Issue 4 Summer 2018 RCPsych INSIGHT COLLEGE NEWS IN BRIEF Contents 04 RCPsych data analysis reveals fatal STEPHEN FRY SAYS ‘CHOOSE PSYCHIATRY’ delays to treat eating disorders Fry encourages medical President’s students to enter the profession The proportion of children with an eating 95% of children under the age of 19 with an disorder starting urgent treatment within one eating disorder should access NICE-approved week of referral remains far higher in treatment within a week in urgent cases and update than the rest of the country. This was one of within four weeks for routine cases. the findings from our latest analysis of the NHS The story was covered by the national media, England Mental Health Five Year Forward with quotes from Professor Wendy Burn and Professor Wendy Burn View Dashboard. The figures showed that in Dr Louise Theodosiou arguing that if the start of London, 84% of urgent cases began treatment treatment is left for longer than a week, it could Welcome to this issue for an eating disorder within a week, but in the prove potentially fatal. They also highlighted the of Insight. This year has 06 north of England this was true in only 67% of urgent need to recruit more psychiatrists to tackle given us much to celebrate, cases. By 2020/21, NHS England have said that the lengthy waiting times that some patients face. INTERNATIONAL including the NHS’s 70th CONGRESS 2018 birthday and the centenary of women’s right to vote. Find out what’s on at the Find out what it’s like to be an SAS doctor on p14 big event of the year Psychiatrists in Northern Ireland campaign Take a look at Our NHS Heroines – a piece which to end country’s mental health crisis investigation into the combines the two! 08 I love this edition’s front deaths of mental health patients cover. Stephen Fry has WORLDWIDE MENTAL been endlessly supportive HEALTH LEGISLATION The College has been the leading voice background to the tragic deaths was of our Choose Psychiatry How do mental health for clinicians in the recent debate about an underfunded and struggling mental preventable deaths in mental health trusts. health system. In a comment piece in The campaign. You can read policies shape up across about our recent event at the globe? An investigation by The Guardian found 271 Independent, she said that there were some highly vulnerable NHS mental health patients tragic cases where a death occurs, and which he enthralled medical had died over the last six years due to failings that the after-effects are felt by psychiatrists students as he talked about in their care. Patients were reported to be not for a long time. Psychiatry is a judgement how much psychiatry has 11 properly supervised despite being suicidal, call – and that is why consultants’ training, helped him. DRAMA IN THE EXAM ROOM discharged from inpatient care with inadequate expertise and knowledge are invaluable. Not long until Congress How actors with intellectual support, or did not receive the recommended The piece explained that accountability now and I’m following the disabilities are helping treatment. is important, but learning from serious speakers’ blogs on our Professor Wendy Burn said in The Guardian incidents is key. The College was clear that psychiatrists to pass their exams website with interest. Here that NHS mental health trusts were not doing a no-blame culture in the health service was enough to adopt changes that would prevent vital for suicide prevention strategies to be is why Professor Simon future loss of life – but made clear that the as effective as possible. Lovestone recommends a career in psychiatry: Sir Je rey Donaldson MP, Dr Gerry Lynch, Chair of RCPsych in NI, and Alastair Campbell in parliament “Because listening to people’s lives, hearing their uses RCPsych thoughts and stories, trying RCPsych in Northern Ireland took action on The event in parliament, also attended by to understand and to help the “worsening mental health crisis” in Northern RCPsych Fellow Alastair Campbell, was research in PMQs 14 Ireland earlier this year, travelling to London to publicised in the national media, highlighting is the most extraordinary THE SAS LIFE petition Westminster MPs and Government. the fact that more people have died by suicide For the first time ever, RCPsych research was journey and the best use of After a year without a devolved government in in 18 years of the peace process (4,400), raised by the leader of the opposition during all of those attributes and What’s it like to be an Belfast, Dr Gerry Lynch, Chair of RCPsych in than were killed during the 30 years of the Prime Minister’s Question Time. Labour motivations that made you SAS doctor? NI declared: “It is imperative that mental health Troubles (3,600). Leader, Jeremy Corbyn said: “Why does the want to be a doctor in the policy and service development doesn’t stagnate The delegation of mental health campaigners analysis by the Royal College of Psychiatrists first place.” 18 in the absence of a devolved administration. in Westminster called for release of the £50 show that mental health trusts have £105 I hope you enjoy this issue Given the underfunding of mental health care million funding for mental healthcare over five million less than they had six years ago?” which celebrates the journey OUR NHS HEROINES in Northern Ireland, new policies and reforms years, pledged last year under the DUP- He also raised our concerns about the falling he describes. A look at some of the leading must be driven forward as a matter of urgency.” Conservative deal. number of child and adolescent psychiatrists. Jeremy Corbyn, Labour Party Leader women in mental health

Editors: Hannah Perlin, Gemma Mulreany, Rebecca Couper and Kim Catcheside Design: Lee Braithwaite and Gemma Mulreany Want to contribute or offer feedback? Contributors/writers: Gabrielle Nathan and Sarah Chalmers Cover illustration: Martin Rowson Send in your suggestions to Photographers: Emily Long, Rachael Meyer, Paul Slater and Stanley Awuku Inside illustration: Kipper Williams [email protected] 2 Clinical Editor: Dr Tony Rao #RCPsychInsight 3 YOUR CAMPAIGN FEEDBACK NEWS Stephen Fry shows his support RCPsych Activities for Choose Psychiatry Encouraging Medical Students to Choose Psychiatry

