KM v Cambridgeshire: the Supreme Court’s decision is not about assessment

“I’m just hoping that after tomorrow the link between value of cash payment and cost of meeting need is not utterly broken!”

…I tweeted yesterday, contributing to a debate about our hopes and expectations for today’s Supreme Court ruling in KM, R (on the application of) v Cambridgeshire County Council 2012] UKSC 23 (31 May 2012). This blog is about that case. I’m pleased to say that my hopes have been fulfilled. But I had set my sights low. I am utterly bemused by some of the other claims being made for this judgement.

Community Care: three key questions

Adult Community Care issues can generally be boiled down to three questions:

• Assessment: deciding what needs should be met
• Funding: deciding who is going to contribute what to the cost
• Delivery: deciding how the needs are going to be met

The KM case was about direct payments, so where do direct payments fall to be considered? Answering that question is key to understanding this judgement. Although direct payments involve the flow of money between local authority and service user, they are not about how the package is funded. And although there are tools to determine how much a direct payment should be, these need have little to do with assessment of eligible need. Direct payments are, pure and simple, one of a number of ways of delivering a service.

What the Supreme Court said about assessment

To be fair, the Supreme Court said a fair bit about how to assess eligible need:

• It set out the legal framework (paragraph 11ff);
• It affirmed that the statutory guidance ‘Prioritising Need in the Context of Putting People First’ gets the framework right (paragraph 16);
• It reaffirmed that once a local authority has determined eligible need, it must meet that need (paragraph 21);
• It decided not to revisit the case of Barry, which held that resources could taken into account during the assessment process (paragraph 43);
• It decided that the assessment of eligible need in KM’s case was not irrational (paragraph 38).

What the Supreme Court did not do is say anything new. It certainly said nothing that would turn a previously ineligible need into an eligible need. And therefore it said nothing that would turn someone who was previously ineligible into someone who is elible.

And therefore I am bemused by the Guardian headline, ‘Court ruling means thousands more disabled people could get access to care‘.

Where the RAS fits in: service delivery

Roughly, local authorities have three possible approaches to delivering the services to meet eligible need. One is to deliver it directly. One is to commission someone else to deliver it. And one is to allow the service user to commission services themselves.

It is here that the RAS fits in. Essentially, the RAS is a tool used in the process of converting eligible need into a cash value, so that the service can be delivered in cash instead of in kind.

Though this is hardly a secret, I am very cynical abut the RAS. Not only is it a tool used to convert eligible need into a cash value, but it is used to obscure the process. In theory, there is a scientific basis. The RAS uses an algorithm. According to that reputable source, Wikipedia,

“Algorithms are essential to the way computers process data. Many computer programs contain algorithms that detail the specific instructions a computer should perform (in a specific order) to carry out a specified task… Thus, an algorithm can be considered to be any sequence of operations that can be simulated by a Turing-complete system.”

Sounds scientific? But according to Luke Clements (2011) ‘A Sideways Look at Personalisation and Tightening Eligibility Criteria’ in Elder Law 1 pp47-52, along the way, “any science in the process is jettisoned in favour of witchcraft.” The computer does the sums, but what the end result has to do with the original assessment of need is anyone’s guess.

Remember, there are two other ways of delivering services. They can be delivered directly, in which case the local authority must have a fairly good idea how the service delivery meets the eligible need. Or the local authority can commission directly, in which case it will also know how much it costs to meet the eligible need.

It is ironically only when the service user is commissioning their own services that the algorithm – or witchcraft – which obscures the link between the eligible need and the cost of meeting it comes into its own.

Back to KM v Cambridgeshire

KM had his needs assessed. He was seeking direct payments to meet those needs. He has considerable disabilities. Cambridgeshire used the RAS, then another algorithm called the Upper Banding Calculator. Then it jiggled about with the figures a little bit more. Ultimately he was offered £85,000 per annum. But he thought he should get £157,000 per year.

That is a big difference. But was the dispute about what his needs were (i.e. the assessment), or was it about what it would cost to meet them (i.e. the service delivery)?

Here’s the simple answer: Cambridgeshire was so effective at obscuring its decision making process that KM couldn’t tell what the dispute was about. The Supreme Court criticizes Cambridgeshire for three things:

• Failing to be open about its assessment of the mother’s contribution to care (paragraph 30);
• Failing to be open about its rejection of the independent social worker’s assessment (paragraph 34); and
• Failing to explain how it arrived at its own sum (paragraph 35)

It would be correct to characterize this case as being ultimately about transparency and not about assessment or resources.

So is the case good news for service users at all?

A brief history of transparency

Having dismissed the notion that thousands will become eligible, having highlighted that the case says nothing new about assessment, having said ultimately it was just about transparency, is it just a storm in a teacup?

No! It is well worth remembering where we were at before:

In Savva, R (on the application of) v Royal Borough of Kensington and Chelsea [2010] EWHC 414 (Admin) (11 March 2010), the high court upheld the principle of transparency:

“without being able to properly understand the use made of the RAS, the service user and anyone acting on her behalf, is left totally in the dark as to whether the monetary value… is adequate to meet the assessed need… The process of conversion made by the Panel is not explained to the service user. It should have been underpinned by an evidential base, and it was not.”

And as I commented at the time,

“What is being said is that there is a duty to give effect to the rhetoric, and actually demonstrate how the cash payment is adequate to meet assessed need. If the duty to give reasons goes that far, it may help to ensure that the cash payments actually do link to assessed need. Which in turn may undermine the approach of ‘Points mean Prizes’, and defer the day when a computer programme completely replaces the social worker.”

