Monthly Archives: August 2012

The Consortium for Therapeutic Communities Annual International Conference: Delivering Integrity (22-24 Oct 2012)

The IMH Blog is pleased to announce The Consortium for Therapeutic Communities’ (TCTC’s) upcoming Annual International Conference taking place 22-24 October 2012.  This year’s conference theme is Delivering Integrity and it will focus on evidence based practice, value for money and sustainable outcomes.

2012 marks a significant year for therapeutic communities (TCs) with the 40th anniversary and re-launch of the Association of Therapeutic Communities (ATC) into the newly formed TCTC.  TCs are defined as ‘psychodynamically informed planned social environments’ (Boyling, 2011:152) and found in a variety of sectors including children and young people, prisons, addictions, personality disorder and learning disabilities.  Despite some excellent and notable examples of TC research (including, but not limited to, Rapoport, 1960; Bloor et al, 1988; Dolan et al, 1996; Rawlings, 1998; Lees et al, 1999; Chiesa and Fonagy, 2000; Freestone, 2005; Freestone et al, 2006) TCs have a ‘mixed record’ of conducting research, whether qualitative or quantitative (Morant and Manning, 2005:230).  In recent years, more is being done to demonstrate clinical effectiveness as funding becomes linked to evidence based research.  Yet applying outcome based studies in TCs is difficult as TC intervention is holistic and not easily broken down into separate observable components which can be measured quantitatively (unlike pharmacological studies for example).  Thus using the RCT methodology favoured by commissioners and funding bodies is often a challenge for TCs.  In addition, finding common outcomes across TCs can be hard due to the diversity of communities themselves and because what constitutes an outcome can vary widely.  Of course TCs are not alone in this as the same could also be said of other psychotherapeutic approaches,  particularly those styles of therapy (e.g. psychodynamic) which also do not lend themselves easily to RCT methodology.  However in the midst of continued challenges to secure funding, the question of how to show that TCs deliver integrity in therapeutic interventions becomes a central issue.

In particular the upcoming conference will explore:

  • how to develop specialist therapeutic practice
  • the latest developments in research and evidence
  • key messages for commissioners and purchasers
  • experience of large and small groups as method

The conference will be of interest to all those working in, supporting, commissioning or purchasing therapeutic services in the following sectors:

  • children & young people
  • personality disorders
  • mental health
  • addictions
  • learning disabilities

Location
Cumberland Lodge, Windsor Great Park

Prices
TCTC Members (full) £495
Non–‐members (full) £555
(*£100 discount on shared accommodation)
TCTC Members (day 1 or 3) £95
Non–‐members (day 1 or 3) £115
TCTC Members (day 2) £145
Non–‐members (day 2) £165

To book a place, please contact TCTC:
e: post@therapeuticcommunities.org
t: +44 (0)1242 620 077

TCTC Conference Flyer 2012 (PDF)

References:
Bloor, M., McKeganey, N. and Fonkert, D. (1988) One Foot in Eden: a sociological study of the range of therapeutic community practice.London: Routledge.

Boyling, E. (2011) Being Able to Learn: researching the history of a therapeutic community. Social History of Medicine 24(1): pp.151-158.

Chiesa, M. and Fonagy, P. (2000) Cassel Personality Disorder Study: methodology and treatment effects. British Journal of Psychiatry 176(5): pp.485-491.

Dolan, B., Warren, F., Menzies, D., and Norton, K. (1996) Cost Off-Set Following Specialist Treatment of Severe Personality Disorder. Psychiatric Bulletin20(7): pp.413-17.

Freestone, M., Lees, J., Evans, C., and Manning, N. (2006) Histories of Trauma in Client Members of Therapeutic Communities. Therapeutic Communities 27(3): pp.387-409.

Freestone, M. (2005) Overview of an Ethnographic Study of the UK DSPD Pilot Units. Therapeutic Communities 26(4):pp. 449-464.

Lees, J., Manning, N., and Rawlings, B. (1999) Therapeutic Community Effectiveness: a systematic international review of therapeutic community treatment for people with
personality disorder and mentally disordered offenders.
CRD Report 17, York: NHS Centre for Review and Dissemination, University of York.

Morant, N. and Manning, N. (2005) Principles and Practices in Therapeutic Community Research. Therapeutic Communities 26(3): pp.227-243.

Rapoport, R. N. (1960) Community as Doctor. London: Tavistock Publications.

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

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Chris Sampson ~ Considering Time Perception

Chris Sampson ~ Considering Time Perception

Chris works in the IMH building for the NIHR CLAHRC and runs The Academic Health Economists’ Blog: http://aheblog.com/.

