http://news.bbc.co.uk/1/hi/health/6203256.stm A rather damning report on our Mental health services So it begs the question "why are our Doctors and Psychologists getting it so wrong?" Is it fair to blame the doctors or psychologists for the failing when at it's essence psychology is still a pseudoscience ? In reality we don't have a deep enough understanding of the human mind to determine the outcome of every patient. The skills are there to make an informed judgement based on historical data and knowledge gained through experience in dealing with patients with mental health problems, but it's not a science where two plus two always equals four. Does the NHS suffer a shortage of properly trained Doctors and psychologists, or is the issue (as the article states) that there is no smooth transition from ward to community? The numbers stated are certainly of concern, but is there really more that can be done when our knowledge is so limited in this arena.
How the hell are the doctors meant to put a risk rate on a patient ? Most of the time when on medication, they are OK.
my mother works with mental patients in a locked ward and believe me she can tell you which ones are a risk to society.
As a psychologist I can tell you that very often we (psychologists, psychiatrists and psychiatric nurses) do identify when a patient is at risk of harm to self or others long, long before anything happens. But although 25% of GP referrals to the NHS constitute mental health referrals, we sure as hell don't see 25% of the NHS budget. So we simply do't have the resources to keep them all safe. Once we deem them at risk, what can we do? Mental health and social services are overstretched. Management in the community may be the government's ideal, but in reality it is very poorly resourced, and extremely difficult when a patient is at risk. They often live in chaotic, depressingly destitute circumstances, and some may actively withdraw from services and medication, to the extent that we have assertive outreach workers chasing them up every day and trying to keep track of them. We have only basic mental health and social services available outside of working hours or over the weekend. The first port of call for many mental health patients is the GP --but we all know how easy it is to see one of those at short notice. And we are functional. If it is incredibly difficult to contain very disturbed patients safely in the community, it is even harder to admit them to overflowing psychiatric wards (particularly if they have to be admitted against their will). I could tell you stories about the things we have to do to manage a patient safely in the community until a bed can be found, and a psychiatrist and qualified social worker can be pulled from their overstretched schedules to initiate sectioning. Once a patient is inside, they find themselves at close quarters with a bunch of equally distressed, chaotic and at-risk patients who often have to be managed 12 people to four qualified staff during the day, two at nights with some nursing assistants (who are basically untrained) to help out in very tricky, skilled procedures such as continuous observation (of those at risk) and control and restraint. Most psychiatric units are not secure so a patient could choose to walk out anytime, unless sectioned, at which point it is a few (often female) staff who may stand between a six-foot raging psychotic and the door. Politicians and the public may demand to know why this stuff happens, but the reality is that they don't know jack about what really goes on in mental health services, and as long as it is not they who have the mental health problems, they don't want to know either. They don't want to know about the 99.9% of the time we get it right despite all these problems. As a side note: psychology is not a pseudo-science. We train six years for a reason. In Community Mental Health I did risk assessments on average twice a week (for about six years) and I have never been wrong once, and neither have my colleagues. We regularly make life-and-death choices, weighing the patient's rights, desires and needs against public safety, patient risk and resource limitations, in complex balances that frankly would make you crap your pants if you had to take that responsibility. But the system simply has not got the resources to keep 100% of at-risk patients 100% safe.
I imagine that like much of the rest of NHS the Mental Health Services are equally poorly funded in comparison to the needs. What I found most disturbing was not that the patients didn't see a Doctor or Psychologist, they in many case did and were released immediately afterwards. This is why we either have to question the quality of our Mental Heath workers, the methods employed or our lack of knowledge.
No, you are not reading the numbers. 25% of GP referrals are mental health related. But not 25% of the NHS budget goes to mental health. Having worked in various health settings, I can most empathically assure you that not all services are funded equally. Let's look at those statistics again. How many potentially at risk people who saw mental health services in the previous week have not killed anybody? Does it mention how many suicidal people who visited services did not go on to kill themselves? And ah, percentages... What numbers are we really talking about? We also know that: So how many patients is that? Well, in 2000 one in six adults in Great Britain (5.4 million) had a mental health problem (ranging from anxiety and depression to psychotic illness), with one in seven (4.6 million) considering suicide at some point in their lives. Of the one in six, 24 per cent (1.35 million) received some form of mental health treatment, with 19% (1.02 million) receiving medication. There were 26,752 formal (involuntary) admissions to NHS and independent healthcare facilities under the Mental Health Act in the year 2004/05. Consider that: of the 1.35 million people in contact with mental health services, only 1000 commit suicide. How quickly can someone go from "distressed but not at significant risk" to "significant risk"? That's the problem with risk assessment: a lot can happen in a week, and in a sufficiently chaotic life, even in 24 hours. Your assessment can have a short half-life... Tricky if you don't have the resources to follow up that disturbed patient who refuses to engage. And in an overstretched system, where do you draw the line? What risk is still "managable", and what is "severe"? As I said in my post above: we know when people are at risk. The problem is: what can we now do about it? Our services are under-resourced, its cover patchy both geographically and over a 24 hour time span, our staff overworked. The most at risk patients are the ones least likely to engage voluntarily. When someone wants to kill themselves badly enough, they will find a way. Even on the safest unit. And for some people who are really bad off, this risk never quite goes away. You save them today, but what about next week? and next month? And next year? Almost 50% (244,000 of the total UK population) of schizophrenics will attempt suicide in their lifetime. 10-13% (48800 to 63440) will succeed in taking their own lives... In that respect, statistics suggest only 22% of suicides are ultimately preventable. It is easy to judge what you have little knowledge about, and there are no statistics on how many suicides or murders we prevent. But the situation is not nearly as simple as you think. But hey, in April the BBC announced a record low in suicides. So we must be doing something right.
