I’m a Best Interests Assessor as well as an AMHP (Approved Mental Health Professional). There’s a general awareness within the sector about what being an AMHP may be – there’s a lot less understanding about what is involved in being a Best Interests Assessor. The role itself is much newer having developed from the Deprivation of Liberty Safeguards which were a tacked onto the Mental Capacity Act (2005) by the Mental Health Act (1983) as amended 2007.

Lots of dates and lots of legislation but the role came into being in 2008 and created this role of ‘Best Interests Assessors’ who could be nurses, social workers, psychologists or occupational therapists with a couple of years experience who would be trained specifically to carry out particular assessments under these new legislative frameworks and make recommendations on the basis of these assessments as to whether someone who lacks capacity is being a) deprived of their liberty in a hospital or care home and b) whether it is in their best interests.

It can get enormously complicated but that’s perhaps, the reason that the focus has turned to the training of BIAs.

I was an ‘inaugural’ BIA, meaning that my training took place before the legislation had actually ‘gone live’. It took place over five days at postgraduate (masters) level training  delivered by a university and requiring an examined essay and presentation.

The problem is that we were then released into a ‘vacuum’ – there was an incredible feeling of insecurity about what these assessments required but there was also a hope that case law would eventually arrive to clarify! (oh, how deluded we all were!).

As it happens, case law is coming thick and fast now and each legislative decision adds layers of complexity. We have a better idea of the rate of referrals and the amount of time a good quality assessment takes so reappraising the course isn’t a bad idea.

Some AMHP courses now incorporate Best Interests Assessor training. I’m not sure I see this as necessary.

I’m not even sure more than five days is needed regarding an understanding of the legislation.

What is absolutely needed is constant and ongoing updates/training/discussions and forums to promote constant learning.

Currently there are no established and consistent  regulations concerning continuous professional development of BIAs – it is up to the local authorities to themselves decide. I’m fortunate that I have access to a host of BIA update training and a chance for specific supervision related to this role. I see it as fundamentally necessary, particularly at the rate with which the legislation framework changes, to be constantly in touch with the latest developments.

I also think that it is necessary for any new BIA (something that was impossible for me when I trained for obvious reasons) to have a similar experience as AMHPs have of ‘shadowing/fronting’ assessments with a more experienced BIA alongside them to get a feel for the type of work that i is.

This feels like a neglected corner of social work and social care in that it is a role that still is predominantly taken by social workers but few apart from those who actually do it, have an understanding of what it might entail.

We need to support each other on this – especially as so few of the trainers are actually Best Interests Assessors themselves – in my experience. This is an area where peer-led learning and understanding of the role could really move into the fore front.

I revert back to my premise that everyone working in social care with adults needs a better understanding of the Mental Capacity Act. That would form a better basis for those who do go on to become Best Interests Assessors.

I’ll be interested to see if Burstow picks this up. There’s a long way to go to improve both the Deprivation of Liberties Safeguards and the way that they are assessed and implemented. It’s quite right that the training and in particular professional development of BIAs is considered alongside this.

I’d be interested in what other BIAs thought about how training both initial and ongoing could be improved. Please feel free to leave comments!

Photo by anniebby

The Daily Telegraph today prints a letter which sets out the need for a ‘Dignity Code’ in Health and Social Care calling on Hospitals, Care Homes and other institutions to prevent ‘issues of abuse and neglect’.

The article accompanying the letter, the Telegraph says, will encourage care workers to have this code written into their contract.

It is a laudable aim.  The letter itself says

“For too long, too many of those people have been ignored, denied the basic right to speak for themselves or make up their own mind,” the letter warns. “In this era of human rights, too many older people have seen their basic human dignity undermined in situations where they are treated as objects rather than people.”

Very hard to disagree. The article which is definitely worth reading goes on to describe the litany of poor treatment meted out to older adults in our society where abuse and neglect seem to be profligate.  And, the article helpfully tells us that those who sign this, the ‘great and the good’ of the sector, are demanding that this abuse and lack of dignity stop.

Ok, to a letter saying that abuse is a bad thing and should stop isn’t exactly earth-shattering.

What I want to know is what those who sign up to this letter intend to actively to about it other that write out a ‘code’ of conduct for care workers.

