January 9, 2014

The Nick Griffin Cookery Show – I watch it so you don’t have to

The news reports are true. Nick “Fat Hitler” Griffin of the British National Party has posted a cookery TV show online. Personally I’m not entirely comfortable with the idea of no-platforming fascists. Don’t get me wrong, I can see the argument in favour of it. Even so, when Griffin was invited on BBC Question Time, the result was a more effective anti-BNP message than years of Unite Against Fascism’s campaigning – through the simple expedient of letting him open his gob.

So, with that in mind, I’m going to review his culinary extravaganza.

The show opens with the BNP TV logo, which looks strangely like the Eurovision Song Contest logo with a Union Jack slapped over it. The screen cuts to a surprisingly posh-looking kitchen for a man who’s just been declared bankrupt. No doubt his creditors are watching the show with a calculator in hand.

On the table in front of him is some veg, including a bag clearly labelled “British White Potatoes”. Presumably Nick wanted these on display because he’s British, white and has the intellect of a potato.

Nick starts talking about the impact of poverty on food budgets, and how he was at an event where people complained that “they can’t afford – their wives can’t afford to put enough decent food on the table.” Their wives? Who was he meeting with? The Stepford Racists?

He then suggests that the problem here is that a lot of people only know how to cook processed food, and don’t know how to make cheap food from raw ingredients. “Our chaps said to me, you like cooking. Why don’t you show a few examples of how cheap it is, how simple it is to cook really good food for yourself and your family.”

Wow. There actually was a BNP meeting where they decided, “You know what, Nick? See that Jack Monroe? You could do that!” Be very afraid.

1.00 Nick warns “We’ve not done this before. BNP TV does politics, not cookery, but we’ll see how it goes.” Building up the tension here until it’s almost noticeable.

1.20 Nick takes us through the ingredients, which he’s spent about £10 on. He provides the startling revelation that a good place to find reduced prices is in the the reduced section of the supermarket. I have a feeling there’s going to be a lot of this sort of revelations.

1.35 He found some stewing steak in the reduced section. Naturally it’s made from British beef. “Good stuff!” He’s got some carrots, onions, parsnips and swede. But there’s an important warning. “You can have too much swede, unless you’re a goat.” The nation’s goats breathe a sigh of relief.

2.05 There’s some condiments too – some salt, pepper and in a magnanimous gesture to Johnny Foreigner, some tabasco sauce.

3.00 He launches into a sob story about how he used to be living hand-to-mouth when he first moved to London. This doesn’t seem so much to be to empathise with the nation’s poor as to justify having a bottle of beer to hand. No doubt this would elicit more sympathy if he wasn’t a fat man standing in a very expensive kitchen.

4.15 Having bleated his poor-me history, Nick then promptly starts bragging about how nice his kitchen is, and to be fair, it is a nice kitchen with a great big Aga. Or at least it will be until the bailiffs arrive next week. However, he reassures us that in order to heat up a pot of stew you don’t need a fancy cooker, just any old burner. That’s right. Tesco Everyday Value fire is just as hot as Marks and Spencer’s fire. Well, I never.

4.25 “Different things take different times to cook, so obviously you’ve got to make sure that the things that take longest are done first of all.” Glad to hear we’re getting to grips with the concept of time.

4.40 I am now watching the leader of a political party explain how to chop an onion, while explaining that you don’t actually eat the peel. You won’t other political leaders doing that, eh? EH?

6.10 Hey up, we’re off. He’s starting to cook, though not before explaining that there are different types of cooking oil.

6.30 After explaining how time works, we now have more basic physics as we learn that a handy way to speed up the cooking is to put the pan on a hotter ring. He then grabs a wooden spoon, presumably the one he was awarded at the last election.

7.00 Sometimes meat comes ready-chopped. If this isn’t the case, Nick helpfully advises that as an alternative you can cut it up yourself.

7.40 It seems not only are there different types of cooking oil, there’s even different types of meat! “You could use pork, you could use chicken.”

8.00 Handy hint from Nick. If you buy a slow cooker, you’re getting a cooker and a pan for £12. How he hasn’t got a sponsorship deal from Russell Hobbs, I’ll never know.

9.14 Time to peel some vegetables. “You can peel with a knife.” YES YOU CAN!

10.05 According to Nick, British cooking used to be the best in Europe, but was scuppered by Ze Germans. “It became very simple after the Hanoverians came over from North Germany.” Fear not though, since “I spend a lot of time on the continent” and he now believes British cooking is becoming the best in Europe again.

10.50 Oh no! An onion has escaped the round-up. He leaps on it like it’s a fleeing immigrant.

11.30 Speaking of immigrants, “Don’t let people tell you that you need huge numbers of immigrants to have good cooking. We’ve got a Mexican restaurant in a town near here. The place isn’t swamped with Mexicans. You take the recipe, that’s really all you need.” Though to be fair, his attempts to recreate the dishes at home probably don’t include those “extra ingredients” they probably secretly slip into his food when they see him walking into their establishment.

12.20 Time to move the pot of stew onto a smaller ring. He conveniently tells those with a one-ring burner that they can get the same effect by turning the gas down.

14.05 Nick’s Handy Economy Tip! Too skint to buy meat? “Go to a butcher, and tell him you’ve got a dog. Can you have some dog bones?” Then scrape off the meat. Apparently he’s tried this himself, although your butcher may not sneak out back and wipe his bum on the dog bones first, like Nick’s presumably did before handing them to him

16.10 “With a stew, if you find you haven’t cooked if for long enough, just cook it for longer.” Amazing.

17.40 Another one of Nick’s Handy Economy Tips. Can’t afford to buy a recipe book? Just go into a shop use a camera phone to take photos of the recipes.

20.40 Brief rant about “all that green bullshit”. He really doesn’t like anything coloured.

21.20 Important advice on using stock cubes. Take the tin foil wrapper off because “tin foil really is unpleasant in your food. It’s not a good additive.”

