On Therapy as Social Control

I was reading an interesting article in the Medical Humanities journal, about use of psychological therapies to “help” unemployed people find work. The article, rightly in my view, points out that such therapies are on very dubious ethical ground.

There’s a view out there, which I think is utterly erroneous, that therapy and psychiatry can act as a remedy for all sorts of social ills. Give everyone enough CBT and fluoxetine, so the idea goes, and poverty, social inequality, abuse, bad housing etc will simply cease to be a problem. Does it work? Of course it doesn’t.

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.

 

 

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.

 

Angle Management

In among the tributes for the centenary of the Titanic, there’s one little-known incident which didn’t get mentioned. I shall now remedy that:

On the deck of the Titanic, all the lifeboats had gone. A group of terrified children huddled together as the ship began to tilt and the stern slowly rose out of the water. Suddenly, the captain walked over to them.

The captain said, “I’ve been asked to have a word with you about your angle problem.”

“Our angle problem?” The children were confused. “Do you mean the fact the angle of the deck is starting to tilt?”

“Yes, that’s right, your angle problem. You have a problem with angle control. Your parents and teachers have gone to the lifeboats, but they feel you need some angle management.”

“Angle management? Isn’t there something wrong with the ship? We saw an iceberg earlier.”

“Never mind that. You need to understand and accept that you have an angle problem, and you need to engage with the angle management programme that your parents and teachers agree that you should undertake.”

“What are they doing in the lifeboats? Surely they can’t just leave us here!”

“Now, now, they don’t have an angle problem, but you do, and it’s your responsibility to sort it out not theirs. Anyway, let’s get to work on the angle management. We’re going to start with some preliminary sessions on how to use spirit levels, so that you can recognise when your angle is getting out of control. Then, we’ll work on some cognitive-behavioural strategies that you can use to regulate your angle.”

The children then complete the angle management work with the captain, who uses a morse lamp to signal the parents and teachers in the lifeboat, informing them that the kids have had their angle management as requested. The deck then finally floods and the children all drown.

A slightly silly tale, but is it any sillier than the constant requests I get from people who want an abused, traumatised child, often living in dysfunctional circumstances, to undergo anger management? Why do these otherwise-intelligent people believe that this will have the slightest benefit to the child or anyone else?

Support or Social Control?

Communities Secretary Eric Pickles’ announcement that he’s going to focus on ‘troubled families’ had a slightly familiar ring to it. It smacks of an attempt to co-opt health and social care agencies into getting those who are a nuisance to behave themselves.

In Child and Adolescent Mental Health Services (CAMHS) we’ve been here before. Pickles’ ‘troubled families unit’ reminds me of the recent fad for anger management classes.

You all know the scene. The violent husband is confronted on the TV chat show. The audience boos. The host gives him a long spiel about how he needs to change. The wife nods patiently. Then the host offers him the chance to save his marriage by signing up for anger management with the show’s in-house psychologist. The husband gratefully agrees, the audience cheers and the credits roll.

What happens next? Quite possibly he goes along to six sessions of anger management, dutifully completes them…and then goes back to merrily knocking seven bells out of his wife.

In CAMHS we keep getting requests for anger management from parents, GPs, teachers and social workers, because a child “has an anger problem”. Anger management came into vogue a few years ago, and I can see why it’s attractive – especially to policymakers. Disruption in the classroom? Youth offending? Antisocial behaviour? Not to worry, it can all be therapied away in 6 sessions. I’ve no doubt that if I spent a while on Google Scholar I could come up with a few research papers to say that anger management is an effective, evidence-based intervention for children.

But here’s the problem. Of all the kids I’ve seen who’ve been sent for anger management, I’ve been struck by how many of them have actually benefited from it.

None of them.

A lot of anger management classes are, quite frankly, a bit dire. They talk about the causes of anger, the fight-or-flight response, about breathing techniques and distraction. All too often, what they don’t ask is, “Why is this child angry?”

Children usually don’t become automatically angry. More likely, something has made them angry. Abuse, trauma, neglect, being in an environment where anger is a default way of expressing emotion. Labelling the child as having “an anger problem” ignores the wider context.

Worse, it can reinforce child-blaming. Sending the child for anger management can give out the message from services, “Yes, we agree. The child is the problem. He’s the bad one, it’s his fault and he needs to go away and sort out the problem.” I’ve seen kids attend an anger management class, and then be handed back to their parents, who start bellowing and swearing at him before they’ve even left the reception. Those parents are the first to us that we’re rubbish, because we still haven’t sorted out their kids “anger problem”. Often they tell us this while going into a long, loud tirade about what a terrible kid he is, while jabbing an accusing finger in his direction.

Anger management not only ignores the wider context, it also focuses on one particular emotion at the expense of others. An angry child is usually a distressed child. Anger just happens to be the problem that others (parents, teachers etc) want dealt with, because they want the child to behave. Others may say that the kid has an anger problem. The kid might just feel he has a problem. Or indeed, a world of problems.

No doubt the ‘troubled families’ that Pickles wants to target will also have a world of problems. He’s even kind enough to list them.

A family with multiple problems has been defined by the cabinet office as “no parent in the family is in work; the family lives in poor quality or overcrowded housing; no parent has any qualifications; the mother has mental health problems; at least one parent has a long-standing limiting illness, disability or infirmity; the family has low income (below 60% of the median); or the family cannot afford a number of food and clothing items”.

So, does Pickles envisage these families getting a comprehensive package of support, or some politically-attractive non-solution like anger management? Here’s a clue.

Pickles revealed a single problem, or troubled, family can cost the state up to £300,000 a year and predicted this figure can be cut by £70,000 annually simply by reducing the number of agencies involved.

Some of these families can be involved with the local authority, schools bodies, drug and alcohol services, the police and an array of social service departments. Pickles claimed less than 1% of the population can cost the economy over £8m a year.

Well, I’ve certainly come across cases of “agency overload” where too many professionals have become involved with a family, but are we supposed to say that if a child goes to CAMHS they can’t also go to, say, a young carer service? If not, what on earth is multi-agency working for?

So, to summarise, the message from Pickles is, “We’re cutting back the support you guys offer. Oh, and at the same time, we also expect you to sort out the stuff that gets voters irate.”