this is my critique of the IAPT paper published in the current issue of the British Journal of Clinical Psychology, and the Editor has just accepted it for publication. Wakefield et al (2020) will be invited to respond.
Not quite sure when it will see the light of day, but hopefully it is at least the beginnings of open discussion.
An area I’ve not touched on, in my paper is the effect of IAPT on its staff. Some are taking legal action against IAPT for bullying and have highlighted massive staff turnover. But it is very difficult for them to go into detail with litigation pending. Others are suffering in silence to become financially secure enough to leave. Staff are in an invidious position, at best they might hope for an out of Court settlement. But unsurprisingly there is no great Organisational demand for whistleblowers. Gagging clauses it appears are still about and I heard of one being used recently by an employer against a victim of the Manchester Arena bombing.
We need a national independent inquiry not only about the speed with which lockdown was imposed, but also about what has been happening in IAPT. But today I was talking with a survivor of the 1989 Hillsborough Football disaster, that I’ve kept in touch with since shortly afterwards, and we reflected on how long it has taken to get anywhere. He was too exhausted to follow through on the Statement he gave that was doctored by the police.
Bullying tends to centre on what the Organisations contend are ‘one or two bad apples’, which at a push they might make some compensation for, to avoid adverse publicity, and without admitting liability. But I think there is a bigger phenomenon of Organisational Abuse that operates in an insidious way akin to racism, that needs to be called out.
It is 2 years since the Manchester Arena bombing, Cheryl has been absent from school since, despite 5 sessions of counselling at a well known Children’s Hospital. She and her Aunt (also a victim of the bombing) were invited to consider variously that Cheryl may be autistic, her difficulties may be a product of her mum’s childhood stressors, she may have PTSD and they need family therapy. All of which I found to be total rubbish.
The limited counselling she had only occurred because the Manchester Hub (set up to simply signpost people in the aftermath of the bombing) made regular contact with the Hospital. In fact all she was suffering from was panic disorder with agoraphobic avoidance and illness anxiety disorder. Within 2 sessions she has already made rapid progress.
Her aunt has had twelve sessions with an IAPT service followed by group therapy which she dropped out of. She was never offered any diagnosis. Two years on she is still struggling. Neither Cheryl or her Aunt have had anywhere significant to turn to to protest (the Hospital has made a half apology about being short staffed). But for both children and adults it is not just a question of money, the quality of service is woeful.
There is a pressing need for an action line for those failed by Mental Health Services.
Two years ago I wrote the book ‘Towards a Mental Health System That Works’ London, Routledge, the system is no better, just that some agencies are highly skilled at self-promotion and thereby expansion, MPs have been taken in by this and like to be seen to be on the side of mental health.
Young people effected by the bombing are having to wait 7-8 months for CAMHS services. The most debilitated adults have sought private counselling or been placed on a CBT waiting list. These findings are from the Kerslake report on Services response to the Manchester bombing published last week. Worryingly there is no indication that evidence based CBT has yet been made available. This is not to say that most people have not been grateful for the assistance they have had to date, but this is not unexpected as only a significant minority of trauma victims suffer long term debility.
The following are the psychological abstracts from the report:
2.27. Feedback about the NHS Manchester Resilience Hub (established after the attack
to coordinate the care and support for children, young people and adults whose
mental health has been affected by the attack wherever they may live) was largely
positive, although many commented they would have liked something sooner.
Participants appreciated the three-monthly contacts from the Hub and felt
reassured that someone was there for them.
“I think the services set up to help those struggling with their mental health
following this event are great too and I feel happy knowing there is always
someone I can talk to if I need to.”
“I do however feel that there is a lack of counselling for young people.”
“The counselling support provided in the hospital did not appear to have the skill
level or approach for this type of situation. The counsellor was super-intrusive
coming into the room at 7am.”
“I contacted the Resilience Hub and both me and my daughter filled out the
questionnaire. Someone contacted us straight away and felt that my daughter
needed further support, which was arranged quickly. I felt there was lots of
support available. I also felt it helpful that the Hub were going to keep sending
questionnaires every three months to check how people are doing.”