The College’s campaign to encourage medical students Student Associates are a form of • The Student Associate grade is a free • The Choose Psychiatry section to choose psychiatry achieved celebrity endorsement membership to the Royal College of membership grade giving access to great of our website gives comprehensive earlier this year. Psychiatrists, exclusive to medical benefits to support them to network, learn, careers information on what it’s like to be a students interested in a career in stay up to date and practise their skill. psychiatrist, how to train and more. psychiatry. Membership is free and offers benefits such as being invited to events • Psych Socs: We support student-run • We respond to individuals’ careers like these, and is part of a concerted Psych Socs in all UK medical schools by queries via email at [email protected] FEEDBACK effort by the College to harness the providing funding, literature and materials and by phone on 0203 701 2625. We also exceptional talent pool of students. and putting them in touch with local share information via social media Members can also get discounted rates psychiatrists and speakers. using #ChoosePsychiatry @Choose_Psych Gr8 mag. Quick read. Makes me # to the College’s International Congress, feel connected to the college + The National Student Psychiatry We support ad-hoc initiatives and the biggest psychiatry event in the UK • • psychiatrists in other specialties. Conference is held at a different medical activities encouraging recruitment into attended by psychiatrists worldwide, school each year helping medical students Well done! #RCPsychInsight psychiatry. Activities have included and subscription to our academic to find out more about the specialty. Tweeted by Dr Sabina Burza, supporting a local mentoring scheme and journals BJPsych, BJPsych Bulletin, and the PsychArt conference. Consultant psychiatrist in BJPsych Advances. • Pathfinder Fellowships, worth up to rehabilitation Other benefits include free access to a £5000 each, offer unique opportunities to • We promote and support Medical Student trainee module in psychiatry. support medical students over three years Psychotherapy Schemes and Balint groups. I’m writing to congratulate you on Fry, who has had a well-publicised in a critical time in their career decision Insight magazine – inspiring, well making process. Our annual conferences including struggle with mental health, cut straight • written and deftly laid out. It enthused to the chase, urging the audience to International Congress and #PsychMedEd me in my career and I hope it did • Careers events – we run careers provide students with an opportunity to ‘Choose Psychiatry’. events such as Psychiatry: Mind and the same for other psychiatrists. I “Physical health is important meet leading psychiatrists and present their also hope it has a wide circulation – Body in the 21st Century giving students own research. but nowhere near as exciting the opportunity to hear from inspirational beyond psychiatrists. as the science of cognition and speakers and learn about developments in • We campaign to improve the teaching of Dr Hugh Grant-Peterkin, consciousness,” he told them. psychiatry. psychiatry in medical schools. @MRCPsych And he urged the students at Barts and The London Medical School: “The Could you just explain to me brightest and the best minds must join why it is necessary to send your the fight against mental illness.” magazine, Insight, wrapped in College President, Professor Wendy medicine and medical care. Ania, who a clear plastic envelope? At a Burn had introduced the comedian as a is also Chair of the Undergraduate time when even the government ‘national treasure’ but of course to those Education Forum at the College, works is turning its mind to the plastic who have followed his work and his own to overcome stigmatising attitudes catastrophe that is overwhelming mental health journey, no introduction to mental health, and improving us, surely the psychiatric community was needed. professional standards and well-being could take a responsible line on this In 2006, he fronted a ground-breaking in medical students and doctors. and do away with plastic? documentary The Secret life of the Dr Gareth Cuttle, Project Manager of Anonymous Stephen Fry, speaking at a College event for Choose Psychiatry Manic Depressive and revealed he the Gatsby/Wellcome Neuroscience has bipolar disorder. A decade later he Project at the College, spoke about undreds of medical followed up with another documentary, the exciting future which beckons students crowded into Barts looking at changes in attitudes. Last for tomorrow’s psychiatrists, thanks Editor response: and The London Medical Autumn he supported the College’s to advances in neuroscience and Thank you for raising this important School in February to hear #ChoosePsychiatry campaign which The lecture theatre packed with medical students our improved understanding of the issue! The College takes plastic waste Stephen Fry speak about offered information, prizes and events relationship between mental health extremely seriously, and has ensured the debt he owed to psychiatry. for medical students and foundation schedule at a time when his own health and the brain. that all our magazine sleeves are H Fry, more used to addressing a room full doctors interested in psychiatry. was compromised, further solidified Finally, Dr Derek Tracy, Clinical Director made of totally biodegradablewww material. of actors, actresses and film executives At February’s event, Fry was brutally the seriousness of his message – that at Oxleas NHS Foundation Trust, and Following feedback from College staff, during one of his many stints hosting the honest with the audience about his own psychiatrists are vital to us all and the Editorial Board Director of BJPsych, we have also banned the following The event panel, including Stephen Fry (third from left) BAFTAs, looked just as at ease when he mental health problems and credited discipline must continue to do all it can took to the floor for a lively talk about plastic products from Café 21, our took to the stage to address the would- open to Student Associates. his psychiatrist for saving his life. After to attract the best candidates. the evolution of the human mind, which College canteen: straws, cutlery, food be psychiatrists of tomorrow. The College is proud to now have his speech, there followed a lively panel The event also included excellent talks had students learning and laughing in containers, cups for water, bottled The event, ‘Psychiatry: Brain, Mind and a record 2,773 Student Associate discussion, with more food for thought. on neuroscience. equal measure. water, and bottled Ribena. Body in the 21st Century’, was jointly members and events such as these Just days after the hugely successful Professor Ania Korszun, from Barts By the time the evening drew to a close Please send your feedback to organised by the College and Barts and are not only hugely popular but also event, it emerged that Fry had been and The London Medical School, set the audience had been left with much [email protected] or tweet The London Students’ Association, and help showcase the myriad career suffering from prostate cancer. the scene with a talk which advocated to think about – not least how fulfilling a us with hashtag #RCPsychInsight was the latest in a series of free events opportunities within psychiatry. The fact that he took time out of his psychiatry’s role at the centre of career in psychiatry could be.

#RCPsychInsight #RCPsychInsight 4 5 INTERNATIONAL CONGRESS

International Congress comes to Birmingham RCPsych’s annual International Congress is back and better than ever, with a theme – Psychiatry: New Horizons – that reflects the exciting programme of speakers and events.