In economic evaluations in health, time matters. More time in a bad health state is necessarily worse (or no better) than a smaller amount of time in said health state. Likewise, the value of an intervention increases with the duration of benefit. The standard QALY framework takes this into account. Furthermore, time preferences matter. Economists deal with this in a present value framework; discounting future costs and benefits. But there is another aspect of time which is not taken into account; time perception. Issues surrounding our perceptions of time recently appeared in the usual pop science outlets following the release of Claudia Hammond’s new book ‘Time Warped‘. As medical, neurological and psychological understandings of time perception improve, is it time economists weighed in?

Economists have considered the effects upon time perception of things like ‘awe‘ and the cognitive resource demands of tasks, while others have investigated the interaction between time preferences and time perceptions. It seems none have investigated the implications for an area in which time perceptions might play their most important role; health.

Why might it matter?

Time is an abstract idea, but economists rarely treat it as such. This means that people’s perceptions of time are overlooked. This may be a reasonable approach if we are working at the mean and people’s perceptions of time are consistent across health states. But what if they aren’t? Consider a basic illustrative QALY example:

  • Scenario A: 2 weeks in 0.8 health, followed by 2 weeks in full health
  • Scenario B: 1 week in 0.6 health, followed by 3 weeks in full health

Clearly these scenarios give the same QALY result. If one perceives time to pass more slowly in a worse health state then we might be able to add to the scenarios that in ‘A’ the first 2 weeks “feels like 3 weeks”, while in ‘B’ the first week “feels like 2 weeks”. If we were to weight the QALY values in these periods according to perceived time we would have a preference for scenario A. With these re-weightings, 2 weeks of 0.8 in scenario A would become equivalent to 2 weeks of 0.53, while 1 week of 0.6 in scenario B would become equivalent to 1 week of 0.3; increasing the difference between the two health states.

Applications

We all experience fluctuations in our own time perception. Time flies when we’re having fun. It might fly when we’re healthy too. It may be the case that a general and testable model of time perception exists in health. The most likely relationship seems to be that being in poorer health would be associated with a perception of time moving more slowly. There may also be differences in time perception between different groups of people (men and women, children and the elderly) that we may or may not want to adjust for. Some interesting implications of time perceptions for the burden of waiting times have already been identified.

Particular health conditions can affect an individual’s perception of time, and this is where the consideration of time perceptions could be crucial. Children with ADHD, for example, have been shown to perceive time in very different ways to those without ADHD. Likewise, cancer patients with evidence of disease have been found to perceive time as progressing more slowly, compared with those without. If a condition causes individuals to perceive time to move more slowly in a consistent and measurable way, then specific rules could be established to assign greater weight to treatments for said condition.

Implications

The relationships above are all testable and quantifiable. Time perceptions can be easily tested by denying well and unwell patients access to a clock and calendar, and then asking them about the ways in which they perceived their time in these states. It is important to note that during these times our perception of time may be affected by other things; whether we are confined to a hospital bed, stuck in the office or asleep at home. All of these things could be controlled for in an experiment.

The real question is whether or not we (the public) want to take this into account or not. If the public’s stated preferences do not reflect the effects of time perception then should we artificially weight their preferences to do so? The issue seems analogous to that of adaptation (to which time perceptions would no doubt be subject!). Public valuations of the effects of time perceptions could be captured with the usual time trade-off, standard gamble or discrete choice experiment techniques. One difficulty would be in ensuring that there is no double-counting. It seems likely that this would not apply in the specific applications, where the general public’s valuations would not consider ADHD’s effects on time perception, for example. However, it seems possible (likely, even) that the general public would consider time perception effects associated with being generally unwell.

Perceptions of time have been discussed in economic and health economic literature in respect to experienced utility and biases of memory in retrospective valuations. There has been little contribution to theories about individuals’ present time perception. I believe it may be time for these ideas to be explored further, particularly in relation to specific health conditions, and applied to preferences and expected utility in health.

How do you see time perceptions influencing quality of life? To what extent do you think differences in time perception either could or should influence health care decision making? Please comment below.

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Dr Simon Clarke ~ All in the mind? The Dynamics of Chronic Pain

As a clinical psychologist working in chronic pain (CP), the question I get asked most by lay people (apart from whether I am reading their mind) is why bother? The thinking is usually this: pain is a physical experience that results from an injury of some sort, which surely requires a physical (usually medical) remedy. The implication from this, of course, is that I’m a psychologist and so I deal with ‘mental’, and not physical, experience. And as pain is clearly a physical experience, what am I doing in pain?