The judgements in KM’s case in both the High Court and the Court of Appeal below were bad news for transparency, and therefore bad news for anyone like me who wants a link between the cost of meeting need and the value of the cash payment. In KM, R (on the application of) v Cambridgeshire County Council [2010] EWHC 3065 (Admin) (26 November 2010), the Court said this:

“[The Claimant] criticises the Defendant for failing to provide an explanation setting out the services required to meet the Claimant’s needs. That appears to me to be a complete misunderstanding of the system of self-directed support. Both the RAS and the Upper Banding Calculator, compared as they were with the assessment and operated using the skill and experience of social workers, were assessment of needs and not services but the RAS was a tool for translating needs into a sum which was adequate to provide the services for those needs by reference to the average costs of the provision by the authority of meeting those needs for other disabled people.”

Upholding this decision last year, in KM, R (on the application of) v Cambridgeshire County Council [2011] EWCA Civ 682 (09 June 2011), the Court of Appeal observed that, “There does not need to be a finite absolute mathematical link” between payment and need.

In short, the history of this case is a history of judicial approval of algorithms and witchcraft, of obfuscation and lack of transparency. The beauty of today’s ruling, the reason I can consider it a victory, is that it reaffirms Savva on the need for transparency. Particularly poignant is the observation in paragraph 36:

“that a local authority’s failure to meet eligible needs may prove to be far less visible in circumstances in which it has provided the service-user with a global sum of money than in those in which it has provided him with services in kind. That point fortifies the need for close scrutiny of the lawfulness of a monetary offer.”

Or to put it another way, it is concerning that it is too easy to use direct payments to obscure potentially unlawful cuts that would be quite obvious if they were delivered or commissioned directly.

The RAS should still go!

The RAS has survived another level of challenge, see paragraph 26. But I still think it should go.

The argument in defence of the RAS in paragraph 24 of the judgement is:

“To set about costing each of the services identified in answer to the question at the [eligible need] stage upon, as it were, a blank sheet of paper would be unacceptably laborious and expensive. So a mechanism has been devised in order to give the exercise a kick-start. It is called a Resource Allocation System (a “RAS”); and many authorities, including Cambridgeshire, have developed one for their own use.”

I am resolutely unconvinced. If we can cost the services to meet the needs on a blank sheet of paper when we need to commission them, then we can cost them on a blank sheet of paper when the service user is going to commission them.

If the RAS is only “the generator of a “ball-park” figure, subject to adjustment up or down” (paragraph 26), then it is a wholly unnecessary extra step rather than a kick start to the calculation.

This is the heart of my concern. Arriving at a cash value of need by generating the starting figure by computer and the final figure by magic is not the most simple way of doing it, it is the most complicated. @TheSmallPlaces has shown in a series of blogs how local authorities actually value the complexity of the process:

• How ‘transparent’ are personal budgets?
• Relaaaaaaax, just have (blind) faith in your RAS
• Hi Ho, Hi Ho, off to the ICO we go… (more on RASs and transparency)

In this, the Supreme Court got it wrong. It was right to approve clear and transparent reasons. It was wrong to approve the RAS as simplifying the process. The RAS is the very antithesis of clear and transparent reasons. In this case, it helped to obscure not only the reason for the sum itself, but also disputes about the assessment. It should go.

Allan Norman (@CelticKnotTweet) is a registered social worker and a solicitor at Celtic Knot – Solicitors and Social Workers.

AMHP training – What it is and How it is – A Review by the GSCC

The GSCC published a report yesterday (pdf)  which is a a review of their inspections of AMHP (Approved Mental Health Professional) courses. My experience of my training as an Approved Social Worker (as it was when I trained) is that, without doubt, it was the highest quality training course I have ever undertaken. It was tough. Very tough. But it needs to be. The role of making such important decisions which affect the liberty of those who are in moments of need, illness and distress is not something which can be glossed over.

In some ways, I’m surprised there isn’t an equivalent, high quality, intellectually rigorous post-qualification course in children’s services before social workers are able to remove children – maybe it would be too costly – but it’s an interesting reflection on the ways in which the different ‘streams’ in social work have progressed.

The report reflects on the GSCC role in approving AMHP training, despite the fact that the training is no longer restricted solely to Social Workers (Psychiatric Nurses, Occupational Therapists and Clinical Psychologists are also able to train up to this role).

There are some interesting tidbits in the summary that caught my attention. There are 22 AMHP courses running in England. Of those who have undertaken them (936 since 2008 when the switch from ASW to AMHP occurred) there have been 936 people who have completed the course. 84% of those completing the course have been social workers and 15% nurses (I’m presuming the overlap is down to some people who are dual trained – I’ve come across a few people who are both nurses and social workers). There have been no psychologists training (surprise) but there are some OTs ( I have personally met one OT AMHP) but it is given as <1%.

The gender breakdown is a 70% female to 30% male of those who have completed training. It would be interesting to compare this with the Social Work training as a whole.

So what are the courses like?

Recruitment is generally by employer sponsorship and some areas have been better at promoting cross professional access to the training than others. There have been issues regarding payments and increments which more often than not have affected whether a nurse or a social worker might be put forward by employers to train but the universities have been willing to accept applications across the eligible professions.

There are very low ‘fail’ rates, possibly due to the selection which would take place in-house before a candidate is interviewed by the university.

Content I’ve had a few people ask ‘how long’ the training to be an AMHP is and explain how it was in the course I did but different courses manage the learning in different ways. For example, I did a full time course. The actual requirements are 600 hours of study with at least 150 of those hours as taught. It is delivered at ‘Masters’ level – but usually needs a ‘top up’ of other modules (which may or may not be offered’ to make a ‘full’ Masters degree.

The emphasis on knowledge of mental health law was considered in the report as it is fundamental to being an AMHP. Universities assess this knowledge in different ways, between exams – either open or closed book – case studies or classroom work.  As an AMHP it is necessary to continue to attend legal updates regularly.

Training in safeguarding legislation as it pertains to children and adults also has to form a part of the course.  This may be a precondition to attending the course – ensuring that this training has been undertaken ‘in house’. It’s also important that Mental Capacity, Equality and Human Rights legislation is covered.

