Challenges to Government’s principles used to define the care of mental ill-health

by Julia Evans on July 15, 2010

From:             Julia Evans

Subject:        Challenges to Government’s principles used to define the care of mental ill-health

Date:             15 July 2010

To:     Circulated widely within both Houses of Parliament

There are four areas of concern in the following message.   These areas drive many of the decisions now being taken.  The principles, from which Government policy is derived, are not robust.

Is the government’s systematic provision of risk-free cures with or without human contact in the treatment of mental ill-health justified?

Is the prevention or cure of mental ill-health possible or a viable Government policy?

Is the undermining of our well-established system of law and justice by the use of Privy Council powers, for example, Health Professions Order 2001, needed or justified by the alleged outcome: the prevention of unskilled and unscrupulous practitioners (and probably criminals) preying on vulnerable people?

Thank you for your attention

Julia Evans July 2010 (contact details at the end)

These questions are examined using information from the public domain under the following headings:

Challenge to Anne Milton’s, 2nd June 2010, statement in Parliament

Summary: The statement: ‘There is no doubt that vulnerable people are often preyed upon by unskilled and unscrupulous practitioners’ is challenged.  There is no evidence which supports this allegation.  It must be withdrawn.

Assumptions used in Medical Research Council’s Mental Health Review Group’s research strategy

Summary: Is it possible to prevent mental ill-health?

Are techniques of ‘preventive medicine’ appropriate for use within the area of mental ill-health?

The MRC’s report sets out to eliminate mental ill-health using techniques from preventive medicine.  This paper argues that the elimination of mental ill-health is neither possible nor desirable. Symptoms of mental ill-health have been with us for more than 7,000 years.  Taking steps to make the mentally ill disappear , by political decree, diminishes what it is to be human.

Evidence: The probability that paying attention to human subjects is at least as effective as drugs.

Summary: Clinical trials are being abandoned by drug companies in the area of mental ill-health as there is no way to absolutely define symptoms of mental ill-health and there is evidence that giving attention to the sufferers works at least as well as drugs.

The transfer of the industrial definition of risk and use of systems into health care to produce units of wellbeing as defined in the legislation

Summary: Examples from White Papers are given of the inappropriate transfer of industrial definitions of risk to health care.  Examples of how Government gives over responsibility for the treatment of human beings, from human practitioners to a centrally defined system.  The use of ‘safeguard’ and ‘wellbeing’ in the Order regulating the Health Professions Council is questioned.  It is inappropriate at best for a Government to promise to safeguard individual subjects from harm let alone bring their wellbeing up to a centrally defined standard by the imposition, from the centre, of multifarious rules, regulations and working practices backed with the weight of law.

Industrial definitions of risk (first written and circulated in 2006)

The system controls practice (Written and circulated in 2009)

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Challenge to Anne Milton’s, 2nd June, statement in Parliament

Anne Milton (Parliamentary Under Secretary of State (Public Health), Health; Guildford, Conservative)  2nd June 2010 to House of Commons:

“There is no doubt that vulnerable people are often preyed upon by unskilled and unscrupulous practitioners.”

Please note:  “Practitioner’ probably refers to the previously mentioned psychotherapists and counsellors or professions allied to health care.

Some questions which the Government should answer:

a) What is the Government’s definition of preying, beyond that in use already in the legal definition of criminal acts: fraud, misrepresentation, stalking, harassment, and so on?

b)  By what characteristics does the Government distinguish vulnerable people from the rest of us?  How are they more vulnerable?

c)  How many ‘unskilled and unscrupulous practitioners’ exist?

I assert that there are in excess of 100,000 talking therapists in practice either as volunteers to charities or within churches or working within the NHS or its contracted suppliers or self-employed.

d)  What evidence does the Government have for the breakdown of numbers of talking therapists working in the State sector, the voluntary sector (including churches), and self-employed?

e)  How many talking therapists are included in this definition of ‘unskilled and unscrupulous’?

f)  What is the size of the problem?