21.50 Nick laments the fact that although you can get beef, lamb or chicken stock cubes, you can’t get pork ones. However, he has a solution. “I reckon if you put one beef one in and one chicken one in, you’ve more or less got pork.” How much time has Nick spent experimenting with mixed stock cubes?

22.05 “Food without salt is absolutely disgusting”. Between his political speeches and his salt advice, he really isn’t doing wonders for the nation’s blood pressures.

22.45 We now learn that opening a tin of tomatoes requires a tin opener “unless of course, you look for the tomatoes which have a lid with a pull-ring, and then you don’t need a tin opener.” At this stage, I’m starting to worry that watching this show is causing me to become dumber.

23:20 Nick cheerfully sloshes some rather nice-looking Hobgoblin beer into the stew, before taking a swig from the bottle. “The fact that you’re able to drink the beer as you’re cooking makes it worth cooking.” I am now regretting watching this while sober.

24.00 Nick explains how the Mexican police use tabasco sauce as a torture instrument. Perhaps in future they’ll just use his cookery shows instead.

30.20 With the stew cooking nicely, Nick puts in a request for “serious, constructive criticisms” of the show. Naturally, the online masses will hear this request as, “Troll him! TROLL LIKE YOU’VE NEVER TROLLED BEFORE!”

31.10 It’s now time for those immortal words, “Here’s one I prepared earlier”, as Nigella Hitler dishes out his stew to two old guys and a teenage girl. The girl looks embarrassed to be there.

31.30 Adolf Ramsey scoops the stew into bowls. It looks like a cowpat with carrots.

32.30 The old guys declare the stew to be “first class, delicious.” Nick doesn’t ask the girl what she thinks, probably because she’s wishing she could sneak out to the Mexican restaurant that Nick slagged off earlier.

And that’s it. Nick tells us he’ll be putting a list of the ingredients online – because nowhere on the Internet could we find a recipe for beef stew – and the show is over. This is something of a relief because if I’d had to watch any more of it then my IQ would have probably dropped to the level of Nick’s stew. Or possibly that of a BNP supporter.

.

January 7, 2014

Just what do I do all day in CAMHS?

 

 

 

 

 

Last year there was a picture meme going around on the theme of What people think I do/What I actually do. After I made some sarcastic remarks about the meme on Facebook, I was challenged to come up with one for my own role as a nurse therapist in Child and Adolescent Mental Health Services (CAMHS). Being one never to ignore a thrown-down gauntlet, I went on a trawl through Google Images, and promptly knocked together the following illustration.

BdNq1zICMAAbsUn

 

 

A few days ago, I noticed that this graphic (which I’d probably devoted an entire half-hour to creating) was being passed around on Twitter. Since that’s the case, perhaps I should elaborate on it a little, and explain the different images. that I selected

What adult mental health services think I do.

Okay, it’s probably an exaggeration to suggest they think I work with Teletubbies. Even so, there is something of a disconnect between adult services and CAMHS. Our core client groups are palpably different, and so too are our ways of working.

We don’t work a lot with people who have psychosis. Despite the American fad for diagnosing “pediatric bipolar disorder” (which even the Americans have been backtracking on in the last couple of years), conditions such as schizophrenia and bipolar disorder are rare in children. I see maybe one psychotic young person a year, usually in their mid-to-late teens. I do work with young people who hear voices, but it tends to be at the level of pseudohallucinations rather than outright hallucinations.

One unfortunate consequence of this is that on those odd occasions when a psychotic child comes to a CAMHS team, they may not be as geared up to supporting them as an adult service. Conversely, adult services often aren’t as geared up towards treatment of eating disorders as CAMHS.

Another difference is that people with depression and anxiety are more likely to be seen in primary care during adulthood, and in secondary care during childhood and adolescence.

These difference tend to result in all kinds of problems when a young person turns 18. They often discover that they’re either transitioning to a very different kind of service, or they simply aren’t being offered a service at all.

What Peter Breggin thinks I do.

It is true that use of psychiatric medication has risen in the UK in recent years, and I’d be lying if I said I’m entirely comfortable with all aspects of that. Despite this increase, it’s still fair to say that CAMHS are much more cautious in their use of medication than either their American counterparts or their colleagues in adult services.

I could count on one hand the number of medications I’m likely to come across in any given working day. If a young person is prescribed an antidepressant, 9 times out of 10 it’s likely to be fluoxetine, not least because it’s the only one licenced for under-18s. For ADHD there’s some relatively new drugs on the market, such as lisdexamfetamine aka Elvanse, but they’re not being prescribed much. The great bulk of young people with ADHD are still prescribed good old-fashioned methylphenidate (you know it as Ritalin, but it’s far more likely to be issued in various slow-release preparations such as Concerta XL, Medikinet XL or Equasym XL) with a smaller number taking atomoxetine aka Strattera. For sleep problems there’s melatonin. For highly agitated children there’s some use of low-dose antipsychotics (this has usually been risperidone, though there’s increasing use of aripiprazole instead) – and it’s this use of antipsychotics that I tend to feel uncomfortable about, even at low doses.

Outside of the higher-tier services dealing with deeply-unwell young people, that’s pretty much all the medication you’ll see. Despite the controversies about dubious use of psychiatric medications in childhood (by no means all of which are unjustified) a high proportion of the kids I work with are on no medication at all.

It’s also worth pointing out that I’ve worked with quite a few kids whose lives have been significantly improved through some judicious, well-monitored use of fluoxetine or methylphenidate.

What the Church of Scientology thinks I do.

All I have to say to this one is…If their argument is that psychiatry is superstition masquerading as therapy, and it’s all just a big scam to control people and take their money….Well, that’s a bit rich coming from the Church of Scientology.

What society thinks I do.

This image illustrates one of my major bugbears about what mental health services are perceived to be for. There’s a whole plethora of language devoted to it. “Oppositional defiant disorder.” “Conduct disorder.” “Behavioural problems.” “He has an anger problem.” “He needs anger management.” “She has difficulties with impulse control.”