It is also a requirement that social perspectives on mental distress is covered sufficiently.  Indeed, the report comments that while

Traditionally social workers have been viewed within mental health services as the champions of the social perspective model of mental distress

This has needed to be covered extensively in the AMHP training as other professions are being drawn in. Interesting perspective though when you consider the move in some areas to shifting social workers OUT of mental health teams and what that might mean.

But back onto the topic at hand.

User/Carer Involvement in Courses This was an area I felt was strong and particularly useful in the course I undertook. I think it is also worth noting that social workers can be users and carers of mental health services too and certainly the course I was on some people attending the training self-identified as such which was really very useful for us to gain these perspectives.  Formally though, 20 out of 22 courses met the requirement for involving users and carers in the training of AMHPs.

Universities used different models from commissioning teaching directly to drawing on a pool of identified users and carers to participate or commissioning a local user network to be involved in course planning and assessment.  Only half the courses involved users on the selection panels. I was surprised this wasn’t higher.

Being Approved The ‘approved’ part of the name comes back with the Local Authority when the course is completed and we would go our separate ways. Different local authorities have different ways of approving but it is always for a maximum of five years before re-approval is necessary.  Most graduates were approved within three months of finishing the course – that was the case within  my LA where I was expected to conduct a specific number of assessments with an experienced AMHP and then come to a panel with my reflections and face another legal test before being approved. However some LAs will approve more quickly than others.

Practice Assessors – AMHP candidates are ‘on placement’ and have a supervisor who themselves, are an AMHP. Few courses require any qualification from their Practice Assessors (other than. of course, being an AMHP themselves). I’ve never taken this role on specifically for AMHP training but it’s something I’m vaguely interested in doing at some point. Interestingly the GSCC acknowledge that these roles of ‘practice assessors’ may be underappreciated by the universities and the GSCC is recommending that some of the ‘Practice Educator’ standards for Social Workers extend into AMHP training.

The report makes interesting reading for anyone who is curious about the AMHP role and what the training actually involves. Reading it made me reflect both on my role as an AMHP and the training I undertook and continue to undertake to carry out the role to the best of my ability.

Actually, it made me quite proud. I know I’m biased but it is a rigorous system but it was the best training I ever did. It’s not a role I’d say I like or enjoy but it is something I feel I can do with sensitivity, thought and care.

There is a strange kind of ‘camaraderie’ among AMHPs that I’ve not experienced in any other situation. Possibly because it’s so hard to explain to other people what we do and how and why we do it.

photo Eric E Johnson Flickr

More from the Independent Group of Analytical Psychologists

Continuing my exploration into the murky world of psychotherapy regulation, I’ve just had another e-mail from the Independent Group of Analytical Psychologists.

The story so far…I discovered that it had taken three and a half years for a fitness to practice hearing to find seven allegations proven against a Jungian analyst, John Smalley. Despite this no sanctions were issued against him. Mr Smalley is a member of the Independent Group of Analytical Psychologists (IGAP), a member organisation of the United Kingdom Council for Psychotherapy.

I’d been exchanging e-mails with IGAP, who confirmed they found no case to answer against Smalley (the complainant then appealed to the UKCP, which found their decision “perverse and incorrect”).

My last e-mail read.

Thank you for your information.

In such cases where there has been a breach of the Code of Ethics, where are they publicised? How many such cases have there been?

Does IGAP intend to sign up to the Central Complaints Process?

Zarathustra

The UKCP’s new Central Complaints Process (CCP) is intended to replace the current “two-tier” complaints system, where people first complain to the member organisation and then can appeal to the UKCP if unsuccessful.

Dear Zarathustra

Since the UKCP Central Complaints Process is not yet finalised, it is too early to say if IGAP will sign up to it or not, but is likely to do so if it is felt to match our professional standards and has nothing that contradicts our existing Code of Ethics.

As regards breaches of our Code of Ethics, we keep any such cases on file, as required, for a minimum of six years. There has been no such breach for several years now, so there is nothing publicised anywhere.

Being a small organisation we do not have the resources to continue a correspondence. Please direct any further enquiries to UKCP.

Regards

IGAP Ethics Committee

Hang on a minute, the UKCP is saying that the CCP “will be in place for all UKCP registered members by the end of next year.” But here’s at least one member organisation with a view that basically amounts to, “Well, we’ll consider it.”

That begs an interesting question. What will happen if a member organisation simply refuses to sign up to the CCP? Will they be expelled from the UKCP?

Not that the CCP exactly covered itself in glory during the Smalley case either. The process took two years to decide that there was misconduct, but they weren’t going to do anything about it.

Interesting also, that IGAP has admitted that the reason I couldn’t finding any hearing outcomes on their website is because they haven’t found a breach of their Code of Ethics in years. Okay, they’re a small organisation (I counted 56 analysts on their member list), but not one instance of misconduct in years? That doesn’t inspire confidence, especially when we’ve found at least one instance when a “no case to answer” decision by IGAP was ruled “perverse and incorrect”.

 

 

The Smalley Case and the Independent Group of Analytical Psychologists

This weekend I published the findings of a fitness to practice hearing for a Jungian analyst with the UK Council for Psychotherapy. It took three and a half years to find seven allegations proven, but not to apply any sanction. The UKCP is planning to replace its current “two-tier” complaints system, where people complain first to the therapist’s member organisation, and then UKCP hears appeals if the complaint is successful. Under the new system, there will be a single Central Complaints Process (CCP) which all the member organisations will be expected to sign up to.

The analyst, a Mr John Smalley, is registered with a UKCP member organisation, the Independent Group of Analytical Psychologists. A complaint was initially made to them, and they found no case to answer, which prompted an appeal to the UKCP. IGAP’s decision was found to be “perverse and incorrect”, and the complaint was sent to the new CCP.

I decided to ask IGAP their views on the case, and got some terse and unhelpful replies before they stopped replying altogether. Arguably these e-mails show a distinct lack of transparency on the part of some psychotherapy organisations, and possibly a lack of communication between the UKCP and their members organisation.

