NPT

Hafal Neath Port Talbot hosts the penultimate local event on this summer's 22 county "Road to Recovery" campaign. Guests enjoy an edible version of the VW microbus while reinforcing the key messages of the campaign.

Among local issues in NPT the question of housing is raised, something I have discussed in the context of cost-effectiveness (see this post) but which deserves an airing in the wider context of the individual care plans which the Mental Health Measure will prescribe for all users of secondary mental health services.

Housing is self-evidently one of the most important "life areas" which care plans must cover but there has been a history of disconnected thinking which needs to be put right if truly responsive services are to be commissioned with individuals in mind.

At present there is a concerted move to "repatriate" patients from private high-dependency services often far from home. This is being driven significantly by cost-savings but is also usually the right thing to do. However, commissioners still need to take that further step back in planning services to see the whole recovery pathway for patients from hospital through to independent living...



...because clearing some blocks will only expose weaknesses elsewhere in the system.

The key to getting this right is two-fold:-

(i) Resources saved through repatriation are urgently required to meet the major deficits elswhere in the pathway (low secure services in particular). That, surely, was the point of the Minister's ring-fence on NHS mental health funding which MUST include funding from the Continuing Healthcare budget typically used to fund the out-of-county (sometimes out-of-Wales) placements. Otherwise the ring-fence is virtually valueless.

(ii) Commissioners need to work towards using individual care plans as the only point of reference for commissioning housing services. If that sounds simplistic then answer this - how can you justify any secondary mental health service in the future which does not feature in one or more individual care plans? The logical extension of this is the creation of NHS individual budgets - or, better still, combined health and social care individual budgets.

For Hafal's guide for commissioners of housing services see here.

Bear Necessity

Some peculiar members of the squash family have appeared in the garden, I think because of cross-breeding between varieties including odd plants growing unplanned (we call them "volunteers") near the compost heap which have come from discarded seeds of exotic types bought at market.

They are edible but otherwise could be used to combat wild animals as a plucky housewife from Montana has demonstrated. She fought off a 200 lb black bear using a home-grown courgette - see the news here. She must have been glad that she had left it to grow too large because the bear might not have been impressed by a 4 inch example, a size I would recommend if you just want to steam them whole.

The pictured horror from my garden - a sinister marrow/pumpkin hybrid - would make a formidable weapon but, before you report me to the relevant authorities, be reassured that it has been "decommissioned" into a big pot of courgette à la grecque, a sound fall-back for this delicacy when overgrown. For each lb of thickly-sliced courgette add 1 tsp salt, 3 tblsp olive oil, juice of ½ lemon, ½ pint water, 1 bay leaf, 1 sprig thyme, 6 black peppercorns crushed, 6 coriander seeds crushed, 3 tomatoes skinned and chopped, 1 clove garlic crushed. Bring to the boil, simmer gently for 25 minutes and refrigerate before use.

For the "Bare Necessities" song, a fine hymn to Epicurean philosophy featuring a pawpaw which looks very like my squash, see here.

Also Sprach Zarathustra

A pleasing Superman experience (Nietzschean or DC Comics - take your pick) climbing Pen-y-Fan the "hard way" from the North in just 1hr 35m starting from the old Cwm Gwyn army camp above Brecon. On the way down, more circuitously via Corn Du and the Tommy Jones obelisk, the going gets tough as my knees protest and feet grow numb and oddly squishy (serious walkers will know what I mean). After nearly five hours superhuman fantasies are replaced by middle-aged stiffness and the car is a welcome sight.

I've climbed the mountain at least once a year since the 1980s but rarely in such good conditions: a cold start (serious frost on the car this morning for the first time this autumn) but bright sun and crystal clear air.

It's hard not to feel on top of the world up there and I congratulate myself on choosing a "staycation" this week having nearly pressed the buttons on my computer to fly to Syracuse, Sicily, for seven hot days of mollycoddling and Marsala courtesy of Thomson's Holidays' fancypants brand ("Gold"? Or is that the one for oldies?). Mrs Blog says she agrees but there is something wistful in her expression.

