience of mental health problems, student mental health professionals and researchers.

In June 2010, I was successful in an application for a part-time post at the hub: and now work as a ‘Clinical Studies Assistant’ where my remit is to engage and encourage people with personal experience of mental health problems who live in the East Midlands and South Yorkshire area to get involved with both the work of the hub and Service Users in Research, and to introduce them to research teams who want expert input and advice. Researchers in the area are very keen to get people involved with their studies,’ what tends to happen is that they approach me first of all, and then I approach individuals who have the relevant experience.’

The structures and terminologies used in mental health research are many and varied and can be quite scary. In my future postings I hope to look at some of these and give you my thoughts on them. Time has been good to me and I have attended many meetings and training events to learn the language. It’s like living in another world. But don’t be put off by that Mental Health is a very exciting area of research and if I can just get one more person involved I shall be happy.

Take care till next time.

Debbie Butler
Patient and Public Involvement Coordinator
NHIR Mental Health Research Network
Mental Health Research Network
East Midlands Hub

From the Vice-Chancellor’s desk » Opening of The Institute for Mental Health

This week we have a guest-blog, from the Vice-Chancellor of the University, talking about the opening of the institute.  You can see the original blog, and other posts from the Vice-Chancellor the link below.

From the Vice-Chancellor’s desk » Opening of The Institute for Mental Health.

Last week we opened the new Institute for Mental Health on the Jubilee Campus, with Dame Sally Davies, the Chief Medical Officer, as our Guest of Honour.

The incidence of mental ill health is growing. According to NHS data, the proportion of the English population meeting the criteria for one common mental disorder has increased from 15.5 per cent to almost 18 per cent over the last 20 years. This incidence is forecast to grow further as a consequence of demographic change, principally an ageing population.

Mental illness causes considerable personal and familial distress. Indeed, recent work at the Harvard School of Public Health estimates that mental health is the leading cause of all disability-adjusted life-years, followed by cardiovascular disease and cancer. It also has significant economic costs, estimated at over £105 billion per annum in the UK in 2009 (up from £77 billion in 2007).

Despite its growing incidence, the distress it causes and its consequences for individuals, families and communities, mental health remains something of an under-researched and under-resourced area. This is no doubt partly due to competing priorities, partly because it is a complex spectrum of illness, and partly because research is inherently multidisciplinary. The last of these makes it harder to build the teams necessary to address complicated conditions and have impact on patient care and outcomes.

Working in partnership with Nottinghamshire Healthcare Trust, we created The Institute of Mental Health in 2006, under the leadership of Professor Nick Manning. Remarkably quickly it gained a national and international reputation for its fundamental and service facing research. In part this is due to the health of the University – NHS relationship and what we each bring to the partnership. In large measure it is down to the skill of Professor Manning and his research leaders in bringing together staff from such a wide array of disciplines: Medicine and Health Sciences, Business and Management, Education, Law, Sociology and Social Policy. The Institute now has the biggest concentration of interdisciplinary research power in the UK; creating critical mass at this scale not a straightforward task.

Almost 200 staff in Nottingham are now focused on, among other things: old age and dementia, ADHD and neuro-developmental disorders, mood disorders, recovery and integrated healthcare. About two thirds of those are University staff and one third NHS staff. The Institute also has a wide range of partners – regional, national and international – and multiple sources of funding, most notably from the National Institute for Health Research.

Mental health research is a profoundly important area and meeting the needs of an expanding patient population will be an increasing challenge for society in general and the NHS in particular. The IMH is already making a significant contribution to our understanding of a distressing range of complex illnesses, their diagnosis and treatment.

As Dame Sally Davies noted in her address, the IMH is a genuine partnership between higher education and the NHS, a partnership grounded in a shared agenda to make a difference in what is sometimes described as a ‘cinderella’ area.

The combination of high quality research undertaken at scale persuaded the University and Nottinghamshire Healthcare Trust to invest in a new building. Bringing together our research teams and clinicians into a single purpose built facility will create even more opportunities for collaborative and transformative research. In time that can only benefit patient care and recovery.