On 18th May, I sent them the following e-mail:

To the person responsible for handling press queries

My name is Zarathustra. I am a blogger who writes for the Not So Big Society at https://notsobigsociety.wordpress.com. In particular I write about the regulation of psychotherapy.

I understand that an IGAP/UKCP psychotherapist, John Smalley, was recently the subject of a UKCP fitness to practice hearing, and the result was that four allegations were found proven, but no sanctions were applied.

IGAP originally found that there was no case to answer against Mr Smalley., but this decision was found to be “perverse and incorrect” by the UKCP Central Final Appeals Panel. Does IGAP stand by its previous findings?

Are you satisfied with the manner that the UKCP conducted the hearings? I understand that it took two years for them to resolve the issue. Do you consider this to be a timely response?

Do you still have confidence in Mr Smalley’s fitness to practise?

Does IGAP intend to sign up to the UKCP’s Central Complaints Procedure?

The outgoing UKCP chair recently stated, “There has been too much crony-ism and amateurism in the conduct of complaints for far too long.” Do you agree or disagree with this comment?

The deadline for the article I am writing is Friday 25th May.

On the 22nd May, I got the following reply.

In response to your queries we have to state that IGAP’s ethical obligations about confidentiality prevent us from giving information beyond publicising the outcome of a hearing where there has been a breach of our Code of Ethics and Practice.

In the case you mention we confirm that IGAP found no case to answer. We cannot confirm the statements you made referring to UKCP.

IGAP Ethics Committee

Not a very detailed response, I have to say. I decided to press them for more detail.

Thank you for your response.

I couldn’t actually find those hearing outcomes where there has been a breach of the Code of Ethics. Where do you publicise them? How many such outcomes have you published in the past?

Has IGAP yet made a decision as to whether to sign up to the UKCP Central Complaints Process?

regards

Zarathustra

I still haven’t found anywhere that lists hearing outcomes for breaches of the IGAP Code of Ethics. As far as I can take, they’re not listed anywhere on their website. For that matter, the website doesn’t even seem to display their Code of Ethics. It doesn’t even say how to make a complaint. For comparison purposes, here’s the very extensive Professional Conduct pages for the British Association of Counselling and Psychotherapy, with their Ethical Framework here, outcomes published here and an online complaint form here.

Anyway, on the 25th May, I got this reply from IGAP.

Dear Zarathustra

Nothing is publicised where there has been no breach of the Code of Ethics.

IGAP has had no further information from UKCP in the case you refer to.

Regards

IGAP Ethics Committee

Well, that really didn’t answer my question. Though I find it very interesting that UKCP found seven allegations proven against an IGAP-registered therapist, but IGAP appear to be suggesting that UKCP haven’t told them that! Or have I read that wrong?

I sent them another e-mail.

Thank you for your information.

In such cases where there has been a breach of the Code of Ethics, where are they publicised? How many such cases have there been?

Does IGAP intend to sign up to the Central Complaints Process?

Zarathustra

So far, no response to this e-mail. [Edited to add: I’ve since had a further reply from IGAP. The discussion continues here.]

This shows the lack of transparency of some UKCP member organisations. I still don’t know where they publish outcomes of breaches of ethics, or what their Code of Ethics even is, for that matter. I don’t know whether they plan to sign up the Central Complaints Process. But I just can’t get over their claim that they’ve “had no further information from UKCP” regarding the case.

Should men embrace feminism?

Just recently I’ve been marshalling my thoughts about the male view of feminism. Should men engage with feminism, take an active part in it, even call themselves feminists? I’ve come to this topic at least partly as a result of a bizarre, distressing sequence of events that happened to me over the past year.

First off, I’ll present a dissenting view. Stuart Sorensen is a blogger with whom I rarely disagree. His training resources and opinion pieces on mental health are of consistently high quality, and he is clearly a very decent guy who cares passionately about improving the care received by people who use mental health services. But if I agree with him on mental health, I have to disagree with his views on feminism.

I support the rights of all people but because of reactions such as this I and a great many men cannot support feminism. This is not because I disagree with womens’ rights but because I cannot & will not ally myself with this sort of bigoted, superficial reasoning.

At its heart feminism has some very laudable aims which I do support. But I’ll never call myself feminist because I don’t want my support for reasonable political principles to be hijacked by those who seem determined to maintain a divide between the sexes.

In all fairness to Sorensen, his view on feminism has been coloured by an unpleasant experience where he’d been falsely accused of domestic abuse by a former partner. Also to be fair, the feminist movement does have its nasty extremes. Only last week, there was an uproar on Twitter about the RadFem2012 conference, which plans not only to ban men from the premises, but also transgender women who were born as men. A classic case of the oppressed becoming the oppressor.

I certainly wouldn’t subscribe to any demonisation of men (or transgender people, for that matter). I don’t think men have to apologise for being men, and I certainly don’t think men accused of abuse should be considered guilty until proven innocent. But feminism is a broad church, not a narrow ideology. If I would reject the bigots of RadFem2012, I would also accept that certain branches of feminism contain little, if anything, that I would disagree with. Sex-positive feminism, for example, echoes a lot of my views on gender, sexuality and censorship.

I suspect, ultimately, my disagreement with Stuart Sorensen may amount to little more than a semantic debate about what does or doesn’t constitute feminism, rather than any dispute about how people should be treated.

If it was a nasty set of events that propelled Sorensen away from feminism, it was an equally unpleasant experience that has recently drawn me towards it. A couple of years ago I was editing a group blog called Mental Nurse, which had developed a reputation (which I like to think was deserved) for campaigning for the rights of people with mental health problems, and for challenging stigma. At the time that the site closed in March 2011, it was one of the UK’s most popular mental health blogs.

In August 2010, somebody e-mailed me a link to an article about borderline personality disorder, written by an American psychologist. The tone of the article shocked me.

Cluster B’s aren’t “mentally ill” like Schizophrenics and Bipolars are mentally ill. Schizophrenics and Bipolars can’t control their bizarre thoughts, behaviors, impulses and/or hallucinations without medication and deserve our compassion and sympathy. Many self-identified BPD’s and other Cluster B’s plaintively bleat the following statements with great regularity:

“But I can’t help the way I am!”