Does Paul Burstow, a proud signer, include the need to put more money into care for older adults – remember Mr Burstow, he’s the one who said there was ‘no funding crisis in care’, but to cut him some slack for a moment, money isn’t the only issue regarding dignity – however in a care system that does consistently regard older people as commodities, it is not hard to see how this objectification came into play.

I’m sure Burstow would bleat about personalisation and his desire to move everyone onto direct payments. I would reply that yes, this is a wholly laudable goal which should be encouraged and potentially allows a geniunely different way of regarding people who use care services but as long as I see local authorities stick to the same ‘managed budgets’ with ‘block contracts’ type of support package with no alternative options for older adults (particularly those who might lack capacity to manage budgets and not have family/friends/advocates to assist) this will just be cheap talk.

So what will actually improve the consideration that older people have in hospitals and in care homes?

I have some ideas – but they may involve money, I’m afraid, Mr Burstow. Let’s see if your money is where your mouth is.

• Increased and mandatory use of advocates – particularly for those who don’t have family.  Help people to know about their rights to decent and humane treatment. Allow safe complaints to be made. This should be accessible within hospitals and care homes and must include, as a priority, non directed advocacy for those who lack capacity.

• On a related issue, I would  appoint a ‘champion’ in every care home and hospital. This must be someone absolutely committed to the care of older adults who can speak to the people who use the services and complain in more general terms. Ideally it would be someone independent.  These would be people on the ground at all times. The difference with an advocate is that this person would be responsible beyond the individual for the group experiences of care.

•  Improve information and accessibility for family carers where they are around. Improve support for carers. It is one of those areas where you spend more to save more – improving quality of life along the way.

•  A wider societal appreciation of older adults. This takes longer and is a part of the longer term goal. Age doesn’t have to be feared and certainly isn’t to be swept under the carpet in the hope that it will go away. We need to regard older people as individuals worthy of respect and not ‘burdens’ on the state. While people discuss the ‘crisis’ of the ‘ageing population’ we are at risk of shifting blame onto those who are older and unwell.

Similarly, the setting off of ‘baby boomer’ generation against today’s youth sometimes encourages rather than closes these generational gaps. There is more than unites us than divides us.

I made a somewhat flippant comment a few weeks ago relating to the BBC documentary ‘Protecting our Children’ about child protection social workers in Bristol wondering if there would ever be interest enough in a parallel ‘Protecting our Parents’ type programme which looks at the work which goes on in Adult Safeguarding. Of course it was a rhetorical question.

I would have concerns about programmes which reflect painful realities in the lives of the people filmed and have a certain ethical concern with a fly on the wall programme which would show these matters so I don’t want to see such a programme commissioned  but on a broader matter, safeguarding work in adult social care (which I do a lot of, for the record) doesn’t carry the same emotive pulls.

I think there’s an inherent human fear of the ageing process. I feel it myself. Some people like to think it will never happen to them. Or their parents. Until it does. As a society we really need to face up to how our system treats older people and the inherent ageism that exists that allows different standards to exist for abuse dependent on the age of the person who is violated.

When we eliminate ageism, we eliminate the need for a dignity code. Until then, it feels like lip service from the top to castigate care workers and nursing staff at the bottom of the ‘chains of command’ so politicians and leaders can absolve themselves of the responsibilities they face in creating systems that lack such dignity.

Photos by daoro, fatseth and  Filippo Maver

The e-mail poses a series of questions to the candidates in the forthcoming election for UKCP chair. The author suggests, “It has been said by some of those in positions of authority in the UKCP that the members should keep quiet and let the Board get on with running the organisation” and that “There is little transparency in the spending of the members’ money”.

The author also appears to have a low opinion for the current proposals for psychotherapy to have “assured voluntary registration” (where self-regulating bodies such as the UKCP get a stamp of approval from the Council for Healthcare Regulatory Excellence) rather than statutory regulation. They ask, “Those with statutory titles i.e. psychiatrist, practitioner psychologist, psychiatric nurses, social workers etc are already perceived as being more professional. By going the VQA route do we not join the licensed service professionals such as hair dressers, beauticians, carers and day care workers?”

The full text is below.