Symbolically it is entirely appropriate that the new building is located on Jubilee Campus, itself a beacon of regeneration and renewal.

Professor David Greenaway

Vice-Chancellor

Dr. Hugh Middleton – Dig Till You Gently Perspire

There has been something of a tea-cup storm over publication of findings from the TREAD study in the British Medical Journal on June 9^th (Chalder et al 2012). TREAD is an inventive acronym for the NIHR funded TREAtment of Depression with physical activity study which was conducted in Bristol and Exeter between August 2007 and October 2010. The BMJ paper was published online on June 6^th 2012 and so cyberspace was already buzzing before my own paper copy came through the letter box. The reason why is of course because the findings, as they were presented, were counter-intuitive and challenged practices many GPs and their patients find attractive. The episode also provides insight into ways in which a combination of the press’ and professional’s separate but complementary interests in simplifying the complex can result in misleading impressions.

Martin Robbins provides an account of how it went from a journalist’s perspective. The paper’s abstract reads “The addition of a facilitated physical activity intervention to usual care did not improve depression outcome or reduce use of antidepressants compared with usual care alone.”. A related press release read “New research published today [6 June] in the BMJ, suggests that adding a physical activity intervention to usual care did not reduce symptoms of depression more than usual care alone.”, and included a quote from Prof. John Campbell, General Practice and Primary Care, University of Exeter: “This carefully designed research study has shown that exercise does not appear to be effective in treating depression.”. In the early hours of June 6^th, only a short time after the press embargo had been lifted the BBC reported “Combining exercise with conventional treatments for depression does not improve recovery, research suggests.”. Later that morning the Guardian appeared with the headline “Exercise doesn’t help depression, study concludes. Patients advised to get exercise fare no better than those who receive only standard care, researchers argue”. This was followed by a number of online reactions by other journalists writing for the Guardian and the Daily Telegraph, and other commentators. Sharp eyed colleagues spotted all of this and the original BMJ paper was the subject of our clinical work-place journal club on June 11^th.

One of the earliest responses posted by the BMJ was from Stephen Pilling and Ian Anderson who led the development of NICE Guidelines for the Treatment and Management of Depression which were published in October 2009 and which recommend the use of exercise as a “treatment” for depression (Anderson et al 2009). On June 8^th they posted criticism of the TREAD report drawing specific attention to two perceived shortcomings. The first of these was that the intervention “tested” by TREAD was not in fact exercise itself, but contact with an exercise facilitator. Their NICE recommendations had been based upon understanding of research directly considering structured group exercise and as a result they did not regard the TREAD intervention as comparable. The second was that their recommendation was that exercise should be used as a treatment for “mild” to “moderate” depression, and the mean Beck Depression Score of TREAD subjects on entry into the trial (32.1) suggested that they were better thought of as in the “moderate” to “severe” range.   Other postings identify a variety of other technical and anecdotal concerns about the trial.

All of this could be nothing more than a storm in a tea-cup were it not symptomatic of several familiar and consistent strands, and didn’t result in misinforming or confusing vulnerable people who listen to the radio or read newspapers. Three questions are worth considering, and there may be more.

• How did so high profile a medical journal publish findings from so flawed a trial?
• Why did the press pick up upon its conclusions in so misleading and uncritical a way?
• What are the wider implications for understanding how we conduct and disseminate mental health research?

Was the trial flawed? What would Austin Bradford-Hill, credited father of it make of contemporary use of the term “Randomised Controlled Clinical Trial”? Chandler et al acknowledge that “Owing to the nature of the intervention, none of the participants, general practices, clinicians, or researchers performing the outcome assessments could be blinded to treatment allocation.” (page 2). Somehow the strict experimental requirement of double blinding has been allowed to lapse and clinical trials are considered randomised controlled clinical trials and elevated to premier status in the evidence hierarchy even when subjects and those involved in their treatment are aware of their treatment status. The whole purpose of RCT methodology is that it provides a way of controlling for the effects of that myriad of variables, predictable and unknown, which might influence the outcome of a complex phenomenon such as an episode of illness or emotional distress. We know that placebo or expectancy effects are considerable in mental health and yet we have drifted away from strict adherence to research protocols which control for them. Where investigated some 80% of antidepressant trial subjects correctly guessed whether they were taking control or trial medication on the basis of experienced side effects (Rabkin et al 1986). Someone I am clinically involved with who had agreed to take part in another investigator’s trial of a psychosocial intervention informed me that they had been allocated to the control arm. “How did you figure that?” I asked. “Because they told me.” was the reply. I doubt that Austin Bradford-Hill would respect that as an RCT and he would probably have similar difficulty with TREAD, but both are likely to be considered RCTs and their findings respected as such.