“My son was referred for counselling through the Manchester Resilience Hub and
is on a waiting list for CBT as they feel he may have Post-Traumatic Stress
Disorder. The counsellors from Reflections in Oldham are brilliant.”
“My GP was extremely helpful and made a referral to CAMHS, however, there is a
seven-month waiting list.”
“My daughter has been referred to CAMHS for PTSD and low mood, however,
there is an eight month wait for this.”
“The counsellor at my daughter’s school is very good and offered to do some
sessions for me too. I went back multiple times and found it helpful.”
“The caller said she was told how she was feeling was normal and that they would
call her in three weeks. This wasn’t helpful as at the time she needed to speak to
somebody.”
“I feel as though the email received in October could have been sent earlier to
those who had been affected by the attack. I feel as though I have come a long
way since May. I’m less jumpy, having less nightmares and emailing my story was
nice to get it off my chest.”
“The attack has affected my mental health to the extent that I have been unable to
start my university course as planned. My mental health deteriorated, I had to
seek private psychotherapy after being diagnosed with PTSD and anxiety.”
“I have been in touch with the Survivors’ Network as well as the Manchester
Resilience Hub and they all provided great support. The Foundation for Peace
have written to the children’s school with tips on how to support them.”
“My place of work paid for private counselling sessions; I was a mess and did not
stop crying for the first three sessions. I have not been in work since the attack. I
spend most of my time talking to a war veteran who gives me support.”
4.39. The strategy was to communicate a ‘normalisation’ and support message not only
in Greater Manchester but via NHS national networks. The advice given was that
directing people into treatment at an early stage was potentially harmful and was
an inappropriate response to normal responses which people experience after
such an incident. If, after four weeks, people were experiencing difficulty e.g.
mood shifts, trouble sleeping, experiencing panic, then they should be pointed to
further mental health support. This advice relating to psychological reactions to
traumatic experiences was widely circulated within hours of the incident,
describing what were normal reactions, when to seek help, and from where to get
help. Efforts were made to circulate these messages through a range of media
platforms including digital and broadcast
Dr Mike Scott
NOTE: Victim Support provided the front door in the 1st 4 weeks after the bombing
But trauma therapist are going to make you at the drop of a hat. Surprise, surprise lots of people drop out. The problem is that therapists are poor at making the distinction between cognitive avoidance and saving normal.
Ms X was on a works training course , but got upset when discussion got around to the Manchester bombing and she left the room. She had escorted her 2 children from the arena. Ms X was referred to Occupational Health and seen by a therapist who said that she was not suitable for learning to manage workplace trauma. Ms X’s reaction was arguably a normal reaction to an abnormal situation , it had not been ascertained whether she was suffering from PTSD or any other recognised disorder.
The therapist had not appreciated that traumatic memories have to be handled with ‘kid gloves’ , there is a normal aversion reaction to such encounters. Recognising and accepting Ms X’s response is acknowledgement of the need to ‘save normal’ . This is not to say that on occassion , there is not a need to learn a better way of handling an intrusive memory when it is significantly impairing functioning (e.g in PTSD) or to reconstruct the memory so that it is a better template for predicting everyday life. But the burden of proof is with the therapist to demonstrate that this is necessary.
Can there be a more glaring illustration of the disparity between physical and mental health, when a victim of the Manchester bombing is subjected to a series of telephone conversations (IAPT) about her distress and it takes 6 months for a face to face consultation to take place. The public are rightly alarmed at the hours it took some of the Emergency services to be able to offer medical help, but it is as nothing compared to the time taken to address the person’s mental health. But there is no outcry about this from either GP’s, MP’s or mental health staff, there is tacit approval of the disparity.
Recently it was the centenary of the 3rd Battle of Ypres, in which my grandfather was killed on October 28th 22017. To my knowledge nobody ever suggested that the ‘shell shocked’ from the conflict should be catered for by telephone.
Rather there were dedicated Hospitals like Craiglockhart in Edinburgh and Moss Side in Liverpool and such Hospitals continued functioning after the 2nd World War. Being face to face with victims is surely the least we can offer.
A thought for Remembrance Sunday ‘A century on, are we really any more respectful?’