ur International Congress sphere. Listen to 14 keynote speakers returns to the ICC in and 80 parallel sessions that cover an Addressing suicide risk in A conversation with mental health activist The rise of the Birmingham from 24–27 eclectic range of topics, from clinical vulnerable groups Jonny Benjamin and his father cyberpsychiatrist June 2018 for four days practice to cyber-psychiatry and from Sunday 24 June 14:15 −15:30 Wednesday 27 June 14:10 −14:40 Tuesday 26 June 11:30 −12:45 of unmissable sessions, cutting-edge science to the implications inspirational keynote speakers and of Brexit. O “There are over 3.5 billion internet stimulating social events. Previous Here, we highlight four sessions, “A decade ago, a systematic review on Award-winning mental health diagnosed with psychosis, particularly Congresses have been described as including an unmissable discussion mental disorders, suicide and self-harm in campaigner Jonny Benjamin if that involves a hospital admission. users worldwide but the rising use of “excellent” and “not to be missed” and between award-winning mental health lesbian, gay and bisexual people found a MBE will appear at Congress as a This is why we felt it would be digital technology has been weirdly this year’s promises to be even better, activist Jonny Benjamin MBE and his two-fold increase in risk of suicide attempts keynote speaker, in conversation really useful to hear his father’s neglected by psychiatry when thinking with a programme featuring talks from father. More information including the full in LGB people. It was shocking at the time with his father. “Our talk will touch perspective.” about the risks it presents to patients academics, patients, families and opinion programme and tickets can be found on and generated widespread interest but little on how mental health issues affect and the complex challenge it poses to leaders from the social and political our website. in the way of research until a recent study not just the individual but also those psychiatrists,” states Dr Golnar Aref disseminated the risk factors and found four around them; something which is from the Division of Psychiatry at UCL, out of five related to the family, suggesting often disregarded,” explains Jonny. who is presenting a talk entitled ‘Risk we need to focus on families to understand Dr Erin Turner, a consultant assessment in the Digital Age’. Conference Talks the attitudes young people face at home,” psychiatrist in early intervention The talk is one of three in a session explains Dr Alexandra Pitman, Senior and psychosis at Birmingham chaired by Gabriella Landy of the West Brexit and Britain’s mental health workforce: Brain drain or gain? Lecturer in Psychiatry at UCL. She’ll be and Solihull Mental Health NHS London Mental Health NHS Trust and presenting ‘Understanding risk of suicide Foundation Trust, will be guiding the focuses on the concept of digital risk. “I Tuesday 26 June 15:00 −16:15 and suicide attempt in LGBT communities’, session. She says, “I first became first became aware of this about seven part of a trio of talks under the umbrella aware of Jonny when I watched his Mental health activist Jonny Benjamin years ago, while working in eating Dr Adrian James, Registrar of the Howard Ryland, who represents all the ‘Addressing suicide risk in vulnerable documentary ‘The Stranger on the disorders; lots of the girls were getting Royal College of Psychiatrists, will chair European trainee psychiatrists, will be groups’ chaired by Professor Michael Bridge’ which follows his quest to Jonny, who published a book earlier ideas from pro-anorexia websites and a three-part session centring on the offering us the European perspective King. The second talk will focus on the find the stranger who gave him hope this month documenting his experience, being motivated by cyber-bullying.” implications of Brexit. “It’s probably the alongside Dr Mariana Pinto da Costa, suicide risk among refugees. to keep living; he’d been recently hopes listeners will take away how Dr Aref has worked with the other two topic of most concern in the UK – Brexit from Queen Mary University of London. Part three of this session is a talk by Mx Talen diagnosed with schizoaffective important and valuable the role of speakers, Dr Richard Graham, who is something that interests everybody,” Dr Subodh Dave, Associate Dean for Wright, MSc student at UCL, on the subject disorder and run away from hospital carers, families and friends are in is presenting ‘Digital resilience in the says Dr James. “In terms of the medical Trainee Support, is going to give the of ‘Transgender and Gender Diverse (TGD) to Waterloo Bridge to end his life helping to support an individual with a Cyberage’ and led the launch of the UK’s and psychiatric workforce, at the moment global perspective on Brexit.” suicidality: an overview of the risk literature when a stranger talked him down. mental health problem. “My Dad didn’t first Technology Addiction Service at the it raises more worries than hopes as Dr James continues on a positive note, and addressing the clinical needs’. “Studies “Jonny was detained in hospital and get the help and advice he needed Nightingale Hospital, and Annie Mullins, we take a very high proportion of our “Brexit is an opportunity to foster new found that 29% of TGD adults had attempted later used social media to find the when I was first diagnosed, admitted to internet safety expert of EU ICT Coalition workforce from the EU and any threat links and we’ve always had those links in suicide compared to 3.7% of the general stranger, Neil Laybourn, so he could a psychiatric hospital and sectioned. for Children Online, who is presenting ‘The to our source of psychiatrists is of great psychiatry. For example, a large number population. These rates are staggeringly high thank him for saving his life. I was This had an adverse impact on him world is changing…with or without you’. concern.” of Indian psychiatrists have worked in the and not dropping, so it’s crucial to understand so inspired by this fantastic story, I and many other family members. If “Together with Dr Graham and using The presenters may instil optimism. UK. There might be training opportunities what’s going wrong, particularly when contacted Jonny and asked him to he’d been given more information results from a ground-breaking study I’ve “We’ve got three excellent speakers, in the UK for psychiatrists from all over you consider referrals of TGD people to attend an event for young people and support it would have helped us carried out, we’ve created a framework to including Dean Dr Kate Lovett, who as the world, as well as options for British mental health professionals are increasing.” with psychosis. all greatly. I believe there’s a need to help psychiatrists think about the virtual college lead for trainees is obviously psychiatrists to train in very different This timely talk builds on the College’s “Meeting Jonny’s family made involve loved ones, where possible, in world and tackle the subject of digital risk interested in creating an environment environments abroad which could recent position statement on supporting it clear that families are really the treatment and care of mentally ill by asking relevant questions when seeing that attracts trainees from the EU. Dr diversify their skillset.” transgender and gender-diverse people. traumatised when a member is patients.” patients. It needn’t be a blind spot for us.”

#RCPsychInsight #RCPsychInsight 6 7 INTERNATIONAL NEWS

SCOTLAND ESTONIA

Mental health legislation Scotland’s own mental health legislation, the Estonia introduced its Mental Health Act in 1997, establishing criteria Mental Health (Care and Treatment) Act, for involuntary treatment and regulations for psychiatric care. It is, has seen various changes. The most recent however, the only EU country without a harmonised mental health of these, introduced in 2017, aimed to allow policy, and therefore does not have policy on many areas including around the world people with mental illness access to effective mental health promotion, prevention and self-help, and organising treatment quickly and easily, and improve adequate treatment. Activities and interventions taking place have not While the Independent Review of the 1983 Mental Health Act (England patients’ involvement in their care. The Scottish been strategically planned, interdisciplinary responsibility is unclear, and Wales) continues, we take a moment to consider some of the acts Government, through its 2017–2027 mental and assessment of the success of various interventions is inadequate. health strategy, plans to introduce a rights-based and policies in place in the rest of the UK and across the globe. approach to how legislation is implemented and Estonia has among the world’s highest mental health disability to review how legislation addresses the needs of adjusted life years (DALYs) per 100,000 people. It was once at the top people with intellectual disabilities and autism. of the world’s rankings for suicides, but now has improved to the level of western European countries. Another recent improvement was the opening of the country’s first mental health centre for children in 2015. NORTHERN IRELAND