The press by their own subsequent acknowledgement picked up upon a sensational sound-bite without questioning its source or its provenance. Exercising to improve well being is folk lore. When a prominent medical figure says “This carefully designed research study has shown that exercise does not appear to be effective in treating depression.” news is breaking. “Prominent medical figures” are under pressure to maximise the impact of their research and might be tempted to present findings in a way that attracts press attention. Quoting experts is not the same as conducting one’s own investigative journalism, and it is certainly easier and less risky. Sensational medical stories are popular and so the temptation is understandable. News items reporting medical research findings that promise “a breakthrough” are all too common. However, the cynic doesn’t find it difficult to hear and see the appeal for more research funding or how far away the “breakthrough” actually is if by “breakthrough” what is meant is a radical improvement in everyday experiences of this, that or another condition. Perhaps we should consider the need for a “Medi-Levenson”, to consider the relationship between “prominent medical figures” seeking funding and good impact ratings, and the press seeking newsworthy reports of medical advance.

Two strands of this might be considered particularly relevant to the world of mental health. One is that devaluation and degradation of the strict experimental requirements expected of a definitive randomised controlled clinical trial are a particular problem in this area. The other is that our clientele are vulnerable and desperate by definition, and therefore particularly susceptible to misinformation.

The first of these is a direct consequence of the nature of the field. Expectancy and/or placebo effects do make a powerful contribution to outcomes from all forms of “mental disorder” and so it is particularly important to control for them in the course of evaluating a treatment. Unfortunately that is very difficult to do. All of our drugs have prominent side effects and trialists are obliged to warn participants of their possibility. Psycho-social interventions are even more difficult obscure. The result is that our old friend, the Emperor’s Clothes, becomes a little see-through in this context as well. We should not claim to be offering treatments that are truly tested by exacting RCT methods in the same way much of medicine presents itself as doing, but we do.

The second is self-evident but possibly deserves a little elaboration. A core feature of that most widely accepted psychosocial intervention, cognitive behaviour therapy, is acknowledgment of the reality and relevance of cognitive distortions. The problem is as much how the experience; ruminations, others’ voices, palpitations, dysphoria, anger, etc. is understood as it is the presence of the experience itself. What psychiatrists as authorities in the field tell people about the nature of emotional distress and how it might be mitigated plays an important “public health” role. Possibly one of the most damaging acts of unintended harm things we perpetrate is to claim we have answers, when in fact we don’t. This little story about exercise and depression might be a timely reminder. If you add TREAD to the other research concerned with this question then the answer has to be “this sort of research doesn’t and can’t provide a definitive answer”. If you are feeling low and you think it might help, do exercise.

To quote from Rudyard Kipling:

The cure for this ill is not to sit still,
Or frowst with a book by the fire;
But to take a large hoe and a shovel also,
And dig till you gently perspire;

 

Will ill-applied RCT methodologies ever truly improve on this?

Hugh Middleton June 2012

Clinical Associate Professor,
University of Nottingham School of Sociology and Social Policy
Honorary Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust

References

Melanie Chalder, Nicola J Wiles, John Campbell, Sandra P Hollinghurst, Anne M Haase, et al (2012) Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. British Medical Journal OPEN ACCESS, BMJ 2012;344:e2758 doi: 10.1136/bmj.e2758 (Published 6 June 2012).