“I didn’t ask to be BPD!” (Reminds me of a disaffected teen shouting, “I didn’t ask to be born!” Yeah, well, you’re here now, so what’re you gonna do about it?)….

Instead, let’s call them what they are; sociopaths. All the Cluster B disorders are just similar flavors of sociopathy. Giving Cluster B individuals and their ilk the protective cloak of “mental illness” provides them with a “get out of jail free card” and allays our existential dilemma on the concept of evil. Instead, we tell ourselves, “She has problems. She’s sick. We have to be patient and understanding.”…

There’s a lobby of BPD activists who want the psychiatric community to change the term “Borderline Personality Disorder” to Emotional Dysregulation Disorder. Aside from having to edit all of my previous posts, I say a rose by any other name would still have nasty, hooky little thorns. Pardon my language, but I think the terms crazy asshole, mean jerk, toxic person or bad person are better than diagnostic labels. Why? Because everyone knows that you should avoid crazy assholes at all costs and whenever possible.

This is stigma. Pure and simple. And against a very vulnerable group of people. I don’t believe people with borderline personality disorder are simply bad people. As a CAMHS practioner, I’m a strong believer in early interventions, getting them into therapy at a young age to help them to develop the coping skills in order to function with life.

I didn’t know it at the time, but the psychologist in question was part of what’s come to be known as the “Manosphere”. They go by various names – the Mens Rights Movement, Mens Rights Activists, Men Going Their Own Way. They advance a view that men are emasculated in contemporary society, by feminism, by false allegations of rape and so on. The psychologist’s rant against borderline personality disorder was intended as a warning about the dangers of manipulative or deceitful female partners.

Whatever one thinks about such a viewpoint, these Mens Rights Activists (MRAs for short) have an unfortunate tendency to come out with statements can be, quite frankly, vile, to an extent that they have come to the attention of anti-hate organisations such as the Southern Poverty Law Center.

There are literally hundreds of websites, blogs and forums devoted to attacking virtually all women (or, at least, Westernized ones)…While some of them voice legitimate and sometimes disturbing complaints about the treatment of men, what is most remarkable is the misogynistic tone that pervades so many. Women are routinely maligned as sluts, gold-diggers, temptresses and worse; overly sympathetic men are dubbed “manginas”; and police and other officials are called their armed enablers.

For an eye-opening (and frequently hilarious) primer on the antics of the Manosphere, I highly recommend David Futrelle’s Manboobz (Warning: possible abuse triggers) blog, which documents and mocks online misogyny.

I didn’t know about the wider Manosphere back then. I just knew that I was reading a spectacularly hateful article by a self-proclaimed mental health professional. Some British women attempted to debate with the psychologist on her (yes, her – the Manosphere has a Women’s Auxiliary) blog, and got some very obnoxious replies for their trouble.

As tends to happen when a bunch of British people come across a bunch of Americans being not only very nasty but also with a total lack of self-awareness, the result was a minor explosion of mickey-taking, on the Mental Nurse site, on other blogs, on Facebook and on Twitter. After Mental Nurse started being described by the MRAs as “the primary enabler site”, several people amended their Facebook profiles to read “Mental Nurse is my primary enabler”. Admittedly some of the ridiculing did become rather juvenile and silly, but no worse than many of the regular Twitterstorms that erupt whenever somebody says or does something offensive.

A couple of months later, when we’d by and large forgotten all about it, the Mental Nurse site got an e-mail from a UK solicitor, who had been hired by the psychologist, demanding damages and information about various people who she held responsible, including me. We then did what most people do when they get a legal nastygram – we bricked ourselves and backed down on the spot. All references to the psychologist were removed from the site, we e-mailed other people to warn them to take stuff down, and then my co-editor e-mailed the solicitor asking him for an update on the situation. We got no reply.

No response? Fair enough, we’ve had a nasty letter intended to scare us and scour her Google rankings of anything negative about her. That seems to be the end of it.

Or that’s what we thought.

What followed was a long saga in which the psychologist – initially entirely unkown to any of us – went to extraordinary and expensive lengths to track down the people who had ridiculed her views – sending solicitors letters to domain providers, hiring bailiffs to go to peoples’ homes, obtaining court orders for internet providers to reveal peoples’ addresses.

In February 2011 she found someone, and submitted a court claim against him. Bizarrely, the defendant was in Scotland, but the claim was submitted in England. It was struck out on the spot on jurisdiction grounds, and never went to court.

The defendant was concerned that she might try again to sue him in Scotland, and decided to write to her solicitor and offer a settlement. He had taken legal advice and been assured that she had no case. Even so, the eye-watering amounts of money needed to fight civil litigation mean that it’s not at all unusual for people with good defences to cave in rather than risk being bankrupted by the cost of fighting.

Fast forward to June – I and two other people got e-mails from the defendant. The claimant wanted our personal details as a condition of settlement. Did we consent to our details being handed over? We all wrote back refusing consent.

In July, one of the other two people got a letter from her solicitor to his. It transpired the identities had been passed to her as demanded. I don’t blame the guy for doing so. He was just trying to protect himself and his family. To his credit, there was one identity that he didn’t reveal. I don’t think it’s a coincidence that it’s the person who he regarded as the most vulnerable if publicly outed.

This second defendant was entitled to Legal Aid, and so was able to fight. There was a court hearing, and the judge ruled that the psychologist’s claim was so riddled with errors (both factual and procedural) that she would have to re-draft it, pay for wasted court time and also pay a deposit sufficient to cover the defence costs if she were to lose. Predictably, she never showed up to the next hearing, and that was that.

She now owes an absolutely ridiculous sum of money in legal costs. Naturally I would never indulge in Schadenfreude.

By encountering this woman and her MRA goons, I feel like I’ve stared hate in the eyes. I’ve had nearly a year of living in fear, experiencing anxiety, nightmares, thinking every estate agent that parked up on my street was a bailiff hired to look for me.