All of which translates as, “Please make this child behave themselves.”

There seems to be an idea out there that all of society’s problems – unruly classrooms, chaotic family lifestyles, juvenile delinqency, crime – can be therapied away with six sessions of anger management. I can see why it would be an attractive idea to politicians, civil servants, parents, teachers, GPs, social workers – but it ain’t true. The psychiatric profession hasn’t helped itself in this regard by coming up with silly non-illnesses such as “oppositional defiant disorder”, but I don’t think mental health services should be there to get children to behave themselves, and I don’t think we generally do a good job when we try. If anything we can make the problem worse by trying to distil a wider systemic or social difficulty into a “condition” that the child has “got”. Hence why many CAMHS teams simply don’t accept referrals for ODD or conduct disorder.

What I think I do.

It would be fair to say I’ve put in quite a lot of training and studying into what I think I do. I’ve attended training on cognitive-behaviour therapy, as well as enhanced CBT for eating disorders. I’m currently paying out of my own pocket for some postgraduate study in systemic and family therapy. Over the years I’ve ploughed through a reading list of the great and the good. John Bowlby. Carl Rogers. RD Laing. Carl Jung. Paul Watzlawick.

What I actually do.

What do I do? Listen. Talk. Try to be a listener, an ally, a facilitator of reflection and problem-solving. Someone who works to build a relationship with young people and their families, and at times to help them build their relationship with each other.

When one puts it like that, perhaps what I do isn’t that complicated after all.

 

December 1, 2013

How much therapy abuse is out there?

I recently had a question posted in the comments thread to one of my blog posts, by ‘Reading Enquirer’.

Is there actual evidence that a community of statutorily regulated health professionals commit fewer abuses on average than the unregulated? Does this cure depend only on supposition and faith or is there an actual peer-reviewed evidence base? Is there evidence that statutorily regulated health professionals have greater efficacy in the relief of human suffering than the unregulated?

This is an important question, and one which raises a further question – how can we know how much abuse by psychotherapists is out there?

Abuse, by its very nature, is something that happens behind closed doors, without records being kept. No practitioner – regulated or unregulated, is likely to be auditing how much people they’ve abused. Not everyone who has been abused reports it. Still less of those who report it have their allegations proven in a fitness-to-practise hearing and/or a court of law.

If we’re talking about unregulated professionals, then that does beg the question of who they can report it to. Historically, even being a member of a professional body has not necessarily been a guarantee that a complaint will be heard properly. Until recently, complaints-handling at the UK Council for Psychotherapy was dominated by “crony-ism and amateurism” (not my words, but the words of the then UKCP chair). To give an idea what this “crony-ism and amateurism” looks like, one can read the decision letter for the UKCP’s application to be accredited by the Professional Standards Authority.

The Panel considered a summary of the main themes identified in the Call for Information, and the UKCP’s response to these submissions. It observed that many were related to UKCP’s previous complaints processes, involving the handling of complaints by itself and its OMs. It was felt that the former complaints system was characterised by lengthy times from initial complaint to completion, poor communication from the UKCP and OMs and a lack of support for complainants. There were suggestions of conflicts of interest and procedural failures that appeared not to consider public protection.

The UKCP has now instituted a series of reforms to address these issues, with the result that they’ve now achieved PSA accreditation, though the PSA is insisting on auditing their complaints-handling after 6 months. To be fair to the UKCP, they’re now publishing a growing number of complaints decisions, which appear to have been handled in a considerably improved way.

But…what psychotherapy has at the moment is only regulation-lite, not full statutory regulation. “Psychotherapist” and “counsellor” are not protected titles and you don’t have to belong to a professional body to call yourself one. Indeed, the UKCP recently struck off a psychotherapist called Julia Eastwood. She’s still advertising herself for coaching and counselling.

And then there’s all those people who use other titles similar to psychotherapists and counsellors. Even if those professions became protected titles, there’d still be all the Jungian analysts, life coaches, shamanic therapists…did I mention Ms Eastwood also advertises herself as a “conscious channel of the Archangel Gabriel”? Good luck finding someone to complain to if your conscious channel engages in misconduct.

Still, even if you can’t find anyone to complain to, you could always sue them, though that can be hugely expensive, and you’ll only get no-win no-fee if you have a strong case. So presumably we could find out how much misconduct is out there by looking at the number of lawsuits?

I spoke to somebody who sued their psychotherapist. According to them, their solicitor knew of about 30 ongoing cases, which sounds like a worryingly high number. However, we don’t get to hear about many of these cases, for the reason that most of them end in a civil settlement. These settlements tend to include a confidentiality clause, effectively stuffing the complainant’s mouth with gold.

If it’s a serious form of abuse, say, if someone was sexually exploited, there’s also the police route. But conviction rates for sexual assault are shockingly low. No guarantee there’ll even be a prosecution, never mind a conviction.

One could simply try to publicise one’s case. But that carries the risk of being clobbered by our notoriously draconian libel laws, which have a well-documented “chilling effect” on free speech in the UK. Even with the recent reforms to defamation law, the risk of being hit by a lawsuit would make a lot of people think twice.

So, to answer Enquiring Reader’s question as to whether there’s evidence that unregulated professionals commit more abuse than regulated ones – the simple answer is we don’t know. The reason for that is that without regulation we can’t know the extent of the problem, because there’s nobody to complain to.

On a more pragmatic level, I think it’s important that people have the confidence that if something goes wrong, they have access to a robust complaints procedure. For that reason, my advice to anyone seeking a therapist is to ensure that they use someone either in a state-regulated profession (e.g. clinical psychologists or arts therapists, which are regulated by the Health and Care Professions Council), or belong to a PSA-accredited body (e.g. the BACP, the UKCP or the National Counselling Society). If they don’t fulfil those basic criteria, don’t use them.

