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Over the last six
months while other organisations have been taking a strong position
opposing the mental health bill you have been advising the government
how to make their controversial proposals more 'workable'. I would
challenge your recent standpoint on engaging in such a dialogue
than opposing the bill outright. Is this not another example of a
opportunity for psychologists to make a real difference to people's
rather than be compromised by professional self
Ten years ago I was hoping that psychological approaches to psychosis would be a Trojan Horse that would overthrow narrow-minded understandings and oppressive practice within the very bastions of biological psychiatry. My disappointment is that evangelising psychologists with cognitive behavioural manuals as their bibles are presenting themselves not as allies to the disempowered service users but as a New Psychiatry. This I feel is symbolised in your decision to helping the government fine-tune their draconian Mental Health Bill.The danger of this New Psychiatry position for Psychology in the mental health field is that whilst it may lead to better jobs for psychologists, it will not actually have much impact on improving the opportunities for people's recovery at the grassroots level. Psychologists may feel themselves to a be a cuddlier option than their older sibling psychiatry but in general they are still peddling an expert-led individualistic approach that excludes the possibilities of participating in truly collaborative and emancipatory relationships with service users. This is evidenced firstly in Cognitive Behavioural Therapies insistence on retaining much of the medical language that saturates psychiatric thinking about mad experience (e.g. symptoms, intervention, mental illness, insight, relapse). Secondly there is a notable lack of strong links between cognitive behavioural therapies and self help approaches. This is perhaps not surprising as while self help initiatives stress the benefits of self determination and the expertise of the individual concerned, psychological therapies promote such processes as belief modification, insight promotion, compliance therapy and psychoeducation, all belonging to a rather more traditional 'doctor knows best' paradigm. In my experience you only really make a difference in the mental health arena if you are prepared to take a strong stand against the mis-use of power widespread in the current system. The government appears to be set on reifying in mental health law the media driven mythology that psychotic patients represent a significant danger to the public and that dangerousness is a mental illness. In the past, Peter, in many a public presentation, you have been successful at raising awareness of the falseness of this ideology. This makes your current stance difficult to understand. I think your willingness to advise the government on practical ways to implement the proposed increase of compulsory and detention powers is a setback for the movement for a more collaborative open-minded psychiatry. In the progressive BPS report Understanding Recent Advances in Understanding Psychotic Experiences which you were a co-editor the final sentence reads 'We hope that this report will be part of a major shift in public attitudes that sees prejudice against people with mental health problems become as unacceptable as racism or sexism.' Your more recent actions I would argue undermine this admirable vision. If introduced the Mental Health Bill will prop up and promote a prejudiced view of people with psychosis as dangerous and therefore entitled to less citizenship than the rest of the public. How do you account for this apparent betrayal of interests?
What an interesting approach. Robust, is the word!
I am certainly not betraying our shared interests, I am representing them at the highest levels I can reach. And I am neither compromising my principles nor undermining my friends. I think, to begin, I should correct a few misapprehensions. Your contrast between my approach to the draft Mental Health Bill and that of other organisations is highly spurious and almost insulting. It's also difficult to reconcile with my recent writings. First, I represent the British Psychological Society in negotiations and do not represent myself. But that to one side, the contrast between my approach and that of other organisations is unambiguously the opposite of that you suggest. The Mental Health Alliance termed its policy document 'Constructive Engagement' and begins with the statement that ".this document highlights a number of ways of improving the Mental Health Bill." The minutes of the latest Campaigns Group of that organisation indicates that the Alliance has shifted its position ". from a 'No campaign' to 'Yes with reservations'.". The Alliance clearly believes that it is right to suggest amendments and wrong to oppose the Bill outright. I actually agree, but my point is that the suggestions I have made on behalf of the British Psychological Society are far more radical than those of the Alliance. I'm not in favour of "yes with reservations", I'm in favour of radical change.