Hate needs to be challenged. This mens rights “movement” is an affront not just to women but to common human decency. That is why I now think it’s right that men should align themselves with feminism.

Do I think there should be a Mens Auxiliary of the kind imagined by Valerie Solanas, in which men are expected to repeat, “I am a turd, a lowly, abject turd”? No. Men are entitled to proudly and unapologetically be men. Just not at the expense of women.

For feminism to truly succeed, there needs to be a cognitive and behavioural shift in men. We need to be willing to challenge assumptions, both in ourselves and others. I commend Manboobz author David Futrelle for doing exactly that, in a very educational and entertaining way.

I’ll say it now. I am Zarathustra, I am a man, and I am a feminist. To the psychologist who’s occupied my mind so much over this past year, I say this. I owe this conversion to you.

UKCP takes 3 and a half years to not sanction a therapist

Back in February I obtained some court documents relating to a psychotherapist who was on a fitness to practise hearing with the UK Council for Psychotherapy. The case was a failed attempt by John Smalley, a Jungian analyst, to have a judicial review of his hearings on the grounds of delay. Since then a copy of the final ruling has landed in my e-mail inbox. On 16th March 2012, the UKCP complaints panel decided that seven allegations had been proven, but that these did not impair his fitness to practise, and that there would therefore be no sanction.

From the time a complaint was originally received by his UKCP member organisation, it’s taken a grand total of three and a half years to reach this conclusion (over 3 years of which were spent in UKCP’s Central Final Appeals (CFAP) and Central Complaints (CCP) procedures), stringing out both complainant and registrant for an inordinate length of time. The case illustrates some of the problems in complaining against a UKCP-registered psychotherapist.

Mr Smalley is a member of the Independent Group of Analytical Psychologists (IGAP), which is a member organisation of the UKCP. Currently anyone making a complaint must first complain to the member organisation. If the complaint is rejected, they can then appeal to the UKCP. This process has such a poor reputation that even the UKCP’s own former chair recently admitted that, “There has been too much crony-ism and amateurism in the conduct of complaints for far too long.” The UKCP complaints archive is surprisingly small. In fact, it lists only two decisions in the last three years – one of which was Derek Gale, a notorious abuser who was struck off by the Health Professions Council before the UKCP struck him off.

At present the UKCP is moving towards replacing this two-tier system with a single Central Complaints Process (CCP), though this has reportedly been met with resistance from some of the member organisations.

In August 2008 IGAP received a complaint against Smalley from a former client (or analysand, as they’re sometimes called in psychodynamic therapies). IGAP initially ruled in November 2008 that there was no case to answer, and also turned down an appeal in January 2009, but the complainant then appealed this decision to the UKCP’s Central Final Appeals Procedure (CFAP) in February 2009.

The CFAP ruled that IGAP’s decision had been “perverse and incorrect”, and ordered that the case be heard before the new Central Complaints Process. Incredibly, it took them until March 2010 – over a year – to come to this decision.

Cue another year and a half of procedural faffing and delays, resulting in the attempt by Mr Smalley to have a judicial review on grounds of delay, before the final UKCP hearings were scheduled for December 2011. And finally in March 2012 (another four months later!) the UKCP gave its ruling.

A number of other allegations were found to have been not proven.

The panel ruled that Mr Smalley had reflected on his errors, that there was no evidence of financial gain from his misconduct, and that no other complaints had been received. For that reason they decided not to apply any sanction.

It’s taken three and a half years from the time IGAP first received a complaint, and over three years since the complainant first lodged an appeal with the UKCP. All to arrive at this not-very-impressive result. For comparison purposes my own regulator, the Nursing and Midwifery Council, aims to resolve Fitness to Practise hearings within 18 months.

During the process, Mr Smalley’s services continued to be advertised on the IGAP website, with no mention that his fitness to practice was being called into question.

From what I’ve been told, it sounds like both Mr Smalley and the complainant have remonstrated bitterly about this inordinate length of time.

I e-mailed IGAP for comment, and received the following reply.

In response to your queries we have to state that IGAP’s ethical obligations about confidentiality prevent us from giving information beyond publicising the outcome of a hearing where there has been a breach of our Code of Ethics and Practice.

In the case you mention we confirm that IGAP found no case to answer. We cannot confirm the statements you made referring to UKCP.

The UKCP said of the case:

Our fitness to practise and complaints processes aim to be fair, transparent and proportionate, and to work in the public interest. At present we have a two-tier system, with our organisational members dealing with the first stage of a complaint and UKCP acting as the appeal body. This can mean that cases take longer to conclude than we would like. We work hard to reduce delays but sometimes they occur for reasons outside our control – for example, the availability of all parties.

This particular case took longer than normal, partly because it was considered by two separate panels when an appeal panel referred it to UKCP’s Central Complaints Process.

We are confident that we gave sufficient opportunities to the parties and their legal representatives to put forward their views to receive a fair and transparent consideration and this inevitably lengthened the timescale. We had four public hearings, including a two-day hearing, one judicial review application, both in writing and a high court hearing. The parties were able to present their views, and all parties were legally represented. There was further delay when one hearing had to be adjourned because of circumstances beyond our control.

The final hearing of this case was decided by an independent panel, and they documented their decision and reasons.

Complaints against UKCP psychotherapists do not normally take 3 years to resolve. In fact we have never had a case like this one, and hope we never again have a case that takes so long to resolve. We recognise that there is room for improvement and we are committed to review and improve our processes. For example, we are currently introducing a centralised complaints system which will replace the two-tier system. This will be in place for all UKCP registered members by the end of next year.

I e-mailed Mr Smalley for comment, but did not receive a reply.

If I was a client of a UKCP-registered psychotherapist, I’d be worried about this. If I were to make a complaint, I’d like to feel it would be processed without excessive delay.

Likewise, if I was a UCKP registrant, I wouldn’t be very happy either. I wouldn’t want to be strung out for three years wondering whether I might be struck off.