Questions for Candidates
1. How will you ensure that voluntary quality assured (VQA) regulation, (CHRE) will have the same status as statutory regulation? Those with statutory titles i.e. psychiatrist, practitioner psychologist, psychiatric nurses, social workers etc are already perceived as being more professional. By going the VQA route do we not join the licensed service professionals such as hair dressers, beauticians, carers and day care workers?
2. What are the cost of the systems, i.e. standards monitoring, central complaints system, information systems, PR, compliance cost and other items for being prepared to APPLY for the CHRE QA kite mark?
3. It has been said by some of those in positions of authority in the UKCP that the members should keep quiet and let the Board get on with running the organisation, how would you respond to that statement?
4. How would you ensure that the visibility, integrity and credibility of the office of Chair and Chief Executive of the UKCP is increased and maintained?
5. One of the basic ways of devolving power is to ensure there is a good budgeting processes empower functions such as Diversity & Equalities, the Colleges and Faculties Committee, the Quality Assurance and Change Management processes etc . This gives the functions of these committees and departments the power to carry out their duties without interference from officers who may abuse their power. What budgeting process would you put into place?
6. Could you comment on the number of volunteers we have working on external projects and representing the UKCP in places like IAPT, NHS Commissioners, NICE, Mental Health Organisations, Service User Organisations and Parliamentary Enquiries? How could this be improved?
7. Given the low level of interest in the UKCP elections as evidenced by the number of directors elected unopposed and the cancellation of the debate scheduled for the 23rd of February, what level of voting by the membership would you consider to be enough to give a clear mandate for the elected chair. Would you ask for another election if you achieve less than 10% to 15% of the membership’s votes that are cast? Would you allow the Vice Chairs to act as Chair until the election took place?
8. One of the difficulties that exist with the UKCP’s leadership is a matter of visibility. Would you consider publishing appointments and meetings on the web for the membership and public?
9. There is little transparency in the spending of the members’ money and that individuals benefit financially from work they do on behalf of the UKCP. Would you publish expenses and monies paid to individuals for work done on behalf of the UKCP? Would you advertise for all positions that attract an honorarium?
10. Given the nature of our profession and the involvement of our membership it would be counter cultural to impose a pure business model on which there are different classes of shareholders and a board remote from the membership. What is your commitment to ensure that the organisation has a high level of consultation about the work of the organisation?

The case is important because of the self-regulating nature of psychotherapy in the UK. The UKCP is currently trying to position itself to become an “assured voluntary regulator” for the profession, whereby its complaints and disciplinary procedures will receive official endorsement. Cases such as this could cast doubt on its ability to take on such a role.

At the moment, there’s no statutory regulator for counsellors or psychotherapists. There’s also no minimum qualification. A psychotherapist could be somebody who’s undergone an arduous post-graduate training lasting several years, or they could be just some yahoo with “psychotherapist” printed on their business card. They might belong to a professional organisation, or they might not. If they get struck off by one organisation, they can just join another one, or they can remain unaffiliated to any body and still practice.

Of the professional bodies out there, the two biggest are the British Association for Counselling and Psychotherapy (BACP) and the United Kingdom Council for Psychotherapy (UKCP). The BACP has a good, accountable complaints system with clear procedures.

With the UKCP, the complaints system is far more muddy, which is partly down to its nature as an umbrella body for nearly 80 smaller psychotherapy organisations. If you want to complain about a UKCP psychotherapist, you first have to complain to their member organisation. If the member organisation rejects your complaint, you can then appeal to the UKCP. These 80 organisations all have different complaints procedures.

For some of these organisations say, the Association for Family Therapy, their complaints systems are of good, robust quality. Others are clearly not.

Take a look at the Code of Ethics for the Guild of Psychotherapists. In particular Parts 4 and 5. A complaint has to be proved to the criminal standard of “beyond reasonable doubt” (the usual standard of proof for such procedures is the civil standard of “on the balance of probabilities”). The complaint is heard by members of the Ethics Panel, with no provision for lay members at the hearing. Oh, and “the Panel shall have the power in its discretion…to require the Complainant to pay such costs and expenses in the event of the complaint not being upheld.”

Yep, that’s right. If you can’t prove the complaint beyond reasonable doubt, to a panel made up of the therapist’s colleagues, you could be handed a huge legal bill! And only then can you take your complaint to the UKCP. Most people would just back away and not complain.

