Tagged: Mental health

Mental health funding FOI responses update

I asked Treasury:

Blame for insufficient mental healthcare funding has been passed around between Department of Health, NHS England, and individual Clinical Commissioning Groups (CCGs), however, the source of funding is the Treasury. Although CCGs and other mediating organisations make decisions about how much funding mental health receives, this is as a proportion of budgets decided at Treasury level. Any budgetary planning at Treasury level must therefore take mental health into consideration, alongside other areas of healthcare.

I am writing to request:

(i) names of individuals at Treasury and above, including advisors by official name or function, who are responsible for decisions made in relation to mental health care budgets;

(ii) documentation on budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration.

To (i) they said they don’t hold the information. To (ii) they said they do, but wouldn’t share it, citing Section 35 of the FOI act.

(Full response here.)

I asked the Department of Health:

CCGs and other mediating organisations make decisions about how much funding mental health receives, but this is as a proportion of budgets decided at Treasury level. Any budgetary planning at Treasury level must therefore take mental health into consideration, alongside other areas of healthcare.

I am writing to inquire about advice provided by Department of Health to Treasury on mental health budgets.

1. Who in DH provides this advice?

2. What advice has been provided to inform the most recent budget allocation for health?

They also confirmed that they held relevant information but refused to share it, citing s35(1)(a).

(Full response here.)

I asked NHS England the same question:

[…] I am writing to inquire about advice provided by NHS England to Treasury on mental health budgets.

1. Who in NHSE provides this advice?

2. What advice has been provided to inform the most recent budget allocation for health?

They provided a response.

1. Who in NHSE provides this advice?

Paul Baumann, Chief Financial Officer for NHS England, has responsibility for the organisation’s budgets including providing advice on these budgets. NHS England is an Arm’s Length Body (ALB) of the Department of Health (DH), much of the advice the Treasury would receive on Mental Health would be coordinated by the Department.

2. What advice has been provided to inform the most recent budget allocation for health?

NHS England’s view of the overall funding requirements of the NHS were set out in financial analysis conducted for the Call to Action (July 2013) [see, especially, the technical annex] and the Five Year Forward View (October 2014), which have been shared with DH and Her Majesty’s Treasury.

This analysis projects “do-nothing” expenditure using assumptions about the three main drivers associated with current health care demand and costs: demographic growth, non-demographic growth (e.g. technological development and medical advances) and health cost inflation. Historic trends for these drivers were reviewed and an estimation of future pressures developed for six service level ‘assumption sets’: Acute, Mental Health, Specialised Services, Primary Care, Prescribing and non-activity based costs. This high level analysis thus includes assumptions related to cost and demand growth for mental health services as part of the overall modelling.

Detailed analysis and costing is completed by NHS England on specific initiatives, the output of these models are used to inform budget announcements and the planning guidance information. These costings are developed by the Medical Directorate and Finance Directorate working together.

(Link to response here.)

Why can psychological therapy be helpful?

Research explaining how therapy might help is filled with very technical terminology, e.g., invoking “transference”, “extinction”, heightening access to “cognitive–emotional structures and processes”, “reconfiguring intersubjective relationship networks” (see over here for more).

Could simpler explanations be provided? Here are some quick thoughts, inspired by literature, discussing with people, and engaging myself as a client in therapy:

  • You know the therapist is there to listen to you — they’re paid to do so — so there’s less need to worry about their thoughts and feelings. One can and is encouraged to talk at length about oneself. This can feel liberating whereas in other settings it might feel selfish or self-indulgent.
  • The therapist keeps track of topics within and across sessions. This can be important for recognising patterns and maintaining focus, whilst allowing time to tell stories, meandering around past experiences, to see where they lead.
  • The therapist has knowledge (e.g., through literature, supervisory meetings, and conversations with other clients) of a range of people who may have had similar feelings and experiences. So although we’re all unique, it can also be helpful to know that others have faced and survived similar struggles — especially if we learn what they tried and what helped.
  • Drawing on this knowledge, the therapist can conjecture what might be going on. This, perhaps, works best if the conjectures are courageous (so a step or two away from what the clients says) — and tentative, so it’s possible to disagree.
  • There can be an opportunity for practice, for instance of activities or conversations which are distressing. Practicing is a good way to learn.
  • Related, there’s a regular structure and progress monitoring (verbally, with a diary, or using questionnaires). Self-reflection becomes routine and constrained in time, like (this might be a bit crude but bear with me) a psychological analogue of flossing one’s teeth.
  • (Idea from Clare) “… daring to talk about things never spoken of before with someone who demonstrates compassion and acceptance; helpful because allows us to face things in ourselves that scare us and develop less harsh ways of responding to ourselves”
  • (added 27/10/2014) The therapist has more distance from situations having an impact on someone than friends might have so, e.g., alternative explanations for interpersonal disputes can more easily be provided.
  • (added 27/10/2014) It’s easier for a therapist to be courageous in interactions and suggestions than for a friend as — if all goes wrong — it’s easier for the client to drop out of the therapeutic relationship without long-term consequences (e.g., there’s no loss of friendship).
  • (added 15/01/2015) Telling your story to a therapist gives you an audience who is missing all of the context of your life. Most of the context can feel obvious, until you start to tell your story. Story telling requires explaining the context, making it explicit. For instance who are the people in your life? Why did you and others say and do the things they did? Perhaps this act of storytelling and making the context explicit also makes it easier to become aware of and find solutions.