 

November 19, 2013

Professional Standards Authority formally announces UKCP Accreditation.

The PSA have sent me the following press release:

Independent quality mark for The UK Council for Psychotherapy

The UK Council for Psychotherapy’s (UKCP) voluntary register has been accredited by the Professional Standards Authority for Health and Social Care an independent statutory body, accountable to Parliament.

Psychotherapists on UKCP’s register will be able to display the Accredited Voluntary Register quality mark, a sign that they belong to a register which meets the Professional Standards Authority’s robust standards.

David Pink, UKCP Chief Executive, said:

“The quality mark will give extra peace of mind for anyone looking for a psychotherapist, letting them know that anyone who holds the mark is committed to high standards. UKCP is pleased to offer the quality mark to psychotherapists that meet the far reaching standards of our register, as approved by the Professional Standards Authority.”

Harry Cayton, Chief Executive of the Professional Standards Authority, said:

“We are very pleased to accredit UKCP’s register of psychotherapists. Bringing psychotherapists into a broad framework of assurance is good for patients, service users and the public and is the best way to promote quality. The scheme offers enhanced protection to anyone looking for health and social care services, and gives psychotherapists the opportunity to demonstrate their commitment to good practice.”

Accreditation does not imply that the Authority has assessed the merits of individuals on the register. This remains the responsibility of UKCP. It does not mean that the Authority has endorsed a particular therapy, people will need to consider the information provided and decide if it is suitable for them. Accreditation means that UKCP’s register meets the Professional Standards Authority’s high standards in governance, standard-setting, education and training, management, complaints and information.

As the scheme develops, accredited registers will encompass a growing range of occupations and organisations, and the Professional Standards Authority may accredit more than one register in any particular occupation. Further information on the accredited voluntary register scheme is available atwww.professionalstandards.org.uk/voluntary-registers

November 17, 2013

What’s in a Word? Patients, Clients, Service Users…

Part of my job is to mentor student nurses. This week I had a look at the recently-revised competency portfolio that the students have to bring on placement. This is a hefty document about the size of the Yellow Pages, which lists all the skills students have to learn with me, and which I need to sign off to say they’ve learned. It’s very detailed and long, with a dizzying array of competencies in it. I’d challenge anyone who thinks a nursing degree is an easy option to read through it and then say so. However, there was one thing that struck me about the competencies.

They didn’t make a single use of the word “patient”.

Don’t get me wrong, it isn’t that the competencies weren’t aware that nurses work with people, but they were constantly referred to as “service users” and “clients”. The word “patient” was conspicuous by its absence. Apparently nurses don’t have patients.

There seems to be a view out there in mental health that “service user” and “client” are good and “patient” is bad. I don’t buy it. I’m not saying there aren’t people who don’t like being called patients, but I’ve also come across people with mental health problems who loathe being called service users or clients. Besides, anyone who’s ever been to the dentist is technically a patient.

The wording on the student competencies is particularly ironic because I work in Wales. Recently the Welsh Assembly Goverment passed the Mental Health Measure, a very progressive piece of legislation that enshrines certain rights for people receiving a mental health service into Welsh law. It gives, for example, the right to have a care and treatment plan that’s formed collaboratively between patients and staff, and a right for people who’ve been in secondary care to self-refer back to services. It’s a very good piece of law aimed at putting the person using the service at its centre. Even so, the term used in Mental Health Measure documentation is “relevant patient” not client or service user.

I suspect there isn’t a “right” or “wrong” answer when it comes to whether one should use patient, client or service user. It all depends not only on what those words mean, but also what people take them to mean. For example, when we talk about “health” some people would take that to mean a fairly narrow, medical model of diagnosis and treatment. However, if you go by the World Health Organisation’s definition of health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

….then that’s a much broader concept.

It’s also worth pointing out that the meanings of words can be changed, often due to a conscious effort by those to whom they apply. A good example of this comes from the recent #mentalpatient furore that erupted on Twitter and into the mainstream news. The Asda website was discovered to have a “mental patient” fancy dress costume (which Asda has since removed and apologised for) on its online store.

 

The response of various Twitter users was to post pictures of themselves in their own “mental patient costumes.”

As well as patient, client and service user, the term “expert by lived experience” has also been bandied about in mental health debates. I recently asked Twitter users what they thought of this particular wording, and got a high number of responses which I’ve Storified here. The answers varied wildly. Some loved it, some hated it, and quite a few people gave nuanced answers somewhere in between.

I’m not sure that I have an opinion as to which is the “right” wording to use (and as I’ve said, I’m convinced there even is a right answer). I’d hope that whatever wording is used, people are treated with dignity, respect and in a collaborative way that upholds their rights and wishes.

 

 

 

November 16, 2013

UKCP finally achieves PSA accreditation

It seems to be a big week for news involving the UK Council for Psychotherapy. Having recently struck off a therapist for the first time since 2009, the UKCP have, after a long process, finally achieved accreditation by the Professional Standards Authority.

The decision letter is up online at the PSA website. The UKCP is now one of five organisations offering psychological therapies (the others are the British Association for Counselling and Psychotherapy, Play Therapy UK, the National Counselling Society and the National Hypnotherapy Society) to have so far achieved “assured voluntary regististration” status with the PSA.

The decision letter makes for an interesting read. This may not be an entirely scientific measure but comparing it to the outcome letters for other AVR bodies, something that stands out is that the UKCP’s is the longest. It’s 19 pages long, compared to 11 pages for Play Therapy UK, 13 pages for the National Counselling Society and National Hypnotherapy Society and 10 pages compared to the British Association for Counselling and Psychotherapy. This is speculation on my part, but that leaves me wondering about the amount of reform that was needed compared to other bodies. Certainly the letter strikes me as pretty packed with recommendations.

One thing that the letter does confirm is that – finally – the new Complaints and Conduct Process covers 100% of the UKCP membership.