The UKCP is currently trying to replace this clearly-inadequate system with a new Central Complaints Procedure, but this is very much a work-in-progress. As the UKCP’s latest bulletin admits, only a third of member organisations have so far signed up for it. In a startling piece of candour, the same bulletin also admits, “There has been too much crony-ism and amateurism in the conduct of complaints for far too long.”

Under the previous Labour government, plans were underway for counselling and psychotherapy to be regulated by the Health Professions Council, which already regulates clinical psychologists and arts therapists. While many psychotherapists supported this move, there was also a vociferous campaign against it. The UKCP chair, Professor Andrew Samuels, has spoken against HPC regulation.

The new Coalition government currently favours a different approach of “assured voluntary registration”. Under such a system, the Council for Regulatory Healthcare Excellence (the uber-regulator that oversees bodies such as the General Medical Council, Health Professionals Council etc) will be renamed the Professional Standards Authority. This body will be able to give an official mark of approval to self-regulating bodies such as the UKCP.

Providing, of course, that they can show that they’re able to effectively police their own profession. However, a previous UKCP Bulletin admits that without reform, “we will not pass muster at CHRE/PSA.” The apparently mishandling of the Smalley case would certainly cast doubt on the ability of UKCP to be a credible self-regulator.

In all the meetings I’ve attended over the past three weeks, conversation has turned to the latest programme as soon as a lull in proceedings appeared and often when it didn’t. Generally it’s gone down very well, in sharp contrast to the scant few past series covering our world. I remember one dire effort that I think looked at a social work team in the north. Eminently forgettable, I nevertheless recall it began with a social worker guiltily shovelling down a giant doner kebab whilst at his desk then playing up to the camera in a manner that would have embarrassed David Brent. Gloomily we watched well-intentioned but ill-conceived and executed direct work with a young child and a succession of families unsure about what was happening.

 

Outside the profession I’m not sure what the impact has been. Ashamedly unscientific, but no one I know who is not a social worker has mentioned it to me. The one time when people have an opportunity to chat about my work, and nothing.

We’re all familiar with the ‘social worker at a party syndrome’. The dreaded, ‘and what do you do?’ followed by hesitation and a vacant look as the reply is digested. Best to move on. People at least take more time to consider their response these days, which is progress of a kind. When social work was getting an even worse press than it does now, I used to say I worked for the council. Safer that way.

Being a social worker is very handy if approached by a comedian, by the way. At a recent gig, lumbered in the front row, Rich Hall came my way looking for some sport. I told him that I worked with children in care who were fostered. He was visibly stunned, acknowledged how worthwhile that was and moved on. The perfect protection – no gags there. Try it next time you’re in a comedy club, works wonders. Unlike the guy at the other end of the row who told Rich he was ‘an independent social worker’. Two social workers, same gig, same  row, what are the chances? Hall thought this a crazy concept and conjured up visions of this man approaching anyone he saw and counselling them or removing their children.

It’s hard to draw conclusions about the impact of Protecting Our Children on the perception of social work in society on the basis of my friends and family. In the Guardian last week, Terry Philpot persuasively argued that it cannot alter the public view of social work because the profession has no deep roots in society or in popular culture. There’s another related question – why don’t the public know in the first place?

One reason is that social work in general does media and PR appallingly badly. Also, we don’t have an organisation and/or figurehead that consistently speaks up for us and gets air-time. Then there’s fiction. We don’t have a cuddly TV series to soften the hard edges and provide a stream of gritty realism with happy endings. I’ve seen one or two draft scripts for popular dramas that include a social worker in an episode: the characters are laughable stereotypes, their actions far from good practice.

Another reason is that people think they know. They have a vague but laudable notion of social workers visiting, talking and, dare I say it, helping the vulnerable and sick. This is of course true, but there are other truths too. Even those who recognise the different role of taking children into care tend to have  a similar core view – I could do that. The reason that people say they would prefer not to relates to the emotional level (“I couldn’t possibly do what you do, I’d get too upset”) rather than the skills required. The vast majority do not realise even the basic point that our role with children and adults is framed by legislation.

Because they think they know, most people don’t wish to find out more. Add this to the perception that anyone could do it and the profession is fatally undermined. The current government calls for more common sense in fostering and adoption assessments, not greater professionalism or expertise. We’re not far from Virginia Bottomley’s force of streetwise grannies.