Northern Ireland recently passed innovative mental health legislation, the Mental Capacity Act (Northern CHINA Ireland) 2016. The Act, yet to be implemented, will introduce a fusion China’s first mental health law came into approach to mental capacity and effect in May 2013. It forbids the violation mental health law for those over 16 of human dignity, stipulates prevention years of age. RCPsych in Northern should be the guiding principle of mental Ireland is working with DoH in NI health work, and states that government on developing the Code of Practice and employers must promote psychological for this Act. In the meantime, the wellbeing. It also gives an important role to Mental Health (NI) Order 1986 and family members in assuming responsibility common law continue to apply. for supervision and management of care where appropriate. However, the law reads more like general statements of goals than enforceable GUYANA procedures or mandate. Many people with mental illness in China never receive Like many other countries in the Caribbean, Guyana does not have treatment and it appears that there is a a mental health policy. It has fewer than 10 full-time psychiatrists, a lot of stigma in society. Many see mental shortage of social workers and psychologists, and the highest suicide disorders as a sign of weakness or being rate in the world. possessed by evil spirits and regard them as socially contagious; a relative of Mental illness is misunderstood in the country, with symptoms someone with a serious disorder may find it often attributed to witchcraft, and help mainly given by religious hard to marry. leaders. Some efforts to decrease the suicide rate are being taken by the Guyana Foundation, a private philanthropic institution. The Pan-American Health Organization worked with Guyana to launch region-wide initiatives that address treatment gaps in mental health. INDIA PHILIPPINES India’s new Mental Health Care Act was passed in April 2017, replacing the 1987 Act. It attempts to The Mental Health Act of 2017, the first in the country’s history, address many pre-existing issues by empowering includes provisions to ensure the government provides psychiatric, SIERRA LEONE individuals to have a say in their treatment, psychosocial and neurological services in hospitals and basic mental decriminalising suicide attempts, and prohibiting health services in communities. It also integrates mental health into Sierra Leone is one of the world’s poorest countries and medical care generally isn’t free. ECT without muscle relaxants and anaesthesia. the country’s education system. After decades of civil war, flooding, and the Ebola crisis, Sierra Leone is experiencing a For the first time in Indian mental health law, the The Act underwent extensive deliberation before eventually being mental health crisis, particularly in relation to trauma. The country is being supported by the Act adopts a rights-based framework for people passed. A particular issue was the topic of informed consent, with World Health Organization, having launched its National Mental Health Policy and Strategy who have mental health problems, guaranteeing some questioning whether people with mental illness would have the in 2012, as well as training its first cohort of mental health professionals the same year. access to care and protection from cruel, capacity to give consent or whether doing so was even necessary. The most recent mental health act in the country is the Lunacy Act of 1902 which, as its inhumane or degrading treatment. It also aims Many people in the country do not believe mental illness is real, name suggests, does not protect or promote human rights of people with mental health to remove the stigma attached to mental illness. meaning there are questions about whether the Act will be taken problems. The dominant cultural belief is that mental illness is caused by demons or evil Implementation will be its greatest challenge due seriously, and concerns about implementation considering the many spirits and is highly stigmatised. to the lack of infrastructure, resources and staff. competing pressures for funds and resources.

#RCPsychInsight #RCPsychInsight 8 9 CURRICULUM FACULTY FEATURE FEATURE

n urgent parliamentary question on emergency hospital admissions sends trainee psychiatrist Dr Susan Howson racing downA the corridors of Westminster. As a parliamentary scholar, Susan has just a few hours before the debate to brief Lord McColl, often by drawing on her own clinical experience. Under the scheme set up by Baroness Hollins, Dr Ian Hall, Associate Dean at the Royal College of Psychiatrists Susan is spending one day a week as a parliamentary researcher to develop t’s not often that the worlds of the skills necessary to influence policy drama and psychiatry intersect. But on mental health issues. Initially, the trainee psychiatrists get a taste of programme was only open to psychiatrists this when taking their MRCPsych Drama in the specialising in intellectual disabilities but exams. The assessment involves last year it was extended to trainees from Lord Ian McColl with trainee psychiatrist Dr Susan Howson Ia test of clinical skills, in which candidates all psychiatric sub-specialities. Each of are observed in 16 scenarios (known as them is teamed with a different peer from stations) by assessing and treating an exam room across the political spectrum. actor playing the role of a patient with Susan is attached to Lord Ian McColl of mental health problems, or a relative, Dulwich, a general surgeon and professor. carer or professional involved in the case. Dr Ian Hall reveals his motivation for involving actors with Is there a doctor intellectual disabilities in the assessment of trainee psychiatrists. “Working with Lord McColl is fantastic; During the exam, the ability to assess he’s a really kind, generous and thoughtful and treat people with intellectual disability person. It’s inspiring to learn how he’s is also tested. Prior to 2014, the person developed his interests and concerns in the House? with an intellectual disability would have through his experiences with his patients.” been simulated by an actor without an came from also did a lot of work with the For Lord McColl, the experience of intellectual disability. But four years ago, actors in rehearsing them for the scenario.” working with Susan has been equally Our pioneering programme, partnering psychiatrists with that changed. The preparation paid off. “The statistics for positive: “It’s been great having Susan members of the House of Lords, is giving peers a deeper In 2014, Dr Ian Hall, Consultant the stations are very good – distinguishing here; she’s fitted in well. We’ve had lots insight into mental health. Psychiatrist, Associate Dean and member good candidates from poor candidates of questions and answers from the of the Examinations Subcommittee at better than other stations that used actors experts and I have learnt a lot.” the Royal College of Psychiatrists, had without intellectual disabilities to play Susan’s days at parliament vary; after an idea. “Why not use actors with an people with intellectual disabilities. They meeting up with Lord McColl, she may “It’s inspiring to learn I attend parliament on my special interest intellectual disability, as surely they will were also more difficult to pass than go through the House’s programme to day and my travel expenses are covered be able to play those with an intellectual average,” reveals Dr Hall. “Feedback from identify opportunities to brief peers on how he’s developed his by the College.” disability more authentically?” the actors has been brilliant: one of the Actor George Gavasin (centre) in a previous role issues related to mental health, attend interests and concerns Participating in the scheme has Working closely with colleagues and the role players said to me, ‘this is the best meetings, sit in on debates and even view though his experiences also helped Susan become a better director of the professional role player day of my year’, and many were keen to also shows candidates that people with Prime Minister’s Question Time. Highlights with his patients” psychiatrist; “it helps me understand the company that recruits actors for the perform more times,” Dr Hall explains. It’s intellectual disabilities can take on valued include meeting Dr Sarah Wollaston MP, broader context and not sink into blaming exams, Dr Hall designed and piloted a sentiment shared by George Gavasin, social roles – in this instance as actors Chair of the Health Select Committee, to lack of resources for every problem an examination station using actors an actor with intellectual difficulties who with a job in the assessment of doctors. discuss the children and young people’s but instead try to be more constructive with intellectual disabilities. “We had 64 has been performing for 17 years and For me, the best thing about it is it’s mental health provision green paper. in thinking about how we do things. In candidates being examined at the same involved in with MRCPsych exams for demonstrating something very positive “Having someone who works on the practical terms, it’s allowed me to have time and eight different stations involving the last four. He says, “I really enjoy role about people with intellectual disabilities.” frontline of mental health can have an more compassion for colleagues in other an actor with an intellectual disability playing in the exam because it’s really In the future, Dr Hall would like to see this impact on how parliamentarians shape member’s bill through parliament. “It’s a services (particularly social care) who may running simultaneously. We needed to interesting seeing how the candidates pioneering assessment method adopted policy change; during the meeting, I was great opportunity learn how legislation be struggling to manage their caseloads. make sure all the actors were playing react to the scenario. I think it’s important by other Royal Colleges. “People with able to get across concerns about children is formed.” This compassion helps us all work the role in the same way so we did a lot trainee doctors are given experience in intellectual difficulties can and do present out of school and those with complex “Taking part in the Scholars Programme together for the best for young people.” of work beforehand – meeting them to dealing with people who give answers at any part of the health service, from situations with social care involvement, is an enriching experience and I would Ultimately, the scheme has affected discuss how the role was to be played, they wouldn’t think of or expect, and are A&E to oncology clinics, but sadly there’s which was really satisfying.” definitely recommend applying, especially Susan’s career plans. “I love my patient giving them the scenario in an accessible encouraged to explain things in a less lots of evidence that they don’t get the Susan, a former award-winning to those living outside London who may contact but participating in the programme way by making the language simple and clinical way.” best treatment. That’s why it’s important mathematician, has also been involved not have such opportunities on their has made me realise that it’s important to clear, and using pictures to support the For Dr Hall, the station goes beyond a every doctor is able to work with people in Lord McColl’s work steering a private doorstep, as it’s practical and viable. have a wider perspective.” words. The theatre groups the actors test of candidates’ communication; “it with intellectual disabilities.”