I wouldn't expect all services to be equally funded, each service requires funds based on costs not on number of patients referred. Obviously there is an indirect relationship, not direct. You being employed in this area would be much better equipped to answer that question than I. I would refer you again to the two article quotes in my previous post, which show the numbers that, regardless of the staffing issues, geographical location and severity of their mental condition, did in fact meet with mental health professionals and went on to either commit homicide or suicide, that is a problem. You eagerness to defend your profession does offer up an interesting insight into the mind of a clinical psychologist, an almost god like complex, an air infallibility, you at no point accept that on some occasions mistakes may occur. As for Psychology being regarded as a pseudo-science. I think most outside the mental health community would regard psychology as a pseudo-science, they level of training involved bears no relation to whether it is a science or not. It just goes to prove what a difficult subject you have to deal with. However, I do accept that much of your work does employ scientific methology. I can throw ten apples up in the air and all ten will fall to the ground, I can throw ten psychopaths into the air and god only knows what would happen What I’m saying is that science deals with fact or at least known experimental data that returns the same results. When dealing with people with psychological problems, no two will be alike. You may of course play the percentage game and eliminate the erroneous data to make it appear more scientific, but that maybe why these problems stated in the article arise in the first place.
Luckily, we have your godlike knowledge and insights on all things mental health and psychology to bring naive deluded fools like me back down to earth. What is it that you do for a living again? I'd now like to refer you to the numbers in my last post. You seem to struggle with the concept of how large sample test results can be reduced to single case studies, or how single cases can be scaled up to large sample predictions. You will be relieved to know that psychology has considered this problem at length, and that curiously similar problems occur in biology and physics (quantum again). As such we can extrapolate the impact of individual differences. We are all not as unique as you'd like to think... And you know as well as I do that when we scale up human behaviour to large groups, it becomes eminently predictable. So what we do have, for instance, is very large comparative studies that prove for instance that cognitive behavioural therapy produces better and longer lasting results in depression than chemical anti-depressants (or doing nothing at all). Funnily enough, I am able to apply models and theories based on large sample research to the individual sitting in front of me. I also know when I cannot, and why. My clients generally improve and benefit, but I also know that a small proportion of them would do so regardless (and why). But then again, a significant proportion of those taking Prozac would improve regardless, so I don't feel too bad about it. Over time, I can also observe patterns in people's problems and presentations. Again, sometimes we like to think that we are more unique than we are, just as at other times we make the mistake of thinking that surely the other would see things exactly like we do. And yes, if I throw ten psychopaths in the air, I can indeed predict what will happen.
What you are talking about is statistical analysis, and it can be employed to a great degree to determine the outcome on the vast majority of cases, what this report questions is what happens to those that fall outwith the model. The question is why are we failing those people and the casualties that result. I deal with jeopardy management, training and software beta/acceptance testing.
I just told you. The system is imperfect. Life is imperfect. Busses and trains do not run on time, cars break down, planes crash (despite the best scientific understanding and application of mechanics and aerodynamics), the NHS fails. But this is not to do with lack of competence or lack of science, as you seem to suggest. It is to do with lack of resources, and with life being life.
I'm not suggesting that the fault lies solely with the competence of mental health workers, but also with the lack of funding, resources, bureaucracy, mismanagement and life being life. The simple fact is all have to accept a portion of the blame to help prevent such occurrences from happening again. There will always be errors, but the first step to alleviating those problems is to accept that they exist in the first place.
as i posted above i have limited experience of how a secure mental health ward works and it is fact that patients are wrongly released into the community where they can do harm. luckily in the cases i have heard of their freedom is brief as more often than not they return to the ward on a regular basis. under the mental health act there is no need to release a patient as they can be securely detained for up to six months and this can then be reviewed and renewed if neccesary. i think the point yodasarmpit is making is that it is the failure of hospital staff to implement this with patients who in reality should never be allowed unsupervised access to the outside world.