Ich würde nur an einen Gott glauben, der zu tanzen verstünde

The Great Unwashed

We are glued to the telly this morning watching Hafal's representatives giving evidence to the National Assembly on PTSD and wider mental health problems experienced by veterans of UK armed forces. I have previously blogged on this matter (see this post) but our evidence today has the added force of personal experience presented by Hafal Practice Leader John Davies and Staff Volunteer Paul Cleary plus a written personal account from Terry, a service user with a telling story of army life and what followed.

It must be the military background of our witnesses which makes their testimony so pungent and to the point (calling an entrenching tool an entrenching tool as it were). John startlingly takes service commissioners to task for treating the voluntary sector as "the great unwashed", specifically for not respecting the first-hand experience of charities which assist veterans. Andrew R T Davies AM repeats this term back to John (with some relish I suspect) to check he did hear right! Terry's account is also eloquent and I quote from it here...

I joined the army in 1989, the Gulf War started the following year and I went out as a Combat Engineer. I saw some terrible things but what affected me most was six months of isolation in the Gulf, being stuck with a bullying corporal who could make life difficult. The army can be a good cover-up for anyone who has depressive symptoms as the culture revolves around working hard and being rewarded in beer. Army life is full of "high highs and low lows", it can be a melting pot for people with a mental disorder and drinking covers up a lot of it.

Army officials should have realised I was ill then because I was wandering round the camp in the middle of the night cleaning things. Eventually I went to the town’s cathedral thinking I was going to get married. I bought a £400 ring for a bride I was convinced was going to come. Eventually I sat at the back of the church and collapsed, crying. A priest found me, called the police and I was sent to Catterick Military Hospital. The hospital's psychiatrist told me I had bipolar disorder, I was hyper-manic and that on a scale of one to ten I was 15.

The staff tried to give me medication but because of my memories of the rave scene, I thought taking pills was wrong, so I refused. After a few days five nurses waited until I was unaware and jumped me. Four held my limbs down, the fifth injected me. That was the worst moment of my life. They gave me a massive dose of Haloperidol which did not agree with me; this meant that one second I was conversing with angels the next I was suffering the worse depression imaginable.

Since then, when medics have tried to give me Haloperidol, I’ve tried to run away. During my last episode (in 2008) I tried to tell those treating me how bad it was but they wouldn’t listen and tried to force it on me, so I ran away from a hospital in North Wales and ended up being beaten up in Cheltenham.

You can view the Assembly session here, an interview with Hafal's Alun Thomas here and Mental Health Wales' coverage here. Terry's account will feature in our new publication "12 Lives" - personal stories of people who have experience of serious mental illness. Watch this space.

Aktion T4

The comparison being drawn between the French government's current persecution of Roma people and the Nazi persecution of Jews is a strange one. Surely the more obvious comparison would be with the Nazi persecution of the Roma people, of whom perhaps one million were murdered in the Holocaust. The understandable focus on Nazi antisemitism seems to have led many to forget other victims, not least the Roma (whom we in Britain traditionally call Gypsies) and also people with schizophrenia and bipolar disorder many of whom were murdered in the names of eugenics and cost-savings under the policy "Aktion T4". As we celebrate the 70th anniversary of the Battle of Britain it is worth remembering that this victory ultimately prevented the slaughter of countless people with a serious mental illness across the world (the "Few" may not have known it at the time but I don't suppose they would have been surprised).

The poster shows the poor German worker shouldering the financial burden of supporting inmates of the mental hospital in the background - the 50,000 Reichsmark life-time cost could be saved by the simple expedient of killing them.

Postscript: like all proper schoolboys in the 1960s I made an Airfix Spitfire. The great dilemma was whether to glue the undercarriage down so it could stand alone or up in which case there was a rather rubbish stand. I went for up and no stand so it only made sense being whizzed manually around the kitchen with a-a-a-a-a! machine-gun commentary.

Mental Exhaustion

To the New Theatre, Cardiff, to see Simon Callow's one-man performance of Shakespeare, The Man from Stratford. After his curtain call and tonight only Mr Callow comes back on stage to answer questions and I get in quickly on behalf of my blog-readers to ask whether he believes Shakespeare was essentially a happy man or, like many geniuses, a troubled one beset with neuroses. He replies to this effect:

• He must surely have had deep and varied experience of the range of human emotions and mental states in order to recreate those experiences in drama and poetry.