#RCPsychInsight #RCPsychInsight 10 11 NEWS FEATURE A positive diagnosis

“Awakened. Liberated. Validated.” The aversions and that was the missing key. When words 31-year-old Sara uses to describe I met Dr Ian Davidson, he said my sensory herself following her autism diagnosis. aversions were so obvious, he questioned how “I’d spent years feeling fundamentally I’d slipped through the net for so long.” different, thinking I may be crazy, struggling Sara says her autism diagnosis at the age of with depression, experiencing severe 27 “gave me back my sense of self. For the food aversions and suicidal thoughts, and first time, I had an explanation of why I was believing there was something inherently having a meltdown and the knowledge of what wrong with me.” is likely to provoke one so I can manage my Sara’s mother had noticed there was lifestyle and gain self-control and emotional something different about her daughter, regulation. Although I’m still making sense of who would chatter away to and mimic my autistic identity, I thank goodness for the adults but wouldn’t communicate with team of professionals who assisted me in my children and refused to eat or let herself be self-discovery and diagnosed me. It’s turned hugged. But health visitors told her Sara my life around.” was very intelligent and bored. Growing up, Sara didn’t know why she needed to move, sing and tap, or why she struggled to comprehend social narratives. “I didn’t understand the predominant rules and thought I was crazy, broken or abnormal. That way of thinking fed into my low-self-esteem, depression and anxiety.” Sara received therapy and even saw psychiatrists but, despite her growing desperation, no one ever diagnosed autism. “They had no answers because they never once asked about my sensory Sara, who was diagnosed with autism

Consultant Psychiatrist and autism specialist Dr Juli Crocombe

magine growing up feeling you’re masking of symptoms can be immense concurs. “Autistic women whose of autism will be missed.” different from your peers yet and come at the cost of academic condition hasn’t been recognised Fortunately, work is being done to desperate to fit in. You believe work, which tends to suffer as girls are very disadvantaged as they are ensure autistic females are diagnosed you’re mentally ill, but never have Equality in Autism spend more time learning how to fit in vulnerable to low self-esteem and all earlier and more frequently. “The an explanation for your thoughts than studying. And it’s not just school sorts of mental and physical health policies I’m striving to introduce in my Iand behaviour. Shockingly, this is an work that suffers, as Dr Crocombe problems. Autistic people are more work as the Chair of the advisory board experience girls with undiagnosed Why do girls with autism often go undiagnosed? explains. “Left undiagnosed, autism in likely to have a range of physical to the all-party parliamentary group on autism are highly likely to endure. women typically manifests as anxiety, healthcare conditions and are less autism focus on increasing recognition Currently, about 700,000 people in depression and self-harm, which can likely to seek help in an effective of autism in men and women among the UK are diagnosed with autism have devastating consequences.” manner because if they are in pain, relevant professionals in health, social but just 20% of them are female, a Dr Ian Davidson, the Royal College they may not be showing signs of pain care, education and employment,” says figure disputed by autism experts. “interact a lot, albeit in quite bizarre or of Psychiatrists Autism Champion, the person treating them expects to Dr Crocombe. “The number of women with autism “Left undiagnosed, inappropriate ways”. see because they don’t communicate Crucially, having a diagnosis ensures is likely to be heavily underestimated autism in women While the majority of boys with autism in a conventional way.” “proper understanding and support because females are diagnosed less typically manifests as are identified when or even before they Dr Davidson suggests another reason and allows people with autism to often than men,” explains Consultant start formal education because their why women are not diagnosed with understand their own needs and gives Psychiatrist and autism specialist Dr anxiety, depression behaviour causes concern, girls tend autism even when they come to the them the opportunity to fulfil their true Juli Crocombe, who believes the ratio and self-harm, which to slip through the net. “Quite often, attention of professionals is that “a lot potential”, says Dr Crocombe. is more likely 3:2 male to female. She can have devastating girls at school are very quiet, studious of the tools used to diagnose autism “If you know you’re autistic, a diagnosis cites a number of reasons for the and well-behaved so they don’t come were designed to work with boys with can help in identifying how best to discrepancy, including the fact that consequences” to the attention of teachers. Plus, girls intellectual disabilities”. An example use and manage your strengths “most people simply aren’t looking for tend to be better at mimicking and he gives is a tool which assesses and weaknesses, which can be autism in women; they tend to have learning socially acceptable behaviour communication and social interaction. empowering,” states Dr Davidson. He very stereotyped views that it affects so are less likely to be perceived as “Women tend to do better on that continues, “The vast majority of people only boys”. unusual or to engage in behaviour that because as girls they’ve learnt the who receive a diagnosis of autism say Other misconceptions, for example spectrum on which the nature of social causes a problem,” she explains. In social rules by rote so find it easy it’s beneficial. They still need help with that people with autism don’t interact impairment can be very varied,” says short, “girls put more effort into fitting to get through the tasks. So if the the adjustment but they will tell you it with others at all, can also hinder Dr Crocombe, who points out that in with their peer group”. assessment relies on diagnostic tools actually empowered them to start being diagnosis of females. “Autism is a many women and girls with autism can But the effort involved in the so-called Dr Ian Davidson, RCPsych Autism Champion rather than a proper history, the signs themselves.”