The main reason however is that the public don’t want to know. Uniquely amongst the professions, social work exposes a side of society that is deeply embedded but which the public would prefer did not exist. Peter Connolly suffered in the midst of a community and there are other children suffering in a similar manner at this precise moment. Older people are dying lonely, forgotten and ill-cared for in the midst of plenty. Social work holds up a mirror to our society and most turn away. We, those in the profession, have no choice but to stand and stare.

What the public want are nice easy solutions. Even the profession itself buys into it. The highest profile long-running fundraising campaign in social care, the NSPCC’s ‘Full Stop’ to child abuse, perpetuates the myth that a solution exists to a problem that has been going on ever since there were children. Good tag line, simple hard-hitting message plus a dinky little green lapel badge, it’s a PR marketing dream. It’s one of the few campaigns recognised by the notoriously insular Premier League, whose players once a year dress up in t-shirts pre-match and the managers ruin their ludicrously expensive suits with the badge. The other one is ‘Kick Out Racism’, and look how well that’s gone lately. Won’t make a blind bit of difference. The public need to know that.

Protecting Our Children will at least be a reference point if we who value the significance of our role want to stand up for ourselves. However, the reality is that our job is getting tougher. Social workers are at the front end of the cuts. We have to explain to the public that the services they want and that we would wish to provide aren’t there any more. It will take some television programme to overcome that.

Yesterday the UK government released its first figures about the ‘Mandatory Work Activity’ programme (a workfare system). This scheme as the Guardian explains empowers Job Centre managers

to make unemployed people do a month’s work experience at charities, government offices or high-street chains if they feel claimants “fail to demonstrate the focus and discipline necessary to seek out, secure and retain employment opportunities”. If they do not take part, claimants have their benefits removed for 13 weeks. A second failure to take part means benefits are removed for six months.

They also go on to explain about another parallel scheme where

managers can also ask jobseekers to take up unpaid work experience (WE) for eight weeks. However, under this programme, people can refuse to do the work or pull out within the first week without having benefits docked

Surely these opportunities will help young people ‘get into the habit’ of work? Isn’t that the way the argument goes? I am not against help being offered but I am against that help or shall we call it work, being unpaid.

Worryingly, the Guardian picks up a differential in the referrals made to the voluntary and mandatory schemes depending on gender and race.

The figures show a wide variance between gender and race groups entered into the two schemes. Of those being referred to the mandatory scheme, 75% (18,000) were male, while 66% were male in the non-mandatory WE scheme.

Figures for ethnicity reveal that 24% of those being forced to do work experience were from minorities compared to only 13% on the voluntary WE scheme.

No explanation of these variations in figures have been given by the DWP but it’s useful to bear in mind that these referrals and the decisions about which referrals are made to which scheme (the sanctioned scheme or the ‘voluntary’ scheme) are at the discretion the of manager of the job centre.

The sanctions and social control extended to those on workfare placements is also balanced by the benefits to involved companies. They receive a cheap (free) workforce and their own costs fall. Work provided is often low or non-skilled and potentially displaces those who would otherwise have been employed at least on minimum wage.

I tried to look up some studies about the effectiveness of ‘workfare’ to put this in an international context. I found a study from the Centre for Labour Market Research (Aalborg University) called ‘Flexicurity, workfare or inclusion? The Politics of Welfare and Activation in the UK and Denmark’ (pdf)

While the paper is from 2005 so refers mainly to Labour’s ‘New Deal’ some of the research evidenced is interesting in a current context.

The authors, for example, establish that

the failure of mainstream social and welfare services to deal effectively with the problems associated with poverty (homelessness, poor health, drug and alcohol addiction, learning difficulties) act as barriers  for returning to the labour market. Disengagement from the labour market is seen as the fault of the individual, rather than the result of inadequate social support.

The paper (which makes interesting reading) explores how much (or little) those who are socially excluded through poverty have been engaged to coproduce government policy which relates to promoting employment. For me, it raises interesting parallels with work on the personalisation agenda in social care. We are, quite rightly, moving to systems where we are trying to equalise the power divide (despite its constant presence) between users and government agents of delivery (aka social workers!) while in the field of benefits and promoting work we are infantilising claimants and forcing them to work without day. Don’t similar principles of improved outcomes by involvement and coproduction exist? Would it be better to work with people and find to really what the barriers are to work – whether that be the availability of work in a particular area or field, broader sociological issues such as poverty or those issues explained above.