The section on the Call for Information – where the PSA had asked the public to write in with any feedback about the application – is particularly interesting. Various people (me included, but I was by no means the only one) leapt at the chance to send the PSA some of the horrific stories that have been discussed on this website and elsewhere. This seems to be alluded to by the PSA.

The Panel considered a summary of the main themes identified in the Call for Information, and the UKCP’s response to these submissions. It observed that many were related to UKCP’s previous complaints processes, involving the handling of complaints by itself and its OMs. It was felt that the former complaints system was characterised by lengthy times from initial complaint to completion, poor communication from the UKCP and OMs and a lack of support for complainants. There were suggestions of conflicts of interest and procedural failures that appeared not to consider public protection.

Regular readers of this blog will have a good idea of what’s being referred to here.

The Panel reviewed the summary and noted that the new Complaints and Conduct Process has been developed to address such concerns. As quality assurance for the new procedure the Panel instructed UKCP to allow the AVR team to review a sample of CCP outcomes in six months’ time to ensure that it is achieving its objectives, as discussed in Standard 11.

So, they’re getting the accreditation, but the CCP is going to be audited in 6 months.

Comparing the UKCP letter to the Call for Information in the letters for other organisations, what stands out is that in most of the other letters it’s a much briefer section. It reads like the only other organisation to have had a similar public response is the Complementary and Natural Healthcare Council (scathingly referred to as “OfQuack” by its critics). Concerns with the CNHC seem to have been mostly around how they deal with complaints alleging false advertising. As in, “Sticking this candle in your ear will help your diabetes.”

It looks like the PSA process has resulted in considerable reform at the UKCP. I hope that our efforts have provided some impetus to that process. It certainly looks like the PSA has taken notice when giving instructions to the UKCP.

Although it’s me who’s written these blog posts, I think I should state that I’ve only been able to do so because of a variety of people who have gathered information and passed it to me. Some of them have shown considerable courage in doing so. I’d like to take this opportunity to thank them, even though I can’t name them.

Sadly, these changes come too late for people who were not properly listened to or supported when they tried to speak out about a rogue’s gallery of unethical therapists – Derek Gale, John Smalley, Geoffrey Pick, Stuart Macfarlane – and that’s just the names in the public domain.

I don’t doubt there are likely to be other rogues out there among the UKCP membership. However, they should no longer be able to rely on “cronyism and amateurism” (to quote the former UKCP chair) to protect them from accountability. Those rogues may now have to shape up or ship out of the UKCP.

 

November 14, 2013

UKCP strikes off first psychotherapist in four years

In the past the UK Council for Psychotherapy has had a pretty dreadful record for complaints-handling. Up until recently the only person they’d ever struck off in recent years was the notorious cult leader Derek Gale, booted off the register in 2009 for sexually, emotionally, physically and financially abusing his clients.

Since then there’s been ongoing, but painfully slow work to improve their procedures, not least due to the need to obtain accreditation from the Professional Standards Authority. Hopefully it’s a sign of this improvement that the UKCP has now, for the first time since the Gale case, struck off a therapist.

The dubious honour goes to a Leeds-based therapist by the name of Julia Eastwood. The reason why she’s been struck off are pretty straightforward.

It has come to UKCP’s attention that the respondent has and continues to advertise and offer services as a psychotherapist. The FTPT were provided with links of websites (listed below) which demonstrated non-compliance of the suspension order of 26 June 2013.

www.juliaeastwood.co.uk
http://www.youtube.com/watch?v=wRzryzvfqw4
http://www.julia-eastwood.com/#!stayslimforever/c1jox
https://www.youtube.com/watch?v=S2SfLH0ZSDU
https://www.youtube.com/watch?v=NLzLhjT0T1w

UKCP invited the respondent to address the evidence in relation to her continuing practise. The respondent did not refute nor address the allegations. She stated that she is no longer a member of UKCP and that UKCP are not to write to her again.
The FTPT were particularly concerned that the respondent’s website shows unequivocally that she is offering psychotherapy services despite being advised by UKCP that she should not be practising or offering psychotherapy services whilst she has a suspension order in place.

So, she hasn’t complied with her suspension, is therefore struck off. I’ve been heavily critical of the UKCP in the past, but I think it’s only fair to state that this is an entirely correct decision.

Sadly, the fact that “psychotherapist” and “counsellor” aren’t protected titles means this happens fairly regularly. I’ve come across several examples of suspended or even struck off therapists who have just carried on practicing regardless. Ms Eastwood’s website certainly continues to advertise her services.

As it happens, there’s another psychotherapist, Rob Waygood, who is currently on an interim suspension order with the UKCP, pending a hearing for gross professional misconduct…

…and as it also happens, he’s continuing to advertise his services online too.

robwaygood

Screenshot taken at roughly 8.30pm on 14th November 2013.

October 30, 2013

Does ADHD exist?

One of the joys of working in child and adolescent mental health services (CAMHS) is that I regularly get asked whether I think ADHD exists. It’s a topic that has two polarised camps. In one camp you get those who think it’s an attempt to medicate away all kinds of family and social problems, giving bad parents a handy excuse while lining the wallets of Big Pharma. In the other camp you have those who insist that those voices are simply pillshaming a debilitating but treatable condition.

I’m going to give my answer to that question, and it’s slightly more complicated than either pole. Quite possibly I might wind up sounding like Bill Clinton’s notorious comment that, “It depends what the meaning of the word ‘is’ is.”

To start off, what do we mean when we say that a child (or adult, since adult diagnoses are on the increase) has “got ADHD”? Well, the first thing to remember is that ADHD, as with most psychiatric diagnoses, is a descriptive statement about a collection of thoughts, feelings and behaviours that somebody happens to be displaying. There’s not a blood test or a scan for ADHD (or depression, or psychosis, or post-traumatic stress disorder etc etc).