#RCPsychInsight #RCPsychInsight 12 13 CAREERS NEWS FEATURE FEATURE

with them. So for me, being an SAS doctor was a positive choice. It gives me the fulfilment and sense of purpose in doing a job I love without the management responsibilities that often can’t be left at the clinic door.” This lower stress model appeals to some who seek greater work-life balance and to maintain their own mental health. But it also has a positive impact on patients too. “With fewer things competing for a specialty doctor’s time, he or she has more time to devote to clinical work and thus can appear more accessible to Dr Afzal Javed, former Chair of the Midlands division of RCPsych and Chair-Elect of the World Psychiatric Association patients and get to know the patients well,” explains Monique. hen asked about On the downside, there has been a his progression historical tendency amongst some to from newly qualified feel undervalued and not respected by psychiatrist to Psychiatrist on consultants and trainees. “Some used president-elect of the to see SAS doctors as people who lack WWorld Psychiatric Association (WPA), Dr ambition or have chosen to go into dead- Afzal Javed explains, “It honestly feels end roles,” says Monique. like a dream. I say that as somebody top of the world “But this is definitely changing. Specialty who started his career in psychiatry doctors have found their voice and the in a department that was confined to Dr Afzal Javed charts his journey from medical student College is hugely supportive of them. one small room with no facilities.” From to psychiatrist, to president-elect of the World Psychiatric We have reinvigorated the Specialty these humble beginnings in Lahore, Association. Dr Monique Schelhase, Associate Specialist in eating disorders Doctor Committee with new members, Pakistan, Dr Javed has become a and with greater representation on other consultant psychiatrist at the Coventry committees within the College”. and Warwickshire NHS Trust, as well as Monique says there is scope for career an honorary clinical associate teacher development within the umbrella of at the University of Warwick’s Medical “The first and most important thing to focus specialty doctors, which she describes as School. He also holds senior roles in the “The first and most on is improving the image of psychiatry The SAS life “a heterogenous group of people, some of WPA and other international psychiatry important thing to and psychiatrists. As an international whom have completed consultant training organisations, including the Asian focus on is improving organisation representing almost 250,000 Dr Monique Schelhase talks about life as a specialty and but for personal reasons choose not to Federation of Psychiatric Associations. the image of psychiatry psychiatrists around the world, the WPA associate specialist (SAS) doctor. take up a role.” His achievements are even more needs a clear vision about how to promote She is glad that the College is recognising impressive when you consider the and psychiatrists” psychiatry as a promising career for the value of this dedicated group of obstacles he encountered as a medical undergraduate medical students. physicians, something the public have student. “Psychiatry was not respected “The second thing concerns the major ecoming a psychiatrist does “I love psychiatry and I long appreciated. as a medical specialty and the stigma problems in psychiatry; by the age of 25, not always mean training as And if personal circumstances change, came from inside the medical profession. more than 60% of mental illnesses will a consultant. Approximately love being a psychiatrist or a doctor later decides he or she This is typical in lower and middle income have developed. To help our patients, 13% of RCPsych members and working with does want to become a consultant but countries, but I’m sure the scene is no as Deputy then as Associate Registrar. He the most important thing is to identify, have chosen another challenging patients but doesn’t hold a Certificate of Completion different in the developed world.” Despite was elected Chair of the West Midlands support and manage their problems valuableB and hugely rewarding position I also recognise the need of Training (CCT) there are other routes these barriers, Dr Javed remained division then, in 2005, was voted onto during the early periods of their lives, within the discipline: SAS psychiatrist. available. He or she can complete their steadfast in his decision to become a several WPA committees. “I was again so establishing more child, adolescent Dr Monique Schelhase, Associate to have a life outside training or gain a Certificate of Eligibility psychiatrist, which was partly influenced lucky to have guidance and support from and youth mental health services in all Specialist in eating disorders, based in medicine as well” for Specialist Registration (CESR) by by one of his uncles, “the first professor the presidents, and that really shaped my countries is going to be vital. Leeds, chairs the College’s Specialty providing documentation to satisfy the – and a real pioneer in the field – of thoughts on international psychiatry and “The third thing is promoting the concept of Doctor Committee and thinks specialty College and the GMC that the applicant’s psychiatry in Pakistan. Another factor was more importantly about the issues and public mental health. That means while we and associate specialist doctors are practice meets consultant standard. my teachers, who suggested that this practicalities of low-income countries.” prioritise treatment, the different aspects experiencing something of a renaissance. Monique says that whichever path you field was going to be very important in the Is it really luck that has propelled Dr of promotion and prevention need to be “I love psychiatry and I love being a role which has no new appointees since choose, there is a route that is right coming years.” Javed? He concedes, “I feel that actually given equal importance.” psychiatrist and working with challenging the introduction of the new NHS contract. for you. “I would encourage people to In the 1980s, while working as Assistant it was my interest in and passion for this Of course, he can’t implement these plans patients but I also recognise the need to For her this was a lifestyle choice: consider their needs – both physical and Professor of psychiatry at King Edward specialty which has brought me to this alone. “The WPA gets its strength from have a life outside medicine as well.” “I have a long working week – 50 hours mental – and identify a specialty doctor Medical College Lahore, Dr Javed was position.” He will bring this interest and its members and the younger generation Monique, like one in 10 psychiatrists, – Monday to Friday 8 until 6 – but when role as a possibility, particularly if they offered a scholarship to study at the passion to the role of president of the are essential because they will be the chose to become a specialty doctor – later I am at home and with friends and family come across obstacles in the path to University of Edinburgh. A decade later, Dr WPA, a post he will assume in 2020. Until backbone of the service and the most being promoted to associate specialist, a I am able to be absolutely in the moment becoming a consultant.” Javed became involved in RCPsych, first then, he’s honing his action plan. important pillars in promoting psychiatry.”