For example, I have called for ECT, psychosurgery, polypharmacy and prescriptions over BNF limits to be prohibited by law. The Alliance has not. And on the crucial issue of the criteria for compulsion, the Alliance has itself suggested that people who are "dangerous" could be detained under the Mental Health Act with no other applicable criteria; they have recommended that the widely-discussed capacity criterion only apply if people are not dangerous. I can't see how this differs from the 'draconian' approach of the Government. I, on the other hand, have suggested that no person should be subject to the powers of a Mental Health Act if they retain the ability to make decisions about health care for themselves.
Now in fact I do believe that engagement with policy makers is correct, but get the facts right. The organisations you refer to have NOT been opposing the Bill outright - they have been posturing. In the final analysis, however, they have made recommendations that are weak and irrational. I have been engaging with Government and have always suggested advising the Government on how to "make their controversial proposals more workable", but in doing so I have actually been advocating a radical agenda. I believe it is hypocritical, weak and counterproductive to promulgate a stance of 'opposition' when at the same time AGREEING with the Government's central aim to use the Mental Health Act to lock up people merely because they are dangerous.
I do not believe that I am helping the Government 'fine-tune' their Bill. I am engaging with Ministers to suggest radical and thorough-going change. I am engaging, but that means I can make the points and be sure that they are at least heard (if not acted upon).
You ask who I want as friends. Anyone who has the potential to make life better. And at what cost? Well not at the cost of principles. You comment on a radical psychological agenda to undermine a biomedical approach to psychiatry. I agree. And I agree that many people are wrongly exposed to overly paternalistic, drug-based, biomedical psychiatry. That should end. And how do we end it? Well, I propose that radical individuals should engage actively with policy makers exactly to achieve this end. I don't think we should speak only amongst ourselves, I believe that we should speak to people who might listen to our ideas, but have not yet heard the message.
How, then, do we prevent biomedical paternalism dominating the care of people under compulsory powers? Well there are currently two important areas, the Mental Health Act and the generation of National Guidelines for care. These are both important. We know the importance of the Mental Health Act. It strikes me as important to use this legislation to undermine paternalistic psychiatry. Thus we must ensure that the Act does not either enshrine power in the hands of psychiatrists. This is why it is good that the Secretary of State could empower persons other than medical practitioners to be Clinical Supervisors. I know there are psychologists who do not want psychologists to be given the Clinical Supervisor role. I recognise their approach, but I am not happy to leave statutory powers in the hands of doctors - for God's sake that's the paternalism that we are railing against. It is important that the Act also does not enshrine inappropriate concepts of mental health. This is why I am keen to engage with Ministers to ensure that the criteria for compulsion reflect the centrality of the person's own ability to make decisions for themselves (an issue generally ignored by organisations other than the British Psychological Society and the Law Society). A good Mental Health Act would therefore presage a radical and positive shift.
Engagement with Government agencies responsible for drawing up national guidelines is also important, in my opinion. Two examples are the NICE guidelines on atypical antipsychotic medication and the more recent and more general NICE guidelines for the treatment of schizophrenia. Both these documents are very positive - not perfect, but positive. When I started out in this profession I was told that it was unethical for a psychologist to work with people who experienced psychosis, their treatment should be left to doctors. It is now government policy that 100% of people with schizophrenia be offered CBT. Now I'm probably even more sceptical than you about "therapists with their CBT bibles", but the undermining of paternalistic biomedical psychiatry is continuing apace.
You seem confused: "I think your willingness to advise the government on practical ways to implement the proposed increase in compulsion". No. No. No. I am not willing to do this at all, of course I'm not. I am willing to engage actively with the Government. But I repeat, to recommend: that doctors are no longer given sole professional powers, that mental health care is no longer considered a 'medical' issue, to give psychologists more powers (yes, I know), to outlaw ECT, psychosurgery, polypharmacy and hyperprescription and, most crucially, to recommend that no patients, even if believed to be potentially dangerous, are subject to powers under the Mental Health legislation if they retain the ability to make decisions about their own health care. This will not, if adopted, assist the Government in increasing compulsion; it will assist the Government in getting their legislation genuinely right. I cannot see how this undermines our shared ambition, especially when all of these calls are more radical than those of the Mental Health Alliance.