At present there is no statutory regulator for psychotherapists, though organisations such as the UKCP are supposed to provide self-regulation of the profession. The previous Labour government was proposing that psychotherapists become regulated by the Health Professions Council, which currently regulates arts therapists, occupational therapists and clinical psychologists. The Con-Lib coalition shelved that plan in favour of a proposal for “assured voluntary registration” where the likes of the UKCP could apply for an official stamp of approval from the Council for Healthcare Regulatory Excellence (to be renamed the Professional Standards Authority).

This case appears to show that the UKCP’s complaints system has some serious problems. The therapist’s member organisation decided there was no case to answer, even though he was smoking in therapy! It then took over a year just to agree to hear the complainant’s appeal and send it forward into the new Central Complaints Process.

But even then the CCP took two years to find at least some of the allegations proven, but not do anything about it.

Is the UKCP ready yet to receive approval from the CHRE/PSA? I’d say this case raises some question marks about that.

The Importance of “Stuff”

I have been reflecting recently on the issue of work space and particularly how your work space can support you in developing your skills for critical reflection. Critical reflection means different things to different people but for me and for the purposes of this post I would describe it as an activity undertaken to reflect on situations and consider your actions. Importantly this reflection should be balanced; we should recognise the things we did well as well as those things that we could improve. In undertaking this activity we develop and grow as practitioners, and I would argue, as people.

For the last twelve weeks I have been teaching on a module that student social workers undertake prior to going out on their first placement. Students are required to engage in an interview with a service user and demonstrate their ability to engage with the service user. Students are required to demonstrate a range of competencies. These relate to the students abilities to actively listen to the service user and to allow the service user the “space” to tell their story. Students are urged not to try and “fix” things, rather they are asked to be open and encouraging, to be supportive and to allow the service user to develop their own understanding of their issue through a supportive dialogue.

All too often these skills are described as “soft” skills and all too often I have described them thus. Having taught on this module and reflected on my own performance I have came to realise that describing these skills as soft is erroneous. I believe that these are fundamental skills as they are skills that separate professionals working in the care sector from professionals in other sectors. They are obtainable and many of the students I have taught have some basic awareness that they have a facility in this area but they are often in need of support to develop this understanding and then further support to implement them in a way that is empowering and transformational.

Students are asked to reflect on their performance in the taped interview and describe how they felt they managed. In essence they are required to demonstrate their own ability to critically reflect. I enjoy teaching on this and for me this has been a transformational experience as it has allowed me to reflect on my own awareness and to consider how effective I am and have been at critical reflection. Un surprisingly I have found that in practice I used these skills without being fully aware of them and sadly all too rarely. A greater commitment to allowing people the space and time to arrive at a deeper understanding of their own issues would undoubtedly have led to a more enduring change. In my rush to fix things I overlooked the importance of a more fundamental set of skills that would have been far more effective and have given service users a greater sense of their own capacity to resolve come of the issues they are faced with.

Arriving at this conclusion was an empowering process, one which I undertook while surrounded by my own stuff. Here at my desk on my right hand side is a small collage of family photographs. My son and daughters provide a link back to my home life reminding me of the importance of the balance I often fail to strike. A reproduction print of St. Cecelia and the Angel sits over my left shoulder, it reminds me of my love of music and it is a thing of beauty. Next to it is Nasirean the giraffe. Well not a real giraffe of course. It is a print given to me by an African student who bought it while on holiday in Africa. Nasirean has a special significance, I remember the student giving to me and feeling a sense of gratitude and humility. A student thought of me in the cradle of civilization and brought me something back. It seems that I made enough of an impression on this student that she wanted to bring me a gift back from half way across the world. I am taking that as a positive.

This then is my environment. I have constructed it. Partly it comes from me but partly from others. It is a personal space in a large institution in what was once the second city of an empire and it is here that I write this. Here that I reflect on my own abilities, here that I recognise my achievements and consider what I can do better. The quality of my fundamental skills development is directly affected by the environment that I operate in any adjustment to this environment to me would adjust my ability to undertake a key aspect of what makes me the person and the professional I am.

I have a digital environment as well, my Twitter feed represents who and what I am. My timeline keeps me up to date with the professional and personal aspects of my life and provides encouragement, support and a virtual network that I have developed over the last two years. I have contributed to this and I have given and received support and encouragement and it is a two way relationship that I now cannot imagine not having.

Without these real and digital locations I would not have developed or written this post, and as a social worker I believe that any de personalisation of the environment that we operate in would have an impact on the quality of the fundamental skills that we seek to develop and promote. Your environment provides a sense of self and of place, mine provides me with a sense of security and ownership and I am comfortable in it, it is the personalised space in a diverse, fluid organisation that alters and changes, often outwith my control.

So stuff is important, not just for security and comfort but to develop fundamental skills and to allow for critical reflection. Do you agree?

What makes residential care good?

I was asked this morning on Twitter what I felt made a ‘good care’ in a residential home. Sometimes it’s hard to elaborate in 140 characters so thought it would be useful to explain my thoughts in a little longer form.

I’ve worked in social care for a number of years, either as a care worker/support worker in a couple of residential homes (and as a ‘bank’ carer in even more) and as a social worker in adult and mental health services.

I’ve been into a lot of residential care homes and I’ve seen massively varying standards  from the home the time I left a home with such heavy concerns that I left a message for the CQC inspector on my way back to the office to the homes I would both be happy to live in myself and would be happy for any of my family members needing care to move into immediately.

So how do I judge what is ‘good’ (and these aren’t necessarily in order!) – especially in the time limited fashion that often involves me walking in and out in an afternoon.

Culture – which can be hard to quantify but you know it when you see it. From the decor and the welcome you receive when you walk in or when you call on the phone to the small interactions you might see in the lounge area and the amount and type of items you might see. Is the lounge empty except for a few paperbacks that look untouched and are mostly large saga-type romances with little variety? Are the (as there was in a home I went to earlier this week) lines of VHS videos stacked up next to the TV? (without a video recorder, incidently)? These things show care, or lack of it to the details.