#RCPsychInsight #RCPsychInsight 14 15 OPINION RESEARCH PIECE NEWS Off-label prescriptions has helped devise the guidelines, wanted to make the recommendations simple and Revised College guidelines help to simplify the process of readily usable in everyday practice. prescribing medication outside the terms of its licence. In psychiatry in particular, a one-size-fits- all solution is very often not practical. “Lots of patients won’t respond to a succession of psychological and pharmacological treatments that are within licence, so doctors then think about prescribing medicines outside the terms of Dr Nuwan Dissanayaka, executive member of RCPsych’s Rehabilitation Psychiatry Faculty their licence,” David explains. “Doctors shouldn’t be afraid to do this as long as they can demonstrate their actions have been logical and there is evidence to Taking the road less travelled: support their prescription. Both things they would do anyway, whatever they were prescribing. “For example, the drug Sertraline, Why I chose psychiatry although licensed for depression, can be used to treat General Anxiety Disorder (GAD) because there is a lot of evidence As RCPsych gets ready to launch the next phase of our to show it is also effective in treating GAD. Choose Psychiatry campaign, Dr Nuwan Dissanayaka, of nurses. Already an imposing figure, In fact NICE recommends prescribing Consultant Psychiatrist for the Assertive Outreach Team at the man’s presence was amplified by his Sertraline for GAD, so although it is Leeds and York Partnership NHS Foundation Trust, tells us expansive gesticulations and deafening technically off-label, practitioners should what led him into the profession. protests. My timid approaches towards not worry as NICE accepts there is him were met with a wall of racist profanity sufficient evidence to recommend it,” he and I have to admit I was scared. Well out says. of my depth, I called the specialist registrar The same, he says, applies to the for help and after what seemed like an prescribing of Venlafaxine, which is eternity he finally arrived. licensed for depression and GAD but is s a bright-eyed 21-year- “She turned my clumsy What happened next was a revelation. It known to be effective in the treatment old medical student, my attempts to take a took a moment for the man to recognise of PTSD. dream was to become my superior but when he did, somewhere David Baldwin, Chair of the Psychopharmacology Committee David also recommends telling the patient a paediatrician. But all it psychiatric history into deep in the abyss of his psychosis, a pearl – and if possible a relative or partner – of took was a few weeks of a an opportunity to paint of reality broke to the surface, and just the intention to prescribe off-label, and Apsychiatry placement to change my mind vibrant pictures of seeing his friendly, familiar face brought when there is not extensive evidence completely. the patient an immediate wave of relief. cross every discipline in basis to support prescription, obtaining the I can trace the initial spark back to one bygone times” I know now that the magic I saw that night medicine there comes a “Doctors shouldn’t be advice of another prescribing clinician or person − a frail elderly lady who was was the therapeutic relationship. In an era time when a practitioner afraid to do this as long specialist pharmacist. admitted to the psychiatric ward on the which saw the introduction of crisis teams wants to prescribe off-label, as they can demonstrate He goes on to advise starting any off-label day that I started. A familiar face on her and time-limited interventions, I gravitated when he or she is certain their actions have medication at low dose and monitoring its local high street and well-liked by her away from the quick fixes and discarded Aa particular drug will improve clinical effect carefully. community, over recent months she continuity, first towards psychiatric outcomes for their patient. been logical and there Adhering to such guidelines should protect had become increasingly unwell, hiding of the job was brought home to me by rehabilitation and later to Assertive Yet using the medication in such a way is evidence to support the clinician from any legal action and if away, tormented by fears of alien forces. incidents of suicide and homicide. Both Outreach. My passion flows from forging would be outside the narrow terms of its their prescription” the off-label medicine shows no beneficial Over the next few weeks I grew to know exposed me to the tragedy that can lasting relationships with the people I treat, product licence. effects, or if the hazards outweigh the her quite well. She turned my clumsy accompany serious mental illness: the and together we use those relationships From young female acne sufferers being benefits, it should be withdrawn. attempts to take a psychiatric history into devastation it wreaks on people’s lives, as a platform to help rebuild their lives. prescribed the contraceptive pill, to a “Document the reasons why it is being an opportunity to paint vibrant pictures including our own, and the forensic rigour There is something remarkable in the range of paediatric conditions treated with withdrawn,” says David, and then if of bygone times. It was wondrous to see expected of those involved. interaction between people which is drugs that are only licensed for those over treatment is still needed, consider her recovery. Her consultant listened But in that melee, there were moments the lifeblood of psychiatry. It touches 18, this is an issue that affects all areas of alternatives, once more applying deeply to her, giving her his full attention of magic. One Friday in the early hours us deeply and enriches our lives. medicine. guidelines into off-label prescribing, the the same criteria of logic, evidence, and trying to understand the world from I was called to casualty by a fraught And sometimes it is possible for this However, it can be fraught with perceived College decided the time was right to transparency and input from other her perspective rather than judging registrar. “One of your patients is here type of engagement to bring about danger and there are still concerns about update its own 2007 guidelines. The new professionals. her. Psychiatry was something new, causing chaos. You need to get down transformational change. That is more patient safety and medical liability for a guidelines, released in December 2017, As long as a patient’s care is then something different – I was hooked! here now and sort him out!” I arrived in rewarding than anything I know. I am glad clinician to contend with. are available on the College website. monitored and recorded, off-label My early years as a psychiatric trainee the middle of a stand-off: a giant of a I took the road less travelled and I will be With this in mind, and following on from David Baldwin, Chair of the College’s prescribing should be not only safe but presented many challenges. The gravity man with wild hair cornered by a group forever grateful that I chose psychiatry. the GMC’s 2013 publication of their Psychopharmacology Committee, who sometimes preferable.

#RCPsychInsight #RCPsychInsight 16 17 FRONTLINE FOCUS

Our Barbara Robb (1912–1976) Joan Bicknell (1939–2017) Professor Christine Dean NHS heroines Barbara was a psychotherapist Joan was Britain’s first female Christine set up the first Claire Murdoch whose passionate campaigning As we celebrate both the NHS turning 70 and the centenary professor of psychiatry, home treatment service as Claire’s accomplishments include against the ill-treatment of older pioneering the specialty of an alternative to hospital developing a rating system for CCG of women’s right to vote, we take a snapshot of just some of people prompted the NHS to intellectual disabilities. She admissions for people with performance in mental health, and the most inspiring and pioneering women in mental health. review its complaint procedures persistently fought against cruelty acute mental disorders. Home supporting moves to ensure mentally Join the conversation on Twitter and tag more leading ladies for the first time, establish within psychiatric hospitals and treatment services have since ill people, especially children and using the hashtag #MHheroines. an NHS Ombudsman, and was a human rights advocate been adopted nationwide in the adolescents, are treated nearer their release guidance on preventing of institutionalised people with UK, and are recommended by homes. She is currently National Director violence in hospitals. intellectual disabilities. the NHS. for Mental Health at NHS England.