At the risk of simplifying somewhat, ADHD is defined by three core symptoms: inattention, hyperactivity and impulsivity. If you’re inattentive, hyperactive and impulsive, you’ve “got ADHD.” If you don’t have those three things, you “haven’t got ADHD”. What that doesn’t tell you is why somebody is inattentive, hyperactive and impulsive.

Back in 2010 there was a big media hoo-hah after a Lancet paper was widely reported as having found a “gene for ADHD.” The media’s eye was particularly caught by a line in the abstract.

Our findings provide genetic evidence of an increased rate of large CNVs in individuals with ADHD and suggest that ADHD is not purely a social construct.

I don’t pretend to be an expert on genetics, but there’s a handy deconstruction of the paper by Neuroskeptic here. The upshot of it is that this particular piece of genetic evidence is likely only to account for 7% of individuals with ADHD. Fine, but what about the other 93%?

I guess some researchers would be keen to say “other genes”. But if ADHD is essentially a description of symptoms, why do we need to think either all or none of it is down to genetics?

We don’t assume that say, anxiety is caused by one single thing, be it biological or environmental. I see a lot of anxious children due to psychosocial events. I also worked a while back with an anxious child who turned out to have abnormal hormone levels. When the hormones corrected themselves, the anxiety disappeared.

I’m not an ADHD nurse specialist – I’m something of a CAMHS jack-of-all-trades – but I run a regular nurse-led ADHD clinic. In that there are children who, for no apparent reason, seem to have been hyperactive, inattentive and impulsive from birth, and for those children a genetic component to their behaviour certainly seems plausible. There are also children who developed those symptoms after a head injury.

And yes, there are children who have a strong history of being subjected to various psychological, family and social stresses.

A while back I was running one of my ADHD clinics. For confidentiality reasons I won’t go into the details of the cases. However, what I will say is that after reading the notes I discovered that every child booked into my clinic that morning had either been sexually abused or exposed to domestic violence during early infancy. A lot of people outside psychiatry and psychology tend to assume that this would be unlikely to affect the child later on, because they wouldn’t remember those very early experiences. It’s true that these children probably don’t consciously remember what happened to them. However, at that very early age their fight-or-flight responses would have been going off like the clappers, right at the time when they would be starting to form those early attachment bonds that go on to develop the basis of somebody’s personality.

What would a child be like if they developed an attachment style based on an aroused attunement to perceived danger? Jumpy? Fidgety? Finding it hard to sit still and focus on a schoolbook?

What childhood condition does that sound like, eh?

But here’s the thing. At every one of those appointments that morning, both the child and the parents agreed that he or she was benefiting from the medication. I don’t mean in a simple, “He’s behaving himself and not causing trouble” kind of way. As in they were coping better with the school day, able to progress in their education, able to make and sustain friendships. They were able to get on with being a child.

This isn’t entirely surprising when you think about the medication involved. There’s various ADHD medications on sale: atomoxetine (aka Strattera), lisdexamfetamine (aka Elvanse) but by far the most commonly-used is methylphenidate. You all know it by its more famous name Ritalin, but that’s a brand name one doesn’t often see these days. It’s more likely to be prescribed in various slow-release preparations – Equasym, Concerta, Medikinet – or as generic methylphenidate.

Methylphenidate is basically a performance-enhancing drug. One child psychiatrist (not one I work with) told me that when parents tell him that their child’s school grades have gone up since starting methylphenidate, he thinks back to his time at university, when he took speed to help with his exam revision. Methylphenidate is a stimulant that helps people to concentrate and stay on task, and can provide symptom relief to those who have trouble with that, regardless of why they have trouble with it.

Throughout human history, people have used pharmacological products to improve their functioning on a personal, social or cultural level. Anyone who says otherwise simply doesn’t own enough Beatles albums. Little Johnny might be taking methylphenidate. His Mum is being prescribed fluoxetine to help her cope with the drudgery of her life. Dad is medicating himself from the stress of work with some diluted liquid ethanol from his local pharmaceutical supplier at Thresher’s. Meanwhile, Johnny’s teenage sister deals with her anger at Dad by smoking some herbal tetrahydrocannabinol that she obtains from an amateur, unlicensed pharmacist. Along the way she discovers it has some interesting effects on her art A level coursework. As the song goes, it’s a chemical world.

 

 

 
If that sounds like a cynical way to put it, I should point out that methylphenidate is, unlike some of those other products mentioned, relatively safe. Not completely safe, but then no medication is. Even so, as long as there’s regular monitoring of fairly basic things such as height, weight, pulse and blood pressure the risks are low and manageable. Often those risks are much lower than simply allowing a child’s educational, emotional and social development to carry on being disrupted by whatever is causing them to become inattentive, hyperactive and impulsive.

So, to go back to the question, “Does ADHD exist?” If by that do we mean that children can become hyperactive, inattentive and impulsive and that this can be corrected with medication, then yes, it does exist.

If by that do we mean it’s a single condition with one single cause that affects every child who has it, I’d say not.

To paraphrase President Clinton, I suppose it depends on what we mean by “exists”.

Of course, this is not how the speakers would put it at a drug company-sponsored ADHD conference.

October 17, 2013

BACP closes regulatory loophole

A few weeks ago I wrote about a loophole that could enable an unscrupulous psychotherapist to evade a misconduct hearing. Of the various professional bodies, it usually isn’t possible to bring a complaint against a practitioner who has resigned their registration prior to the complaint being made. Admittedly this is true for other professions such as nursing. But there’s a difference in that “nurse” is a protected title and in order to practice you have to be registered with the Nursing and Midwifery Council. Any nurse who resigns in anticipation of a complaint is effectively striking themselves off.

This isn’t true of psychotherapy. “Psychotherapist” and “counsellor” are not protected titles, and although various professional bodies exist (the British Association for Counselling and Psychotherapy, the UK Council for Psychotherapy, the British Psychoanalytic Council etc) there’s no legal obligation to belong to one of them. So, if a counsellor or psychotherapist gets wind that a complaint of misconduct is about to be made, they can just resign from their professional body and carry on practising. No complaint can then be made, therefore there’s no record of any safeguarding concerns that could put vulnerable adults or children at risk.