Why are we assuming that ‘disengagement from the labour market is seen as the fault of the individual’.

If people ‘choose’ not to work, why? What is there within society that pushes this agenda.

Another interesting study comes from the DWP itself published in 2008 looking at ‘workfare’ in the United States.(pdf)

Again, interesting and worth reading but the evidence produces jumps out from the first page (so you don’t need to delve very deep) where it explains that there is a fall in welfare claimants however that may be because people drop out of the system.

But it also concludes that these ‘workfare’ type programmes work best in jobs that actually pay a wage rather than just the benefit level itself and they do not increase the likelihood of claimants actually finding jobs and are particularly poor at delivering ‘results’ for those who have ‘multiple barriers’ to work. Indeed, it may be more punishing to those who experience more of these barriers because they are more likely to be sanctioned.

So where are we now? With a hotchpotch scheme invented by a government that wishes to punish people for unemployment when the unemployment rate is skyrocketing.

Offer work placements, by all means, but offer placements that allow the dignity of a payment of at least the minimum wage to be made. Private companies are growing rich on the back of those who have the least and that seems to be an underlying theme for this government.

Is WorkFare Fair? Not at all. But from a government that seems to like to through the word ‘fair’ round and attach it’s own values to it, I don’t see this changing.

We need to throw their own research back to them. The evidence is there. The way is to push through more co-productive ideas. The way is for more jobs to actually exist and not punish and stigmatise those who are not able to find them.

I couldn’t fail though to be moved by the pictures that came in from Athens on Sunday night as the city burned while the politicians argued as they risked plunging Greece into ever sharper constraints demanded by the International Monetary Fund and the European Central Bank to fund another bailout.

While sometimes it’s easy to think of numbers such as 130 Billion Euros as beyond imagination – when a number reaches such a great number it becomes an intellectual equivalent to an statement of infinity, the figure, unfortunately, is real and the debt will be met at considerable human cost.

It’s not going to be those politicians who vote on this matter that will be punished by these measures.

CNN lists some of the proposed ‘savings’ and we can see exactly where the ‘pain’ is going to be felt

• Reduce the minimum wage straight away from €751 ($989) to €600 ($790) per month. For those under 25, the minimum wage will be slashed by 32%

• Cut pension provision and include a “strict link between contributions and benefits”

• Make 15,000 public sector workers redundant by the end of the year.

So who is going to pay the highest price to the IMF, European Central Bank and European Commission?

Those who have the least spare. The young, the unemployed (whose ranks will be growing with redundancies) and the pensioners.

We can joke about bloated public servants – and I won’t vouch for every one of those 15,000 jobs ( note that our own government does the same here) but public sector workers do have functions to serve and do work with people across all income brackets. These functions will be lost.

Again in the CNN article, chillingly, it is noted there are proposals to reduce spending on overtime of hospital doctors and make 1 billion euro savings on medication.

While there is a proposal to push through measures against tax evasion, that really is too little too late. The price is being paid by citizens for actions of previous governments and ruling classes who were more attentive to looking after their own then building better systems for their citizens.

As for the future, as well as the spectre of a move towards extremism across Europe as the impact of the bank-created recession builds there is likely to be more generations of emigrants of those most able to leave the countries that struggle the most. This will mean that those left behind struggle to a greater degree.

Unemployment in Greece is currently touching 21%. and it may yet defaulton the payments that have been demanded.

Caught between two evils, it’s hard to know or see a way out but there will be as there has to be.

We cannot ignore the pain inflicted on the southern fringes of Europe. Where Greece go, others may follow. Although we are not facing the same situations in the UK, the instinct of the ruling and political classes to save ‘their own’ at the expense of those who have least to give certainly rings true and while I doubt the empathy and solidarity of one social worker in the UK will have much significance to the people of Greece, it’s all I have to give. It seems so little.

Millions of healthy people – including shy or defiant children, grieving relatives and people with fetishes – may be wrongly labeled mentally ill by a new international diagnostic manual, specialists said on Thursday.

In a damning analysis of an upcoming revision of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other experts said new categories of mental illness identified in the book were at best “silly” and at worst “worrying and dangerous.”

I’ve occasionally been asked what all this will mean for Child and Adolescent Mental Health Services (CAMHS) in the UK. To be honest, I don’t think this is going to be the real issue for us. I think other issues are going to define what we do and how we do it.