This form of thinking, which the philosopher John Searle called ‘residual dualism’ (Searle, 1984), is perhaps understandable in non-professional people, especially since such dualisms permeate many aspects of Western culture. However, such ontological faux pas are less forgivable with experienced medical professionals who perhaps should know better. The amount of times I have been asked by medics whether this patient’s pain is “all in their head”, or if I can please tell them whether their pain is “psychological” or “physical”. As if these things are mutually exclusive! Sometimes archaic, cod-Freudian gems are wheeled out for effect: a patient is described as having “psychogenic” pain or being a “somatizer”.

Unfortunately, these statements quoted above betray a fundamental misunderstanding about the nature of body/brain perception. Pain is a complex experience that involves a dynamic interplay between physiological, emotional and psychological (cognitive) elements. Theories based on experimental neuroscience see CP as a failure of the brain and nervous system to regulate pain signals from previously damaged pain areas. Pain can thus be likened to a faulty alarm system that has not been switched off, even though the initial emergency has passed (see Weich & Tracy, 2009). Psychological factors such as heightened pain expectation, experiential avoidance, trauma, mood disorders and stress are crucial factors maintaining this alarm system (Gatchel et al., 2007). As the International Association for the Study of Pain have pointed out, “[pain] is unquestionably a sensation in a part or parts of the body but it is also always unpleasant and therefore also an emotional experience [emphasis added]” (Merskey, 1986, p. 1, as cited in Gatchel et al., 2007). The pain experience is integrative: you simply cannot separate the “physical” from the “psychological”. It is phenomenological nonsense.

Suffering with a pain condition can be a horrible experience. CP disrupts vocational/educational functioning, relationships, sexual functioning, interests/hobbies and overall quality of life. It is very common for people to have repeat hospital appointments with different departments, have to undergo multiple scans/investigations/medication etc. which usually leads to inclusive diagnosis and/or treatment. Often they have to battle with stigma from family, friends, wider society and even within the medical professions. They are often accused of making it up, exaggerating their symptoms or malingering. Not surprisingly given all of this, mood problems in people with CP are common (Gatchel et al., 2007).

Medical systems perpetuate this process with the notion of a catch-all diagnosis and binary, either/or dichotomous evaluations. A careful balance has to be struck with patients between gently pointing out the importance of psychological factors, without reinforcing earlier messages that they are making it up or it is all “in the mind”. This can be a liberating message for patients that can help people finally move on with their life. Isn’t it time for our medical systems to do the same thing?

Posted by:
Dr Simon Clarke
Clinical Research Psychologist (Physical Health Speciality)
University Of Nottingham and Nottinghamshire Healthcare NHS Trust

References:
Gatchel et al. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133, 581-624.

Merskey, H. (1986). International association for the study of pain: Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain, 3(Suppl.), 1–226.

Searle, John. (1984). Minds, Brains and Science: The 1984 Reith Lectures. Harvard University Press.

Wiech, Katja, and Irene Tracey. (2009). “The Influence of Negative Emotions on Pain: Behavioral Effects and Neural Mechanisms.” NeuroImage 47, no. 3,  987–994.

 

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Deborah Kitson, CEO, Ann Craft Trust, University of Nottingham

Deborah Kitson, CEO, Ann Craft Trust, University of Nottingham

Link to UoN press release: http://www.nottingham.ac.uk/news/pressreleases/2012/august/will-we-learn-from-the-winterbourne-view-findings.aspx

A leading national charity committed to safeguarding disabled children and vulnerable adults from abuse says it hoped that lessons can be learned from the cases of abuse uncovered at Winterbourne View.

Responding to the serious case review, commissioned by South Gloucestershire’s Safeguarding Adults Board and published today, the Ann Craft Trust says although the findings are ‘sadly predictable’ it hopes it will result in safer services for vulnerable adults living in residential services across the country.

Deborah Kitson, Chief Executive of the Ann Craft Trust which is based at The University of Nottingham, said: “Poor management, lack of training, service users and staff not being listened to — these are all common themes that we have got too used to hearing about.

“Put these issues alongside staff who have little respect for the people they are supporting and who achieve some misguided sense of satisfaction and enjoyment from taunting vulnerable adults and you will always have the potential for very serious abuse.

“A member of staff raised the issue at Winterbourne a number of times both within the organisation and to the Care Quality Commission but still nothing happened resulting in the abuse continuing over a long time. Did anybody encourage the people who were living there to complain and to voice their concerns? And most crucially would anybody have listened if they had? Vulnerable adults, those with mental health needs and learning disabilities often rely on those supporting them to raise concerns on their behalf. We have to make sure that when they do their concerns are acted upon promptly and that the abuse is stopped.”