Just so people know why I mentioned this particular loophole, it’s because the above scenario isn’t a hypothetical one. It’s happened. On more than one occasion by the sound of it.

I previously had an e-mail from the British Association for Counselling and Psychotherapy, which is the UK’s largest psychotherapy body. They said they were “currently engaged in the process of changing this procedure.” It now appears they’ve done exactly that.

The BACP have published the following amendment to their Professional Conduct Procedure.

1. Page 1, paragraph 1.3 ‘Complaints against non-members’ is now replaced with:

1.3 Complaints against non-members / former members

a) The Association cannot deal with complaints against individuals or organisations that were not member/registrants of the Association at the time of the alleged misconduct.

b) The Association can deal with complaints made against a former member/registrant if that former member/registrant was a member at the time to which the complaint relates, subject to the provisions of paragraph 1.5.

c) Members/registrants of the Association referred to herein will be deemed to include former members/registrants.

d) Paragraph 1.3 b) only applies to members/registrants whose membership was current at the time of the adoption of this revised paragraph 1.3 by the Association by resolution of its Board of Governors pursuant to 5.1 of the Standing Orders of the Association on the 20th day of September 2013.n [emphasis added]

That should prevent any unethical practitioners from thinking they can avoid a BACP hearing through a just-in-the-nick-of-time resignation. This is welcome news, and I hope the other professional bodies will follow suit.

There’s been a couple of other developments recently with regard to professional regulation in psychotherapy. Under the previous Labour government there were plans to make counselling and and psychotherapy state-regulated professions under the auspices of the Health Professions Council (now the Health and Care Professions Council) which already regulates clinical psychologists and arts therapists. This was shelved by the Conservative-Lib Dem coalition in favour of regulation-lite or “assured voluntary registration” where the existing professional bodies could apply to be accredited by the Professional Standards Authority. So far only the BACP has achieved this accreditation.

In July Geraint Davies MP tabled an early day motion, calling for the previous plan to be reinstated.

That this House notes that anyone can set themselves up as a counsellor or psychotherapist without training or experience with no recourse for the patient if something goes wrong; further notes that there are more than 50,000 registered counsellors or psychotherapists and an unknown number unregistered; further notes that millions of people, often with mental health problems who are therefore vulnerable and at risk, are being given therapy in an unregulated industry with no uniform code of conduct or ethics; and calls on the Government to regulate counsellors and psychotherapists by bringing them into the jurisdiction of the Health and Care Professions Council.

So far 53 MPs have signed it: mostly Labour, though with a fair sprinkling of MPs from the other parties.

Back when HPC regulation was first mooted, there was a small but very noisy campaign by certain psychotherapists who predicted that the sky would fall in if psychotherapists had to be accountable for their actions in the same way as doctors, nurses, social workers or just about any other profession that routinely works with vulnerable people.  I’ve previously (and only semi-jokingly) referred to those campaigners as “the worst bunch of malevolent hippies since the Dharma Initiative in Lost.”

Their argument was essentialy that state regulation would bring in “market values” to psychotherapy. If that argument sounds oxymoronic, then…well, that’s because it is. They used a lot of left-wing language to argue against regulation, but essentially what they were saying was that psychotherapists should be left to regulate themselves, much in the same way financial services and the tabloid media were. And we all know how well that ended.

If you’re wondering about the commitment of these anti-regulation campaigners to protecting the public from abuse, take a look at this beyond-parody article by Denis Postle, reporting on the hearings for Derek Gale, struck off by the HPC as an arts therapist for running a nasty therapy cult.

The imaginal universe of the human condition is ubiquitous. Since the Vedic traditions, Buddha, and Freud, we know we can’t turn it off. It runs. It leaps. We may hide from it but we can’t escape. We resonate with the world, the world reverberates through us. As practitioners we know that grasping the ‘real’ is matter of navigating multiple transferences and embodied foregone conclusions, this article included. The HPC as it seems to me stands in defiance, studied intentional defiance of this. The HPC has spectacles through which it sees only categories. Health. Standards. Competence. Treatment. Note-keeping. Effectiveness. This is a ‘hearing’ and in this room, as we were repeatedly reminded, what matters are ‘particularized facts’.

Also in defiance but of another order, from another paradigm, is Mr Gale, who for almost thirty years has had a private practice of individual psychotherapy and groupwork.

His defiance, as was apparent from the first three days proceedings, has its roots in Humanistic Psychology and the Human Potential movement, personal development traditions that stand outside the HPC’s medicalised models of healthcare.

I guess it was the HPC’s “medicalised models” that decided that Gale was sexually, physically, emotionally and financially abusing his clients. I’d attempt to deconstruct Postle’s article, but at this point we’re not talking about oxymoronic arguments. Just plain moronic.

Postle is a leading figure in the Alliance for Counselling and Psychotherapy, which helped coordinate the anti-regulation campaign. What are they doing now? Among other things, they’re crying foul about another development, in which the BACP has apparently applied for a royal charter. If they’re successful, this could mean that the BACP might bestow such titles as “chartered counsellor” or “chartered psychotherapist”.

The Alliance has written an open letter objecting to this.

We do not believe that BACP’s desire to bestow chartered status on its members will do anything for the field as a whole, nor do we think it in the interests of service users or of the public generally. On the contrary, we consider BACP’s move to be a potentially divisive and retrograde step which could be construed as a predatory attempt to steal a march on other organisations at a time when the government’s new voluntary register system, under the PSA, is just beginning to find its feet.

In due course, we will be writing to the Privy Council, the Department of Health, MPs and Peers, asking them to join with us in resisting this move by BACP. But we feel that the major membership organisations of counselling and psychotherapy should
join with us and we invite you to allow us to mention your names in whatever further communications we send out.

Or, to put it another way….