Feedback – I listen to people who use the services. Communication can be at different levels and there are sometimes people in care settings who don’t want to be there but often users respond to kindness and listening to the feedback of those who use the services and family/friends who visit is vital to understanding the quality of the service. Of course, it’s useful to read the official reports but they are so rare now and often out of date – while issues around quality of care can change quickly, that we need to look in other areas and understanding how well homes respond to individuals and their needs, wishes and wants is fundamental.

Staff – How am I greeted, that’s one this but more importantly are the interactions I see between staff and residents and not necessarily the residents I’m there to visit. Is there eye contact, is there any touch involved? Are the staff sitting in the lounges responding in conversation rather than requesting things are done/not done? Is there any interaction between residents? How is this facilitated? What is the staff turnover like? I might ask the member of staff showing me round how long they have been working there, do they enjoy it? Often they’ll say yes, anyway, but sometimes you get a glimmer of something else.

Size – I have an issue with stacking up older adults in large residential homes in a way that we wouldn’t in other user groups. We have residential and nursing homes now with 50+, 90+ residents. There can be good care in these places but are they ‘homely’? Are they able to meet individual needs? Or is it a hark back to institutionalisation and long stay hospital type settings. It feels like it is about cost and age discrimination. I would be happy to care delivered in small settings. Large doesn’t necessarily mean bad and small doesn’t necessarily mean good but do we really think there is a justification for 100 bed ‘units’ in the current day. The only justifications are cost and economies of scale. I don’t think that’s good enough.

Individualised responses – are the residents individuals? Can they pursue different activities if they don’t want to sing music hall songs? What if I resident moves in who prefers Led Zeppelin to Knees up Mother Brown (real story, incidently!). What if they wanted to do things or go places that weren’t on the ‘programme’? Yes, individualisation can cost but it doesn’t need to – it can be able to things that don’t necessarily raise a charge. How is this done? I want examples in every home of how individual needs are met.

Those are some of my initial thoughts. I’d welcome thoughts from others about what and how they make judgements about what good care in a residential setting involves.

Thanks for Bill Mumford for inspiring me to write!

RiPfA and Social Work Value

Research in Practice for Adults (RiPfA) will shortly be launching a manifesto for adult social work. They were asking on Twitter for people to feedback using the #socialworkvalue hashtag to explain in 140 characters or less the value of social work.

Being verbose, I couldn’t restrict myself to 140 characters. They are kindly hosting my thoughts here.

It’s an interesting debate to be had so join in by leaving comments on that post or on Twitter by following @ripfa and/or using the #socialworkvalue tag with your thoughts.

Dementia Awareness Week – My Wish List for Health and Social Care Professionals

Today is the start of Dementia Awareness Week. The Alzheimer’s Society are running a campaign ‘Remember the Person’ which is a good byline, if only it could be remembered.

In the wave of headlines talking of ‘dementia timebombs’ and ‘care crises’ its unsurprising that the presentation of ageing and dementias (although important to note that dementia is not a part of the ‘natural’ ageing process) is seen in negative lights and that ‘remembering the person’ is often the last thing that happens.

This is important generally, but it is particularly important in health and social care settings when all too often systems have been commissioned and organised for people who do not have dementia – and services are not making allowances for the additional time and skill needed to be able to give people who have dementias the dignity of improved communication and facilitated communication.

While the Alzheimer’s Society concentrates on the ‘Remember the person’ in day to day life, I’d like to add my own ‘wish list’ to their campaign in terms of health and social care professionals, managers and commissioners and add a few pleas.

 

-Remember that caring for someone with a dementia, whether at home,  in hospital or in a residential setting, requires particular skills and commission appropriately. Time for training for staff and space and time to promote communication has to be built into commissioning costs. This cannot be done in 15 minute slots. It cannot be done by agencies that do not offer consistency of care. This is detrimental to the individual who is cared for and the family around them.

 

– Remember to support the family and friends of those who care for people with dementia. Do not punish a family financially and through pulling back support because you are relying on their family because the more pressure that is put on family carers without support, the greater the costs in terms of longer term ill health and distress. Support doesn’t always have to have a high financial cost. It can be about support in other ways and linking in with carers services. They are there for a reason.

 

But

 

–Remember that not everyone who has dementia has family or friends around to advocate for them or support them. When you roll out programmes like ‘personalisation’ and automatically assume that everyone wants ‘direct payments’ and deliver two tier qualities of service, they may (and currently do)  exclude those who may not be able to manage the direct payments themselves and who don’t have family to advocate for them. There is an imperative to bring the voice of people who lack capacity to the agenda of ‘choice’. My own solution would be to build in the requirement for independent advocacy into the processes and into the budgets. We must demand better in terms of personal care delivery for all, but especially those who cannot or do not feel able to (due to power imbalances) speak up for themselves.

 

– Remember that the person who is being cared for is not one of ‘the elderly’. They are a person and an individual  who has loved and who has been loved. They are a person with aims, ambitions and goals. They might not be able to express them as well as in the past but having memory problems does not mean that someone necessary lacks capacity or communication skills – it can though, take more time – regard humanity as having worth. When we have to make decisions on behalf of others, remember to treat everyone as you would want to be treated but remember not everyone wants what you would want.

 

– Remember not to dismiss or diminish those who have dementia. While, depending on the type of dementia ‘recovery’ can mean different things, what it absolutely does mean is not giving up hope and building on the strengths of those around. We have to think about living positively with dementia. Too often within social care and health services, I have seen other services discriminate against people with dementias and older people because they make assumptions which are dismissive. We should never make assumptions and never extinguish the hope of facilitating a better quality of life which build of the strengths of individuals. Never.

 

Let’s hope that Dementia Awareness Week is successful and makes providers and commissioners dwell on the need for awareness of the issues of dementia, as well as the ‘general public’.

photo by Susan NYC Flickr

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