• Like many creative geniuses (Dickens, Beethoven, Mozart, for example) the overwhelming life experience of Shakespeare was surely mental exhaustion arising from his sheer, immense creative productivity and the toll that must have taken.

• For evidence consider Shakespeare's early retirement and early death.


• Note the famous engraved portrait of Shakespeare by Droeshout in the first Folio: you can see a man broken down before his time.

I am sure Callow would concede that all this is pure speculation. Shakespeare may have retired early because he had made a fortune (he certainly had) and lived on sprightly and content until struck down unexpectedly by an illness aged 52. But the idea of mental exhaustion is an interesting one: I wonder if it is distinct from mental illness or a cause of it.

And what about the play? There is a problem with performing Shakespeare which exercises actors and directors, namely how to perform the extremely hackneyed bits which are overfamiliar to the audience and have therefore lost dramatic effect (the best approach is not to try to do them in an unexpected, and therefore usually daft or counter-intuitive way, but rather just to get through them conventionally knowing that most of the play is not so familiar). Arguably this production rather asks for trouble by mainly comprising a lot of overfamiliar bits used to illustrate what is effectively an enthusiastic lecture on S's life delivered by Callow leaping around in a curious velvet suit. In the interval I grumble that it can't be long before we find ourselves outside the walls of Harfleur. The curtain goes up and sure enough (and to Mrs Blog's ill-concealed amusement) SC is bearing down us sword in hand to urge us "Once more unto the breach, dear friends, once more". It is also hard not to associate him with his unctuous Rev Beebe character in Room with a View where he is caught starkers while wild-swimming. Incidentally the second-best question put to the actor is "When are you going to do some real Shakespeare?" which he answers very graciously even though it sounds a bit pointed, and to the point for that matter.

I would have preferred Callow actually playing Shakespeare and he could have derived a fantastic script from Christopher Rush's Will, a fictional autobiography of WS reminiscing on his deathbed (and definitely broken down as in Callow's theory). Not that I would not also recommend the author of this play Jonathan Bate's non-fiction Soul of the Age: The Life, Mind and World of William Shakespeare.

For all that the whole evening is good fun and, anyway, what is the alternative? Slumping in front of the telly watching tedious and uncritical coverage of the Pope pontificating (nice to use that word so appropriately) on British society punctuated with equally banal whinging from agitated "humanists"? As to that debate I am tempted to deploy my own Shakespearean cliché - A plague on both your houses! (Romeo and Juliet Act 3 Scene i).

On the way back to the car we are hailed by Hafal Chair Elin Jones who, it turns out, has been at the same performance and also stayed for the questions - so my intervention in the theatre will hopefully illustrate to my boss that I am never off duty...

"Dictionary Johnson"

I am reading David Nokes' Samuel Johnson: A Life (having previously read Peter Martin's Samuel Johnson: A Biography) and it sends me back to Johnson’s strange moral tale The History of Rasselas, Prince of Abissinia (1759) which I first read last year.

It is widely held that modern psychiatry emerged from ignorance and darkness in the early 20th c. and I suppose there is some truth in that. But Rasselas contains a startlingly modern and sympathetic portrayal of schizophrenia in considerable analytical detail. It also offers a rationale against prejudice and an explanation of our universal exposure to mental illness.

Most remarkably it sets out a therapeutic technique for the cure of schizophrenic symptoms based on kindly and respectful engagement with the patient and a subtle awakening of rationality which carefully avoids provoking paranoia and confrontation with delusional thoughts. This thoughtful and well-observed take on mental illness is little known and indeed Rasselas is hardly read even by scholars of Dr Johnson. He wrote the book in just a week when he was in dire poverty to raise money to help his dying mother. I believe Johnson’s insights into mental illness were based on his personal knowledge of and care for people with a serious mental illness (including the poet Christopher Smart) and his own Tourette’s Syndrome - and much deeper and darker symptoms of mental illness which terrified him throughout his life. Though famous for his dictionary, essays, poetry, etc in fact Johnson is most remarkable for his larger-than-life, boundless humanity – a timeless colossus of decency putting the likes of Voltaire into the shade.