I'm concerned that even you have failed to appreciate that I can remain radical while 'engaging'. But I have made my position clear. In my recent article 'Winning friends and influencing people', I stated the Government's initial position was viewed by many as incompatible with the Human Rights Act 1998 and repeated that I (on behalf of the British Psychological Society) have strongly recommended the compulsion is only justified if a person cannot themselves make decisions about health care. I cannot, simply cannot, see this as wickedly assisting the Government's draconian plans. In contrast, I see this as an assertive lobby on behalf of the agenda you and I share.
Thank you for your comments about some of my public statements. I have indeed publicly stated that it is a myth that dangerousness is a mental illness. You will be pleased, I guess, that I said the same thing to Ministers. I have suggested that discrimination against people with mental health problems should be as unacceptable as racism and sexism. and I repeated this to Ministers. By engaging with government about the Mental Health Bill I have been able to say these things and the other radical agenda for legislative change. I'm not a very complex person. I have been fortunate to be able to put my point of view to the people who formulate policy. Why on earth would I not say the exactly things I hold most dear? And why is it not a GOOD thing to be able to say such things to people who make decisions, rather than merely speak to the converted at conferences attended by people who probably agreed with me before I got up to speak?
It could be argued that I am being paternalistic. I am, you might claim, representing a professional organisation, and 'cozying up' to Government. It could be argued that I should not be abusing such privilege, and I should instead applaud the user movement in gaining power itself. Well, I do applaud that. But I do have power. I have the opportunity to discuss these issues with Ministers of State. I could ignore that opportunity, or I could assertively grab the opportunity to put forward a more humane view of madness. That's what I've been doing, and you seem unhappy.
Thanks for your informative reply. It's helpful to get a clearer idea of what is going on. Yes you are right I am unhappy that you and others believe that more can be achieved by negotiating with the government rather than opposing the Mental Health Bill out-right. I realise the government has a huge majority but the 'no campaign' was going very well in the media and in protests before everybody in the mental health charities started negotiating with Whitehall. Your stance of engaging early (i.e. in September last year while other MHA groups were at least posturing resistance) with the government may have prompted them to engage with them themselves in this `Yes with reservations' dialogue. Do you think your actions influenced this capitulation by the Mental Health Alliance?
Your co-operative stance means that you are not opposing Community Treatment Orders which is a massive liberty infringing proposal. In the next few years this will have a massive impact on legally enslaving people to long-term neuroleptic treatment. Uncompliant patients will hate services even more and those that have their will broken by CTO's will stand even less chance of actively taking back control of their lives. Where is your mandate or evidence base for backing Community Treatment Orders? Community Treatment Orders will not provide an alternative to hospital treatment they will be drug life sentences for many people. Sustained Compulsory treatment is spirit-breaking. The policy of enforcing drug treatment is driven by and will sustain the mythology that society is significantly threatened by dangerous psychotic people who won't take their medication. CTOs are a disaster for a more open minded approach to psychosis.
How can you justify your position on this? My suspicion is that you want psychologists to look like they can handle being tough on the use of compulsory powers to back up the idea of psychology as a 'new psychiatry'. Well I do not think a paternalistic psychology is much of an improvement on a paternalistic psychiatry. For example, state of the art Cognitive Behavioural Therapy fails to engage many people because of its wooden dry approach to rationally testing out perceptions of reality. Doug Turkingdon's study in Newcastle recently found that 'paranoid service users' faired better with befriending schemes than they did with Cognitive Behavioural Therapy but you wont find him rushing to publish that finding. Such hidden research findings clearly indicate that a much more social approach to mental health is needed to transform mental health services. Individualistic psychology that locates the problems of madness and distress and the solutions largely within the individuals' mind will not create the sea change in mental health practice you may wish to see. Furthermore with the added pressures to section (and prescribe) psychologists will not have time to look anything other than a slightly more cuddly psychiatry.