Some people have suggested to me that the draft DSM means that CAMHS are going to wind up diagnosing the entire world. Every child will have its own medicalised label – be it oppositional defiant disorder for naughty behaviour, or social anxiety disorder for shyness. We’re going to be out there gleefully sorting and categorising the nation’s kids into little boxes.

The first response to that is that in the UK we mostly use the ICD-10 rather than the DSM for diagnostic categories – though I wouldn’t be surprised if the next revision of ICD (due in 2015) winds up being influenced by the DSM.

But I suspect that in the months and years to come the defining issue for us isn’t going to be diagnostic criteria but referral criteria. The reason for this is – surprise, surprise – a need to conserve resources during a period of austerity.

I’ve been hearing a lot of talk from our higher-ups about the need to focus on our core client base. Historically, CAMHS emerged out of what used to be called “child guidance clinics” (interestingly, I recently discovered that they still call them that in the Republic of Ireland) and have tended to have a broader outlook than adult mental health services, dealing with a lot of social and family problems. Increasingly, the party line is likely to be that we are a mental health service and it’s only our job to deal with mental health problems.

In the four years I’ve worked in CAMHS, I’ve noticed the referral criteria getting stricter, and that’s accelerated recently due to the cuts. In particular, I’ve noticed us getting more strict on not accepting two particular types of referral:

Behavioural/Conduct Problems

We still regularly get letters from GPs along the lines of, “This child is displaying angry and defiant behaviour, parents are at their wits end, please assess with a view to anger management.” CAMHS used to run anger management classes for these kids, and parenting classes for the parents. Anger management, as I’ve said before is a type of therapy that I regard with a scepticism bordering on contempt. I’ve seen lots of kids being sent for anger management, and virtually none of them come back any less angry or better-behaved. It’s a vapid, crass, sticking-plaster non-solution of a therapy that doesn’t address the rather obvious question, “Why is this child angry?” (Clue: an angry child is a distressed child.) It’s also often started for the wrong reasons. “He needs anger management to control his anger management” is often a euphemism for, “Please get him to behave for me.” Under such circumstances, it’s easy for CAMHS to fall into the trap of having a parent handing them responsibility for parenting their child. That sets everyone up to fail – CAMHS, the parents and most importantly the child him or herself.

School refusal

This is another thing we still get referrals for. Despite everybody’s best efforts, a child,for whatever reason, isn’t going to school. So, a letter goes to CAMHS asking us to see them for “school phobia”.

As with behavioural problems, school refusal is something that CAMHS simply isn’t successful at “treating” anyway. The longer a child stays out of school, then the more difficult it can be to get them back in, until it starts to feel like an exercise in pulling teeth. Either way, the effort needs to come from schools rather than a mental health service. Apart from the general lack of success, involving CAMHS can be interpreted as a medical reason not to go to school, because the child is “mentally ill”.

So, regardless of whether there’s a psychiatric diagnosis that can be used to label such problems – be it “oppositional defiant disorder”, “conduct disorder” or “school phobia” – we’re increasingly unlikely to accept referrals simply because a child won’t behave themselves or go to school. Our role is to work with conditions such as depression, anxiety, self-harm, eating disorders, ADHD, ASD, psychosis and so on. Personally, I think that’s as it should be.

One other effect of the cuts is a narrowing of disciplines as well as referral criteria. In some places, social workers in CAMHS have been provided by social services rather than the NHS, so it makes them vulnerable to being pulled out by social services departments who’ve been told they have to lose staff. Why lose social workers in your own office when you can get rid of or redeploy the ones who are over at CAMHS?

Also vulnerable for the chop are the psychotherapists – they’re more likely to get culled, and less likely for new posts to be advertised. We’re seeing a bonfire of the family therapists, psychodynamic therapists, art therapists, play therapists…retreating onto the core disciplines of doctors, nurses and clinical psychologists. You wouldn’t think it from some of my views on psychotherapy regulation, but I find this deeply depressing and worrying. The chance to work alongside family therapists has been genuinely transformative on my clinical practice, and I’ve had some fascinating case discussions with our psychoanalytic therapist. I worry that new staff coming into CAMHS won’t get those experiences that I’ve had, and that the service will be poorer for it.