Some thoughts…

A farcical proposal for mental health outcomes measurement

If you’re going to develop a questionnaire for something resulting in a total “score” — quality of life, feelings, distress, whatever — you’ll want all of the questions for one topic to be related to each other (as a bare minimum). This questionnaire probably wouldn’t be very “internally consistent”:

THE GENERAL STUFF QUESTIONNAIRE

  1. How often do you sing in the shower?
  2. What height are you?
  3. How far do you live from the nearest park?
  4. What’s your favourite number?

(You might still learn interesting things from the individual answers.)

This one would:

THE RELIABLE FEELINGS QUESTIONNAIRE

  1. How do you feel?
  2. How do you feel?
  3. How do you feel?
  4. How do you feel?
  5. How do you feel?
  6. How do you feel?
  7. How do you feel?
  8. How do you feel?
  9. How do you feel?
  10. How do you feel?

However, you might wonder if questions 2 to 10 add anything… (So internal consistency isn’t everything.)

There are many ways to test the internal consistency of questionnaires, using the answers that people give. One is to use a formula by Lee Cronbach called Cronbach’s alpha. Answers run from 0 to 1. Higher is better (but not too high; see the second example above).

In England, it is now recommended (see p. 12 of Mental Health Payment by Results Guidance) to use scores on a “Mental Health Clustering Tool” to evaluate outcomes. I think there are at least two problems with this:

  1. It’s completed by clinicians. It’s unclear if service users even get to know how they have been scored, never mind to what extent they can influence the process.
  2. The questionnaire scores aren’t internally consistent.

The people who proposed the approach write (see p.30 of their report): “As a general guideline, alpha values of 0.70 or above are indicative of a reasonable level of consistency”. Their results: 0.44, 0.58, 0.63, 0.57. They also refer to previous studies showing that this would always be the case, due to “its original intended purpose of being a scale with independent items” (p. 30). So, by design, it’s closer to the General Stuff Questionnaire above: a list of “presenting problems” to be read individually.

Not only are clinicians deciding whether someone has a good outcome (are they really in the best position to decide?), but the questionnaire they’re using to do so is rubbish — as shown by the very people proposing the approach!

Undergraduate psychology students wouldn’t use a questionnaire this poor in their projects. Why is it acceptable for a national mental health programme?

“… something more besides [psycho]analysis…”

“When the ego has taken its defensive measures against an affect for the purpose of avoiding unpleasure, something more besides analysis is required to undo them, if the result is to be permanent. This child must learn to tolerate larger and larger quantities of unpleasure without immediately having recourse to his defense mechanisms. It must, however, be admitted that theoretically it is the business of education rather than of analysis to teach him this lesson.”
—Anna Freud (1966, pp. 64-65)

Reference

Freud, A. (1966). The ego and the mechanisms of defense (revised ed.). New York: International Universities Press.

FIGJAM-based practice

Alternative to evidence-based practice: FIGJAM-based practice.MM0726_Fig_Jam__66623_std
(F**k I’m Good, Just Ask Me.)

Evidence is for the bureaucrats.
Trust us, we’re experts.
Join the school of the FIGJAM.
Throw your positivist randomised trials on the fire.

“I used the FIGJAM approach and I felt better.”

Coming to a social enterprise near you soon.

Book review: Power, interest and psychology by David Smail (2005)

Power, interest and psychology argues that psychotherapists need to take seriously how the social forces of interest and power affect how we all – therapists and clients alike – think, feel, and behave. The main targets of the book are (what Smail believes to be) the over-ambition and limited reach of therapists’ actions; operating, as they usually do, through transference, warmth, empathy, and cognitive behavioural interventions. These influences, argues Smail, are dwarfed by the social environment outside the clinic. I read this book with interest as a (non-clinical, academic) lecturer who works with many kinds of psychotherapists and counsellors.

Smail rejects interventions which assume that insight leads to therapeutic change, that we have will power which therapy can encourage, that conscious thoughts accessible in therapy precede action. But what about clients who show improvement during the first few sessions of therapies which use these forms of intervention? He argues (pp. 24–25) that “such initial gains tend not to last… Rather like tender plants that thrive only in a greenhouse, it seems that people find that there is still a cold and hostile world waiting for them at the end of their therapy sessions…” The exceptions cited are clients who are young, attractive, verbal, intelligent, and successful. There is some research support for this clinical experience, for instance showing that cognitive ability positively correlates with outcomes (e.g., Mathiassen et al., 2012). A counterargument is evidence showing that “early responders” tend to sustain  better outcomes at long term follow up (Haas, Hill, Lambert, & Morrell, 2002; Lambert, 2005). However these correlational studies are open to attack: perhaps the early response just signals existing resources which were easily activated by therapy.