Dr Helen Boyle Anna Freud (1895–1982) (1869–1957) Widely considered one of the founders Helen was the first of psychoanalytic child psychology, clinician to make Anna Freud, the youngest child of Professor Sheila the mental health treatment Sigmund Freud, came to Britain in 1938 Baroness Hollins available to patients to escape Nazi Europe. Her pioneering Sheila has served as Dame Fiona Caldicott before crisis. She also work led to the establishment of what President of both RCPsych Fiona was the first woman to founded the Medical is now called the Anna Freud National and the BMA. In the House become President and Dean Women’s Federation, Centre for Children and Families. of Lords, she has worked of RCPsych, and worked the Child Guidance passionately to improve closely with RCPsych’s Council and the National the lives of people with Women and Mental Council for Mental Professor Annie intellectual disabilities and Health Special Interest Hygiene (now Mind). Altschul (1919–2001) mental health conditions. Group. Fiona chaired the She was the first female It was her amendment to Caldicott Committee into president of the Royal Annie, a refugee the 2012 Health and Social the protection and use of Medico-Psychological from Nazi Europe, Care Act which enshrined patient information. Her Association, the markedly improved in law the concept of parity work changed the way data forerunner of RCPsych. psychiatric nursing care of esteem between physical is shared in the NHS and through her research and mental health. improved confidentiality. in the field. She was eventually awarded a CBE, a fellowship of the Royal College Lorna Wing of Nursing, and the (1928–2014) Altschul Award for Lorna was a pioneer in scholarly writing. the field of childhood developmental disorders, and helped advance the understanding of autism worldwide. She introduced the term (1924–2009) ‘Asperger syndrome’, Professor Dame Sue Bailey Jacqueline Dyer Professor Wendy Burn Dr Sula Wolff and was involved in Sula conducted pivotal research into emotionally founding the National Sue has served as President of RCPsych Jacqui is a passionate mental Wendy set up the Yorkshire School of withdrawn children and mentored many other psychiatrists Autistic Society. Lorna and is now Chair of the Academy of health campaigner with a focus Psychiatry and was its first Head. She who made major contributions to the field. She was also was appointed OBE Medical Royal Colleges. In 2002, she on highlighting the mental health was Dean of RCPsych for five years and one of the founders of modern British child psychiatry. in 1994. was appointed OBE “for services to Youth stigma within BME communities. became President in 2017. She also leads Justice” and in 2014 she was promoted She is Vice Chair of the NHS the Gatsby Wellcome Neuroscience Project to DBE “for services to Psychiatry and for Mental Health Taskforce and was at the College. Her main clinical interest is voluntary service to People with Mental awarded an MBE for services to dementia and she has contributed nationally Health Conditions”. mental health. to improving care for this group of patients.

#RCPsychInsight #RCPsychInsight 18 19 BRIGHT IDEAS

decade ago Dr Susan Mizen, frustrated by the lack of psychotherapeutic help for people with serious mental health problems, noticed Athat a small minority of complex patients absorbed a huge proportion of mental health funding in Devon but did not receive the therapeutic treatment they needed. They had multiple issues and were being treated in specialist out of area placements. After studying the mammoth costs – often £200,000 per patient per year – combined with the fact that the vast spending didn’t produce tangible results which were sustained outside hospital, she won funding to try another method. Susan drew on her experiences as a trainee at the Cassel Hospital in West London and devised a whole-system intervention that combined intensive therapy in county, with well-trained staff and supported housing provision. The number of out of area placements substantially reduced. By Dr Susan Mizen, Chair of the Medical Psychotherapy Faculty 2016, when the last figures were available, the cost of out of area placements in Devon had dropped from £7.4m to £1.4m. The total health and social care cost of treating those patients in Devon is Investing currently being calculated, but is likely to be considerably less than the £6m saving in out of area placements. As a psychiatrist who specialises in in success psychotherapy, Susan, who is now Chair of the Medical Psychotherapy Faculty at Dr Susan Mizen has pioneered a therapeutic model that has the College, based her treatment plan on a saved millions in funds for mental health services in her area. psychotherapeutic treatment model: “We offer a three-year psychotherapy programme. The first nine months is psychotherapy team see relationships detained under the Mental Health Act. psychoanalytic psychotherapy and and attachment as the driver for shifting A gatekeeping assessment from the psychosocial nursing offered four days a states of mind, impulsive riskiness and medical psychotherapist followed, and Miss week in a day programme. This is followed other symptoms, with family roles being N, feeling she was understood and that by out-patient therapy for two years and re-created in patient’s relationships with the therapeutic treatment was available, began three months. team, each other and their bodies. Medical to feel motivated to get out of hospital to “This is all offered alongside intensive and risk management are therefore part attend the therapeutic programme. housing support in which staff are trained and parcel of this holistic approach.” She was offered highly supported to offer a psychologically informed Susan says she is planning to submit a housing and a Psychologically Informed environment. health economic analysis of the model Environment (PIE). The therapeutic “The patient group who end up going out of to BJPsych Bulletin soon and to begin a team undertook a psychodynamic risk area are complicated for several reasons. clinical trial of the model. assessment with the housing team. This They often have severe personality There are many examples of the process gave Miss N further confidence disorders and have additional issues on effectiveness of this way of working. She that the team understood the severity of top of this like eating disorders, substance cites a typical case, Miss N the daughter her problems and were prepared for all the misuse or autistic spectrum disorder. of a single mother with mental health risky behaviour that therapy was likely to “These patients aren’t accepted by problems who spent time in foster care bring. She left the hospital to embark on specialist services oriented to one diagnosis and was self-harming and anorexic by the three-year programme. The treatment and often fall through the net. So, we the time she was a teenager. As an is arduous and demanding for the patient developed a whole-team model – The adult she worked relentlessly, but quickly and the team but it means that very high Relational Affective Model – in which became suicidal when she lost her job. levels of disturbance are managed. This everyone works to a formulation describing It was then that she came to the attention ultimately benefits patients but it also the underlying psychological difficulty. The of mental health services. As the relieves some of the pressures on the local medical psychotherapist, nursing staff and attempts on her life continued she was health economy.

#RCPsychInsight 20