The Government’s evidence, please.

g)  What is the Government’s definition of ‘often preyed’ upon?

Is it 1 session a week for each of 100,000 therapists?  Or 2 practitioners a year who prey on all their clients? Or what? What does ‘often’ mean?

I know of 2 cases in the last 3 years where talking therapists have been found guilty of criminal acts with respect to their clients.  Does this figure match the Government’s researches?

In addition to these 2 criminal cases, how many cases of the ‘vulnerable’ being ‘preyed’ upon is known to the Government?  Please give a figure – this serious allegation needs substantiating.  It is now down as fact in Hansard.

So the practitioners who prey on vulnerable people are unskilled and unscrupulous.  These are serious allegations.

What is the Government’s definition of unskilled or unscrupulous?

How has the Government reached this conclusion?

And on such fantasies as these, a raft of authoritarian control and ubiquitous regulations is put expensively in place……

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Assumptions used in the Mental Health Review Group’s for the Medical Research Council’s research strategy

Some of the unfounded assumptions in a recent Lancet article (see end of section).  Quotations are in italics:

The numbers game.  There are lies, damned lies and statistics…..

16% of adults in the UK have a common mental disorder such as depression at any one time.

Nearly 10% of children aged 5-16 years have a clinically diagnosable mental health problem which can often persist into adult life.

Challenge:  How sound are these figures? Where does the 16% come from?  Are diagnoses of depression, especially using NICE definitions, comparable?  I think not.  These descriptions are subjectively applied.  What is the Government’s evidence for the reliability of this figure? How are you certain that the sufferer’s circumstances: unemployment, death of close relative, are not playing a role?  Just how sound are these categories that are in use? Ditto for clinically diagnosable mental health problems in children.

Mental health problems are also an enormous financial burden to society and the economy.

Challenge:  This is how Lord Layard (see here for the ‘Happiness czar’ explaining the politics of happiness) sold IAPT to a gullible government.  What is the evidence for this assertion?  Or is it just those receiving long term sickness benefit who are counted?  How is the ‘enormous financial burden’ calculated?  Is it possible for a Government to eliminate this financial burden?  Where is your evidence?

To ensure an economically competitive and flourishing society, we have to reduce the burden of mental ill-health

Challenge: What is the Government’s evidence for this statement which connects an economically flourishing society with a reduction in the burden of mental ill-health?  How does the Government define a flourishing society?  One where individual difference and the right to be miserable, are removed?  What is your definition? I remind you that the Third Reich also thought it knew how to reduce the burden of ill-health.  Is its reduction really a proper concern for a Government?

An innovative vision for a national mental health strategy

Challenge:  Is a national mental health strategy possible?  If yes, do you start at the top and define what a Government-approved standard unit of wellbeing is, or at the bottom, with the individual sufferer?  Discuss.

The prevention of mental illness is a long-term aim

Wow!  A history lesson is in order.  The following was found in Wikipedia on Melancholia, here, on June 30th 2010.

From the 5th and 4th centuries BC, the Greeks were able to define non-specific depression by low levels of energy and activity. Schizophrenias and bipolar disorders were also known to them.  They classified mental ill-health by their common cause rather than by their properties as NICE does. Rather than NICE definitions, personality types were determined by the dominance of one of the four humours.  Hippocrates, in his Aphorisms, characterized all “fears and despondencies, if they last a long time” as being symptomatic of melancholia.  The Arab psychologist, Ishaq ibn Imran (d. 908), used symptoms to describe “cerebral melancholia” or “phrenitis” such as sudden movement, follish acts, fear, delusions and hallucinations. Ali ibn Abbas al-Majusi (d. 982) discussed mental illness in his medical encyclopedia, Kitab al-Malaki, which was translated into Latin as Liber pantegni.  One of his descriptions: “Its victim behaves like a rooster and cries like a dog, the patient wanders among the tombs at night, his eyes are dark, his mouth is dry, the patient hardly ever recovers and the disease is hereditary.” In The Canon of Medicine (1020s), Avicenna (980–1037 CE) dealt with neuropsychiatry and described a number of neuropsychiatric conditions. He described a depressive type of mood disorder in which the person may become suspicious and develop certain types of phobias . Avicenna suggests many causes including the fear of death, intrigues surrounding one’s life, and lost love. As remedies, he recommends treatments addressing both the medical and philosophical sources of the melancholy, including rational thought, morale, discipline, fasting and coming to terms with the catastrophe.  Robert Burton, whose The Anatomy of Melancholy (1621) treats the subject from both a literary and a medical perspective. wrote that music and dance were critical in treating mental illness.  The Turkish writer Orhan Pamuk in the book Istanbul: Memories of a City elaborates on the ancient term hüzün as used in modern Turkish. It has come to denote a sense of failure in life, lack of initiative and to retreat into oneself.