 

The BACP are of course entitled to apply for a royal charter. If other bodies feel that’s giving the BACP an unfair competitive advantage, then they could apply for one too, and take their place among such august organisations as Marylebone Cricket Club and the Worshipful Company of Lightmongers. Unless of course, such bodies simply aren’t good enough to meet the criteria for a royal charter.

If the BACP are successful, then that would be very good news for them indeed. It would mean that they’re the only psychotherapy body that could give a practitioner both chartered status and PSA accreditation. In other words they’d be the gold standard that any respectable counsellor or psychotherapist would be expected to be registered with.

These anti-regulation campaigners wanted to be free from the shackles of a single state regulator, so they could be left to set their own standards. Well, they got that. Now, for all their anti-market rhetoric they could well be about to discover exactly what happens in the marketplace when your product is visibly inferior to that of your competitor.

I can’t say I feel sorry for them.

September 27, 2013

The Stuart Macfarlane case – the UKCP responds

Today I published the story that Stuart Macfarlane, a psychotherapist registered with the Guild of Analytical Psychologists and UK Council for Psychotherapy, had been suspended for two years due to serious sexual misconduct with a mentally ill patient. The normal sanction for this kind of misconduct is a striking-off, not a suspension.

Earlier in the week I’d e-mailed the UKCP. This is what I asked them.

Thanks for your e-mail. I was just about to contact you as it happens. The story is regarding Stuart Macfarlane, who is currently suspended for two years by the Guild of Analytical Psychologists (formerly the Guild for Analytical Psychology and Spirituality).

Can you confirm that this was for serious sexual misconduct with a patient (a vulnerable adult with mental health issues)? 

Does the UKCP have an opinion on GAP’s decision to suspend rather than strike off Mr Macfarlane?

Is there a reason why Mr Macfarlane’s case is not on the UKCP complaints archive?

Will Mr Macfarlane be allowed to re-register with the GAP/UKCP at the end of his suspension?

I’ll be aiming to publish on this story on Friday, so I’d appreciate any response from the UKCP before then.

The UKCP’s response arrived Friday lunchtime, so wasn’t included in my original post. That said, it’s quite a long response, so it’s probably worth giving it a post of its own.

The complaint against Stuart MacFarlane was handled by a UKCP member organisation. I am sure you will address your questions about the detail of the case to that organisation. We are unable to comment on their complaints process or details of the case because we are an appeals body.

We do not publish decisions made by other organisations because this falls outside our policy on the publication of decisions. This policy is available on our website:http://www.psychotherapy.org.uk/ukcp_standards_and_policy_statements.html

We are unable to make speculative comments on whether a named individual would be allowed to re-register. We have a proper process for cases to be considered. What we can say is that for any member wishing to re-register at the end of a sanction, UKCP’s Registrar would consider the possibility in light of whether the sanctions were complied with, along with other factors.

The UKCP member organisation that has made decisions about Mr Stuart MacFarlane, has issued public statements about the case which you can find here:

http://www.analyticalpsychology.org/simpleblog/upload/file/Decision%20regarding%20Stuart%20MacFarlane%282%29.pdf

We are utterly in favour of strong regulation. We have regulatory systems to protect the public and the privacy of those involved. Those systems include controls on qualifications, entry to our register and fair systems for dealing with those cases where there is reason to question whether someone should be allowed to continue on the register. And within these strict processes we have lay and professional involvement, and access to appeals where someone feels a case has not been handled properly. For that reason we can’t engage in speculation about cases or trial over the internet.

So, if a UKCP-registered therapist is disciplined by a UKCP member organisation, this doesn’t get published by the UKCP? That’s surprising, to say the least. I looked up their publications policy for fitness to practise decisions, and there it indeed is.

Decisions of Member Organisations
22. UKCP will not publish the determination of an organisational member, where complaints had originated from the organisational member complaints process.

The policy is dated 29th November 2012. I presume this must be a change in policy, because they’d previously published the determination for Geoffrey Pick, suspended by the Arbours Association in May 2011, also for serious sexual misconduct (he was subsequently allowed to re-register both with Arbours and UKCP, and then resigned when the media started to take an interest).

Admittedly this is an issue that eventually should become moot for future cases as all the member organisations sign up with the UKCP’s new centralised Complaints and Conduct Process. However, that doesn’t protect the public in this particular case.

I think I’ll address their final comment about “trial over the internet”. I’m not a fan of trial by internet either. I’m a fan of trial by…well, trials. Or at least trial by fitness to practice hearing. And Mr Macfarlane has indeed had a hearing where there was a finding of fact. I’ve e-mailed the GAP, the UKCP and Macfarlane, and so far none of them have disputed the facts that I’ve queried. Admittedly that’s partly because they didn’t tell me much anyway. Even so, none of them have e-mailed me back saying, “No, no, it definitely wasn’t serious sexual misconduct!”

What concerns me here isn’t so much the fact finding as the way it was published (or wasn’t), and the kind of sanction imposed. At the risk of repeating myself from previous posts, here is the indicative sanctions guidance that the Nursing and Midwifery Council uses.

 In all cases of serious sexual misconduct, it will be highly likely that the only proportionate sanction will be a striking-off order. If panels decide to impose a sanction other than a striking-off order, then they will need to be particularly careful in explaining clearly and fully the reasons why they made such a determination, so that it can be understood by those who have not heard all of the evidence in the case.

Given that this is not only a case of serious sexual misconduct, but one in which significant harm was inflicted on a vulnerable adult, it seems inconceivable that this wouldn’t have resulted in a striking-off anywhere else. And even if it was conceivable, there’s that line about how panels should be “particularly careful in explaining clearly and fully the reasons why they made such a determination.” The GAP’s statement is clearly not particularly careful to explain this. If anything, it’s particularly vague. If I hadn’t gone digging, it wouldn’t be clear at all that it was a case of this severity.

For that reason, what I’m engaging in here is not trial by internet, but the use of Google as safeguarding by other means.

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