Anderson, I. Pilling, S, Barnes, A. et al (2009). Clinical Practice Guideline No.90: Update: Depression in Adults in Primary and Secondary Care (Update). Gaskell/British Psychological Society. London

Rabkin, J. G., Markowitz, J. S. and Stewart J. (1986). How blind is blind? Assessment of patient and doctor medication guesses in a placebo-controlled trial of imipramine and phenelzine. Psychiatry Research, 19, 75-86

Kipling, R. (1902) Just So Stories. How the Camel Got His Hump. Accessed on line June 14^th 2012. http://www.boop.org/jan/justso/camel.htm

Sarah Dale – You don’t have to be mad to work here…

The twenty-first century workplace can be a bewildering setting in which to spend most of your waking existence. Those of us in western professional jobs could be considered blessed compared with our ancestors. Few can complain about risks of physical injury or life-threatening injustice.

Scratch the surface, however, and there are frequent examples of mental health under strain: sleepless nights; anti-depressant prescriptions and loneliness, to name a few.

As an occupational psychologist, I have listened to many people’s experience of work. Quite a number have been in higher education across a range of institutions, others have been in a variety of professional jobs: social workers, architects and doctors amongst others. There are some almost universal themes.

Most people are coping. In fact, most are more than coping. They are often very successful. Their colleagues or clients would probably be amazed to hear that they feel fragile psychologically, some or all of the time.

Behind the scenes, however, many feel that there are few people they can trust. They feel in fierce competition with colleagues especially if there are redundancies in the air. Some feel a sharp sense of so-called imposter syndrome – living in fear that they will be exposed for not being as good at their job as others think they are. They may rarely experience a satisfying sense of a day well spent. They are trying to meet conflicting demands on their time. They are tired. They may have an increasing sense of being overlooked or side-lined for unclear reasons. They may feel that they “are owed” by their employer, after many hours of overtime, or having prioritised their work over their family or leisure time once too often. They may simply feel that they have an overwhelming workload.

This mindset arrives gradually. Most begin enthusiastically, and most continue to be enthusiastic about their field or subject, some (if not all) characteristics of their employing organisation, and at least some of their colleagues. But it can become a draining cycle of mistrust, exhaustion and conflict.

This often results in a modern fight or flight response. Going into meetings with all guns blazing, or maybe engaging in something of a more Machiavellian nature; or alternatively, working to rule in some way. This may mean working from home as much as possible; focusing on one or two aspects of the job that are considered to have most career benefit or are the most enjoyable; or withdrawing from contact with colleagues. These are all strategies. None of them is especially comfortable (or likely to meet organisational needs effectively) though.

It seems to me that this amounts to a threat to the professional population’s mental health which is often hidden from view. Collectively, how resilient are we? At a time when we arguably need to be ever more productive, creative and collaborative, how are we nurturing a mental strength and flexibility which is up to the task?

In the face of complex working challenges, both organisations and individuals often respond by working yet harder; demanding higher qualifications, longer hours, and, given the technological advances, to be available for work almost all of the time. True, a lot can be achieved by hard work.

But I like to imagine what we might achieve if the majority of us were feeling on top form, able to think clearly and work together to maximise our strengths and support each other. Maybe I’m idealistic.

Nevertheless, just imagine.

Posted by:
Sarah Dale

Sarah Dale is a chartered occupational psychologist and author of Keeping Your Spirits Up. She has a business background as a chartered accountant, and runs her own consultancy, Creating Focus. She is currently looking for inspiring women of age sixty plus to interview or to invite to write letters to her as part of her plans for her next book. For more details, contact Sarah on sarah@creatingfocus.org or 07748 494688.

Sarah’s website is www.creatingfocus.org and she can also be followed on twitter (@creatingfocus) or Facebook (Creating Focus).

Shortlist for IMH Sculpture – Vote for your favourite!

You may recall back in April of this year, Victoria Tischler posted to the blog, discussing the plans for a scuplture to go outside the new Institute of Mental Health building on the Jubilee Campus (see here and here).  Well, we are pleased to announce that the sculpture maquettes are now on display in the lobby of the new building. The decision to choose which artist to commission will take place on the 14th of June.  In the meantime, you can visit the new Institute art pages, where there are images of the macquettes and information about each design, and a poll where you can vote for your favourite.