Conclusions:  Symptoms of mental ill-health have been written about since the 5th century BC – 7,000 years.  The causes of mental ill-health have been a matter of conjecture throughout this time.  The symptoms of mental ill-health as described in NICE clinical guidelines are just the latest futile attempt to rigidly classify signals which vary with each unique human being.  The NICE prescribed treatments are cost-limited sessions of cognitive behaviour therapy or being coshed with drugs.  I think that the 17th century prescription of music and dancing more matches with the Archbishop of Canterbury’s view as expressed to the new Parliament on Tuesday 8th June, 2010.

Dignity was Dr Williams’s key word. “Good government from a Christian point of view is about the acknowledgement and reinforcement of human dignity.” The purpose of strong government was to make strong citizens, he went on: “not by resigning responsibility, but by deliberately building capacity for co-operation”. The vision of shared dignity was one that would “never allow the weak, the supposedly ‘unproductive’, the very old or the very young, the mentally ill and physically challenged and terminally ill to disappear from the radar; on the contrary, it will always ask what are the strengths that they bring, the contribution without which society would be poorer”.  (Church Times, 11th June 2010)

The MRC report sets out to eliminate mental ill-health using techniques from preventive medicine – techniques which have been very successful in eliminating polio, scarlet fever, and so on.  I do not think the elimination of mental ill-health either possible or desirable.  Symptoms of mental ill-health have been with us for more than 7,000 years and I agree with Dr Williams that taking steps to make the mentally ill disappear diminishes what it is to be human.

So how is this Government going to show their responsibility for those who they define as unproductive?  Are they going to continue supporting research based on the factory method of producing wellbeing, as above?  Or listen to alternative approaches to the problem?

Reference: A UK strategy for mental health and wellbeing  www.thelancet.com Vol 375 May 29, 2010 pages 1854-1855 by Barbara J Sahakian, *Gavin Malloch, Christopher Kennard, on behalf of the Mental Health Review Group  Department of Psychiatry and MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK (BJS); Medical Research Council, London W1B 1AL, UK (GM); and Department of Clinical Neurology, University of Oxford, Oxford, UK (CK)

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Evidence: The probability that paying attention to human subjects is at least as effective as drugs.

The problems indicated by the evidence in a Financial Times article (reference at end of section):

1)  Drugs cannot be proved to work any more reliably than interventions based on giving recognition.

2)  There is no such thing as a standard depression or normal functioning, so trials to prove effectiveness cannot take place.  Evaluation against normal functioning does not work in the field of psychic distress or mental ill-health.

3)  The effect of taking notice of people’s distress, needs to be taken very seriously indeed.  It is the same as the Hawthorne effect.  If human beings pay attention within a relationship of care to another human being, they start to feel better……  Further, psychopractitioners are trained in working within relationships of care to either stabilise or change.  Why does the government persecute us?

Drugs are a high-risk area for investment within mental health – it is official.  Science does not give new leads. – extract in italics.