The Ann Craft Trust has completed research looking at whistleblowing in learning disability services and found that the experience for many had been traumatic. Many were not believed, were blamed for criticising services and were labelled as troublemakers — most worryingly many said that they would not do it again.

Deborah Kitson added: “This serious case review may be sadly predictable but it needs to be read and lessons need to be learned. It is not rocket science — this is about ensuring that we value and respect people, that we listen to concerns when they are raised and that we have processes in place that ensure that appropriate action is taken to stop abuse when it does occur.”

The Ann Craft Trust works with staff in the statutory, independent and voluntary sectors to protect people with learning disabilities who may be at risk from abuse. It also provides training regarding sex education for people with learning disabilities. www.anncrafttrust.org

 

 

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Dr Rex Haigh ~ Has CBT killed the human spirit?

The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we’re up against, originally posted on 17 June 2012 entitled ‘Has CBT killed the human spirit?‘.

Much as psychoanalysis set the cultural tone for our understanding and conduct of relationships for most of the twentieth century, cognitive behavioural therapy (CBT) has been leading us into a much less forgiving place for the last twenty years or so.

CBT Circle

In the world of psychotherapy, CBT has numerous siblings and cousins: most with three letter abbreviations to make a multiflavoured soup of ‘alphabetti spaghetti therapies’. Two flavours of the month are Dialectical Behaviour Therapy (DBT)  and Menatlisation Based Therapy (MBT). DBT, with its trendy ‘mindfulness’ plus new age and hippy edge, give its authoritarianism a warm fuzzy feeling; mentalisation has considerable weight of respectability afforded to it by years of attachment research in the experimental psychology departments of prominent universities – and charismatic professors with superstar status to market it. There are many other manualised and packaged ‘new therapies’, easily findable with your favourite search engine. But my overwhelming feeling is that they are all missing the point, and engaged in a pointless horse race with celebrity status prizes for the academics who reduce the interventions to dumbed-down therapy cookbooks, and then make sure everybody is following the recipes with multivariate statistical analyses backed up by powerful regulators like NICE. To me, this all seems like a very elaborate, somewhat sinister and ruthlessly inexorable way of taking the essential human qualities of the therapeutic relationship out of the picture.

Mandala

It feels like these ways of working are all fashions of the moment – holding onto the coat tails of …of what? That is the big puzzle. All sorts of vaguely pejorative words and phrases get bandied about by malcontents like myself – without understanding the precise definitions – such as reductionism, materialism, biogenic dogmatism, logical positivism, determinism, behaviourism, scientism, alienating modernity, market managerialism. The best one I’ve seen lately is instrumental rationality: “A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end”.

At its root, at least from where I stand at the moment, seems to be the need for certainty – and the fear of chaos that would ensue were we not able to measure, predict and control everything in our working lives. It is interesting indeed that complexity – what we have to deal with on multiple levels in our work every day – is only a step away from chaos, and indeed ‘creative chaos’ is an important ingredient of therapeutic communities, and perhaps all group therapies. Along with ‘therapeutic ordinariness’ and Keats’ Negative Capability (being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason) we seem to be in the world of the romantic poets, postmodernists, and idealists – dealing with moral philosophy, semiotics and aesthetics. Truth and love and beauty, maybe, rather than rigour and technique and effectiveness.

I would maintain anywhere that we need all of both sets of values in the world of the complex and often chaotic systems that determine human development, and we confront daily in psychotherapeutic work. We need multivariate regressions, p-values and confidence intervals for instrumental reasons – but they should be our tools rather than our purpose. Perhaps complexity and chaos theories could provide a conceptual, and even mathematical, bridge between these two worlds.

After an ill-tempered social meeting with two senior colleagues, and months of fighting the ‘corporate machine’ in my day job I think these considerations have wider relevance – in academia, public policy and health service management. What links them may be the impossibility of allowing any human being working in these systems to trust another – an no longer allowing people to hold that uncertainty, rather than algorithms and risk registers.

Universities are now run by financial considerations where the security of grant income subordinates everything else: they have to ‘play it safe’. We end up with students mounting legal challenges when they do not agree with the results when their work is marked, and researchers who produce numerous programmes, projects and papers with very little real value – and only need to show that their strategy does not cause any risk to the projected income stream.