There is scarcely anything written about Rasselas from a psychiatric perspective (perhaps they don't like it that he got there before them!) but I found this article from the 1960s which gives a thorough critique.

For a 21st c. guide to schizophrenia and recovery see Hafal's possibly less literary but bang-up-to-date leaflet here.

Bridgend

A fine turn-out in Bridgend for the microbus now on the home straight on the "Road to Recovery". Poor weather cannot dampen enthusiastic crowds enjoying the surf vibe at the same time as learning from the show-case of Hafal's variety of services in the County.

One of the local concerns raised is the lack of psychological services - and this is not a problem confined to Bridgend. There is a curious phenomenon about talking therapies which Hafal has observed, namely an unspoken but pernicious prejudice that such therapy is suited to low level mental health problems but a bit pointless for people with a serious mental illness. The false reasoning for this prejudice would be that (i) serious mental illness is probably genetic and at any rate to do with chemical dysfunction so talking is pointless; (ii) serious mental illness often results in a lack of ability to follow a discussion so talking therapy won't work; (iii) talking therapy can be distressing and you don't want to upset somebody that ill; and (iv) serious mental illness requires the sledgehammer of powerful drugs so talking therapy won't make any significant difference. Talking therapies are sometimes grudgingly acknowledged as having a marginal function in alleviating distress but not really touching the illness itself. Sometimes carers and family,
especially parents, may resist the idea of talking therapies because they fear the revelation that poor upbringing could have caused the illness (and there are bad memories still around of the simplistic, "blame the parents", Laingian ideas from the 1960s).

A further problem is that there is a lack of evidence about the effectiveness of talking therapies, largely I believe because the studies have not been done - there is little incentive for the pharmaceutical companies to fund such research though there are exceptions.

But I suggest that common sense tells us that talking therapies can make a decisive difference. The evidence for this is the experience of patients who, when they pursue recovery holistically or (put another way) get their lives sorted out, can overcome significantly, and sometimes completely, the symptoms of mental illness, the damaging effects of symptoms, the risk of relapse, and difficulties in recovering from relapse. Talking therapies should be directed towards assisting patients to pursue recovery in this way as well as directly addressing symptoms such as paranoia and depression. In practice many patients are scarcely talked to beyond what is necessary for the purpose of diagnosis and prescription.

Interestingly many members of the public believe that talking therapies are the norm for people with serious mental illness. If you are a mental health services insider try asking an intelligent member of the public what they think goes on in mental health services. I have done just that and most respond that they think the services may be rather shabby but nevertheless they picture the analyst's couch, the group therapy sessions, and the expert staff taking time to assist patients to understand and address their illness. Why would they expect anthing less in a modern health service? They are appalled to learn that in hospital it is a common experience to receive no talking therapies at all and scant communication of any sort. They wonder how it can make sense to pay vast sums for every bed but not pay a little more to have therapists engaging intensively with patients? They are right to be appalled.

And let's be clear that any old talking therapy isn't good enough. There needs to be a proper choice not confined to the superficial massaging of symptoms which much of the current trend for cognitive therapy involves. There is a need for high quality, no-short-cuts therapies which help patients get to grips with their lives. I must declare an interest here: I was lucky to find excellent therapists using transactional analysis to address my own illness in both one-to-one and group work over many months, an experience which changed my life and inspired my career move into mental health services. It still makes me shudder to think what would have become of me if I hadn't had the means to pay for therapy and had to rely on what the NHS could provide - maybe five minutes with a GP and a prescription for happy pills? Things are a little better today but not much I fear.

For a detailed overview of talking therapies and more on the case for "equal status" for talking therapies to treat serious mental illness see Hafal's guide here.