It's good to hear about your recommendations around ECT, polypharmacy psychosurgery and prescriptions over the BNF limit. I am also glad to hear that in your dialogue you are arguing for a capacity component to the use of compulsory powers. However you and I might differ on how we define capacity. I believe that people should have the right to have alternative beliefs about their world and that they should not be subject to compulsion unless they can be clearly shown to lack capacity to look after themselves to a degree that endangers their life or that of others. Many people are able to maintain unusual (and irrational) beliefs and retain the capacity to make decisions about their alternative lifestyles. So while I tentatively support your recommendations around Capacity, I think, as the government has already rejected this proposal made by the Genevre Richardson Committee, I do not think you will be listened to. It is disturbing to hear about how the Alliance have gone soft on the criteria for compulsory treatment. To hear that organisations like Mind, Rethink and Manic Depression Fellowship are against including capacity in the criteria for compulsory detainment is disappointing but not surprising. It seems to me you are being progressive in urging capacity criteria for the use of compulsory powers but regressive in supporting Community Treatment Orders. However while the Alliance push a different line in their own dialogue with Jackie Smith and colleagues you allow the government to divide and rule. If direct protest is not in the BPS lexicon, the most logical and fair approach would be to help the government take in the implications of the 2000 responses they received to their White Paper. Where is your mandate and evidence base for the positions you have taken?
I agree that preaching to the converted at conferences has its limits. That is why I spend a lot of time and energy in taking a debate about mental health to the wider communities via the media. However building a grassroots movement who are confident in the alternatives to 'Doctor knows best' Psychiatry is an important process in itself. The main thing I have learnt from grass roots forums working with ordinary people to effect change in mental health is the skill of listening and not thinking I know the answers. I do not get the impression you have been listening to those grass roots communities. Who have you been listening to Peter?
I think it is clear that you and I agree in terms of principles and aims. We agree on nearly everything, and as we unravel issues such as capacity and Community Treatment Orders, our points of view converge. I also think we agree on the general principle of empowering service users. We only seem to differ on whether we should engage with Government when that Government is pursuing policies that we (both) disagree with.
I suspect, in
that you were cooler on my engagement with Government because you
that my position was opposed to you. I believe that we are in the
that you are disquieted by the fact that I am taking YOUR position to
Like you, I am appalled that the Mental Health Alliance is now backing the Government's stance on the detention and forcible treatment of people who are perfectly able to make valid decisions for themselves. I am not. You will be pleased that I am continuing to call for rationality and humanity. I also agree that until recently the public opposition to the Bill appeared very successful. More recently, however, the Mental Health Alliance shifted its position away from radical opposition to 'constructive engagement'. Now I have always advocated constructive engagement. My radical alternative recommendations have not, however, shifted, whereas the Alliance is now supporting the detention of capacious people, CTOs., forced ECT and criteria for compulsion that are more draconian than the Government's - is it a coincidence that this happened after the Royal College of Psychiatrists joined the Alliance? I have no fears about my stance leading to or precipitating the Alliance's capitulation. I have been arguing strongly against it.
I must also complain about your characterisation of me 'supporting' CTO's. I don't. I don't have a mandate from the BPS to support CTO's, but I don't really have a mandate to oppose them. I agree with you that CTO's are generally bad. Up to recently I have been very quiet on the subject, simply backing the position of the Mental Health Alliance. The Alliance has a position on CTO's which I think is measured. It's not as radical as yours. I guess, on this one issue - which I agree is important. You came up - I'm sorry to say - with a lovely piece of paranoid libel concerning the possible reasons why I'm actively engaging with Government. It fails as a piece of logic on so many grounds. First, I am engaging with Government, but to oppose not to support. So the whole argument falls. But in any case, the BPS position is one of humanitarianism. It is true that the BPS welcomes the possibility for psychologists to have statutory powers under the Mental Health Act, but our reason for this is precisely so that we can challenge paternalistic psychiatry and irrational, coercive medicalisation. And as for prescribing privileges, this has not been raised, mentioned or even thought about (Are psychologists going to prescribe? Now you've mentioned it, I guess it's fair to say that psychologists differ in their views, but I personally would be opposed to psychologists having prescribing privileges). And I'm not doing what I'm doing to 'look tough'. I'm arguing for liberalism and humanity because I think it's right. I'm arguing actively for liberalism, humanity and rationality. I plead guilty to that.