So, that’s what I think the future of CAMHS is likely to look like. Slimmed down to its core client base, and with a less eclectic mix of disciplines. It won’t be about us expanding out to medicalise the nation’s children.

In a chilling parallel, The Not So Big Society has obtained court documents showing a Jungian psychotherapist has been under investigation for alleged misconduct for over three years, apparently with no conclusion reached. Throughout this period he has been able to continue advertising his services with no warning that his fitness to practice may be impaired.

The case is likely to raise serious questions about the way psychotherapy is regulated in the UK.

Unlike doctors, nurses, social workers and teachers, there is no statutory regulator for psychotherapists in the UK. However, there are a number of self-regulating professional bodies. The United Kingdom Council for Psychotherapy acts as an umbrella body for nearly 80 psychotherapy organisations. A complaint against a psychotherapist must first be heard by their member organisation. If unsuccessful, the complainant can then appeal to the UKCP.

John Smalley is a Jungian analyst with the Independent Group of Analytical Psychologists (IGAP), a UKCP member organisation. He trained at the CG Jung Institute in Switzerland and practises in Manchester and West Yorkshire. On 1st December 2011, Leeds Administrative Court refused permission for a judicial review of his UKCP fitness to practice investigation. I was able to obtain the court documents, which show very worrying concerns about the ability of the UKCP to regulate its members.

Links to the documents are at the end of this post. The following points emerged from scrutinising these documents and looking up the IGAP and UKCP websites.

- Mr Smalley applied for a judicial review on the basis of significant delays in the investigation of his conduct. IGAP first received a complaint in August 2008. After the complaint was rejected by IGAP, on 1st February 2009 an appeal was submitted to the UKCP. To quote Smalley’s barrister in the Grounds for the Claim, the UKCP, “took 5 months to decide if it could accept [the complainant's] appeal and almost 10 months more to bring that appeal on for hearing. 21 months will have elapsed since the decision that the complaint should proceed to the proposed substantive hearing date in December 2011.”

- Throughout this period, Smalley’s practice continues to be advertised on the IGAP website, with no warning that his fitness to practice may be impaired.

- Appended to the Grounds for the Defence is a detailed chronology of the case. In the chronology, it is stated that the UKCP panel found IGAP’s decision that there was no case to answer to be “perverse”.

- The chronology states that the complainant initially made 11 points of complaint, which were later followed by another 7, leading to a whopping 18 concerns.

- Unfortunately these 18 concerns are not listed in the documents. However, in the Grounds for Renewal Smalley’s barrister mentions that one of them is that Smalley “is accused of pursuing a therapeutic approach that is not indicated for the treatment of” the complainant’s condition.

- In the chronology, the UKCP panel is quoted as saying, “That it did not occur to Mr Smalley that some of his behaviours at the time might have been a cause for concern, troubles the Panel.” The ability to reflect upon one’s actions is considered a key element of fitness to practice – not only in psychotherapy but in many other disciplines such as medicine, nursing and social work.

- The Grounds for Renewal contains some bizarre comments by Smalley’s barrister. “If this were a clinical case, one would examine the medical records, the medical correspondence and obtain expert reports. Psychotherapy is an oral therapy. There is no record of the therapy.” No record? Where are Smalley’s notes of the therapy? What about his supervisor’s notes?

- According to the court documents, a UKCP hearing was due to take place in December 2011. The UKCP complaints archive lists only two hearings in the past two-and-a-half years. One of them is for Derek Gale, a notorious abuser who was struck off by the Health Professions Council as an arts therapist and by the UKCP as a psychotherapist. The other is for an Arbours Association therapist called Geoffrey Pick. No mention at all of John Smalley.

- A search of the UKCP register finds no listing for John Smalley. There is no information as to whether he has been suspended, struck off or simply left the register.

So, what we have here is a psychotherapist whose fitness to practice may or may not be impaired, but where over three years have elapsed in trying to investigate the issue. All the while he’s carried on advertising his services. If he’s innocent of what’s been alleged, then he’s been strung out for an inordinate and unfair amount of time. If he’s not innocent, then the UKCP may have failed to protect the public.

Now that’s a dangerous method.

The Documents

Claim Form

Acknowledgement of Service

Grounds for the Claim

Grounds for the Defence

Grounds for Renewal

Orders