A History of Early Methodism Part 2

Weekend in a holiday flat at Llwyngwair, Newport (Pembs), with my mum and brother over from Spain to visit our niece. This is the ancient seat of the Bowen family, proper Welsh crachach descended from Gwynfardd Prince of Dyfed when England was still Saxon. In the late C18 a crowd of armed radicals led by the mayor of Newport marched on the manor. The intended victim George Bowen generously got the mayor off the very serious charges which ensued by bribing the main prosecution witness to go abroad. Obviously a decent chap the same Bowen, a supporter of Methodism, welcomed John Wesley (along with William Williams Pantycelyn and others) as a frequent visitor to the house en route from his bedsitter in Bristol (see this post) to Ireland. Never a dull moment for George who also led troops into Fishguard to defend the town against the French invasion of 1797 (see this post). Evidently George was a bit of a radical but drew the line at letting French revolutionaries threaten his inheritance. Much of this is recorded in an article in the Pembrokeshire Historian by the late Wales Herald Extraordinary Major Francis Jones whom I remember coming round regularly to the Dyfed Rural Council offices circa 1982 where I was the surly and uninterested custodian of the magazine's back numbers.

Two good swims in "refreshing" conditions at Aberbach and Cwm-yr-Eglwys plus fishing and shell-fishing (what the French call coquillage) - total yield one big prawn which is spared the pot. We could have got unlimited mussels but this is vetoed for fear of an unholy cooking aroma offending the aristocratic ghosts (and lesser, but living visitors) back at the manor.

Hmmm

News that a German toy-maker has produced a range of animals with mental illnesses (see this link). Patients include Dub the turtle with severe depression, Sly the snake who suffers from hallucinations, Dolly the sheep with a personality disorder and a crocodile which has an irrational fear of water. Though this enterprise is of doubtful good taste and I can't quite fathom the intentions of the creators I note that each toy is supplied with their own medical history, referral letter and treament plan - a better start than many real patients get though if they come out in Wales we will have to see that they get a proper, holistic care and treatment plan under the new Mental Health Measure.

This news raises the question of humour and mental illness which remains a very difficult subject. Most jokes at the expense of people with a mental illness fall into the same category as racist or similar nastiness (though that has not yet been taken on board by mainstream media) but there is of course much sharp and sometimes hilarious humour expressed by people with a mental illness (much of which would shock the sensitive among you) which I hear routinely in our services and you cannot really disapprove of. On the contrary there must be room to counter nasty jokes with funnier ones which may be edgy and uncomfortable but don't have the intention or effect of causing prejudice.

Tenby Triumph

Over 300 people sign our "Road to Recovery" message in Pembrokeshire, a reflection of an excellent event and real public support for the campaign. Highlights include an exhibition of paintings, craft, and photography, musical entertainment, good food, and guided walks around the town. Truly an holistic event covering all aspects of life!

Interesting research about the myth of violence and mental illness is published today:

The rates of violent crime among people who were mentally ill and abused substances were no different to those among the general population who abused substances.

In each group, the rate of violent crime was between six and seven times higher than in the general population.

"Most of the relationship between violent crime and serious mental illness can be explained by alcohol and substance abuse," said Dr Fazel.

"That tends to be the thing that mediates the link between violence and the illness."

He said that if the substance abuse was taken away, the illness itself had a "minimal" or non-existent role in violence.

Dr Fazel said: "It's probably more dangerous walking outside a pub on a late night than walking outside a hospital where patients have been released"

The study said that people with bipolar disorder were 10 times more likely to abuse drugs or alcohol than those in the overall population because they tended to turn to substances to counter the effects of their medication or to get other relief from their symptoms.

A previous paper on schizophrenia, written by several of the same researchers, came to similar findings.

See this link for more.

This will not come as a surprise to Hafal's Members. Indeed many of them would add, I am sure, that substance misuse does not just raise risks but is a substantial inhibitor of recovery whereas serious mental illnesses, of themselves, are very amenable to good recovery in spite of the traditional, pessimistic clinical view and that of many in the public.

Much could be achieved by a focus on assisting people with a serious mental illness to tackle substance misuse problems rather than accepting them fatalistically as "normal" concomitants of the illness. Similarly the life expectancy of patients could be raised by helping them to quit smoking rather than accepting heavy smoking as "the least of their worries". It all comes back to valuing the lives of people who experience serious illness as much as anybody else's. Good on Hafal Pembrokeshire for showing just that when the microbus came to town.