I'm glad you liked some of the statements I have made about the positions I hold on 'capacity', ECT, criteria for compulsion, hyperprescription etc. It's the same position that I first published two years ago. You've had plenty of time to find out. I'm saddened and worried that you would ever have thought that I'd think anything different. You are struggling hard to find differences between us. I don't think you will find many - apart from the fact that I am willing to put our shared concerns to the policy makers.
I don't support CTO's. I, like you, believe that people should have the right to have alternative beliefs about their world and that they should not be subject to compulsion unless they can be clearly shown to lack capacity to look after themselves to a degree that endangers their life or that of others. I agree with your point entirely.. My mandate comes from the Professional Practice Board of the BPS, from a survey of members of the Division of Clinical Psychology and from my judgement of the consensus I receive from the many meetings I have with colleagues. My evidence base is the published work of psychologists, sociologists and psychiatrists.
I'm still confused as to what you dislike. First I thought it was a worry that I was agreeing with the Government. But I don't (I'm about the only person opposing) Now it seems that you're saying that, since the Government won't listen, I should change my message. Bollocks - sorry but this is irritating nonsense. I formulated a position about 18 months ago that is practically identical to the one you are putting forward now. I have been arguing from this perspective - from your perspective - for all this time. I think you are saying that, even though you agree with my position, it's unwise for me to get close to government in case my cooperation leads to my case being ignored, but my closeness being abused. I disagree - there you go, a disagreement. You think it's worthless, I think it's right and proper to put a radical agenda for mental health as close as possible to policy makers. Good, we have disagreement. We agree on the aims, we agree on the principles, we disagree on tactics. But please don't misrepresent my principles or beliefs, and please read what I have written: recommending "...that 'the mental disorder is of a nature or severity so as to impair the individual's judgement to the extent that the individual is incapable of making valid decisions about health care before compulsion is legitimised".
You ask to whom I've been listening. Well, since you and I agree on all these points, maybe you and I have been listening to the same people. I too speak to many 'grass-roots meetings and conferences (although it would be very unwise of us to trade 'closeness to the people' points). You and I agree on practically everything. You just don't think I should speak to policy-makers. As I've said above (but I liked the phrase, so I'll use it again) I'm arguing actively for liberalism, humanity and rationality. I'm also arguing for exactly the same points as you with the sole exception that I am marginally less rejecting of CTOs. I am certainly the only voice in the Mental Health Alliance that is suggesting liberal, humanitarian and rational alternatives. You've been convinced by the spin. MIND say that they oppose the Bill (nice, sounds good, makes them sound cuddly), but they agree with CTO's, agree with psychosurgery, agree with ECT, and agree with criteria for compulsion that ignore the individual's right to make choices for themselves. My conscience is entirely clear.
I think this
might proceed better if you read a) what I have written - the fact
think the same as you on nearly every issue seems to have surprised
and b) read what your erstwhile friends are actually calling for. You
discover that you and I share identical positions on nearly every
and don't really differ on the remainder. I'm still bemused that you
want this perspective, which is your perspective, represented to
direct words does not disappoint. Paranoid libel eh? Well I think I
embrace the paranoid label in this case. I define paranoia as the
perception that others have a planned intention that will cause harm.