 Several of the largest drugmakers have recently decided to curb or cease research in the field, reducing the funding and expertise available to find better treatments………………..   The withdrawal reflects growing financial pressures on the industry to cut spending on high-risk low-profit areas such as mental health, where there are few new scientific leads in the laboratory and many cheap generic drugs are coming on to the market

Evaluation fails the test….. drugs have weak “endpoints”.  It is not possible to measure success. from article

In February Andrew Witty, chief executive of GlaxoSmithKline, said his company would stop work on antidepressants, bringing an end to research……. GSK denied that its decision was related to the public criticism, regulatory scrutiny and litigation over suicidal feelings and other alleged side-effects generated by Seroxat in recent years…… Rather, Mr Witty said there were more promising and productive areas of research…, while antidepressants were “among the most expensive, high-risk” drugs to develop, with weak “endpoints” that made it difficult to measure likely success until late in the development process. AstraZeneca took a similar view a few weeks later, winding down its discovery work on depression and other mental disorders as it pared back in-house research spending.

AND mental disorders in human subjects are difficult to identify. Extract from article

At the heart of the problem is the difficulty in first identifying appropriate patients to take part in clinical trials and then proving that they do better on the new drug candidate than on placebo (dummy pills). “That is the number one reason why we as an industry are moving away from an area that has an incredible burden of disease,” says Frank Yocca, AstraZeneca’s head of discovery for central nervous system drugs. Clinical trials are particularly hard to organise for antidepressants because, for a start, medical definitions of depression and its severity are not as clear-cut as for most other diseases. In addition, reliable “bio markers”, objective measurements of disease progress such as brain scans or blood tests, are unavailable.

Everyone, whether on drug or placebo, seems to get better.  AND surprise, surprise, interaction with another human being supports the cure or is essential to the cure.

Then there is the large – and mysteriously growing – placebo effect, which makes it hard to demonstrate statistically that patients taking the active drug are doing better than those on dummy pills. Psychiatrists have long recognised that patients with depression and other mood disorders are susceptible to the suggestion that they will get better. But it is not clear why placebo power should have increased, as analysis of clinical trials over the past 30 years shows it has.

“It would be like invoking magic to suggest that people are becoming more suggestible,” says John Geddes, professor of psychiatry at Oxford University. “The change is more likely to be an artefact of the way patients are recruited to clinical trials.”

Some further experimental evidence of what may be involved

Extracted from Wikipedia here

‘The Hawthorne effect is a form of reactivity whereby subjects improve or modify an aspect of their behavior being experimentally measured simply in response to the fact that they are being studied, not in response to any particular experimental manipulation. The term was coined in 1955 by Henry A. Landsberger when analysing older experiments from 1924-1932 at the Hawthorne Works (a Western Electric factory outside Chicago).’

So the drug companies have expensively refound the Hawthorne effect.  And this Government backs research into finding a cure-all for mental ill-health – a pill which turns a suffering human being into the Government’s One standard of Wellbeing (see Health Professions Order 2001).

Everyone, whether on drug or placebo, seems to get better – “which is catastrophic if you are trying to discover how effective the drug is”, says Prof Geddes, who chaired the depression and anxiety part of the UK Medical Research Council’s recent mental health research review. “Everyone in the field knows that this happens.” So researchers are discussing ways to reduce the problem – for example, dropping placebo-controlled trials and comparing new drugs with the best existing treatments.

Conclusion

There is no evidence that one solution: currently drugs or cbt works better than one human being giving another human being some attention especially if the practitioner is trained and receives regular supervision in working within a relationship.