Goose

Down to West Wales to see my new niece whom we find very bonny as is the proud mother. I slip away to inspect my brother's goose (pictured) which commands respect since I learnt that our local butcher wants £11.80 per kilo for a Pembrokeshire goose this Christmas. That is over £5.35 per lb "in old money" (well literally in the old money it is £5 7s 1/2d). This means £60 or so for a modest bird. Now I like goose but, let's face it, by the time you have cooked a 10 or 12lb specimen half of it has run off as fat (admittedly very nice to keep for artery-furring roast spuds, confits, and so on) and what remains is a thin strand of meat from the breast and a scant mouthful off the legs. Turkey does go further but if you want goose (and you haven't got one in your back yard like my sage and far-sighted sibling) then I suggest buying a £20 one from Lidl (a little smaller but over 4kg) which on past experience is very acceptable.

The small quantity of meat will not seem so bad because the price is within the realms of reason but there will still be a need to eek it out and what better than a stuffing which will absorb some of the fat and fill your plate? Prune stuffing is traditional but (I am firmly advised) don't mess around with the usual recipes relying on breadcrumbs to bulk the prunes - make sure it has sausagemeat.

You need: 8oz prunes presoaked in a glass of red wine, 1 1/2 lb Bramley apples, an onion, grated peel of an orange, 2 or 3 sticks of celery, the goose's liver, 1 lb sausagemeat, handful of walnuts, 2 eggs, herbs to taste, plenty of seasoning. Chop up all the ingredients well, mix (using as much of the wine necessary to keep it moist), and stuff in the neck and the main cavity. Check the extra cooking time required because of the stuffing. Try roasting a whole Bramley or two next to your goose for easy-peasy apple-sauce au naturel.

It helps to face the end of summer if you think of the seasonal delights ahead, though I haven't given up yet and mean to swim comfortably in the sea at least to the end of September.

Shaken Not Stirred

Hafal Deputy Chief Executive Alun Thomas has been looking at the careers section of the Secret Intelligence Service (MI6) website (I know he has a box set of James Bond DVDs but...?) and points out that you cannot apply if you have ever experienced schizophrenia or bipolar disorder. This rule doesn't just apply to secret agents but to administrators, IT wonks, general bottlewashers who never leave the building, etc. It is okay though to have been a user of heroin or similar (as long as you have been clean for just 12 months), to have a criminal record, etc. It was also okay in the last century to have belonged openly to organisations closely connected to the Communist Party as the Cambridge Five found out to their delight and surprise when they applied. Indeed when information was passed to the Service in 1950 that Anthony Blunt was a member of the CP itself they ignored this. Perhaps they were too busy checking whether any of the cleaners in their London HQ's cafeteria had experienced a mild, one-off episode of psychosis 30 years before they applied for the job?

I will ask them about this and let you know what they say.

Merthyr Riot

Great fun at the Merthyr "Road to Recovery" event last week. Practice Leader Shan Davies and her team have turned the whole premises over to display their activities and feed the crowd very efficiently with a choice of mouthwatering and healthy hot and cold food. Staff and volunteers have dressed up sixties fashion and indeed would not have looked out of place in the Summer of Love. Malcolm Lewis (picture below) shows me around and introduces the Mayor and other guests. Not for nothing did Shan get an award for enterprise recently as the entrepreneurial approach to development is everywhere evident, ranging from horticulture to cooking, from woodworking to IT skills. The project is also extensively engaged with the community including hosting a Citizens Advice Bureau both for our clients and for local residents - a really smart move.

Five more events each week in September - Pembrokeshire, Bridgend, Monmouthshire, Neath Port Talbot, Swansea - will take the microbus to the end of her summer tour which will no doubt be a relief to several staff, not least the indefatigable Andrews Mulholland and Mackintosh who have ensured she gets to all the venues, though I sense they too have had a bit of fun notwithstanding the early starts and overall hard work.

Following the tour the next key role of the bus will be modelling for publications and web-based materials where she will lead our development of new information for everybody affected by serious mental illness, including younger people who have responded very enthusiastically to the bus's iconic style.

An early outing will be a new, introductory guide to recovery aimed at patients and families first coming to terms with serious mental illness. The microbus will symbolise the journey to recovery: a Ferrari really wouldn't have worked because we need to suggest the need for patience and careful driving! We know from experience that if patients get a well-informed, practical but "realistically optimistic" vision at an early stage then their prospects are much improved. Watch this space.