think that an 'expert lead' psychology posing as a 'new psychiatry'
do more harm than good. Clinical Psychology is keen to acquire powers
compulsion and prescribing powers are on its way too (see April's
Psychologist magazine as well as one of Tony Blair's speeches last
Look at psychology's poor track record on user-involvement. Take the
Division of Clinical Psychology, in terms of its levels of user
involvement in its national body it does worse than the Royal College
Psychiatry. When you suggest you are making radical suggestions I
it's often useful to read expert-lead. What consultation have you or
BPS done with service users about your stance on the mental health
think you are falsely assuming that professional organisations are
consulted because the government values your views. Wrong, the reason
government is listening now to folks like you is due to the massive
of critique and protest by grass roots groups and individuals. You
BPS could have capitalised on that political pressure by organising
that took on board the real stakeholder's views. But you did not. The
people who will be most effected by the human rights infringing
we are discussing will be service users and their families. By
you know what is best for service-users without asking them you are
letting them down. Your decision to constructively engage with the
government looks like it comes from (the BPS's ) professional self
interest, not the will of the people. We need more democracy in
psychiatry. Your discussions behind closed doors do not promote this.
your article 'How to win friends and influence politicians 'you
you have been arguing the case that 'the central issue in mental
ill-health is the disturbance of psychological processes'. Tell that
homeopath, a systemic therapist, a devout Christian or an Imam. They
laugh at such an idea. Psychology should not seek to colonise
understandings of distress and well-being. History shows us how
that can be. It might be good for the profession it wont be good for
people in all their diverse approaches to life.
calling for guidelines about polypharmacy will achieve little even if
are listened to. We will only ever end polypharmacy through legal
not through guidelines.
I entirely agree that psychology and Clinical Psychology in particular has a poor record of user involvement. We have not had the most wonderful of histories (in our short span as a profession we have been heavily involved in eugenics, the Nazi programme, IQ testing, biological brain research and now compulsion over vulnerable people). I agree. But that does not mean I think we should disengage, I believe we should engage actively, honestly, openly... but we should engage. In particular that means that I believe that there will always be mental health legislation (whether an Incapacity Act or a Mental Health Act). Psychologists could sit back and watch this, or engage. My choice I believe you could predict.
You return to the
point about consultation. First, I do represent the BPS, not
users of mental health services. I (and many colleagues on the Mental
Health Alliance) consistently advice the Department of Health to be
genuine in their consultation with GENUINE user movements. I cannot
not represent users, and I don't think I should try to do that. I
represent professional psychologists. Nevertheless, I believe that I
consult with users and that the BPS position is a user-friendly one.
have attended and talked at several (more than five I would estimate)
conferences, including three 'People's Parliaments'. I freely admit
these have been 'conference-style' rather than focus groups, but I
reasonably guilt-free. But I repeat, I do not try to represent users
represent psychologists. Similarly you comment that a priest or an
would not say that psychological processes are central in mental ill
health. Well of course, but I don't pretend to represent them either
even to represent plurality - I represent psychologists and that is
position. I do happen to believe that such a position is humanistic
inclusive, and this relates to your next main point. First, the BPS
argued consistently for an Incapacity Act. In fact, an Incapacity Act
being prepared. And, of course, I repeat that the BPS position
that capacity (in the wording of 'impaired judgement' - the
consequence of incapacity) should be in the Mental Health Act.
I do believe that you and I agree on aims (and possibly even strategy), but clearly not tactics.
Finally, you ask for actions that will speak louder than words. "When is the BPS going to put pressure on the government for proper financial support for user-lead organisations like Survivor Speak Out?" Well, this is the first I've heard of that call (perhaps indicative of my ignorance or current issues), and I'll have to drag the point through the interminable committees of the BPS, but I shall do it TODAY! "When is the BPS really going to consult service users about its policies, support user led research and real user involvement in psychiatric services?" We have established, within the last month, a User liaison Group in the BPS's Division of Clinical Psychology that will have the power to co-opt members onto every Division subcommittee (and pay people for their efforts). I recognise that this is too little to late, but I hope that you will accept that it is better that we have done this now, too late, than the alternative. "When that happens I will start to have a bit more faith in consultations with government officials about draconian legal proposals."
© Asylum Magazine 2002