Source:  Health: no room for gloom by Clive Cookson and Andrew Jack  Financial Times  14 June 2010:  available here

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The transfer of the industrial definition of risk and use of systems into health care to produce units of wellbeing as defined in the legislation

Wellbeing and safeguarding in the legislation or the legal definition of units of wellbeing

The main objective of The Health Professions Order 2001 (HPO2001, available here) is ‘to safeguard the health and wellbeing of persons using or needing the services of registrants or health professionals’ (S3.4). This is enacted through the Privy Council by the creation of the Health Professions Council. The principal functions of the HPC (from the Order): 22. Section 3: (1) There shall be a body corporate known as the Health Professions Council (referred to in this Order as “the Council”).(2) The principal functions of the Council shall be to establish from time to time standards of education, training, conduct and performance for members of the relevant professions and to ensure the maintenance of those standards.(3) The Council shall have such other functions as are conferred on it by this Order or as may be provided by the Privy Council by order.(4) The main objective of the Council in exercising its functions shall be to safeguard the health and wellbeing of persons using or needing the services of registrants.

‘Safeguarding’ and ‘wellbeing’ in HPO 2001: Wellbeing and safeguarding are two words, constructions, or concepts in use by Government in changing the practice of all health professionals. Comments: the Government by using these terms promises to safeguard wellbeing and health.  Is any Government able to safeguard wellbeing and health? Indeed, is it desirable for Government to safeguard?  Is it possible to agree the One standard, Government-approved and legally enforceable, centralised description of wellbeing?  Is your definition of wellbeing the same as mine? So how can these individual definitions be integrated into the One standard definition?

It is intriguing that a government, from whose collective lips the words ‘evidence-based practice’ fall so easily, produces no evidence of a link between legislation and the public’s wellbeing. The public’s wellbeing is also assumed rather than defined. It is not even defined in the courts as the enactment of HPO2001 is shunted through the Privy Council which is centrally driven.  The process of “causa sui” in use in our primary legal system is foreclosed.  The Privy Council deals in absolutes.  The Privy Council, on behalf of the Government, is in control of all standards including those for education, training, conduct and performance.  (See objective number 2 of HPO2001 given above) This eliminates all practitioner experience and the gathering of that experience within the training organisations.  So the governance and training of a practice is given to remote legally-defined Councils who usually depute this to academia.  So the Government, through its agency the HPC(HCPC), understands a practice better than those who have undertaken years of training and supervised practice.  Yes, it is so – it is on the statute book.  The Government knows what is good for you and your wellbeing.

Reference: These arguments are taken from Julia Evans: Well-Being and Happiness… as used by the UK Government in Psychoanalytical notebooks:  No 16 Regulation and Evaluation May 2007 page 143: available here

Industrial definitions of risk (first written and circulated in 2006)

Risk is used 105 times – usually in conjunction with ‘high’ and ‘industry’ in the White Paper ‘Good Doctors, safer patients’, available here.  For example:

Page viii ‘The bottom line is that lighter-touch regulation of doctors – whether on grounds of cost, regulatory ideology or professional acceptability – would mean that some ongoing risks to patients would have to be tolerated by society.

Page ix  Unsafe care can arise in two main ways: from human error in a weak system (addressed in my earlier report, An organisation with a memory) and from poorly performing doctors; both are important, but the risks posed by the former are many times greater than those posed by the latter.

Page ix Regulation of doctors is much less thorough than that of professionals in other high-risk industries, such as civil aviation.’

Some questions for the Government to answer:

What are the risks to patients which would have to be tolerated?  Define them.  I remind you that criminal acts are not tolerated.

What are the instances of human error in psychopractice which cause unsafe care?  How many and how are they defined?

What is the evidence that the practice of care is an industry?

What is the evidence that the practice of care is high risk – how is this definition reached?

How is civil aviation (or Chernobyl or Alpha Piper disaster) defined as a comparator for health care?

What is the evidence that it is an appropriate comparator?

On sloppy assumptions such as these, expensive safeguarding systems are built………

Reference: White Paper:  ‘Good doctors, safer patients’  Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients A report by the Chief Medical Officer:  Lord Donaldson (Sir Liam Donaldson) Department of Health 2006: available here

The system controls practice (Written and circulated in 2009)

The use of ‘empty’ knowledge by the Government’s enforcing systems has been commented on in my submission to the Health Profession’s Council’s (HPC) ‘Call for Ideas’, available here, from which I quote.