Therapy, Smail argues, tries to boost the perception of clients’ power to change, when in reality it is actual power that clients often need: power over material resources, money, employment, education; personal resources such as confidence and intellect; home and family life, a love life, and an active social life (Hagan & Smail, 1997). These are areas which often cannot be influenced by talk in the clinic. So why has individual therapy grown so popular? Smail argues – and emphasises that it’s nothing to be ashamed of – that therapists rely on income to put food on the table and pay the rent, just like their clients. He illustrates with the example of Sigmund Freud (p. 3) who wrote that “My mood also depends very strongly on my earnings… I have come to know the helplessness of poverty and continually fear it”. Freud, he argues, changed his theories so as not to offend those who paid the bills, e.g., clients’ parents. Smail argues that there is a great mysticism around therapy (p. 8): “rituals of therapeutic cure… bear a strong resemblance to the spells and incantations of sorcerers”, with practitioners rarely explaining to clients how their techniques (supposedly?) work. Together these interests help sustain psychotherapy.

Is it really true that therapists can only intervene in the room with the individual client? Couple therapy takes the first step beyond the individual by bringing a romantic partner into the room, and there is evidence it helps with relationship problems (Snyder, Castellani, & Whisman, 2006). Child and adolescent mental health services frequently intervene in the family (Carr, 2009). Multi-family therapy (Asen & Scholz, 2010) brings a chunk of the social network into one room and encourages families to help each other as the therapists gradually “decentralise” themselves. There is an awareness of the importance of the systems around people suffering distress. Another path outside the clinic is via homework, such as practicing social skills, which is (ideally) jointly agreed and set in a range of different types of therapies (Ronan & Kazantzis, 2006). Outcomes are better when therapies include homework than when no homework is included (Kazantzis, Whittington, & Dattilio, 2010). Smail, however, no doubt would argue that each of these interventions is limited when there are more material challenges at work such as poverty; what then would the homework consist of? Get a job? Make more money?

“The world is in a bloody mess,” concludes the book, “and even though I know, as do many others, what it would look like if it weren’t, I have no more viable idea than anyone else how to get there.” But there are constructive ideas in this text. Awareness that the causes of many of our actions is a mystery can be positive, for example in terms of accepting that social power flows through us and we shouldn’t blame ourselves for our situation or how we feel. A rich analysis is provided of the sources of this social power. The positive and convincing argument of the book is that the main hope of exercising power is through cooperation with others on all levels from friendship through to political activism. Indeed there is some evidence that activists who “advocate a social or political cause” tend to experience more positive emotions than non-activists (Klar & Kasser, 2009). To what extent these broader societal processes are within the scope of psychotherapy will no doubt continue to be debated. But whatever the scope, Smail suggests (p. 84) that the “appropriate role for therapeutic psychology is to record, celebrate and wonder at the extraordinary diversity of human character” – which sounds to me like a valuable starting point for therapeutic research and practice.

 

References

Asen, E., & Scholz, M. (2010). Multi-family therapy: concept and techniques. Hove: Routledge.

Carr, A. (2009). The effectiveness of family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 31, 3–45.

Haas, E., Hill, R. D., Lambert, M. J., & Morrell, B. (2002). Do early responders to psychotherapy maintain treatment gains? Journal of Clinical Psychology, 58, 1157–72. doi:10.1002/jclp.10044

Hagan, T., & Smail, D. (1997). Power-Mapping I . Background and Basic Methodology. Journal of Community & Applied Social Psychology, 7, 257–267.

Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta-Analysis of Homework Effects in Cognitive and Behavioral Therapy: A Replication and Extension. Clinical Psychology: Science and Practice, 17, 144–156. doi:10.1111/j.1468-2850.2010.01204.x

Klar, M., & Kasser, T. (2009). Some Benefits of Being an Activist: Measuring Activism and Its Role in Psychological Well-Being. Political Psychology, 30(5), 755–777. doi:10.1111/j.1467-9221.2009.00724.x

Lambert, M. J. (2005). Early response in psychotherapy: further evidence for the importance of common factors rather than “placebo effects”. Journal of Clinical Psychology, 61(7), 855–69. doi:10.1002/jclp.20130

Mathiassen, B., Brøndbo, P. H., Waterloo, K., Martinussen, M., Eriksen, M., Hanssen-Bauer, K., & Kvernmo, S. (2012). IQ as a moderator of outcome in severity of children’s mental health status after treatment in outpatient clinics. Child and Adolescent Psychiatry and Mental Health, 6(22), 1–7. doi:10.1186/1753-2000-6-22

Ronan, K. R., & Kazantzis, N. (2006). The use of between-session (homework) activities in psychotherapy: Conclusions from the Journal of Psychotherapy. Journal of Psychotherapy Integration, 16, 254–259. doi:10.1037/1053-0479.16.2.254

Smail, D. (2005). Power, interest and psychology: elements of a social materialist understanding of distress. Ross-on-Wye: PCCS Books.

Snyder, D. K., Castellani, A. M., & Whisman, M. a. (2006). Current status and future directions in couple therapy. Annual Review of Psychology, 57, 317–44. doi:10.1146/annurev.psych.56.091103.070154