That is different from suggesting that professionals lack competence or that their science is dodgy. Cars break down on occasion. Are we lambasting engineers for this? Are we rejecting the sciences of engineering as suspect? No. We accept that there is a whole host of interacting variables that can conspire in the malfunction of a device as complex as a car, some predictable and manageable, some not so. Such is life: nothing is perfect, there are no easy fixes. In a complex system such as the NHS, with complex problems in complex people's complex lives, things can go wrong also (statistically it is a miracle that we get things right so often). When things occasionally do go wrong, it is simplistic to assume that a lack of competence or sound science are to blame.
Please don't simplify the work of experienced medical staff to a statistical anomaly that just so happens to fall on the right side of competence! (especially coming straight from the horses mouth; kinda makes me uneasy ) I'm sure all those years in training must have added at least some value.
On most occasions that would be more than accurate, but the report highlighted by the BBC focused on specific cases where the failings lay with health care professionals making the wrong decisions. Accepting that these mistakes occur is paramount to preventing them from happening again, the reasons may be varied from complacence, lack of competence, lack of training, the list is endless. The price of working in the medical profession is you cannot afford to make mistakes, a car breaks down you are late for work, a Doctor screws up someone dies, a Psychologist makes a mistake the wrong person is let loose on society. Members of the medical profession are not infallible, the blame does not always lie elsewhere, sometimes people are at fault, the reasons why they are at fault have to be investigated. We put our lives in the hand of the medical profession, the least we can expect is some humility.
And the least we can expect in return is some basic understanding of the problems before people make sweeping judgements about our proficiency in solving them. Some realistic expectations would be nice. But you start out by questioning psychologists' and psychiatrists' competence, training and even the science on which their profession is based. Surprise, surprise: I object. Then you accuse me of godlike arrogance. I'm not sure that attitude is so different from that of people who vote for some Big Daddy demagogue because he will make their lives all alright (usually by some simplistic solution to complex issues). Truth is, you want us to be gods. Infallible, indefatigable, unlimited in our unconditional acceptance and understanding, noble in our self-sacrifice, always able to find the perfect resolution to all people's woes, no matter how complex. You want us to be perfect parents. And when we show the slightest signs of being humans rather than gods, you feel betrayed and say we are all a bunch of charlatans. You are adult enough not to believe in fairy godmothers. There is no magic wand. Some life problems cannot be solved. Some illnesses cannot be cured. Planes will crash, cars will break down, people will die of cancer, crimes will be committed, and ocasionally someone in really crappy circumstances we cannot even begin to comprehend will kill themselves or someone else. No matter how hard we all try to prevent such things from happening. That's life.
Of course, but generally not through sheer incompetence or because their practices are based on "pseudo-science". That's the difference.
Nexxo, you're taking this a little too personally. We know there is no silver bullet. But we also know that a shrug of the shoulders and "c'est la vie" is not the response we want from healthcare professionals. I know from my own experiences a little about mental healthcare. Yes it's a mess. It's underfunded, still stigmatised, and simply not trendy. Does it mean you guys can't do better with what you have got? No. You can always do better. There is a problem. Yeah, extra funds and resources would be a big help. But until that time, you have to make do with what you have got. And under those conditions, it's fair for the rest of us to ask questions about whether this problem can be mitigated or even solved in the current climate. I've seen first-hand where I think perhaps that money and resources could have been used elsewhere. I'm not sure... I know that minor mental health issues can develop into major mental health issues if left untreated. But it seems that the problem is with people with significant mental health problems being given the equivalent of a band-aid and pushed back out on the street. It might be that the current crop of mental healthcare professionals are indeed doing the best that could be done with the resources that are available. But even so, the problems with the status quo need to highlighted and questions need to be asked. I can assure you that if you are happy to say that "we're doing what we can with what we have got" the government and the NHS administrators will happily let you continue that way. We (all) need to scream if there are problems and let the authorities know that no, we are not coping... yes there is a problem. Perfection won't ever be acheived, but perfection is but a dot on the horizon. The whole NHS is shambolic, but mental health services are especially so.
What you are saying is true, and I can assure you that we are the first people to scream if there are problems and let the authorities know that no, we are not coping... yes there is a problem... repeatedly and frequently. Moreover, we actually try to do something about it, well beyond the hours and obligations we are contracted and paid for. Saying that mistakes are made, and that these need to be openly recognised, examined and corrected is one thing, and I wholeheartedly agree. Calling everyone incompetent and charlatans (which was the opening argument in the first post) is a completely different matter though, and excuse you me if my tired, hard working ass takes exception to such a sweeping and ignorant generalisation. I don't know what people think the problem is all about, but I get the impression that they are not quite seeing the whole picture... I would invite anyone who thinks they can make a difference to join our club, even if just as a volunteer. Many of us joined for that same reason. We don't go to work feeling indifferent about our job and our patients; we could find much easier work to do for better pay. We try to help people and to make a difference. If you, too, feel that a difference needs to be made, I honestly invite you to join us. Don't just stand on the sidelines criticising the few glimpses that you see; please get involved in changing the whole picture.