In public policy, it is utterly unacceptable for anybody in the civil service to admit any failing – however small – that might reflect ill on their political masters. When we have a colossal failing – such as the absence of anything that is genuinely psychotherapeutic in the statutory structures of the whole of a country’s mental health system – then the conspiracy of silence is utterly deafening…

In the corporate world of NHS Foundation Trusts, a similarly sanitised version of reality is all that is allowed to be released for public consumption. When everybody knows that real cuts are being made, it cannot be spoken – even in letters to medical colleagues. Presumably it would be a ‘reputation risk’ for the truth to be acknowledged.

But this ugly truth – of the way we are so often not allowed to relate to each other as human beings any more – might even go to the core of the current global malaise. I met an economics undergraduate the other day, and he was explaining to me the depth of mathematical and statistical techniques that he is struggling to learn. The bursting of ‘debt bubble’, from which we are all now suffering, was built on sophisticated algorithms which allowed financial risk to be packaged and sold at lightning speed, with no intervening human thought about sustainability, or feeling that something morally wrong was being done. Is it not this chicanery, and the political systems which underpin it, that need to be exposed and dismantled?

The answer, I hope, is in the philosophy of greencare. Not particularly in the details of therapeutic horticulture, animal assisted interventions or care farming, but in the better use of land, air, soil, water, sunshine and each other for our mental health; the realisation that we need to live sustainably in a finite world; that mental health care is not scalable like an industrial process; and that it’s only relationships between each other that really matter.

Posted by:
Dr Rex Haigh FRCPsych
www.greenshrink.blogspot.com

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Debbie Butler (PPI Coordinator) ~ 2nd Post

Well what a week. There has been progress with the MHRN Industry Group of service users and carers. This group has met twice now and are preparing to meet again in a few weeks.  The MHRN are pushing for more recruitment to these types of studies and although it is very complicated, we were privileged to have a good few people attend our first couple of meetings and give positive comments on being involved. The next meeting is the subsequent step where we discuss as a group the way forward and look at where we can get involved in the different studies. Personally I find it quite a difficult subject to understand but I am sure I will get there. (Perseverance is the key.) How can we as a small cog in such a massive, global enterprise make our way into what seems a very closed shop when often, so I have been informed that the large organisations that develop these studies have never ever involved the public and users of the medication that they produce. More positive things have happened within the MHRN – we seem to be ironing out difficulties which moving into the new building have bought about.

Another positive for me this week has been on a personal basis really and a big boost to my self-esteem. I have been asked by various members of IMH staff about patient involvement and have been glad to help. Thank you to those who have asked and if I can be of any help to others please let me know. My experience within the Trust has been over a good few years and I have met a quite a lot of individuals from doing this. My mum always asks me if there is anyone I don’t know. It’s not unusual for me to go out without seeing anyone from work or the classical music scene.  Keep fingers crossed for me, I am seeing a new singing teacher today based at the Uni.

Patient and Public Involvement for the MHRN took a great boost on Friday 27th July as I went to the Rosewood involvement centre up in Ollerton to talk to their Friday Group about the MHRN and can I say, I came home feeling like I was walking on air.  The Friday group is a well attended group of service users and carers who get together for support and encouragement to each other and to hear about different things going on in the Trust and outside. The Rosewood centre is the sister Involvement centre to the one at Duncan Macmillan house and is a very thriving place to go. They even have their own belly dancing troop. There was so much enthusiasm from the entire group to listen, ask questions and equally wanting to become involved it was just astounding. Can I post a great big thank you to them all. I have so many contacts to make and friendships to develop, it was extraordinary.  The MHRN as an organisation is obliged to involve service users and my job is to co-ordinate the involvement and recruitment to different research studies. The boost from attending the Rosewood centre was that we could form a group in the North Nottinghamshire area and help researchers who can sometimes be Nottingham centric develop studies in the north of the county. I am sure the group would be very useful. The wealth of experience is an added bonus to anyone in the field of research.

I was one of the first service users to be employed by the Trust way back in 1999 (I think it was then). And have seen a tremendous development in this area. I cannot thank all my friends and colleagues enough for their hard work in developing Involvement. It started off with one young man called Liam O’Neil who sadly is no longer with us but his name is kept alive with one of the Trusts OSCARS bearing his name, and has developed into quite a large staff team.  Liam was a service user who I met when I was a volunteer at the Nottingham Advocacy group; he was quite a cautious man but was very vocal and knowledgeable around involvement of service users in any aspect of their care and the organisation of the Trust. Liam worked on his own to begin with to set up the involvement department in the Trust until a manager was appointed then things seem to go all out to what we have today, two Involvement centres.

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

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