The type of knowledge implied by the HPC’s regulation is inappropriate to the regulation of the practice of Talking Therapy.  Behind each enforcing system (examples given below) is empty knowledge.  Three different forms of knowledge are defined in the submission.  Empty Knowledge or the One Knowledge or the One Standard or the Good or Science has all subjective meaning removed.  It is absolute, unchanging and without meaning.  The One Standard Meaning (usually centrally defined) is enforced in the Government’s raft of regulations.

From White Paper: Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century 2007, available here.  (Please notice the transformation between the two white papers.  The first refers to Doctors and the second to Health Professionals.  Thus, Psychopractitioners become Health Professionals.  This transformation has never been justified by a Government addicted to the words ‘evidence-based.)

Examples of the reliance on inhuman, empty knowledge from the Foreward of ‘Trust, Assurance and Safety’

Professional regulation must create a framework that maintains the justified confidence of patients in those who care for them as the bedrock of safe and effective clinical practice and the foundation for effective relationships between patients and health professionals.

It is all too easy to focus on the incompetent or malicious practice of individuals and seek to build a system from that starting point, …….

We need a system that understands the pressures and strains under which all professionals operate and shows understanding, compassion and support where these are appropriate.

It also means a system that is better able to identify people early on who are struggling – perhaps with personal problems of mental health or addiction – and supporting them,

It means a system that is better able to detect and act against those very rare malicious individuals who risk undermining public and professional confidence.

This reminds me of the tale: The Emperor’s New Clothes.  I am the child saying:  But have you noticed the system is bare?

Has no-one else noticed the UK Government is making a complete fool of themselves whilst systematically showing off their new clothes?

Comments on the Foreward:  Two unconnected statements are joined together to produce:  The system becomes Big Brother.  The system is the foundation of the relationship of care between two human beings.  The system becomes humanised.  The system provides the framework which produces trust.  The system understands pressure and strains.  The system is more able than the police to detect those about to commit criminal acts.

What is the evidence that weak systems cause unsafe care within the practice of talking therapy involving two human beings?

What is the evidence that systems can better treat distressed humans than another human being?

Has anyone in the government read ‘Animal Farm’ or ‘Brave New World’?

The system is inhuman in that it guards the One Empty knowledge and has no doubts about its truth and efficacy.  I define the authoritarian use of this absolute form of knowledge as abusive.  It denies our common humanity.

I suggest that Government-prescribed systems of ‘care’ for those of us with government-defined mental ill-health are much more abusive than practices supported by the diversity of training organisations (the DoH’s 2005 scoping project counted in excess of 570 – available here).

Where is your evidence that I am wrong?

Reference:  White Paper: Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century   Presented to Parliament by the Secretary of State for Health, The Rt Hon. Patricia Hewitt, MP, by Command of Her Majesty February 2007: available here

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regx2 works in relationships with others to:

Enable sufferers from symptoms of psychic or mental distress to choose the treatment or practice which works for them rather than the One prescribed by the government.

Resist the top-down imposition by the law of the One Standard driving practitioners’ training, development, practice, ethics, complaints procedure, etc that produces unhealthy uniformity.  N.B.  The DoH Scoping Project (July 2005), available here, found 571 training organisations.  This strategy seeks to support this healthy diversity rather than protect or prioritise one or a section of its variants.

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From The Guardian: June 29th 2010 ‘Plato’s stave: academic cracks philosopher’s musical code’ by Julian Baggini: available here

Jay Kennedy, historian and philosopher of science, University of Manchester: We now know that underneath all of those genuine dialogues there’s another layer of symbolic meaning.  This is the beginning of a big debate.  It will take years to make sense of all this.

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From Financial Times ‘Editorial: Cameron changes the landscape’ : May 12th 2010: available here

Putting together a common programme is one thing.  Actually enacting it in government is quite another. …

The decision to put representatives of both parties in each department is good in that it cements co-responsibility as a principle.